The document provides an overview of the history and fundamentals of nursing. It discusses: 1) The early origins and evolution of nursing from ancient civilizations through major historical events like wars and the establishment of hospitals and codes of sanitation. 2) The contributions of Florence Nightingale including establishing nursing education standards and emphasizing sanitation practices. 3) The development of nursing in the Philippines including the earliest hospitals and nursing schools. 4) Key nursing concepts like the definition of a nurse, levels of nursing practice, fields of nursing practice, and expanded educational and career roles for nurses.

1. FUNDAMENTALS OF NURSING

2. HISTORY OF NURSING

3. HISTORY OF NURSING
 Early Civilization
 Cause of Disease
 Medicine Man
 Mother Surrogate
 Cause of Disease
 Temples
 Code of Hammurabi: Oldest Sanitation Code
- 1760 BC
- Law codes
- Sanitation

4. HISTORY OF NURSING
 Early Christian Period
 Deaconesses, Crusaders, Hospitals, Good
Samaritan Law
 Parabolani Brotherhood
 Teutonic Knights
 Knights of St. John of Jerusalem
 Knights of Lazarus

5. HISTORY OF NURSING
 Throughout history, wars have accentuated the
need for nurses:
 WWI, WWII, American Civil War, Vietnam
War (Recruitment of Nurses)
 Free Education for Nurses
 Crimean War
 Sir Sidney Herbert
 Florence Nightingale

6. HISTORY OF NURSING
 Florence Nightingale
 1836
 Theodor Fliedner, a German pastor in
Kaiserwerth, opened a hospital with a
training school for nurses
 Training School of Deaconesses
 1847
 Florence Nightingale went to train as a
nurse in Kaiserwerth, Germany
 Where she stayed for 3 months

7. HISTORY OF NURSING
 1853
 Nightingale trained in the Sisters of Charity
 Paris
 Returning to London, she worked as
administrator and director of nurses at the
Establishment for Gentlewomen During Illness
where she remained
 Until she was called into service during the
Crimean War

8. HISTORY OF NURSING
 1860
 Nightingale opened the Nightingale Training
School for Nurses
 Served as model for other nursing schools
 Its graduates traveled to other countries
to manage hospitals and nurse training
schools

9. HISTORY OF NURSING

10. HISTORY OF NURSING
 Nightingales biggest contributions in
Nursing:
 Sanitation Practices
 Nursing Education
 First Nurse Theorist
 Notes on Nursing: What It Is And
What It Is Not

11. HISTORY OF NURSING
IN THE PHILIPPINES
 Earliest Hospitals
 Hospital de Real de Manila (1577)
 San Lazaro Hospital (1578)
 San Juan de Dios Hospital (1596)

12. HISTORY OF NURSING
IN THE PHILIPPINES
 Earliest Nursing Schools
 Iloilo Mission Hospital School of Nursing (1906)
 St. Luke’s Hospital School of Nursing (1907)
 Mary Johnston Hospital and School of Nursing
(1907)
 Philippine General Hospital School of Nursing
(1910)

13. HISTORY OF NURSING
IN THE PHILIPPINES
 Earliest Nursing Universities
 University of Santo Tomas College of Nursing
 Manila Central University College of Nursing
 University of the Philippines College of Nursing,
Manila
 FEU Institute of Nursing
 UE College of Nursing

14. HISTORY OF NURSING
IN THE PHILIPPINES
 Nursing Leaders
 Anastacia Giron - Tupaz
- Nurse Chief Superintendent of PNA
- Founder of PNA

15. HISTORY OF NURSING
IN THE PHILIPPINES
 Nursing Organizations
 Philippine Nurse’s Association (PNA) – National
 First President
 Rosario Delgado
 Current President
 Leah Samaco Pacquiz

16. NURSE

17. NURSE
 Came from the Latin word
 “Noutrix”
 Meaning of the word
 “To Nourish”

18. AS A PROFESSION
 Body of specific and unique knowledge
 Strong service orientation
 Recognized authority by a professional group
 Code of ethics and laws
 Professional organization
 Ongoing research
 Autonomy
 CARE

19. LEVELS OF NURSES

20. LEVELS OF NURSES
 5 Levels of Nurses
 Level I
 No experience
 Novice
 Level II
 Has acceptable performance and has
experienced enough situations
 Advanced beginner

21. LEVELS OF NURSES
 Level III
 Has 2 to 3 years of experience
 Competent
 Employed overseas
 Level IV
 Has 3 to 5 years of experience
 Proficient

22. LEVELS OF NURSES
 Level V
 Highly proficient
 Does not require guidance and rules
 Expert
 Capable of managing hospital units

23. FIELDS OF NURSING PRACTICE

24. FIELDS OF NURSING PRACTICE
 1)Institutional or
Hospital Nursing
 Employment in
hospitals and
health
institutions
 Biggest field of
nursing
practice
 Staff Nurse
 Nurse
Managers

25. FIELDS OF NURSING PRACTICE
 2) Community /
Public Health
Nursing
 Subdivision:
 School
Nursing

26. FIELDS OF NURSING PRACTICE
 3) Private Duty
Nursing
 One to one
care
 Total nursing
care or Case
Management
 Home or
hospital based

27. FIELDS OF NURSING PRACTICE
 5) Military Nursing

28. FIELDS OF NURSING PRACTICE
 6) Company /
Industrial Nursing

29. EXPANDED EDUCATIONAL AND
CAREER ROLES

30. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Clinical Nurse Specialist
 A nurse with an advanced degree,
education, or experience
 Considered to be an expert in a
specialized area of nursing
 Example: Geriatric Nurse, Oncology
Nurse, Maternal and Child Nurse

31. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse Practitioner
 A nurse with an advanced degree,
certified for a special area or age of
patient care
 Delivers independent practice to
make health assessments and deliver
primary care
 Diagnose
 Prescribe medications

32. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse Anesthetist
 A nurse who completes a course of study
in an anesthesia school
 Carries out preoperative visits and
assessments
 Administers and monitors anesthesia
during surgery
 Evaluates postoperative status of
patients

33. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse midwife
 A nurse who completes a program in
midwifery
 Provides prenatal and postnatal care
 Delivers
babies for women with
uncomplicated pregnancies

34. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse Educator
 A nurse usually with an advanced
degree, who teaches in educational or
clinical settings

35. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse Administrator
 A nurse who functions at various levels
of management
 Responsible for management and
administration of resources and
personnel involved in giving patient
care

36. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse Researcher
 A nurse with an advanced degree who
conducts research relevant to the
definition and improvement of nursing
practice and education

37. EXPANDED EDUCATIONAL AND
CAREER ROLES
 Nurse Entrepreneur
 A nurse, usually with an advance degree
who may manage a clinic or health
related business

38. NURSING ROLES

39. NURSING ROLES
 Caregiver
 Primary role of the nurse
 The provision of care
 MOTHER SURROGATE ROLES
 Complete Assistance
 Partial Assistance
 Supportive/Educative

40. NURSING ROLES
 Communicator
 With Patients
 To establish Therapeutic
Communication
 To identify health problems
 With Health Care Professionals
 Documentation
 Reporting / Endorsements

41. COMMUNICATION

42. COMMUNICATION
 It is the
interchange of
information
between two or
more people
 It is the exchange
of ideas or
thoughts

43. ELEMENTS OF COMMUNICATION
 Sender
 Originator of the information
 Message
 Information being transmitted
 Receiver
 Recipient of information
 Channel
 Mode of communication
 Feedback
 Return response
 Context
 The setting of the communication

44. LEVELS OF COMMUNICATION
 Intrapersonal
 Occurs when a person communicates
within himself
 Interpersonal
 Takes place within dyads (groups of two
persons) and in small groups.
 Public
 Communication between a person and
several other people

45. MODES OF COMMUNICATION
 Verbal Communication
 Non-verbal Communication

46. NON-VERBAL MESSAGES
 They carry more meaning than verbal
messages and involves the following:
 Body movement or kinetics
 Voice quality (pitch and range) and non-
language sounds (sobbing or laughing)

47. NON-VERBAL MESSAGES
 Proxemics – use of personal or social space
 Intimate Distance – actual contact to 1.5 feet
 Personal Distance – 1.5 to 4 feet or 3 to 4 feet
for interviews
 Social Distance – 4 to 12 feet
 Public Distance – 12 feet and beyond
 Cultural Artifacts – items in contact with interacting
persons that may act as non-verbal stimuli (i.e.,
clothes, cosmetics, jewelry, cars)

48. THERAPEUTIC RESPONSES IN
COMMUNICATING WITH PATIENTS

49. THERAPEUTIC RESPONSES
 Identify therapeutic and non-therapeutic
phrases
 Open-ended or Closed-ended question?
 ‘Why’ or ‘What’ questions?
 Avoid false reassurances

50. THERAPEUTIC RESPONSES
 Use direct questions for suicidal cases
 Avoid the ‘Authoritarian Answer’
 Giving advices
 In initiating conversation
 Use Broad Openings
 In ending conversation
 Summarizing

51. COMMUNICATING WITH HEALTH
CARE PROFESSIONALS

52. COMMUNICATING WITH HEALTH CARE
PROFESSIONALS
 Documentation
 Reporting
 Conferring
 Referring

53. COMMUNICATING WITH HEALTH CARE
PROFESSIONALS
 Reporting
 Endorsement
 Transferring pertinent information
regarding a patient to a concerned
person
 Outgoing nurse to a incoming nurse
 Staff nurse to physician

54. COMMUNICATING WITH HEALTH CARE
PROFESSIONALS
 Conferring
 To verify information
 Rephrasing
 To validate doctor’s orders
 To validate a nurse’s endorsement

55. COMMUNICATING WITH HEALTH CARE
PROFESSIONALS
 Referring
 To endorse patient’s special concern to a
higher authority or a specialized
department or personnel
A community nurse referring a client
to a hospital or a doctor
A staff nurse to a dietitian

56. NURSING ROLES
 Teacher/Educator
 Providing education about a client’s
health and health care procedures they
need to perform to restore or maintain
their health

57. NURSING ROLES
 Teaching Strategies
 Assess client’s
 Readiness to learn
 Assess the client’s knowledge
 Simple to complex

58. NURSING ROLES
 Teaching Strategies
 One to One Discussion or Group
Discussion
 Explanation and Description
 Answering Questions
 Visual Assisted Learning Programs
 Demonstration
 Actual performance of an activity

59. NURSING ROLES
 What is the best method of teaching?
(December 2007 NLE)
 What is the best indicator of client learning?

60. NURSING ROLES
 Counselor
 Facilitates the patient’s problem solving
and decision – making skills
 By providing information, make
appropriate referrals

61. NURSING ROLES
 Researcher
 The participation in or conduct of
research
 To increase knowledge in nursing and
improve patient care

62. NURSING ROLES
 Advocate
 Safeguarding the rights of the patients
 Patients Bill of Rights

63. THEORIES OF NURSING

64. THEORIES OF NURSING
 Theory
 A hypothesis or system of ideas that is
proposed to explain a given phenomenon
 Purpose:
 Directs and guide nursing practice

65. THEORIES OF NURSING
 Nightingale's
 Environmental Theory
 The act of utilizing the
environment of the patient to
assist him in his recovery
 Linked health with 5
environmental factors
 Pure or fresh air
 Pure water
 Efficient drainage
 Cleanliness
 Light

66. THEORIES OF NURSING
 Nightingale's Environmental Theory
 Addition:
 Education of nurses
 Keeping the client warm
 Maintaining a noise free environment
 Attending to the client’s diet

67. THEORIES OF NURSING
 Hildegard Peplau’s
 Interpersonal Relations
Model
 Peplau is a
psychiatric nurse
 Focus: Therapeutic
process
 Attained through:
Healthy Nurse
Patient Relationship

68. THEORIES OF NURSING
 Hildegard Peplau’s Interpersonal Relations
Model
 Four Phases of the Nurse – Patient
Interaction
 Preorientation
 Orientation
 Working / Exploitation
 Termination/Resolution

69. THEORIES OF NURSING
 Virginia Henderson’s
 14 Fundamental Needs
of a Person
 Assisting sick or
healthy individuals
to gain
independence in
meeting 14
fundamental needs

70. THEORIES OF NURSING
 Virginia Henderson’s 14 Fundamental Needs
of a Person
 1) Breathing normally
 2) Eating and drinking adequately
 3) Eliminating body waste
 4) Moving and maintaining a desirable
position
 5) Sleeping and resting
 6) Selecting suitable clothes
 7) Maintaining body temperature within
normal range by adjusting clothing and
modifying the environment

71. THEORIES OF NURSING
 Virginia Henderson’s 14 Fundamental Needs of a
Person
 8) Keeping the body clean and well groomed to
protect the integument
 9) Avoiding dangers in the environment and
avoiding injuring others
 10) Communicating with others in expressing
emotions, needs, fears, or opinions
 11) Worshipping according to one’s faith
 12) Working in a such way that one feels a sense
of accomplishment
 13) Playing or participating in various forms of
recreation
 14) Learning, discovering, or satisfying the
curiosity that leads to normal development and
health, and using available health facilities

72. THEORIES OF NURSING
 Dorothy Johnson’s
 Seven Subsystems
 Attachment
 Affiliative
 Dependency
 Ingestive
 Eliminative
 Sexual
Achievement
 Aggressive

73. THEORIES OF NURSING
 Faye Abdellah’s
 21 Nursing Problems
 good hygiene
 optimal activity
 safety
 good body mechanics
 oxygen

74. THEORIES OF NURSING
 Faye Abdellah’s 21 Nursing Problems
 nutrition
 elimination
 fluid and electrolytes balance
 physiologic response of the body to disease
 regulatory mechanisms
 sensory function.
 positive and negative expressions, feelings and
reactions.
 accept the interrelatedness of emotions and
illness

75. THEORIES OF NURSING
 Faye Abdellah’s 21 Nursing Problems
 self awareness
 optimum possible goals
 use community resources
 role of social problems

76. THEORIES OF NURSING
 Martha Roger’s
 Science of Unitary
Human Beings
 Views the person as
a irreducible whole,
the whole being
greater than the
sum of its parts

77. THEORIES OF NURSING
 Martha Roger’s Science of Unitary Human
Beings
 Man is composed of energy fields, which
are in constant interaction with the
environment
 Seek to promote harmonic interactions
between the two energy fields (Human
and Environmental)

78. THEORIES OF NURSING
 Dorothea Orem’s
 Self Care and Self Care
Deficit Theory
 Identified three
nursing systems
 Wholly
compensatory
systems
 Partial
compensatory
systems
 Supportive –
Educative
systems

79. THEORIES OF NURSING
 Imogene King’s
 Goal Attainment Theory
 Patient has THREE (3)
interacting systems
 Individuals /
Personal systems
 Group systems /
Interpersonal
systems
 Social systems

80. THEORIES OF NURSING
 Betty Neuman’s
 Health Care Systems
Model
 The concern of nursing
is to prevent Stress
Invasion
 Physiological
 Psychological
 Developmental
 Sociocultural
 Spiritual

81. THEORIES OF NURSING
 Sister Callista Roy’s
 Adaptation Model
 Man is a
Biopsychosocial
Being that requires
a feedback cycle

82. THEORIES OF NURSING
 Sister Callista Roy’s Adaptation Model
 The goal is to enhance life processes
through adaptation in four adaptive
models
 The Physiologic Mode
 Self Consent Mode
 Role Function Mode
 Interdependence Mode

83. THEORIES OF NURSING
 Madeline Leininger’s
 Transcultural Nursing
 Emphasizes human caring
varies among cultures
 Culture Care
Preservation and
Maintenance
 Culture Care
Accommodation and
Negotiation
 Culture Care
Restructuring and
Repatterning

84. CONCEPT OF MAN

85. CONCEPT OF MAN
 Nurse’s Clients
 Individuals
 Families
 Communities

86. CONCEPT OF MAN
 BIOLOGIC like ALL other men
 PSYCHOLOGICAL like NO OTHER man
 SOCIAL like SOME OTHER men
 SPIRITUAL like SOME OTHER men

87. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 5 Human Needs

88. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Physiologic needs
 Oxygen
 Fluids
 Nutrition
 Body Temperature
 Elimination
 Rest and Sleep
 Sex

89. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Safety and security
(Physical and
Psychological)
 Protection
 Security
 Order
 Law
 Limits
 Stability

90. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Love and
Belongingness
 Family
 Affection
 Relationships
 Work group

91. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Self-esteem
 Feeling good about one’s
self
 Two factors affecting
Self-esteem
 Yourself
 Sense of
adequacy
 Accomplishment
 Self worth &
respect
 Others
 Appreciation
 Recognition
 Admiration

92. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Self-actualization –
essence of mental
health
 Personal growth
and fulfillment
 Able to fulfill
needs and
ambitions
 Maximizing one’s
full potential

93. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Self Actualization
 Judges people correctly
 Superior perception
 Decisive
 Capable of making decisions
 Clear notion as to what is right and
wrong

94. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Open to new ideas
 Not adopts new ideas
 Not one track mind
 Highly creative and flexible
 Does not need fame
 Problem-centered rather than self-
centered

95. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Additional needs:
 Need to know and understand
 Aesthetic needs
 Transcendence

96. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Need to know and understand or Cognitive
needs is supported by Richard Kalish who
says that
 Man needs stimulation
 Needs to explore
 Sex
 Activity
 New things

97. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Aesthetic needs:
 Beauty
 Balance
 Form

98. ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Transcendence:
 Helping others to self-actualize

99. ILLNESS, WELLNESS AND HEALTH

100. DEFINITIONS OF HEALTH
Object 5
 World Health
Organization
 Health is the
complete physical,
mental, social
(totality) well-being
and not merely the
absence of disease
or infirmity

101. DEFINITIONS OF HEALTH
 Health is individually defined by each
person
 On a personal level, individuals define
health according to
 how they feel
 absence or presence of symptoms of
illness
 and ability to carry out activities

102. DISEASE
 Objective pathologic process
 Pathologic change in the structure or function
of the mind and body

103. DISEASE
 Acute
 Rapid onset of symptoms
 Some are life threatening
 Many do not require medical treatment

104. DISEASE
 Chronic
 Broad term that encompasses many
different physical and mental alterations in
health
 It is a permanent change
 Requires special patient education for
rehabilitation
 Requires long term of care and support

105. ILLNESS
 Highly subjective
feeling of being sick
or ill
 How the person
feels towards
sickness
 Concerns the Nurse

106. ELEVEN STAGES OF ILLNESS AND
HEALTH-SEEKING BEHAVIOR BY SUCHMAN
 1. Symptom Experience
 Client realizes there is a problem
 Client responds emotionally
 2. Sick Role Assumption
 Self-medication / Self-treatment
 Communication to others

107. ELEVEN STAGES OF ILLNESS AND HEALTH-
SEEKING BEHAVIOR BY SUCHMAN
 3. Assuming a Dependent Role
 Accepts the diagnosis
 Follows prescribed treatment
 4. Achieving recovery and rehabilitation
 Gives up the dependent role and assumes
normal activities and responsibilities

108. CONCEPTS ON DISEASE AND ILLNESS
 Illness without disease
 is possible
 Disease without illness
 is possible

109. MODELS OF HEALTH AND ILLNESS

110. DUNN’S HIGH-LEVEL WELLNESS
AND GRID MODEL
 X-axis is HEALTH
 Y-axis is ENVIRONMENT

111. DUNN’S HIGH-LEVEL WELLNESS
AND GRID MODEL
Quadrant 1 Quadrant 2
- High Level Wellness - Protected Poor Health
in a favorable in a favorable
environment environment
Quadrant 3 Quadrant 4
- Poor health in an - Emergent High Level
unfavorable Wellness in an
environment unfavorable
environment

112. HEALTH BELIEF MODEL BY
ROSENTOCK
 Concerned with what people perceive about
themselves in relation to their health
 Consider perceptions (influences individuals
motivation toward results)
 Perceived susceptibility
 Perceived seriousness
 Perceived benefit out of the action

113. FOUR LEVELS OF HEALTH BY SMITH
1. Clinical Model
 Man is viewed as a Physiologic Being
 If there are no signs and symptoms of a
disease, then you are healthy

114. FOUR LEVELS OF HEALTH BY SMITH
2. Role Performance Model
 As long as you are able to perform
SOCIETAL functions and ROLES you are
healthy

115. FOUR LEVELS OF HEALTH BY SMITH
3. Adaptive Model
 Health is viewed in terms of capacity to
ADAPT
 Failure to adapt is disease

116. FOUR LEVELS OF HEALTH BY SMITH
4. Eudaemonistic Model
 This is the BROADEST concept of health
 Because health is viewed in terms of
Actualization

117. AGENT, HOST, ENVIRONMENT MODEL
BY LEAVELL AND CLARK
 Also known as the Ecologic Model
 Triad is composed of the agent, host and
environment
 Based on the interplay of three components
of the model

118. NURSING PROCESS

119. THE NURSING PROCESS
 Definition:
 The Nursing Process is a systematic,
organized, rational method of planning and
providing individualized, humanistic
nursing care

120. Nursing process
 foundation of the nursing profession
 central to nursing actions
 a process to deliver care to patients
 supported by nursing models or philosophies.
 systematic approach
 enhances research opportunities
 adaptable to different clients in different care
settings
 efficient method of organizing thought processes or
clinical decision-making and problem-solving

121.  Synonymous with the problem solving approach
for discovering the healthcare and nursing care
needs of clients. (UDAN)
 It is an organized method of giving individualized
nursing care that focuses of identifying unique
responses of individual or group to actual or
potential alteration in health. (KOZIER)
 It is a method of problem identification and
problem solving

122. PURPOSES OF THE NURSING PROCESS
 To identify health status
 Actual health problems
 Potential health problems
 To establish plans
 To deliver specific nursing care
 To evaluate nursing care

123. CHARACTERISTICS OF
THE NURSING PROCESS
 Client-centered
 Cyclical (sequence), dynamic (moving)
rather than static
 Data from each phase provide input to
the next phase
 Interpersonal and collaborative
 Work with patients and relatives
 Work with colleagues and other members
of the health team

124. CHARACTERISTICS OF
THE NURSING PROCESS
 Adaptation of problem-solving techniques
and decision making principles in all the
phases
 Problem-oriented, flexible, open to new
information

125. CHARACTERISTICS:
 Problem – Oriented
 Goal Oriented
 Orderly planned step by step
 Open in accepting additional
information during application
 Universally applicable to al patients
family and community that nursing
service.

126. BENEFITS FROM THE NURSING PROCESS
 Improves quality of care
 Ensures continuity and appropriate level
of care
 Long term plans
 Promotes a positive working atmosphere
through collaboration
 Facilitates client participation through
planning with patient

127. BENEFITS FROM THE NURSING PROCESS
 Feedback allows nurse to evaluate care
 Serves as a framework for accountability
through documentation

128. PARTS OF THE NURSING PROCESS
 Assessment Phase
 Diagnosing Phase
 Planning Phase
 Intervention Phase
 Evaluation Phase

129. ASSESSMENT PHASE

130. ASSESSMENT PHASE
 Is the systematic and continuous collection,
organization, validation, and documentation of
data
 Carried all throughout the nursing process
 Diagnosing
 Planning
 Information in assessment is crucial
 Implementation
 Before performing nursing care
 Evaluation
 Assessing the current status to compare with
previous status

131. ASSESSMENT PHASE
 What to assess
 Clients perceived needs
 Client’s responses to health problems
 Asthma
 Difficulty of breathing
 Arthritis
 Pain
 Health practices, values, and lifestyles

132. FOUR TYPES OF ASSESSMENT

133. FOUR TYPES OF ASSESSMENT
 Initial Assessment
 Focus Assessment or On-going
Assessment
 Emergency Assessment
 Time-Lapsed Assessment

134. FOUR TYPES OF ASSESSMENT
 1. Initial Assessment
 When performed:
 At specified time after admission
 Purpose of Initial Assessment:
 To create a data base for problem
identification
 For reference and future comparison

135. FOUR TYPES OF ASSESSMENT
 2. Focus Assessment or On-going
Assessment
 When performed:
 Integrated throughout the nursing process
 Purpose of On-going Assessment:
 To identify problems overlooked earlier
 To determine the status of a health
problem
 Same from database
 Ex before implementation

136. FOUR TYPES OF ASSESSMENT
 3. Emergency Assessment
 When done:
 During acute physiologic and
psychologic crisis
 Where done:
 Emergency Room
 Anywhere
 On site
 Purpose of Emergency Assessment
 To identify life-threatening condition

137. FOUR TYPES OF ASSESSMENT
 4. Time-Lapsed Assessment
 When done:
 Several months after initial
assessment
 Purpose of Time-Lapsed Assessment
 To compare current status of patient
with base line data (initial
assessment)
 Ex
 Diabetic

138. ASSESSMENT PHASE
 Nursing Activities in the Assessment
Phase
 Data Collection
 Data Organization
 Data Validation
 Data Recording

139. CRITICAL THINKING
• It is how the  Over time the
nurse uses the nurse learns to
almost
information to
simultaneously
reason, make review, interpret,
inferences and analyze and
form mental evaluate
picture of what information about
is happening to clients.
• Facione and Facione (1996) define
the client.
critical thinking as purposeful self-
regulatory judgment that is
centrally evident in expert clinical

140. To use this process, the nurse must
demonstrate other fundamental
abilities of:
3. Knowledge
4. Creativity
5. Adaptability
6. Commitment
7. Trust
8. Leadership
9. Intelligence
10.Interpersonal and technical skills.

141. DATA COLLECTION

142. DATA COLLECTION
 Is the process of gathering information or
data
 Data gathering

143. RECORDED DATA
 Types of Data
 Sources of Data
 Methods of Data Collection

144. TYPES OF DATA

145. TYPES OF DATA
 1. Subjective or Covert Data
 Felt by the patient
 During the recording of data, this should
be stated using the patient’s own words
 “Mommy I feel hot”

146. TYPES OF DATA
 2. Objective or Overt Data
 Capable of being observed by use of
senses – sight, touch, smell, hearing

147. SOURCES OF DATA

148. SOURCES OF DATA
 1. Primary Source
 Patient himself, except when:
 Patient is unconscious
 Patient is a baby
 Patient is insane
 Significant others become the primary
source of data (from a secondary source)
 Unconscious brought in the ER?
 Whoever brought the patient to the
hospital

149. SOURCES OF DATA
 2. Secondary Source
 Patient’s record
 Health care members
 Significant others

150. METHODS OF DATA COLLECTION

151. METHODS OF DATA COLLECTION
 Observing
 Interviewing
 Examining

152. METHODS OF DATA COLLECTION:
OBSERVING
 To gather data by using the senses
 Vision
 Overall appearance
 Smell
 Body or breath odors
 Hearing
 Lung, heart, and bowel sounds
 Touch
 Skin temperature, pulse rate

153. METHODS OF DATA COLLECTION:
OBSERVING
 Two (2) aspects of observation process:
 Noticing the stimuli using the senses
 Record the observed stimuli

154. METHODS OF DATA COLLECTION:
INTERVIEWING
 Is a planned conversation with a purpose
 To get or give information
 Provide health teachings
 Provide support

155. METHODS OF DATA COLLECTION:
INTERVIEWING
 Two types of Interview
 Directive Type of Interview
 Non-directive Type of Interview or
Rapport-building Interview

156. DIRECTIVE TYPE OF INTERVIEW
 Structured
 Uses closed-ended questions calling for
specific data
 Yes or No
 How many
 When
 When used:
 When you need to elicit specific data
 When there is little time available

157. NON-DIRECTIVE TYPE OR
RAPPORT-BUILDING INTERVIEW
 Uses more open-ended questions
 Advantage is that it allows the patient to
volunteer information

158. PLANNING THE INTERVIEW SETTING
 Concepts:
 Before the interview, determine what
information you already know
 An interview is a planned conversation
with a purpose
 An interview is a two-way process

159. PLANNING THE INTERVIEW SETTING
 Concepts:
 When is it done?
 When patient is available
 When patient is comfortable
 Recommended distance from the patient
is three (3) to four (4) feet
 Place
 Seating Arrangement
 Language

160. STAGES OF THE INTERVIEW
 1. Opening Stage
 This is the most important part of the
interview
 Rationale
 What was said and done during the
opening stage sets the tone all
throughout the interview
 Establish rapport
 Orientation

161. STAGES OF THE INTERVIEW
 2. Body of the Interview
 Occurs when patient responds to
questioning
 The most productive stage

162. STAGES OF THE INTERVIEW
 3. Closing Stage
 The nurse terminates the interview when

 Theneeded information has been
obtained and given
 The client can no longer take in
information
 Provided support

163. STAGES OF THE INTERVIEW STAGES OF
THE INTERVIEW
 3. Closing Stage
 How to close the interview:
 Summarizing Technique
 To verify accuracy
 It reassures the client that the
nurse listened
 Sense of accomplishment
 Offer to answer questions
 Thank the client
 Plan for the next meeting if there is
one

164. METHODS OF DATA COLLECTION:
EXAMINING
 The physical examination or assessment
 Use of senses
 Use of inspection, palpation, percussion,
and auscultation

165. METHODS OF DATA COLLECTION:
EXAMINING
 Cephalocaudal
 Proximodistal
 IPPA
 IAPP

166. ORGANIZING DATA

167. ORGANIZING DATA
 Clustering of data
 Example
 Nursing Health History
 Current health problem
 Past history of illness
 Family history of illness
 Lifestyle
 Body Systems

168. VALIDATION OF DATA

169. VALIDATION OF DATA
 Act of double-checking the data
 Purposes of Data Validation
 To ensure the:
 Correctness
 Completeness

170. DATA RECORDING

171. DATA RECORDING
 Data Recording COMPLETES the
Assessment Phase
 Complete
 Factual
 Don’t interpret
 Man found lying on the floor
 Brevity
 Short but concise

172. DOCUMENTATION

173. DOCUMENTATION
 It is a written, formal document
 A record of client’s progress

174. PURPOSES OF DOCUMENTATION
 Planning Care
 Communication
 For legal documentation purposes
 For research
 For education

175. GUIDELINES ON DOCUMENTATION
 Timing
 Document patient care as soon as possible
 Observe confidentiality
 Observe permanence
 Use non-erasable ink
 Do not use sign pen

176. GUIDELINES ON DOCUMENTATION
 Signature
 Sign full name and append R.N.
 Accuracy
 Ensure that data is correct
 Avoid biases
 Avoid ambiguous terms
 Appropriateness
 Write only appropriate information

177. GUIDELINES ON DOCUMENTATION
 Completeness
 Use standard terminology
 Brevity
 Make it concise yet meaningful
 Legal Awareness
 Cross out erroneous entry
 Write “Error”
 Countersign

178. TYPES OF RECORDS
 Source-Oriented Clinical Record
 Problem-Oriented Clinical Record

179. PROBLEM-ORIENTED
CLINICAL RECORD
 Same as Problem Oriented Medical Record
 Entry of data is based on CLIENT’S
PROBLEM
 Example:
 Problem No. 1: constipation
 Increase fluid intake: doctor
 Diatabs: pharmacist
 NPO: dietitian

180. FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD
 1. Baseline Data
 All information gathered from a patient
when he first entered the agency
 Assessment of the physician
 Assessment of the nurse

181. FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD
 2. Problem List
 Contains only ACTIVE problems (and
relevant information about the problem)
 Medical Diagnosis
 Nursing Diagnosis

182. FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD
 3. Initial list of orders or Care Plans

183. FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD
 4. Progress Notes
 Includes:
 Nurses’ narrative notes (SOAPIE)
 Flow sheets
 Discharge Notes and Referral
Summaries

184. SOURCE-ORIENTED CLINICAL RECORD
 Classification of information is based on
SOURCE
 Each person or department maintains a
different section on chart

185. COMPONENTS OF A
SOURCE-ORIENTED CLINICAL RECORD
 Admission Sheet
 Nursing Notes
 Medical History and Physical Examination Sheet
 Diagnostic Findings Sheet
 TPR Graphic Sheet
 Doctor’s Treatment and Order Sheet
 Therapeutic Sheet

186. ASSESSMENT

188. DIAGNOSING PHASE

189. DIAGNOSING PHASE
 Nurses use critical thinking skills to
interpret assessment data and identify
client strengths and problems
 Positive or Negative?

190. DIAGNOSING PHASE
 Diagnostic Process
 Analyze the data
 Identify health problems, risk, and
strengths
 Formulating diagnostic statements

191. PARTS OF A NURSING DIAGNOSIS
 1. Problem Statement
 Example:
 Fluid Volume Deficit
 2. Presumed Etiology
 Example:
 …related to frequent loss of bowel
movement
 3. Signs and Symptoms
Example:
 …as manifested by decreased skin
turgor

192. TYPES OF DIAGNOSTIC STATEMENTS
 Basic Two Part Statements (PE)
 Problem and Etiology
 Altered Nutrition Less than Body
Requirements related to difficulty
swallowing

193. TYPES OF DIAGNOSTIC STATEMENTS
 Basic Three Part Statement (PES)
 Problem
 Etiology
 Signs and Symptoms
 Altered Nutrition Less than Body
Requirements related to difficulty
swallowing as manifested by body
weakness

194. TYPES OF DIAGNOSTIC STATEMENTS
 One Part Statements
 Problem
 Rape Trauma Syndrome

195. TYPES OF NURSING DIAGNOSIS

196. DIFFERENT TYPES OF NURSING
DIAGNOSES DIFFERENT TYPES OF
NURSING DIAGNOSES
 1. Actual Nursing Diagnosis
 Problem present at the time the statement
was made
 Example: Ineffective Airway Clearance
related to excessive and tenacious
secretions

197. DIFFERENT TYPES OF NURSING
DIAGNOSES
 2. High-Risk Nursing Diagnosis
 A diagnosis that a patient is more
vulnerable or susceptible compared with
others in the same situation
 Example: Risk for Impaired Skin Integrity
related to immobility secondary to
fractured hip.

198. DIFFERENT TYPES OF NURSING
DIAGNOSES
 3. Possible Nursing Diagnosis
 Not enough evidence about a problem
 Example: Possible Self Care Deficit
related to impaired ability to use left
hand secondary to presence of
intravenous therapy

199. DIFFERENT TYPES OF NURSING
DIAGNOSES
 4. Wellness Nursing Diagnosis
 A positive statement
 Indicates a healthy response
 Examples:
 Potential for increased compliance
related to increased level of knowledge
 Potential for effective coping related to
adequate support systems

200. PLANNING PHASE

201. PLANNING PHASE
 Planning is a deliberative, systematic phase
that involves decision making and problem
solving
 Formulating client goals with the patient
 Designing nursing interventions

202. ACTIVITIES DURING
THE PLANNING PROCESS
 Set priorities
 Client’s problems
 Set goals and objectives
 Identify alternatives of nursing care
 Select nursing measures
 Write the nursing care plan

203. PURPOSES OF GOAL-SETTING
 To set direction
 To provide a time span
 To have a criteria for evaluation
 To enable the nurse and the patient to
determine whether the problem has been
resolved or not
 To help motivate the client and the patient by
providing a sense of accomplishment

204. TYPES OF PLANNING

205. TYPES OF PLANNING
 1. Initial Planning
 Done by the nurse
 When done:
 At specified time upon or after
admission/assessment of the patient

206. TYPES OF PLANNING
 2. On-going Planning
 Who are involved:
 Done by all nurses who worked with
the patient
 When done:
- Before start of shift

207. TYPES OF PLANNING
 2. On-going Planning
 Purposes of On-going Planning
 To determine if the client’s health status
has changed
 To decide which problems to focus on
during the shift
 To set priorities for client care during
the shift

208. TYPES OF PLANNING
 3. Discharge Planning
 Purpose of Discharge Planning
 To ensure continuity of care
 M–E–T–H-O–D-S

209. CHARACTERISTICS OF
THE PLANNING PROCESS
 S
 Specific
 M
 Measurable
 A
 Attainable
 R
 Realistic
 T
 Time bound

210. IMPLEMENTING PHASE

211. IMPLEMENTING PHASE
 Consists of doing and documenting the
nursing care given to the patient
 Putting the care plan into action

212. IMPLEMENTING PHASE
 Purpose of Implementation
 To carry out planned activities
 To help the client

213. IMPLEMENTING PHASE
 Requirements for Implementation
 Adequate knowledge
 Technical Skills
 Communication skills
 Therapeutic use of self

214. IMPLEMENTING PHASE
 Reassess the patient
 Rationale
 To determine if the procedure is still
needed
 Determine the need for nursing assistance
 Understand orders
 Clarify / verify doctors’ orders

215. NURSING ACTIVITIES DURING THE
IMPLEMENTATION PHASE
 Communicate the procedure
performed by documenting the
procedure
 Encourage patient to participate
actively

216. GUIDELINES FOR IMPLEMENTATION OF
NURSING STRATEGIES
 It should be based on scientific knowledge,
research, professional standards of practice
(care)
 Rationale:
 This is done to ensure safe nursing care
 It should be adapted to the individual patient

217. GUIDELINES FOR IMPLEMENTATION OF
NURSING STRATEGIES
 It should always be safe. Do not compromise
 It should be holistic
 It should be accompanied by support,
comfort and teaching

218. EVALUATION PHASE

219. EVALUATION PHASE
 Purpose of the Evaluation Phase
 To determine client’s progress
 To determine the effectiveness of the care
plan
 To determine as to what extent the
nursing goals have been met

220. EVALUATION PHASE
 Importance of doing an Evaluation
 It determines if the care plan will be:
 Continued
 Modified
 Discontinued

221. EVALUATION PHASE
 Activities during the Evaluation Phase
 Identify the OUTCOME CRITERIA to be
used as measurement (Planning)
 Gather information (data) relevant to the
outcome criteria
 Compare outcome (data) with the criteria
 Assess the reasons for the outcome
 Revise the nursing care plan as needed

222. TYPES OF EVALUATION
 1. On-going Evaluation
 When done:
 During or immediately after the
intervention
 Importance:
 Allows the nurse to decide and make
on-the-spot modification/s in an
intervention

223. TYPES OF EVALUATION
 2. Intermittent Evaluation
 When done:
 At a specified time
 Purpose:
 It shows the extent of progress of the
patient
 Importance:
 Enables the nurse to correct deficiencies
and modify the nursing care plan

224. TYPES OF EVALUATION
 3. Terminal Evaluation
 When done:
 At or immediately before discharge
 Importance:
 States the status of a health problem at
the time of discharge
 It determines whether the goals are:
 Met
 Partially met
 Unmet

225. PROMOTING REST AND SLEEP

226. PROMOTING REST AND SLEEP
 Sleep is the altered level of consciousness
in which the individual’s perception of and
reaction to environment are decreased

227. PROMOTING REST AND SLEEP
 What regulates sleep and wakefulness?
 Reticular formation on the Brain Stem
 Ascending nerve fibers
 Reticular Activating System (RAS)
 Sleep Wake Cycle

228. PROMOTING REST AND SLEEP
 Types of Sleep
 NREM
 Non-Rapid Eye Movement Sleep
 REM
 Rapid Eye Movement Sleep

229. PROMOTING REST AND SLEEP
 NREM (Non-Rapid Eye Movement Sleep)
 When the RAS is inhibited
 Sleep
 BODY RESTORATION
 About 75% to 80% of sleep
 Has 4 Stages

230. PROMOTING REST AND SLEEP
 NREM (Non-Rapid Eye Movement Sleep)
 Stage I (Very Light Sleep)
 Lasts only a few minutes
 Drowsy and relaxed
 Eyes roll from side to side
 HR and RR drop slightly
 Readily awakened

231. PROMOTING REST AND SLEEP
 NREM (Non-Rapid Eye Movement Sleep)
 Stage II (Light Sleep)
 Lastsfor 10-15 minutes
 Body processes continue to slow down
 HR and RR decrease furthermore
 Body temperature falls
 Eyes are still

232. PROMOTING REST AND SLEEP
 NREM (Non-Rapid Eye Movement Sleep)
 Stage III
 The HR and RR, as well as other body
processes, slow further
 The sleeper becomes more difficult to
arouse
 The skeletal muscles are very relaxed
 The reflexes are diminished and
snoring may occur

233. PROMOTING REST AND SLEEP
 NREM (Non-Rapid Eye Movement Sleep)
 Stage IV (Delta Sleep or Deep Sleep)
 HR and RR drop 20 – 30% below that
exhibited during waking hours
 Sleeper is very relaxed, rarely moves
and is difficult to arouse
 This stage is thought to restore the
body physically

234. PROMOTING REST AND SLEEP
 REM (Rapid Eye Movement Sleep)
 Occurs about every 90 minutes
 Lasts from 5 to 30 minutes
 “Paradoxical Sleep”
 Resembles wakefulness
 Brain is highly active
 Dreams are usual
 Irregular HR and RR
 May be difficult to arouse or wake up
spontaneously

235. PROMOTING REST AND SLEEP
 For sleep to be normal
 The person must pass through the NREM and
REM
 1 Cycle lasts for 90 to 110 minutes (1 ½ to 2
hours)
 1st 3 Stages of NREM (20-30 minutes)
 Stage IV (30 minutes)
 Back to NREM Stages III and II (20 minutes)
 REM (10 minutes)
 Very brief
 Skipped entirely

236. PROMOTING REST AND SLEEP
 What is/are the longest type or stage of
sleep?
 Stages II and III

237. PROMOTING REST AND SLEEP
 A sleeper who is awakened at any stage
must begin a new cycle
 In a 7 to 8 hours of sleep
 4 – 6 cycles

238. PROMOTING REST AND SLEEP
 To restore the body

239. PROMOTING REST AND SLEEP
 Normal Sleep Requirements
 Newborns
 16 to 18 hours a day
 Infants
 14 to 15 hours
 Toddlers
 12 to 14 hours

240. PROMOTING REST AND SLEEP
 Normal Sleep Requirements
 Preschoolers
 11 to 13 hours
 School Aged
 10 to 11 hours
 Adolescents
 9 to 10 hours

241. PROMOTING REST AND SLEEP
 Normal Sleep Requirements
 Adults
 7 to 9 hours
 Elders
 7 to 9 hours
 Many sleeping problems
 Tendency toward earlier bedtime
and wake times
 Increase in disturbed sleep
 Medical conditions

242. PROMOTING REST AND SLEEP
 Factors Affecting Sleep
 Illness
 Pain or physical distress
 Arthritis, back pain and ulcers
 Respiratory conditions
 Nasal congestion
 Need to urinate

243. PROMOTING REST AND SLEEP
 Factors Affecting Sleep
 Environment
 Noise
 Absence of usual stimuli or the
presence of unfamiliar stimuli
 Namamahay
 Discomfort from environmental
temperature
 Too hot or too cold
 Comfort and size of the bed

244. PROMOTING REST AND SLEEP
 Factors Affecting Sleep
 Emotional Stress
 Considered by sleep experts as the
number one cause of short term
sleeping difficulties
 Preoccupied with personal problems
 May be unable to relax sufficiently
to get to sleep

245. PROMOTING REST AND SLEEP
 Factors Affecting Sleep
 Stimulants and Alcohol
 Caffeine containing beverages
 Coffee
 Tea
 Chocolate Drinks
 Alcohol
 Speed up the onset of sleep
 BUT disrupts REM

246. PROMOTING REST AND SLEEP
 Factors Affecting Sleep
 Smoking
 Nicotinehas a stimulating effect on
the body
 Smoker
 Refrain from smoking after the
evening meal

247. COMMON SLEEP DISORDERS

248. COMMON SLEEP DISORDERS
 Insomnia
 Inability to fall asleep or remain asleep
 Acute Insomnia
 Last 1 to several nights
 Caused by personal stressors
 Chronic
 Persists for longer than a month

249. COMMON SLEEP DISORDERS
 Insomnia
 Chronic Intermittent Insomnia
 Difficulty sleeping for a few nights
 Followed by a few nights of adequate
sleep
 Difficulty sleeping returns

250. COMMON SLEEP DISORDERS
 Excessive Daytime Sleepiness
 Hypersomnia
 Narcolepsy

251. COMMON SLEEP DISORDERS
 Hypersomnia
 The affected individual obtains sufficient
sleep at night
 Cannot stay awake during the day
 Caused by
 CNS Damage

252. COMMON SLEEP DISORDERS
 Narcolepsy
 Disorder of excessive daytime sleepiness
 Sleep attacks
 Cataplexy
 Sudden weakness or paralysis
 Fragmented nighttime sleep
 Cause
 Lack of chemical hypocretin

253. COMMON SLEEP DISORDERS
 Sleep Apnea
 Frequent short breathing pauses during
sleep
 10 seconds to 2 minutes
 ObstructiveApnea
 Central Apnea
 Mixed

254. COMMON SLEEP DISORDERS
 Sleep Apnea
 Obstructive Apnea
 Blockage of the flow of air
 Central
 Defect in the respiratory center of the
brain
 Medulla Oblongata
 Mixed

255. COMMON SLEEP DISORDERS
 Parasomnias
 Arousal Disorder
 Sleep
Walking
 Somnambulism

256. COMMON SLEEP DISORDERS
 Parasomnias
 Sleep Wake Transition Disorder
 Sleep talking
 Exhaustion

257. COMMON SLEEP DISORDERS
 Parasomnias
 Associated with REM Sleep
 Nightmares

258. COMMON SLEEP DISORDERS
 Parasomnias
 Others
 Bruxism

259. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP

260. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Sleep Hygiene
 Referring to interventions to promote
sleep

261. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Supporting Bedtime Rituals
 Most people are accustomed to bedtime rituals or
pre sleep routines
 Adults
 Hygienic routines
 Washing the face
 Brushing teeth
 Voiding
 Relaxation
 Listening to music
 Reading
 Taking a soothing bath
 Praying

262. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Supporting Bedtime Rituals
 Children
 Need to be socialized into pre sleep
routine
 Bedtime story
 Holding onto a favorite toy or
blanket
 Kissing everyone goodnight

263. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Supporting Bedtime Rituals
 Massage
 Warm drink
 Milk
 Tryptophan

264. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Creating a Restful Environment
 Minimal noise
 Comfortable room temperature
 Appropriate lighting

265. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Promoting Comfort and Relaxation
 Provide loose fitting nightwear
 Assist clients with hygienic routines
 Assist or encourage the client to void
before bedtime
 Offer to provide a back massage
 Schedule medications
 For clients with pain, administer
analgesics 30 minutes before bedtime

266. NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Promoting Comfort and Relaxation
 Emotional stress interferes with sleep
 Relaxation Techniques
 Deep Breathing
 Muscle Relaxation
 Guided Imagery
 Meditation

267. PROMOTING NUTRITION

268. PROMOTING NUTRITION
 Nutrition
 Is the sum of all the interactions
between an organism and the food it
consumes
 Nutrients
 Are organic or inorganic substances
found in foods that are required for body
functioning

269. PROMOTING NUTRITION
 Essential Nutrients
 The body’s most basic nutrient need is
 Water
 Nutrients that provide fuel to body cells
 Macronutrients
 Carbohydrates
 Proteins
 Fats
 Micronutrients
 Vitamins
 Minerals

270. MACRONUTRIENTS
CARBOHYDRATES
 CHO
 Two Basic Types
 Simple Sugars
 Complex Carbohydrates
 Starches
 Fibers

271. MACRONUTRIENTS
CARBOHYDRATES
 Simple sugars
 Water soluble
 Produced
naturally by
plants and
animals
 Monosaccharide
 Glucose
 Fructose
Galactose

272. MACRONUTRIENTS
CARBOHYDRATES
 Simple sugars
 Disaccharides
 Two Monosaccharide

273. MACRONUTRIENTS
CARBOHYDRATES
 Food Sources of
Simple Sugars
 Sugarcane
 Table sugar
 Sugar beets

274. MACRONUTRIENTS
CARBOHYDRATES
 Complex Sugars
 Starches
 Grains
 Legumes
 Potatoes
 Cereals
 Breads

275. MACRONUTRIENTS
CARBOHYDRATES
 Complex Sugars
 Fibers
 Supplies
roughage or bulk
in the diet
 Outer layer of
grains
 Skin, seeds
and pulp of
many fruits
and
vegetables

276. MACRONUTRIENTS
CARBOHYDRATES
 Digestion
 In the mouth
 Ptyalin (Salivary Amylase)
 In the small intestines
 Pancreatic amylase

277. MACRONUTRIENTS
CARBOHYDRATES
 Metabolism
 CHO is Major Source of Body Energy
 GO FOODS
CHON
Glucose
Bloodstream Stored
Glycogen Fats

278. MACRONUTRIENTS
PROTEINS
 CHON
 Amino acids
 Essential amino acids
 Those that cannot be produced by the
body
 Nonessential amino acids
 Those that can be produced by the
body

279. MACRONUTRIENTS
PROTEINS
 May be Complete, Partially Complete and
Incomplete

280. MACRONUTRIENTS
PROTEINS
 Complete Proteins
 Contains all
essential amino
acids plus many non
essential amino
acids
 Derived from
animals
 Meats, poultry,
fish, dairy
products, and
eggs

281. MACRONUTRIENTS
PROTEINS
 Partially Complete
 Less than the required amount of one or
two essential amino acids
 Gelatin

282. MACRONUTRIENTS
PROTEINS
 Incomplete
 Lack of one or more
essential amino acids
 Usually derived from
vegetables
 Vegetarians?
 Solution
 Vegetable
combinations
 Corn and beans
 Vegetables with a
small amount of
animal protein

283. MACRONUTRIENTS
PROTEINS
 Digestion
 In the mouth
 Pepsin
 In the intestines
 Trypsin

284. MACRONUTRIENTS
PROTEINS
 Storage
 Protein is stored in the body as tissue
 Growth and Development
 GROW FOODS

285. MACRONUTRIENTS
PROTEINS
 Metabolism
 Anabolism
 Construction
 All body cells manufacture proteins
from amino acids
 Catabolism
 Destruction
 A cell can only accommodate a limited
amount of protein
 Liver

286. MACRONUTRIENTS
LIPIDS
 Organic substances that are greasy and
insoluble in water
 Fats
 Lipids that are solid at room temperature
 Butter
 Oil
 Lipids that are liquid at room
temperature
 Cooking oil

287. MACRONUTRIENTS
LIPIDS
 Classified as
 Saturated
 Unsaturated
 Which is healthier?

288. MACRONUTRIENTS
LIPIDS
 Saturated fats
 coconut oil, and
palm kernel oil
 dairy products
(especially butter, ,
cream, and cheese)
 meat (beef)
 dark meat of
poultry, and poultry
skin
 chocolate

289. MACRONUTRIENTS
LIPIDS
 Unsaturated
 Avocado
 Nuts
 Vegetable oils
such as soybean,
canola, and olive
oils

290. MACRONUTRIENTS
LIPIDS
 Digestion
 Starts in the mouth
 Mainly in the stomach
 Bile
 Pancreatic Lipase

291. MACRONUTRIENTS
LIPIDS
 They become
 Glycerol and Fatty acids
 Energy
 Cholesterol (Lipids plus protein)
 Is Cholesterol needed in the body?
 Important in producing bile
 Excessive
 Atherosclerosis
 GLOW FOODS

292. TYPES OF LIPOPROTEINS
 1. High Density Lipoproteins (HDL)
 Good cholesterol
 Function of HDLs
 Transportsthe bad cholesterol from
systemic circulation to the liver for
metabolism and eventual elimination

293. TYPES OF LIPOPROTEINS
 2. Low Density Lipoproteins (LDL)
 Bad cholesterol
 Function of LDLs
 They clog the blood vessels

295. ENERGY INTAKE

296. ENERGY INTAKE
 The amount of energy that nutrients or
foods supply to the body is their caloric
value
 CHO
 CHON
 FATS
 * ALCOHOL
 7 Calories/Gram

297. ENERGY INTAKE
 Recommended Calorie Intake per Day
 Varies
 Generally
 Men
 2000 – 2500 calories
 Women
 1500 – 2000 calories
 Pregnant
 Plus 300 calories
 Lactating
 Plus 500 calories

298. ENERGY INTAKE
 Compute
 800 grams of CHO
 600 grams of CHON
 400 grams of FATS

299. MICRONUTRIENTS

300. MICRONUTRIENTS
 Required in small amounts
 Vitamins
 Minerals

301. VITAMINS

302. MICRONUTRIENTS
 Vitamins
 Organic compounds that cannot be
produced by the body
 Water Soluble
 Fat Soluble

303. WATER SOLUBLE VITAMINS

304. WATER SOLUBLE VITAMINS
 Vitamins that cannot be stored by the body
 Excess?
 Vitamin C
 Vitamin B Complex

305. WATER SOLUBLE VITAMINS
 Vitamin C
 Ascorbic Acid
 synthesis of collagen
 an important protein used to make skin, scar
tissue, tendons, ligaments, and blood vessels
 essential for the healing of wounds, and for the
repair and maintenance of cartilage, bones, and
teeth
 immune function
 synthesis of the neurotransmitter,
norepinephrine
 effective antioxidant

306. WATER SOLUBLE VITAMINS
 Vitamin C
 Fruits
 Guava
 Strawberry
 Lemon
 Orange
 Mangoes
 Tomato
 Vegetables
 Bell Peppers
 Broccoli
 Cauliflower
 Green Cabbage

307. WATER SOLUBLE VITAMINS
 Vitamin C Deficiency
 Scurvy
 Bruising easily
 hair and tooth loss
 joint pain and swelling
 Related to the weakening of blood
vessels, connective tissue, and bone,
which contain collagen

308. WATER SOLUBLE VITAMINS
 Vitamin B Complex
 Vitamin B1
 (thiamine)
 Vitamin B2
 (riboflavin)
 Vitamin B3
 (niacin)
 Vitamin B5
 (pantothenic acid)
 Vitamin B6
 (pyridoxine)
 Vitamin B7
 (biotin)
 Vitamin B9
 (folic acid)
 Vitamin B12
 (cyanocobalamin)

309. WATER SOLUBLE VITAMINS
 Vitamin B Complex
 Vitamins B1, B2, B3
 energy production
 Vitamin B6
 amino acid metabolism
 Vitamin B9
 Vital for the function and maintenance
of the nervous system and red blood
cells
 400 mcg or 0.4 mg (Pregnant)

310. WATER SOLUBLE VITAMINS
 Vitamin B Complex
 fish, milk, eggs,
liver, meat, brown
rice, whole grain
cereals, and
soybeans, poultry
 Folic acid
 Green vegetables
 Liver
 whole grain cereals

311. WATER SOLUBLE VITAMINS
 Vitamin B Deficiency
 Vitamin B1 (Thiamine)
 Beriberi
 Wernicke's encephalopathy
 Impaired sensory perception
 Weakening of the limbs
 Irregular heart rate
 Korsakoff's syndrome
 Amnesia and confabulation

312. WATER SOLUBLE VITAMINS
 Vitamin B Deficiency
 Vitamin B3 (niacin)
 Pellagra
 Aggression
 Insomnia
 Weakness
 mental confusion
 diarrhea

313. WATER SOLUBLE VITAMINS
 Vitamin B Deficiency
 Vitamin B9 (folic acid)
 In pregnancy
birth defects
 Neural Tube
Defects
 Spina Bifida
 Anencephaly

314. FAT SOLUBLE VITAMINS

315. FAT SOLUBLE VITAMINS
 The body can store these vitamins
 A
 D
 E
 K

316. FAT SOLUBLE VITAMINS
 Vitamin A
 Retinol
 Normal Vision
 Maintaining normal skin health
 Deficiency
 Blindness

317. FAT SOLUBLE VITAMINS
 Vitamin A sources
 liver (beef, pork,
chicken, turkey,
fish)
 carrots
 Broccoli leaves
 sweet potatoes
 butter
 spinach
 pumpkin

318. FAT SOLUBLE VITAMINS
 Vitamin D
 Calciferol
 To maintain normal blood levels of calcium
 Vitamin D aids in the absorption of calcium
 Deficiency
 In children
 Rickets – skeletal deformities
 Calcium
 osteomalacia
 muscular weakness in addition to weak bones

319. FAT SOLUBLE VITAMINS
 Vitamin D
 Fish
 Eggs
 fortified milk
 cod liver oil
 The sun
 as little as 10
minutes of
exposure

320. FAT SOLUBLE VITAMINS
 Vitamin E
 Tocopherol
 Antioxidant

321. FAT SOLUBLE VITAMINS
 Vitamin E sources
 Vegetable oils, nuts,
green leafy
vegetables, and
fortified cereals
 Almonds
 Asparagus
 Avocado
 Nuts
 Olives
 Seeds
 Spinach and other
green leafy vegetables

322. FAT SOLUBLE VITAMINS
 Vitamin K
 K
 Koagulation Vitamins
 Clotting factors
 Stops bleeding

323. FAT SOLUBLE VITAMINS
 Leafy green
vegetables,
particularly the
dark green ones
such as
 Spinach
 Broccoli
 Malunggay
 Avocado

324. MINERALS

325. MINERALS
 Organic or inorganic compounds
 Macrominerals
 Over 100 mg
 Microminerals
 Less than 100 mg

326. MACROMINERALS

327. MACROMINERALS
 Calcium
 Sodium
 Potassium
 Phosphorous
 Magnesium
 Chloride
 Sulfur

328. MACROMINERALS
 Calcium
 Normal growth and maintenance of
bones and teeth
 Deficiency
 Rickets
 Osteoporosis

329. MACROMINERALS
 Calcium Sources
 Dairy products, such
as milk and cheese
 beans
 oranges
 Okra
 broccoli
 fortified products
such as orange juice
and soy milk

330. MACROMINERALS
 Sodium
 Regulation of blood and body fluids
 Water Retention
 Transmission of nerve impulses
 Action Potential (Sodium Potassium
Pump)
 2 to 3 grams/day
 Table salts and most condiments
 Preserved foods

331. MACROMINERALS
 Potassium
 muscle contraction and the
sending of all nerve impulses in
animals through action
potentials
 All meats, poultry and fish are
high in potassium.
 Apricots (fresh more so than
canned)
 Avocado
 Banana
 Cantaloupe
 Milk
 Oranges and orange juice
 Potatoes

332. MICROMINERALS

333. MICROMINERALS
 Iron
 Iodine
 Flouride
 Manganese
 Cobalt
 Selenium

334. MICROMINERALS
 Iron
 Ferrous Sulfate
 Hemoglobin
 Oxygen carriers
 Forms of supplement
 Oral
 Parenteral

335. MICROMINERALS
 Iron Sources
 Dark Green, Leafy Vegetables
 Dried Beans and Peas
 Dried Fruits
 Eggs
 Enriched Breads
 Iron-Fortified Cereal
 Lean Meats
 Nuts
 Raisins
 Spinach
 Tofu

336. MICROMINERALS
 Iron
 Oral Form
 Take on an empty stomach
 If with GI distress, take with food
 Use dropper or straw
 Drink with
 Milk or Orange Juice?
 Increase water
 Decrease fiber

337. MICROMINERALS
 Iron
 Parenteral Form
 Site
 Deep IM
 Z Track
 Don’t massage
 Apply firm pressure for 5 minutes

338. MICROMINERALS
 Iodine
 As element of the thyroid hormones,
thyroxine (T4) and triiodothyronine (T3)
 Deficiency
 Hypothyroidism
 Goiter

339. MICROMINERALS
 Iodine Sources
 Sea creatures
 Seaweeds

340. NUTRITIONAL ASSESSMENT

341. NUTRITIONAL ASSESSMENT
 Anthropometric Measurements
 Height
 Weight
 (best indicator of nutritional status of
an individual)
 Skin Fold Test (fat folds)
 Mid-upper arm Circumference
Measurement
 Body Mass Index

342. NUTRITIONAL ASSESSMENT
 Weight
 Weighing Technique
 Ideal Body Weight
 Rule of 5 for Women
 Rule of 6 for Men

343. NUTRITIONAL ASSESSMENT
 Ideal Body Weight
 Rule of 5 for Women
 100 lbs for 5 ft of height
 Plus 5 lbs for every inch of height
above 5 ft
 Example
 5 feet 1 inch
 Weight = 105 lbs
 5 feet 2 inches
 Weight – 110 lbs

344. NUTRITIONAL ASSESSMENT
 Ideal Body Weight
 Rule of 6 for Men
 106 lbs for 5 ft of height
 Plus 6 lbs for every inch of height
above 5 ft
 Height = 5 ft 1 inch
 Weight
 112 lbs

345. NUTRITIONAL ASSESSMENT
 Anthropometric
Measurements
 Skin Fold Test
 Derivedfrom
reserved fat of
the body

346. NUTRITIONAL ASSESSMENT
 Anthropometric
Measurements
 Mid-upper arm
Circumference
Measurement
 Obtains the
muscle mass of
the body
 This reflects the
protein reserves
of the body

347. NUTRITIONAL ASSESSMENT
 Body Mass Index
 BMI = weight in kg
(height in meter)2

348. NUTRITIONAL ASSESSMENT
 BMI
 Height in Meter
 1 Meter = 3.3 feet or 39.6 inches
 1 Kg = 2.2 Lbs

349. NUTRITIONAL ASSESSMENT
 BMI Results
 Underweight = Less than 18.5
 Normal = 18.5 – 24.9
 Overweight = 25.0 – 29.9
 Obese Type I = 30.0 – 34.9
 Obese Type II = 35.0 – 39.9
 Obese Type III = 40.0 plus

350. NUTRITIONAL ASSESSMENT
 BMI
 Compute
 Weight = 65 kg
 Height is = 62 inches
 Compute
 Weight = 150 pounds
 Height = 5 feet 3 inches

351. NUTRITIONAL ASSESSMENT
 Biochemical Data
 Serum Albumin

352. NUTRITIONAL ASSESSMENT
 Serum Albumin
 Provide an estimate of protein stores
 Albumin
 Serum protein

353. NUTRITIONAL ASSESSMENT
 Dietary Data
 24 hour food recall
 Food Diary
 Obesity
 Eating Disorders

354. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE

355. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Neonate
 Nutritional requirements are met by
breastmilk or formula milk
 Total daily requirements of the newborn
 80 to 100 ml of milk per kg
 Stomach capacity = 90 ml
 Feedings are required every 2 to 4 hours
 Demand feeding
 Burping

356. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Infant
 Solid foods are added when?
 4 to 6 months
 Cereals (Rice)
 Fruits
 Vegetables (Yellows before Greens)
 Foods are introduced 1 at a time
 Every 5 to 7 days
 Honey is not given
 May contain small amount of
Clostridium botulinum

357. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Toddlers
 Toddlers can eat
most foods
 Meals short be
short
 Environmental
distractions must
be eliminated
 Rituals
 Attractive foods
 Avoid sweet
desserts

358. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Preschooler
 These children eat
at school
 Children at this
stage are very
active and may rush
through meals to
return to playing
 Often require
healthy snacks
 Fruits
 Milk
 Yogurt

359. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 School Aged Child
 Watch out for the
foods the child are
eating at school
 High CHO and High
CHON
 Prolonged physical
and mental effort
 Breakfast is important

360. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Adolescents
 Growth spurt
 Self Identity and Peer pressure
 Eating disorders

361. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Young Adults and Middle Adults
 Maintain normal diet of healthy food
options
 Milk

362. NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Elderly
 They have many problems associated with
nutrition
 Difficulty chewing
 Denture
 Chopped and soft foods
 Loss of appetite
 SFF
 Loss of senses of smell and taste
 Favorite foods
 Limited income
 Substitution
 Substitute meat with milk or beans
 Difficulty sleeping at night
 Promote sleep

363. SPECIAL DIETS

364. SPECIAL DIETS
 Clear Liquid Diets
 Limited to
 Water
 Tea
 Coffee
 Clear broths
 Strained and
clear juices
 Plain gelatin
 Hard Candy

365. SPECIAL DIETS
 Clear Liquid Diets
 This provides water and CHO (in the
form of sugar)
 After surgery

366. SPECIAL DIETS
 Full Liquid Diet
 Foods that are liquids
or foods that turn to
liquid at body
temperature
 All foods in the
Clear Liquid Diet
 Milk
 Puddings and
custards
 Ice cream and
sherbets
 Yogurt

367. SPECIAL DIETS
 Full Liquid Diet
 For clients who have gastrointestinal
problems and cannot tolerate semi solid
or solid foods

368. SPECIAL DIETS
 Soft Diet
 All foods in the Clear and Full Liquid Diet
 Meat: Lean, Tender
 Fish, grounded meat
 Vegetables: Mashed or cooked for a very
soft consistency
 Fruits: Cooked or canned
 Breads and oatmeals
 Soft cakes

369. SPECIAL DIETS
 Diet As Tolerated (DAT)
 When the client’s appetite, ability to eat
and tolerate food
 Gag
 Bowel Sounds

370. SPECIAL DIETS
 Modification for Disease
 Diabetic Diet
 Hypertensive Diet

371. SUPPORTING NUTRITION OF THE
PATIENT
ENTERAL AND PARENTERAL
FEEDING

372. ENTERAL FEEDING
 An alternative feeding method to ensure
adequate nutrition
 Feeding through the gastrointestinal
system
 EN
 TEN

373. ENTERAL FEEDING
 Nasogastric Tube
 Nasointestinal Tube
 Percutaneous Endoscopic Gastrostomy
(PEG)
 Percutaneous Endoscopic Jejunostomy
(PEJ)

374. NASOGATRIC TUBE

375. NASOGATRIC TUBE
 Purpose
 For gastric
gavage (feeding)
and lavage
(irrigation)
 For
administration of
medication

376. NASOGATRIC TUBE
 Indications
 Clients who are unable to ingest foods
 The upper gastrointestinal tract is
impaired
 Transport of food to the small intestines
is interrupted

377. NASOGATRIC TUBE
 Single Lumen Tube
 Levin Tube
 Double Lumen
 Salem Sump
Tube

378. NASOGATRIC TUBE
 Procedure
 Position
 High Fowler’s
 Hyperextension of head
 Explain
 Hand Hygiene
 Measure Depth of Insertion
 NEX

379. NASOGATRIC TUBE
 Check Nares
 Irritation
 Obstruction
 Put on Gloves
 Lubricate the tip of the tube
 Insert
 Resistance
 Withdraw then lubricate again

380. NASOGATRIC TUBE
 When the tube reaches the throat
 Ask the client to forward head
 Swallow
 Gag
 Stop
 Give water and encourage to
breath
 Continue insertion

381. NASOGATRIC TUBE
 Ascertain correct placement of the tube
1 – Radiographic Verification
2 – Acidity of pH of aspirate
 Lithmus Paper
 Blue
 Red
3 – Aspiration of gastric content
4 – Ausculate epigastic region

382. NASOGATRIC TUBE
 Secure the NGT to the clients gown
 Document

383. NASOGATRIC TUBE
 Feeding
 Osterized Food
 Average volume of feeding:
 300 ml to 400 ml
 Warmed at room temperature

384. NASOGATRIC TUBE
 Feeding
 Procedure
 Assist the patient in high fowler’s position
 If tolerated
 If not, Slightly elevated right sided lying
 Checks the formula's expiration date
 Check the patency of the tube

385. NASOGATRIC TUBE
 Elevate the tip of the tube to 12 inches
above nares
 Connect tube to a 60 cc syringe
 Flush with 30cc of water
 Run the formula through the tubing and
reclamp the tube
 a rate no greater than 50ml/min is
recommended
 Flush with 30cc of water

386. NASOGATRIC TUBE
 Perform mouth care; brushing teeth, gums
and tongue twice daily
 Apply lip moisturizer or petroleum jelly
unless otherwise ordered
 Discourages mouth breathing and uses
measures to increase salivation such as
chewing gum, sucking on hard candy or ice
if permissible
 Ask the client to remain sitting for
 30 minutes

387. NASOINTESTINAL TUBE

388. NASOINTESTINAL TUBE
 Longer than the nasogastric tube
 From one nostril to the small intestines
 Used for clients at risk for aspiration
 Decreased LOC
 Poor cough or gag reflex
 Restlessness and agitation
 Endotracheal intubation

389. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY
PERCUTANEOUS ENDOSCOPIC
JEJUNOSTOMY

390. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY
 PEG
 To the stomach
 To provide nutrition
to
 Neurologic
disorders such as
a stroke or a
tumor of the
head, neck, or
esophagus

391. PERCUTANEOUS ENDOSCOPIC
JEJUNOSTOMY
 PEJ
 To the jejunum

392. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY/ JEJUNOSTOMY
 Stoma
 Liquid nutritional formulas are put into the
tube and directly into the stomach or
intestines
 Insert a feeding tube to the stoma
 Lubricate tube
 Insert into opening (4 to 6 inches)

393. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY/ JEJUNOSTOMY
 Check patency by getting aspirate
 Administer the feeding
 Hold the barrel of the syringe 3 to 6 in
above opening of the stoma
 Slowly pour solution
 Flush with 30 cc of water

394. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY/ JEJUNOSTOMY
 Remove the syringe and clamp or plug the
tube
 Ensure client comfort and safety
 Remain sitting for 30 minutes
 Assess the stoma
 Washed with soap and water once a
day
 Rotate the tube to avoid sticking in
the stoma
 Petrolatum and other skin protectant
may be applied
 Document

395. TOTAL PARENTERAL NUTRITION

396. TOTAL PARENTERAL NUTRITION
 Or Intravenous
Hyperalimentation
 Used when the
gastrointestinal
tract is
nonfunctional

397. TOTAL PARENTERAL NUTRITION
 Introduced directly to
the bloodstream
 Tube is inserted via
the:
 Subclavian vein
 Internal jugular vein
of the neck
 Femoral vein
 Brachial vein

398. TOTAL PARENTERAL NUTRITION
 Subclavian Vein
 Internal jugular
vein of the neck

399. TOTAL PARENTERAL NUTRITION
 Nursing Responsibilities:
 Maintain aseptic techniques
 Watch out for signs and symptoms of
embolism
 Pain
 Swelling
 Warmth on the site
 Infection

400. TOTAL PARENTERAL NUTRITION
 Care of Insertion Site
 Application of sterile dressing with anti-
bacterial ointment as ordered by doctor
(PRN)

401. BLOOD TRANSFUSION

402. BLOOD TRANSFUSION
 Purposes:
 To administer required blood
component by the patient
 To restore blood volume
 RBC
 WBC
 Platelets
 Plasma Proteins

403. BLOOD TRANSFUSION
 Human blood is classified into four main
groups
 A
 B
 AB
 O

404. BLOOD TRANSFUSION
 Antigens
 Number of proteins in the red blood cell
surface
 Most important in determining blood type
(Blood Type Compatibility)
 Blood type A, Antigen A
 Blood type B, Antigen B
 Blood type AB, Antigen A and B
 Blood type O, No antigen
 Universal Donor

405. BLOOD TRANSFUSION
 Antibodies
 Preformed antibodies are present in the
plasma
 Blood Incompatibility
 Blood Type A, Antibody B
 Blood Type B, Antibody A
 Blood Type AB, Antibody None
 Universal Recipient
 Blood Type O, A and B

406. BLOOD TRANSFUSION
 Rh Factor
 The Rh factor antigen is present
 Rh+
 When the Rh factor antigen is not
present
 Rh –
 Filipinos

407. BLOOD TRANSFUSION
 Procedure:
1. Verify doctor’s order. Inform client and
explain the purpose of the procedure
2. Check for cross matching and blood
typing. To ensure compatibility
3. Obtain and record baseline VS

408. BLOOD TRANSFUSION
4. Practice safe asepsis
5. At least 2 nurses check the label of the
blood transfusion
> Check the following:
- Serial number
- Blood component
- Blood type
- Rh factor
- Expiration data
- Screening tests (VDRL for sexually
transmitted diseases, HBsAg for
hepatitis B; malarial smear for
malaria)

409. BLOOD TRANSFUSION
6. Warm blood at room temperature before
transfusion. To prevent chills
7. Identify client properly. Two nurses
check the client’s identification
8. Use needle gauge 18 or 19. This allows
easy flow of blood
9. Use BT (blood transfusion) set with filter.
To prevent administration of blood clots
and other particulates

410. BLOOD TRANSFUSION
10. Start infusion slowly at 10 gtts/minute. Remain
at bedside for 15 to 30 minutes. Adverse reaction
usually occurs during the first 15 to 20 minutes
11. Monitor VS. Altered VS indicates adverse
reaction
12. Do not mix medications with blood transfusion.
To prevent adverse effects
- Do not incorporate medication into the blood
transfusion
- Do not use the blood transfusion line for IV
push of medication
13. Administer 0.9% NaCl before, during or after
BT. Never administer IV fluids with dextrose.
Dextrose cause hemolysis.

411. BLOOD TRANSFUSION
 Complications:
- Allergic Reaction (flushing, rash, hives, pruritus,
laryngeal edema, DOB)
- Febrile, Non Hemolytic (sudden chills and fever,
flushing, headache, anxiety)
- Sepsis (rapid onset of chills, vomiting, marked
hypotension, high fever)

412. BLOOD TRANSFUSION
- Circulatory Overload (rise in venous pressure,
dyspnea, crackles or rales, distended neck vein,
cough, elevated BP)
- Hemolytic (low back pain, chills, feeling of
fullness, tachycardia, flushing, tachypnea,
hypotension, bleeding)

413. BLOOD TRANSFUSION
 Nursing Interventions When Complication
Occurs in Blood Transfusion
1. Stop blood transfusion immediately
2. Start an IV line (0.9% NaCl)

414. THANK YOU FOR LISTENING 
PLEASE READ FOLLOWING
CHAPTERS ON
SLEEP AND REST
NUTRITION