INT NUR 101 LECTURE

INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
INT NUR 101- INTEGRATING COURSE I • Caregiver: activities that assist the client
Second Semester, Academic Year 2023 – 2024 physically and psychologically while preserving
the client’s dignity. The required nursing actions
may involve full care for the completely
FUNDAMENTALS OF NURSING I dependent client, partial care for the partially
dependent client, and supportive-educative care
to assist clients in attaining their highest possible
1. PROFESSION level of health and wellness. Caregiving encom-
A. Definition passes the physical, psychosocial,
• profession has been defined as an occupation developmental, cultural, and spiri- tual levels.
that requires extensive education or a calling that • Communicator: nurses identify client problems
requires special knowledge, skill, and and then communicate these verbally or in writing
preparation. A profession is generally to other members of the health care team.
distinguished from other kinds of occupations. • Teacher: nurse helps clients learn about their
health and the health care procedures they need
B. Criteria to perform to restore or main- tain their health.
The nurse assesses the client’s learning needs
• (a) its requirement of prolonged, specialized and readiness to learn, sets specific learning
training to acquire a body of knowledge pertinent goals in conjunction with the client, enacts
to the role to be performed; teaching strategies, and measures learning.
• (b) an orientation of the individual toward service, Nurses also teach unlicensed assistive personnel
either to a community or to an organization; (UAP) to whom they del- egate care, and they
• (c) ongoing research; share their expertise with other nurses and health
professionals.
• (d) a code of ethics;
• Advocate: acts to protect the client. In this role
• (e) autonomy; and
the nurse may represent the client’s needs and
• (f) a professional organization.
wishes to other health professionals, such as
• Professionalism refers to professional relaying the client’s request for information to the
character, spirit, or methods. It is a set of health care provider. They also assist clients in
attributes, a way of life that implies responsibility exercising their rights and help them speak up for
and commitment. Nursing professionalism owes themselves
much to the influence of Florence Nightingale.
• Counselors: process of helping a client to
Professionalization is the process of becoming
recognize and cope with stressful psychological
professional, that is, of acquiring characteristics
or social problems, to develop improved
considered to be professional.
interpersonal relationships, and to promote
personal growth. It in- volves providing emotional,
2. NURSING
intellectual, and psychological support.
A. Definition
• Change agent: assisting clients to make
• Florence Nightingale
modifications in their behavior. Nurses also often
o Nursing: act of utilizing the environment act to make changes in a system, such as clinical
of the patient to assist him in his care, if it is not helping a client return to health.
recovery” (Nightingale, 1860/1969). • Leader: influences others to work together to
Nightingale considered a clean, well- accomplish a specific goal. The leader role can
ventilated, and quiet environment be employed at different levels: individual client,
essential for recovery. family, groups of clients, colleagues, or the
community.
• Virginia Henderson
• Manager: nurse manages the nursing care of
o Nursing: “The unique function of the individuals, families, and communities. The nurse
nurse is to as- sist the individual, sick or manager also delegates nursing activities to
well, in the performance of those ancillary workers and other nurses, and
activities contributing to health or its supervises and evaluates their performance.
recovery (or to peaceful death) that he Managing requires knowledge about
would perform unaided if he had the organizational structure and dynamics, authority
and accountability, leadership, change theory,
necessary strength, will, or knowledge, advocacy, delegation, and supervision and
and to do this in such a way as to help evaluation.
him gain independence as rapidly as • Case manager: work with the multidisciplinary
possible” health care team to measure the effectiveness of
• ANA the case management plan and to monitor
o 1973: “direct, goal oriented, and outcomes.
adaptable to the needs of the individual, • Research consumer: Nurses often use research
to improve client care. In a clinical area, nurses
the family, and community during health need to (a) have some awareness of the process
and illness” and language of research, (b) be sensitive to
o 1980: “Nursing is the diagnosis and issues related to protecting the rights of human
treatment of human responses to actual subjects, (c) participate in the identification of
or potential health problems” significant researchable problems, and (d) be a
o 2003: “Nursing is the protection, discriminating consumer of research findings.
• Expanded career roles: Nurses are fulfilling
promotion, and optimization of health
expanded career roles, such as those of NP,
and abilities, preventions of illness and clini- cal nurse specialist, nurse midwife, nurse
injury, alleviation of suffering through the educator, nurse researcher, and nurse
diagnosis and treatment of human anesthetist, all of which allow greater
response, and advocacy in the care of independence and autonomy
individuals, families, communities, and
populations” C. FOCUS
B. CHARACTERISTICS • Nurses provide care for three types of clients:
individuals, families, and communities.

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INT NUR 101 LECTURE
INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
• A consumer is an individual, a group of people, development as well as social changes mark this
or a community that uses a service or commodity. period.
People who use health care products or services
are consumers of health care.
• A patient is a person who is waiting for or HISTORICAL ERAS
undergoing medical treatment and care. The
word patient comes from a Latin word meaning
“to suffer” or “to bear.” Traditionally, the person CURRICULUM ERA
receiving health care has been called a patient.
• A client is a person who engages the advice or • Nursing education shifted from
services of another who is qualified to provide hospital based diploma programs
this service. The term client presents the into college and universities
receivers of health care as collaborators in the
care, that is, as people who are also responsible RESEARCH EMPHASIS ERA
for their own health.
• Nursing practice involves four areas: promoting • This era implies that research was a path to new
health and well- ness, preventing illness, knowledge. It is in this era where research became
restoring health, and caring for the dying.
part of the curricula of developing graduate
programs
D. PERSONAL AND PROFESSION QUALITIES
GRADUATE EDUCATION ERA

• In this era, master's program in nursing emerged

in order to meet the need for nurses with
specialized education training. Nursing theory
and Conceptual Models were included as
courses.

THEORY ERA

• It is the era as the outgrowth of research era.

Research produced without theory produced
isolated information while research produced
3. HISTORY OF NURSING
A. IN THE WORLD with theory produced nursing science.

B. IN THE PHILIPPINES
1. PERIOD OF INTUITIVE NURSING / MEDIEVAL PERIOD
EARLY BELIEFS & PRACTICES
• In this period, nursing was considered to be
• Two words—mysticism and superstitions. These were
"untaught" and instinctive. It was considered as a
the early beliefs of health and illness in the
function of women and there is no evident
Philippines.
caregiving trainings. It is also in this period where
• cause of a disease was primarily believed to be due to
primitive men believed that illness was caused by
either another person, whom which was an enemy, or
the invasion of the victim’s body of evil spirits.
a witch or evil spirits.
2. PERIOD OF APPRENTICE NURSING /MIDDLE AGES • could be driven away by persons with power to banish
demons
• Nursing was developed by religious orders.
• It is in this period that Nursing care was
EARLY CARE OF THE SICK
performed without any formal education and
• early Filipinos subscribed to superstitious belief and
by people who were directed by more
practices in relation to health and sickness.
experienced nurses (on the job training).
• “herbicheros” meaning one who practiced witchcraft.
• Persons suffering from diseases without any identified
3. PERIOD OF EDUCATED NURSING / NIGHTINGALE ERA cause were believed bewitched
19TH -20TH CENTURY by “mangkukulam” or “manggagaway”. Difficult
• In this period, the development of nursing during childbirth and some diseases (called “pamao”) were
this period was strongly influenced by: attributed to “nunos”. Midwives assisted in childbirth.
• trends resulting from wars – Crimean, civil war During labor, the “mabuting hilot” (good midwife) was
• arousal of social consciousness called in.
• c)increased educational opportunities offered to
HEALTHCARE DURING THE SPANISH REGIME
women.
• manifested through simple nutrition, wound care, and
4. PERIOD OF CONTEMPORARY NURSING /20TH taking care of an ill member
CENTURY • male nurses were referred
as practicante or enfermero.
• In this period, Licensure of nurses started • Hospital Real de Manila (1577) – it was established
alongside: specialization of Hospital and mainly to care for the Spanish king’s soldiers, but also
diagnosis, training of Nurses in diploma program, admitted Spanish civilians; founded by Gov. Francisco
development of baccalaureate and advance de Sande.
degree programs, scientific and technological • San Lazaro Hospital (1578) – founded by Brother
Juan Clemente and was administered for many years

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INT NUR 101 LECTURE
INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
by the Hospitalliers of San Juan de Dios; built provided the holding of exam for the practice
exclusively for patients with leprosy. of nursing on the 2nd Monday of June and
• Hospital de Indios (1586) – established by the December of each year.
Franciscan Order; service was in general supported 1920
by alms and contributions from charitable persons. • 1st board examination for nurses was
• Hospital de Aguas Santas (1590) – established in conducted by the Board of Examiners, 93
Laguna; near a medicinal spring, founded by Brother candidates took the exam, 68 passed with
J. Bautista of the Franciscan Order. the highest rating of 93.5%-Anna Dahlgren
• San Juan de Dios Hospital (1596) – founded by the • Theoretical exam was held at the UP
Brotherhood of Misericordia and administered by the Amphitheater of the College of Medicine and
Hospitaliers of San Juan de Dios; support was Surgery. Practical exam at the PGH Library.
delivered from alms and rents; rendered general 1921
health service to the public. • Filipino Nurses Association was established
(now PNA) as the National Organization Of
NURSING DURING PHILIPPINE REVOLUTION Filipino Nurses
• Josephine Bracken — wife of Jose Rizal, installed a • PNA: 1st President – Rosario Delgado
field hospital in an estate house in Tejeros. She • Founder – Anastacia Giron-Tupas
provided nursing care to the wounded night and day. 1953
• Rosa Sevilla de Alvero — converted their house into • Republic Act 877, known as the “Nursing
quarters for the Filipino soldiers; during the Philippine- Practice Law” was approved.
American War that broke out in 1899
• Melchora Aquino a.k.a. “Tandang Sora” — nursed
the wounded Filipino soldiers and gave them shelter 4. DEVELOPMENT OF MODERN NURSING
and food.
• Capitan Salome — a revolutionary leader in Nueva
Ecija; provided nursing care to the wounded when not 5. NURSING THEORIES
in combat.
• Agueda Kahabagan — revolutionary leader in
• Nursing theories are organized bodies of
Laguna, also provided nursing services to her troops
knowledge to define what nursing is, what nurses
• Trinidad Tecson (“Ina ng Biak-na-Bato”) — stayed in do, and why they do it.
the hospital at Biak na Bato to care for wounded
• Nursing theories provide a way to define nursing
soldiers as a unique discipline that is separate from other
• Dona Hilaria de Aguinaldo — wife of Emilio disciplines (e.g., medicine).
Aguinaldo who organized that Filipino Red Cross
• It is a framework of concepts and purposes
under the inspiration of Mabini.
intended to guide nursing practice at a more
• Dona Maria Agoncillo de Aguinaldo — second wife concrete and specific level
of Emilio Aguinaldo; provided nursing care to Filipino
soldiers during the revolution, President of the Filipino
Red Cross branch in Batangas.
A MUCH ESTABLISHED PROFESSIONAL ORGANIZATION A. OVERVIEW
(1921-1931)
a. DEFINITION OF CONCEPT, THEORY,
PRINCIPLE
• The Filipino Nurses Association was established on
October 15, and the organization initiated the THEORY
publication of Filipino Nurse Journal.
• This journal was changed to The Philippine Journal of
Nursing. • Origin: Came from a greek word "Thoeria" which
• Act 2008 was conducted in 1922 under Act 3025 means speculate.
passed by the 5th Legislature - An Act Regulating the • Theory has been described as a systematic
Practice of Nursing Profession in the Philippine explanation of an event in which constructs and
Islands: necessitates all nurses who are practicing the concepts are identified and relationships are proposed
profession to register yearly. and predictions made (Streubert & Carpenter, 2011).
NOTE: • Theory has also been defined as a “creative and
rigorous structuring of ideas that project a tentative,
purposeful and systematic view of phenomena”
• During this period, the Philippine Nursing Act of 2002 (Chinn & Kramer, 2011, p. 257).
was enacted under the Republic Act No. 9173 which
• Theory has been called a set of interpretative
entails changes on existing policies under Republic
assumptions, principles, or propositions that help
Act No. 7164. These changes underscore on the
explain or guide action (Young, Taylor, & Renpenning,
requirements for faculty and Dean of the Colleges of
2001).
Nursing, as well as the conduct for Nursing Licensure
Exam. • In their classic work, Dickoff and James (1968) state
that theory is invented, rather than found in or
discovered from reality. Furthermore, theories vary
College of Nursing according to the number of elements, the
1. UST College of Nursing – 1st College of characteristics and complexity of the elements, and
Nursing in the Phils: 1877 the kind of relationships between or among the
2. MCU College of Nursing – June 1947 (1st elements.
College who offered BSN – 4 year program) • “A set of statements that tentatively describe, explain,
3. UP College of Nursing – June 1948 or predict relationships among concepts that have
4. FEU Institute of Nursing – June 1955 been systematically selected and organized as an
5. UE College of Nursing – Oct 1958 abstract representation of some phenomenon.
1909 (McEwen & Wills, 2019)
• 3 female graduated as “qualified medical- • TYPES OF NURSING THEORIES
surgical nurses” o 1. SPECULATIVE
1919 o yet to be tested through research and found
• The 1st Nurses Law (Act#2808) was enacted to be consistently true in answering
regulating the practice of the nursing questions, solving problems, and exploring
profession in the Philippines Islands. It also phenomenon

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INT NUR 101 LECTURE
INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
o 2.ESTABLISHED o Concrete Concepts. Are directly
o Accumulation of facts, principles, and laws experienced and related to a particular time
that have been repeatedly tested through or place.
research overtime and found to be DEFINITIONS
consistently valid and reliable. • used to convey the general meaning of the concepts
of the theory. Definitions can be theoretical or
ACCORDING TO SCOPE operational
o Theoretical Definitions. Define a particular
o GRAND THEORY concept based on the theorist’s perspective.
§ broadest in scope o Operational Definitions. States how
§ represents the most abstract level concepts are measured.
of development
§ addresses the broad phenomena of
RELATIONAL STATEMENTS
concern within the discipline
• define the relationships between two or more
o 2. MIDDLE –RANGE THEORY
concepts. They are the chains that link concepts to
§ addresses more concrete and more
one another.
narrowly defined phenomena
§ intended to answer questions about ASSUMPTIONS
nursing phenomena yet they did • accepted as truths and are based on values and
not cover the full range beliefs. These statements explain the nature of
o 3.MICRO-RANGE THEORY concepts, definitions, purpose, relationships, and
§ concrete and narrow in scope. It structure of a theory.
explains a specific phenomenon of
concern about a discipline
c. PURPOSES OF NURSING THEORY
ACCORDING TO FUNCTION
• it is widely believed that use of theory offers
o DESCRIPTIVE : to identify properties and structure and organization to nursing knowledge
workings of a discipline and provides a systematic means of collecting
o EXPLANATORY :to examine how properties data to describe, explain, and predict nursing
practice.
relate and thus affect the discipline
• Theories make nursing practice more overtly
o PREDICTIVE : to calculate relationships purposeful by stating not only the focus of
between properties and how they occur practice but also specific goals and outcomes.
o PRESCRIPTIVE : to identify under which • Theories define and clarify nursing and the
conditions relationships occur purpose of nursing practice to distinguish it from
other caring professions by setting professional
ACCORDING TO PHILOSOPHY boundaries.
• Finally, use of a theory in nursing leads to
o “NEEDS “THEORIES : are based on helping coordinated and less fragmented care (Alligood,
2010; Chinn & Kramer, 2011; Ziegler, 2005).
individuals to fulfill their physical and mental
• IN ACADEMIC DISCIPLINE: to explain the
needs fundamental implications of the profession and
o ”INTERACTION”THEORIES : As described enhance the profession’s status.
by Peplau, these theories revolve around the • IN RESEARCH: development of theory is
relationships nurses from with patients. fundamental to the research process, where it is
o ”OUTCOME” THEORIES : portray the nurse necessary to use theory as a framework to
as the changing force provide perspective and guidance to the research
study.
o “HUMANISTIC “THEORIES :emphasizes a
• IN THE PROFESSION: In a clinical setting, its
person's capacity for self actualization
primary contribution has been the facilitation of
reflecting, questioning, and thinking about what
nurses do.

b. COMPONENTS OF A THEORY
d. NURSING PARADIGM
PHENOMENON
• describe an idea or response about an event, a • PERSON
situation, a process, a group of events, or a group of o Person (also referred to as Client or
Human Beings) is the recipient of
situations. Phenomena may be temporary or
nursing care and may include
permanent. Nursing theories focus on the phenomena individuals, patients, groups, families,
of nursing and communities.
• ENVIRONMENT
CONCEPTS o Environment (or situation) is defined as
• Interrelated concepts define a theory. Concepts are the internal and external surroundings
used to help describe or label a phenomenon. They that affect the client. It includes all
are words or phrases that identify, define, and positive or negative conditions that
affect the patient, the physical
establish structure and boundaries for ideas
environment, such as families, friends,
generated about a particular phenomenon. Concepts and significant others, and the setting for
may be abstract or concrete. where they go for their healthcare.
o Abstract Concepts. Defined as mentally • HEALTH
constructed independently of a specific time o Health is defined as the degree of
or place. wellness or well-being that the client
experiences. It may have different

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INT NUR 101 LECTURE
INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
meanings for each patient, the clinical c. Virginia Henderson (1966)
setting, and the health care provider. • The Nature of Nursing Model – 14
• NURSING Fundamental Needs
o The nurse‘s attributes, characteristics, • Conceptualizes the nurse’s role as assisting
and actions provide care on behalf of or sick or healthy individuals to gain
in conjunction with the client. There are independence in meeting the
numerous definitions of nursing, though • 14 Fundamental Needs:
nursing scholars may have difficulty
• Breathing normally
agreeing on its exact definition. The
• Eating and drinking adequately
ultimate goal of nursing theories is to
improve patient care. • Eliminating body wastes
• Moving and maintaining a desirable
position
• Sleeping and resting
B. PERSON, ENVIRONMENT, HEALTH AND • Selecting suitable clothes
NURSING ACCORDING TO:
• Maintaining body temperature
a. Florence Nightingale
• Keeping the body clean and well
• Considered the first nursing theorist and
groomed
earned the title “Nursing with a Lamp”
• Avoiding dangers and injuring
• Environmental Theory
others
• Five environmental factors:
• Communicating with others
o Pure/fresh air
• Worshipping according to one’s
o Pure water
faith
o Efficient drainage ü Cleanliness
o Light (direct sunlight) • Working in such a way that one
feels a sense of accomplishments
• Deficiencies in this five factors produce lack
of health or illness • Participating in various recreation
• Stressed the importance of keeping the client • Learning, discovering or satisfying
warm, maintaining a noise free environment, the curiosity that leads to normal
attending the client’s diet development and health

d. Faye Glenn Abdellah

b. Ernestine Weidenbach
• Patient-Centered Approaches to Nursing
• The Perspective Theory of Nursing Model
• Nursing as the process of identification of a • Identifies 21 nursing problems
patient’s need for help through observation • Defines nursing as a service to individuals
of presenting behaviors and symptoms, and families
exploration of the meaning of those • Conceptualizes nursing as an art and
symptoms with the patient, determining the science that molds the attitudes, intellectual
causes of discomfort, and determining the competencies and technical skills of the
individual nurse into the desire and ability to
patient’s ability to resolve the discomfort, and
help people, sick or well and cope with their
determining the patient’s ability to resolve the needs
discomfort.
• 4 elements of clinical nursing: e. Jean Watson
o Philosophy, practice, purpose & art • Human Caring Theory
• METAPARADIGM • Practice of caring is central to nursing: it is
o PERSON the unifying focus for practice
§ Any individual who is receiving • 10 curative factors
help from a member of the § Nursing interventions related to
health profession or from a human care
worker in the field of health.
o ENVIRONMENT o Formation of Humanistic- altruistic
§ she incorporates the system of values
environment within the o Instillation of faith and hope
realities—a major o Cultivation of sensitivity to one’s self
and others
component of her theory.
o Development of helping – trusting
§ one element of relationship
realities is the o Promoting and accepting the
framework (definition expression of positive and negative
of framework in 5 feelings
realities) o Systematically using the scientific
• HEALTH problem-solving method for
decision making
§ Concepts of nursing, client,
o Promoting transpersonal teaching-
and need for help and their learning
relationships imply health o Provision of a supportive, protective
related concerns in the and/or corrective mental, physical,
nurse— client relationship. societal and spiritual environment
• NURSING o Assisting with gratification of human
needs
o the nurse is a functional
o Allowance for existential-
human being who acts, thinks, phenomenological - spiritual forces
and feels. All
actions, thoughts, and
feelings underlie what the f. Dorothea Orem
nurse does • Self-care and Self-care deficit Nursing
Theory

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INT NUR 101 LECTURE
INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
o 3 systems: o Coordinate human field w/ rythmicities of
§ Self-care environmental field
§ Self-deficit o Direct & redirect patterns of interaction
between two energy fields to promote
§ Nursing system
maximum health potential
o 4 concepts: o Use of non contact therapeutic touch
§ Self-care: performing § NURSES assess & feel
activities independently by energy to enhance healing
individual throughout life to process of patients who are
promote and maintain ill & injured
personal well being • Views the person as an irreducible whole, the
whole being is greater than the sum of its parts
§ Self-care agency: ability
• According to Rogers, unitary man:
to perform self care
o Is an irreducible, four-dimensional
abilities energy field by pattern
• Self-care agent: o Manifests characteristics different from
independent the sum of the parts
• Dependent care o Interacts continuously and creatively
agent: other than with the environment
o Behaves as a totality
the individual who
o As a sentient being, participates
provides care creatively in change
§ Self-care o Is an irreducible, four-dimensional
requisites/needs: energy field by pattern
measures/actions to
provide self-care i. Dorothy Johnson
• Universal • Behavioral System Model
• Developmental: • Each person as a behavioral system is
adjusting to composed of 7 subsystem:
o Injective
change o Eliminative
• Health o Affiliative
deviation: o Aggressive
seeking health o Dependence
assistance, o Achievement
therapies, & o Sexual and role identity
learning to live
j. Sister Callista Roy (2009)
with illness
§ Therapeutic self-care • Adaptation Model
demand: self-care • Input (stimuli)
activities required to • Throughput (control process)
maintain health & well- • Output (behavior/responses)
being • Defines adaptation as the process and
• Defines self-care as performing activities outcome whereby the thinking and feeling
person uses conscious awareness and
independently by individual throughout life to
choice to create human and environmental
promote and maintain personal well being integration
• Identifies 3 types of nursing system: • Goal of model is to enhance life processes
through adaptation in four adaptive modes:
o Wholly Compensatory- for individuals o Physiologic Mode: body’s basic
who are unable to control and monitor physiologic needs
their environment and process o Self-concept mode
information § Physical self: sensation &
o Partly Compensatory- designed for body image
individuals who are unable to perform § Personal self: self-ideal,
some, but not all self- care activities self-consistency, & moral
o Supportive-Educative- for clients who ethical self
need to learn to perform self-care o Role-function mode: performance
measure and need assistant to do so of duties based on given positions
within the society
o Interdependence mode: one’s
g. Myra Estrine Levine relations with significant others &
• Four Conservation Principles support systems
• Proposed principles which are concerned k. Betty Neuman
with the unity and integrity of the individuals • Community health nurse and clinical
o Conservation of energy psychologist
o Conservation of structural integrity • Health Care System Model
o Conservation of personal integrity o Individuals response to stressors
o Conservation of social integrity depends on the strength of the lines
of defense
h. Martha Rogers o 1st line of defense: protecting
normal line & strengthening defense
o 2nd line of defense: strengthening
• Science of Unitary Human Being internal lines, reducing reaction &
o Focus on person’s wholeness increasing resistance factors
o Promote symphonic interaction between o 3rd line of defense: readaptation &
human & environment – to strengthen stability
COHERENCE & INTEGRITY of person • Asserted that nursing is unique profession in
that is concerned with all the variables

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INT NUR 101 LECTURE
INTEGRATING COURSE I
FUNDAMENTALS OF NURSING
BALLESTA, ERIKA B. BSN 4B. – RN, 2025
affecting the individuals response to stress, do so; each px is unique & individual in his or
which are intrapersonal stressors (within the her response
individual), interpersonal (occurs between • Health: does not define health, but she
individuals ) and extra personal (outside the assumes that freedom from mental or
person) in the nature physical discomfort and feelings of adequacy
• Nursing interventions focus on retaining or and well-being (fulfilled needs) contribute to
maintaining system stability health.
• Environment: she assumes that a nursing
l. Imogene King (1981) situation occurs when there is a nurse-
• Goal Attainment Theory patient contact and that both nurse and
patient perceive, think, feel and act in the
• 15 concepts essential knowledge for
immediate situation.
nurses o any aspect of the environment,
o Self even though it is designed for
o Role therapeutic and helpful purposes,
o Perception can cause the patient to become
o Communication distressed.
o Interaction
o Transaction o. Joyce Travelbee
o Growth and development • Human to Human relationship model
o Stress • The therapeutic use of self in communicating
and establishing relationships
o Time
• Finding meaning, during interactions, is
o Personal space
essential to the nurse and patient
o Organization relationship
o Status • Human-to-Human relationships serve to
o Power define and make proficient the practice of
o Authority nursing
o Decision-making • Recognizing the importance of sympathy, as
• Viewed nursing as an interaction process well as empathy, in order to develop human-
between patient and nurse that lead to goal to-human relationships
attainment • A nurse exhibiting sympathy is an act of
• Patient has 3 interacting system courage because the nurse is risking pain,
o Operational system (individuals) and one should recognize the dangers
o Interpersonal system (nurse- involved in sympathy, such as over-
patient) identification, a distorted sense of pity,
o Social system (health care system) causing harm to the patient, becoming too
• Highlights importance of client’s participation soft hearted, or being will paralyzer to the
in decision patient
• Blends art & science of nursing • Involves working through the phases of initial
encounter, emerging identity, empathy,
sympathy, and rapport
m. Hildegard Peplau
• Psychiatric nurse
• Psychodynamic (interpersonal relations) p. Madeleine Leininger
Model (1952)
• Use of therapeutic relationship between • Nurse anthropologist
nurse and the client • Transcultural Nursing Model (Cultural
• 4 phases: Care Diversity and Universality Theory) –
“Sunrise Model”
o Orientation: client seeks help & o Health and care are influenced by
nurse assists client to understand technology, religious &
o Identification: client may be philosophical factors, kinship, social
dependent/independent; nurse systems, cultural values, political
ensure understanding the and legal factors, economic and
interpersonal meaning of patient’s educational factors
situation
• Emphasizes that human caring, although
o Exploitation: client uses available
universal, varies among cultures in its
services; power switches from
expressions, process and patterns; it is
nurse to client
largely culturally derived
o Resolution: old needs and goals
• Presents 3 intervention modes:
are put aside and new one adopted
o Culture care preservation and
n. Ida Jean Orlando
maintenance
• The Dynamic Nurse-Patient Relationship
o Culture care accommodation,
Model / Nursing Process Theory negotiation or both
• Nurses provide direct assistance to meet an o Culture care restructuring and re
immediate need for help in order to avoid or patterning
to alleviate distress or helplessness • Health
• She advocated that the three elements o Health is seen as being universal
across cultures and distinct within
composing the nursing situation are:
each culture in a way that
represents the beliefs, values and
o Client behavior practices of the particular culture.
o Nurse reaction o Components of health: Health
o Nurse action Systems, Health Care Practices,
• Person: behave verbally & nonverbally; able Changing Health Patterns, Health
to meet their own needs, however they Promotions and Health
become distressed when they are unable to Maintenance.
• Environment

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o Worldwide, social structure and the people and society that affect
environmental context the client. To maintain
o Leininger’s description of culture optimum health requires the
centers on a particular
assistance of care providers, a
group(society) and the patterning of
actions, thoughts and decisions that client willing to change and follow
occurs as a result of “learned, guidelines for a healthful life and
shared and transmitted values, surrounding the client with
beliefs, norms, and lifeways supportive family and friends.
Optimum health is the goal of
nursing interactions which goes
q. Rosemarie Rizzo Parse (2010) beyond professional interactions
that occur only when the client is
• Human Becoming Theory distressed by their unhealthy
o Emphasizes how individuals choose state. Nursing professionals strive
& bear responsibility for patterns of to improve health through
personal health
any interaction with clients.
• Proposed 3 assumptions about human
becoming: • Wellness
o Human becoming is freely choosing o Professional nursing has matured
personal meaning in situations in into its current focus of promoting
the inter subjective process of wellness. Wellness is the state of
relating value priorities optimum health. Essentially, the
o Human becoming is co-creating focus of health exams has become
rhythmic patterns or relating in
preventative care. Not only do
mutual process with the universe
o Human becoming is contrascending health professionals treat illnesses,
multidimensional with the emerging they promote lifestyle changes and
possibilities emphasizes how habits that will lower the chances of
individuals choose and bear experiencing illness during one’s
responsibility for patterns of lifetime. Health workers need to
personal health
learn techniques to
• Focuses on:
promote wellness.
o Meaning: person’s interrelationship
with the world C. DIFFERENT VIEWS OF NON-NURSING THEORIES
o Rhythmicity: movement toward
greater diversity
o Contranscendence: process of a. SYSTEMS THEORY
reaching out beyond the self • Ludwig Von Bertalanffy (General Systems Theory)
• “Open Systems Theory” (OST)
r. Joyce J. Fitzpatrick • Universal Grand Theory
• A nurse educator and advocate for nursing • In GST, systems are composed of both structural
geriatrics and functional components that interact within a
• Life Perspective Rhythm Model boundary that filters the type and rate of
• a construct to assist with the exchange with the environment.
professional practice of nursing.
Theorist Dr. Joyce Fitzpatrick based her
• Open Systems Theory Principles
model of practice on Martha
• A system is a unit that is greater than
Rogers’ theory of Unitary Human the sum of its parts
Beings. While Rogers’ theory covered • A system comprises subsystems that
eight separate areas, Dr. Fitzpatrick are themselves part of suprasystems
has built her nursing theory on four • A system has boundaries
subdivisions involving the delivery • Communication and feedback
of nursing care mechanisms between system parts are
• Person essential for system function
o The first of her four areas are the • A change in one part leads to change in
concept of person. The person not the whole system
only includes the client but all • A system goal or end point can be
reached in different ways
people whom he or she interacts
with in their environment.
She considers a human an open b. CHANGE THEORY
system with a set group of rhythmic • Kurt Lewin (Change Theory)
behaviors. These behaviors are o This theory depends on the presence of
drawn from a variety of fields, driving and resistant forces.
including biology, psychology,
human development, theology, o The driving forces are the change
agents who push employees in the
philosophy and the culture of the
direction of change. The resistant forces
client with their surrounding are employees or nurses who do not
society. Clearly, this involves a want the proposed change.
large area to assess. • 3 major concepts:
• Health o Driving forces are those that push in a
o This is an area that focuses on the direction that causes change to occur.
health of the client and their o Restraining forces are those forces
that counter the driving forces.
surroundings. Health includes all

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o Equilibrium is a state of being where B. CARPERS FOUR PATTERNS OF KNOWING
driving forces equal restraining forces, a. Nursing science
and no change occurs.
• 3 stages in change theory
• is a “body of abstract knowledge” arrived
o Unfreezing is the process which • through scientific research and logical analysis
involves finding a method of making it
• is the systematic knowledge and skills in
possible for people to let go of an old
assisting individual to achieve optimal health
pattern that was somehow
• it is the diagnosis and treatment of human
counterproductive.
o The change stage, which is also called • responses to actual or potential problem
(American Nurses Association, 2015)
“moving to a new level” or “movement,”
o The refreezing stage is establishing the • is a blend of the most current knowledge and
change as the new habit, so that it now • practice standards
becomes the “standard operating • it integrates evidence-based findings to provide
procedure.” the highest level of care

b. Nursing ethics
c. DEVELOPMENTAL THEORY c. Nursing esthetics
d. Personal knowledge
• Erik Erickson (Psychosocial Development)
o PSYCHOSOCIAL DEVELOPMENT 7. COMMUNICATION SKILLS
A. Effective communication
§ According to the theory, successful B. Purposes of therapeutic communication
completion of each stage results in a C. Components of communication
healthy personality and the D. Criteria for effective verbal communication
acquisition of basic virtues. E. Guidelines for active & effective listening
§ Basic virtues are characteristic F. Guidelines for use of touch
strengths which the ego can use to G. Developmental consideration in communication
resolve subsequent crises. H. General guidelines for transcultural therapeutic
§ Failure to successfully complete a communication
stage can result in a reduced ability
to complete further stages and 8. NURSING INFORMATICS
therefore a more unhealthy
personality and sense of self.
9. HEALTH AND ILLNESS

A. RECALL CONCEPTS LEARNED ABOUT MAN AS

AN INDIVIDUAL AND AS A MEMBER OF THE
FAMILY

B. DEFINE HEALTH, WELLNESS AND ILLNESS

• HEALTH
o WHO (1947) defines health as a state of
complete physical, mental and social
wellbeing and not merely the absence of
disease or infirmity.
o Persons (1951): the ability to maintain
normal roles
• WELLNESS
6. GROWTH OF PROFESSIONALISM o State of well-being
A. Profession o The basic aspects of wellness includes
a. Specialized education
self responsibility; an ultimate goal; a
dynamic, growing process
• Specialized education is an important aspect of • ILLNESS
professional status.
o Refers to a highly personal state in
• Bachelors’ – Masters’ – Doctorate Degree
which the person’s physical, emotional
intellectual, social, developmental or
b. Body of knowledge
spiritual functioning is thought to be
diminished or impaired.
• As a profession, nursing is establishing a well- C. EXPLAIN THE DIMENSIONS OF WELLNESS
defined body of knowledge and expertise. • PHYSICAL
o Ability to carry out daily task, achieve
c. Ethics fitness, maintain adequate nutrition and
proper body fat, avoid abusing drugs
• The nursing profession requires integrity of its and alcohol or using tobacco products
members; that is, a member is expected to do and generally practice a positive lifestyle
what is considered right regardless of the habits.
personal cost.
• INTELLECTUAL
o Ability to learn and use information
d. Autonomy
effectively for personal, family, and
• A profession is autonomous if it regulates itself
career development. It involves striving
and sets standards for its members.
for continued growth and learning to
deal with new challenges effectively.

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•SOCIAL essential nutrients) can lead to illness or
o Ability to interact successfully with disease.
people & within the environment of o Host. Person(s)who may or may not be
at risk of acquiring a disease. Family
which each person is a part, develops &
history, age, and lifestyle habits
maintains intimacy with significant influence the host’s reaction.
others and develop respect & tolerance o Environment. All factors external to the
for those with different opinions and host that may or may not predispose the
beliefs. person to the development of disease.
• OCCUPATIONAL Physical environment includes climate,
living conditions, sound (noise) levels,
o Ability to achieve a balance between
and economic level. Social environment
work and leisure time. A person’s includes interactions with others and life
beliefs, about education, employment events, such as the death of a spouse.
and home may influence personal
satisfaction and relationship to others. E. DISCUSS THE HEALTH-ILLNESS CONTINUUM
• ENVIRONMENTAL
o The ability to promote health measures
that im- prove the standard of living and • used to measure a person’s perceived level of
quality of life in the community. This wellness.
includes influences such as food, water, • From a high level of health a person’s condition
and air. can move through good health, normal health,
poor health, and extremely poor health,
• EMOTIONAL
eventually to death.
o The ability to manage stress and to
• Developed by Anspaugh, Hamrick, and Rosato
express emotions appropriately. (2011) ranges from optimal health to premature
Emotional wellness involves the ability death
to recog- nize, accept, and express • Movement to the right of the neutral point
feelings and to accept one’s limitations. indicates increasing levels of health and wellness
D. MODELS OF HEALTH for an individual. This is achieved through health
• CLINICAL MODEL knowledge, disease pre- vention, health
o Health is identified by the absence of promotion, and positive attitude. In contrast,
move- ment to the left of the neutral point
signs and symptoms of disease or indicates progressively decreasing levels of
injury. health.
• ROLE PERFORMANCE MODEL • DUNN’S HIGH LEVEL WELLNESS GRID
o Health is defined in terms of an o The grid demonstrates the inter- action
individual’s ability to fulfill societal roles, of the environment with the illness–
that is, to perform his or her work. wellness continuum
o High-level wellness in a favorable
People usually fulfill sev- eral roles (e.g.,
environment. : An example is a person
mother, daughter, friend), and certain who implements healthy lifestyle
individuals may consider nonwork roles behaviors and has the biopsychosocial,
the most important ones in their lives. spiritual, and economic resources to
o According to this model, people who can support this lifestyle.
fulfill their roles are healthy even if they o Emergent high-level wellness in an
have clinical illness. unfavorable environment. An example
is a woman who has the knowledge to
implement healthy lifestyle practices but
• ADAPTIVE MODEL
does not implement adequate self- care
o Health is a creative process; disease is
practices because of family
a failure in adaptation, or maladaptation.
responsibilities, job demands, or other
The aim of treatment is to restore the
factors.
ability of the person to adapt, that is, to
o Protected poor health in a favorable
cope. According to this model, extreme
environment.: An example is an ill
good health is flexible adaptation to the
person (e.g., one with multiple fractures
environment and interaction with the
or severe hypertension) whose needs
environment to maximum advantage.
are met by the health care system and
• EUDAIMONISTIC MODEL who has access to appropriate
o Health is seen as a condition of medications, diet, and health care
actualization or realization of a person’s instruction.
potential. Actualization is the apex of the o Poor health in an unfavorable
fully developed personality, described by environment. An example is a young
Abraham Maslow child who is starving in a drought-
• AGENT-HOST ENVIRONMENTAL MODEL stricken country.
o also called the ecologic model,
originated in the community health work
of Leavell and Clark (1965)
o The model is used primarily in predicting F. ENUMERATE THE STAGES OF WELLNESS AND
illness rather than in promoting ILLNESS
wellness, although identi- fication of risk
factors that result from the interactions 1. STAGE 1: SYMPTOM EXPERIENCES
of agent, host, and environment are • person comes to believe something is wrong.
helpful in promoting and maintaining • Stage 1 has three aspects:
health. The model has three dynamic • The physical experience of symptoms
interactive elements • The cognitive aspect (the interpretation of the
o Agent. Any environmental factor or symptoms in terms that have some meaning to
stressor (biologic, chemical, mechanical, the person)
physical, or psychosocial) that by its • The emotional response (e.g., fear or anxiety).
presence or absence (e.g., lack of

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• the unwell person usually consults others about 10. LEVELS OF CARE
the symptoms or feelings, validating with A. Health promotion
support people that the symptoms are real. At • “behavior motivated by the desire to increase
this stage the sick person may try home well-being and actualize human health potential,”
remedies. • WHO: process of enabling people to increase
2. STAGE 2: ASSUMPTION OF THE SICK ROLE
control over, and to improve their health. It moves
• The individual now accepts the sick role and
beyond a focus on individual behaviour towards a
seeks confirmation from family and friends.
• During this stage people may be excused from wide range of social & environmental
normal duties and role expectations interventions
3. STAGE 3: MEDICAL CARE CONTACT • E.g. enhance nutrition, integrate physical activity,
• Sick people seek the advice of a health provide adequate housing, promote oral health,
professional either on their own initiative or at foster positive personality development
the urging of significant others. B. Disease prevention
• The client may accept or deny the diagnosis. If
the diagnosis is accepted, the client usually
• “behavior motivated by a desire to actively avoid
follows the prescribed treatment plan. If the
illness, detect it early, or maintain functioning
diagnosis is not accepted, the client may seek
within the constraints of illness”
the advice of other health care professionals or
quasi-practitioners who will provide a diagnosis • Primary, secondary, & tertiary prevention
that fits the client’s perceptions.
4. STAGE 4: DEPENDENT CLIENT ROLE C. Health maintenance
• After accepting the illness and seeking • Activities that preserve an individual’s present
treatment, the client be- comes dependent on state of health & that prevent disease or injury
the professional for help. occurrence.
5. STAGE 5: RECOVERY OR REHABILITATION • e.g. screening or surveillance, providing
• During this stage the client is expected to immunizations to prevent illness, and health
relinquish the dependent role and resume education
former roles and responsibilities. For people
D. Curative
with acute illness, the time as an ill person is
E. Rehabilitative
generally short and recovery is usually rapid.

G. DESCRIBE THE THREE LEVELS OF PREVENTION

1. PRIMARY PREVENTION: HEALTH
PROMOTION AND ILLNESS PREVENTION

• (a) health promotion and

• (b) protection against specific health
problems (e.g., immunization against
hepatitis B).
• The purpose of primary prevention is
to decrease the risk or exposure of the
individual or community to disease
• Generalized health promotion and
specific protection against disease. It
precedes disease or dysfunction and is
applied to generally healthy individuals
or groups.

2. SECONDARY PREVENTION: DIAGNOSIS

AND TREATMENT

• (a)early identification of health problems

and
• (b) prompt intervention to alleviate health
problems. Its goal is to identify individuals
in an early stage of a disease process and
to limit future disability.
• Emphasizes early detection of disease,
prompt intervention, and health
maintenance for individuals experiencing
health problems. Includes prevention of
complications and disabilities.

3. TERTIARY PREVENTION: REHABILITATION,

HEALTH RESTORATION AND PALLIATIVE
CARE

• focuses on restoration and rehabilitation

with the goal of returning the individual to
an optimal level of functioning.
• Begins after an illness, when a defect or
disability is fixed, stabilized, or determined
to be irreversible. Its focus is to help
rehabilitate individuals and restore them to
an optimum level of functioning within the
constraints of the disability.

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• Closed questions, used in the
FUNDAMENTALS OF NURSING II directive interview, are restrictive
and generally require only “yes” or
1. NURSING PROCESS “no” or short factual answers that
provide specific information.
PURPOSES • Open-ended questions,
associated with the nondirective
(a) To identify client’s health status interview, invite clients to discover
a. Actual health problem and explore, elaborate, clarify, or il-
b. Potential health problems or needs lustrate their thoughts or feelings.
(b) To establish plans to meet identified needs • neutral question is a question the
(c) To deliver specific nursing care and improve the client can answer without direction
quality of care or pressure from the nurse, is open
ended, and is used in nondirective
interviews.
CHARACTERISTIC OF NURSING CARE • leading question, by contrast, is
usually closed, used in a directive
• Cyclical (regularly repeated events) and interview, and thus directs the
Dynamic (continuously changing) client’s answer.
• Client-centered – organizes the plan or care b. Health history
according to client’s problems rather than nursing 2. Personal profile
goal a. Chief complaint of present illness
Focused on Problem Solving- nursing process • The answer given to the question “What
is directed towards a client ‘s responses to is troubling you?” or “De- scribe the
disease and illness reason you came to the hospital or clinic
• Decision making- involved in every phase of today.” The chief complaint should be
nursing process recorded in the client’s own words.
• Interpersonal and Collaborative
• When the symptoms started
• Communicates with the client and family
• Whether the onset of symptoms was
• Collaborates with other members of the
sudden or gradual
health care team
• How often the problem occurs
• Universally applicable- used in all types of
• Exact location of the distress
health care setting with the clients of all age
group • Character of the complaint (e.g.,
intensity of pain or quality of sputum,
• Nurses must use a variety of critical thinking skills
emesis, or discharge)
to carry out the nursing process
• Activity in which the client was involved
when the problem occurred
COMPONENTS • Phenomena or symptoms associated
with the chief complaint
• Assessment • Factors that aggravate or alleviate the
• Diagnosis problem
• Planning
• Implementation b. Past health history
• Evaluation
• Illnesses, such as chickenpox, mumps,
A. Assessment measles, rubella (German measles),
a. Health history guidelines rubeola (red measles), streptococcal
1. Interview infections, scarlet fever, rheumatic fever,
• planned communication or a conversation hepatitis, polio, and other significant
with a purpose, for example, to get or give illnesses
information, identify problems of mutual • Immunizations and the date of the last
concern, evaluate change, teach, provide tetanus shot
support, or provide counseling or therapy. • Allergies to drugs, animals, insects, or
• focused interview the nurse asks the client other environmental agents, the type of
specific questions to collect information reaction that occurs, and how the
related to the client’s problem. This allows reaction is treated
the nurse to collect information that may • Accidents and injuries: how, when, and
have previously been missed and yields where the incident occurred, type of
more in-depth information injury, treatment received, and any
• two approaches complications
• directive interview is highly • Hospitalization for serious illnesses:
structured and elicits specific reasons for the hospitalization, dates,
information. The nurse establishes surgery performed, course of recovery,
the purpose of the interview and and any complications
controls the interview, at least at the
outset. The client responds to c. Current medications
questions but may have limited • Medications: all currently used
opportunity to ask questions or prescription, over-the-counter
discuss concerns. Nurses medications, such as aspirin, nasal
frequently use directive interviews spray, vitamins, or laxatives, and herbal
to gather and to give information supplements
when time is limited
• nondirective interview, or rapport- d. Personal habits & patterns of living
building interview, the nurse allows
the client to control the purpose, • Personal habits: the amount, frequency,
subject matter, and pacing. and duration of sub- stance use
• TYPES OF INTERVIEW QUESTIONS: (tobacco, alcohol, coffee, cola, tea, and
illegal or recreational drugs)

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• Diet: description of a typical diet on a b. Infants & children – MMDST (Metro Manila
normal day or any special diet, number Development Screening Test)
of meals and snacks per day, who cooks • a screening test to note for normalcy of the child’s
and shops for food, ethnic food patterns, development and to determine any delays as well
and allergies
in children 6 ½ years old and below.
• Sleep patterns: usual daily sleep/wake
times, difficulties sleeping, and remedies • evaluates 4 sectors of development:
used for difficulties § Personal-Social – tasks which indicate the
• Activities of daily living (ADLs): any child’s ability to get along with people and to
difficulties experienced in the basic take care of himself
activities of eating, grooming, dressing, § Fine-Motor Adaptive – tasks which indicate the
elimination, and locomotion child’s ability to see and use his hands to pick
• Instrumental ADLs: any difficulties up objects and to draw
experienced in food prepa- ration, § Language – tasks which indicate the child’s
shopping, transportation, housekeeping, ability to hear, follow directions and to speak
laundry, and ability to use the telephone, § Gross-Motor – tasks which indicate the child’s
handle finances, and manage ability to sit, walk and jump
medications • EXPLAINING THE PROCEDURE. Once the materials
• Recreation/hobbies: exercise activity are ready, the nurse explains the procedure to the
and tolerance, hobbies and other parent or caregiver of the child. It has to be
interests, and vacations emphasized that this is not a diagnostic test but rather
a screening test only. When conducting the test, the
e. Psychosocial history parents or caregivers of the child under study should
be informed that it is not an IQ test as it may be
• Family relationships/friendships: the misinterpreted by them. The nurse should also
client’s support system in times of stress establish rapport with the parent and the child to
(who helps in time of need?), what effect
ensure cooperation.
the client’s illness has on the family, and
whether any family problems are • AGE & THE AGE LINE. To proceed in the
affecting the client administration of the test, the nurse is to compute for
• Ethnic affiliation: health customs and the exact age of the child, meaning the age of the
beliefs; cultural practices that may affect child during the test date itself. The age is the most
health care and recovery crucial component of the test because it determines
• Educational history: data about the the test items that will be applicable/ administered to
client’s highest level of education
the child. The exact age is computing by subtracting
attained and any past difficulties with
learning the child’s birth date with the test date. After
• Occupational history: current computing, draw the age line in the test form.
employment status, the number of days • TEST ITEMS. There are 105 test items in MMDST but
missed from work because of illness, not all are administered. The examiner prioritizes
any history of accidents on the job, any items that the age line passes through. It is however
occupational hazards with a potential for
imperative to explain to the parent or caregiver that
future disease or accident, the client’s
need to change jobs because of past the child is not expected to perform all the tasks
illness, the employment status of correctly. If the sequence were to be followed, the
spouses or partners and the way child examiner should start with personal-social then
care is handled, and the client’s overall progressing to the other sectors. Items that are
satisfaction with the work footnoted with “R” can be passed by report.
• Economic status: information about how • SCORING. The test items are scored as either
the client is paying for medical care
(including what kind of medical and Passed (P), Failed (F), Refused (R), or Nor
hospitalization coverage the client has) Opportunity (NO). Failure of an item that is
and whether the client’s illness presents completely to the left of the child’s age is considered a
financial concerns developmental delay. Whereas, failure of an item that
• Home and neighborhood conditions: is completely to the right of the child’s age line is
home safety measures and adjustments acceptable and not a delay.
in physical facilities that may be required
to help the client manage a physical
• CONSIDERATIONS:
disability, activity intolerance, and § Manner in which each test is administered must
activities of daily living; the availability of be exactly the same as stated in the manual,
neighborhood and community services words or direction may not be changed
to meet the client’s needs. § If the child is premature, subtract the number of
weeks of prematurity. But if the child is more
than 2 years of age during the test, subtracting
3. Functional assessment
may not be necessary
a. Adults
b. Physical activities of daily living
§ If the child is shy or uncooperative, the caregiver
may be asked to administer the test provided
(PADC)
that the examiner instructs the caregiver to
c. Instrumental activities of daily living
administer it exactly as directed in the manual
(IADL)
§ If the child is very shy or uncooperative, the test
4. Functional Assessment Tests may be deferred
a. Newborns – Apgar scoring system
c. Adults

1. Katz Index of independence in ADL

• the most appropriate instrument to assess

functional status as a measurement of the

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client’s ability to perform activities of daily living
independently.

5. Review of systems

c. Vital signs

2. Barthel index • body temperature, pulse, respirations, and blood

pressure.

• The index should be used as a record of BODY TEMPERATURE

what a patient does, not as a record of what
a patient could do.
• The main aim is to establish degree of • balance between heat produced by the body and heat
loss from the body
independence from any help, physical or
verbal, however minor and for whatever • Types of body temperature
reason. • Core temperature: Temperature of the deep
tissues of the body such as abdominal and
• The need for supervision renders the patient pelvic cavity.
not independent. • Surface temperature: Temperature of skin,
• A patient's performance should be SQ tissue and fat. Rises and falls in
established using the best available response to the environment.
evidence. Asking the patient, • Process involved in heat loss
friends/relatives and nurses are the usual • Radiation - transfer of heat from surface to
sources, but direct observation and common surface of one object to surface of another
sense are also important. However direct w/o contact
testing is not needed. • Conduction - transfer of heat from one
• Usually the patient's performance over the surface to another through direct contact
preceding 24-48 hours is important, but • Convection - dispersion of heat by air
occasionally longer periods will be relevant. currents
• Middle categories imply that the patient • Evaporation - vaporization of moisture from
supplies over 50 per cent of the effort. the respiratory tract, mucosa of the mouth
and skin
• Use of aids to be independent is allowed.
• Factors affecting body temperature
• Age
• Diurnal variation (circadian rhythms)
• Highest temp: 4pm to 6pm
• Lowest temp: 4am — 6am
• Exercise
• Hormones (progesterone raises body temp)
• Stress
• Environment
• Alterations in body temperature
• Pyrexia/Hyperthermia/Fever: Body
temperature is above the usual range
• Hyperpyrexia: Very high fever, 41°C
(105.8°F) and above
• Hypothermia: Core body temperature is
below the lower limit of normal; May be
caused by excessive heat loss, inadequate
heat production or impaired hypothalamic
thermoregulation
• Types of fever
• Intermittent fever - body temperature
alternates at regular intervals between

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periods of fever and normal or subnormal • Supine, head stabilized; pull pinna straight back and
temperature slightly downward for children <3 y/o
• Remittent fever - wide range of temp • Put child on adult's lap; pull pinna straight back and
fluctuations more than 2°C for over 24 hrs, upward for children >3 y/o
all of which are above normal • Point the probe slightly anteriorly, toward the
• Relapsing fever - short febrile periods of a eardrum
few days are interspersed with periods of 1-2 • Insert the probe slowly using a circular motion until
days of normal temperature snug
• Constant fever - body temperature
fluctuates minimally but always remains
above normal. • Conversion of Fahrenheit to Centigrade 5/9(°F-
32)=°C
• Fever spike (Staircase) —temperature rises
to fever level rapidly following a normal
temperature then returns to normal within a • Conversion of Centigrade to Fahrenheit
few hours (°Cx9/5)+32=°F

ASSESSING BODY TEMPERATURE

TEPID SPONGE BATH (TSB)
1. ORAL
• When will you start TSB? If there is 1°C to 2°C
• Considered to be the most convenient and most increase in body temperature
accessible • Temperature of water: 32°C
• Wait for 30 mins. before taking oral temperature if the How to apply: Done by patting
client has taken cold or hot drinks/food or smoked • Rationale: To avoid friction, which increases
• Contraindicated to patients with; temperature Do NOT use ALCOHOL when applying
o Oral lesions/ surgery TSB
o Dyspnea • Rationale: Alcohol dries the skin and leads to irritation
o Cough
o Nausea and vomiting PULSE
o Presence of oronasal pack, NGT, ET
o Seizure prone
o Very young children • Wave of blood created by contraction of the left
o Unconscious ventricle of the heart
o Restless, disoriented, confused • Cardiac output is the volume of blood pumped into the
arteries by the heart. Normal CO is 5 L of blood per
minute
• Clean the thermometer before use (from bulb to
stem), and after use (from stem to bulb) • CO = Stroke Volume X Heart Rate
• Place the bulb of the thermometer on either side of • Factors Affecting the Pulse
the frenulum
• Take oral temperature for 2-3 mins. o Age
• Normal range: 36°C to 37.5°C o Gender (male < female)
o Exercise
o Fever
2. RECTAL o Medications
o Hypovolemia
• Considered to be very accurate o Stress
• Contraindicated to patients with: o Position changes
o Anal or rectal conditions/surgery o Pathology
o Diarrhea
o Quadriplegia and Myocardial Infarction • Pulse Sites
• Wear clean gloves and assist the client to assume
lateral/sim's position o Temporal- used when radial pulse is not
• Lubricate thermometer before insertion accessible
• Instruction the client to take a slow deep breath during o Carotid- used during cardiac arrest and
insertion o Radial- readily accessible
• Never force the thermometer if resistance is felt o Apical- routinely used for infants and
• Insert 15 cm (6 in.) in adults and 11 cm for children children up to 3 y/o
o Brachial- used to measure BP and used
• Hold the thermometer in place for 2 mins. during cardiac arrest in infants)
• Normal range: 36°C to 37.8°C o Femoral- used in cardiac arrest/shock and
determine leg circulation)
3. AXILLARY o Popliteal- used to determine circulation on
the lower leg
o Posterior tibia and Dorsal Pedal- used to
• Safest and non-invasive determine circulation to the foot
• Pat dry the axilla. Rubbing causes friction that may
increase surface temperature
• Assessment of the Pulse
• The bulb is placed in the center of the axilla
• Pulse Rate
• Place the arm tightly across the chest to keep the
thermometer in place and leave it for 9 mins.
o Normal pulse rate for adult is 60-100
beats/min
4. TYMPANIC MEMBRANE o Tachycardia- excessively fast heart rate
(over 100 beats/min)
• Frequent site for estimating core body temperature
• Pull pinna back and upward (adults) o Bradycardia- heart rate in adult that is less
than 60 beats/min

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• Rhythm o Bradypnea- abnormally slow breathing
o The pattern of the beats and the intervals (<12cpm)
between beats. o Apnea- cessation of breathing
o Irregular rhythm is referred to as dysrhythmia o Hyperventilation- rapid, deep breathing
or arrhythmia o Hypoventilation- shallow respirations
• Pulse Volume (Amplitude) — force of blood with o Cheyne-Stokes- very deep to very shallow
each beat breathing followed by temporary apnea
• A normal pulse can be felt with moderate pressure of o Kussmaul's- rapid, deep and labored
the fingers breathing
• Full bounding pulse is a forceful volume that is o Dyspnea- difficult and labored breathing
obliterated with difficulty o Orthopnea- ability to breathe only in upright
• A pulse that is readily obliterated with pressure from sitting or standing position
fingers is referred to as weak or thready o Stridor- shrill, harsh sound heard during
• Arterial Wall Elasticity inspiration
A healthy, normal artery feels straight, smooth, soft o Stertor- snoring or sonorous respiration
and pliable o Wheeze- high-pitched musical squeak or
• Pulse Deficit whistling sound occurring on expiration
Discrepancy between the apical and radial pulse o Bubbling- gurgling sounds heard as air
passes through moist secretions in the
• Scale in Pulse Assessment
respiratory tract
o 0 - Absence or cannot be felt
o Biot's (cluster) respirations - Shallow
o 1+ - Weak or thread
breaths interrupted by apnea
o 2+ - Normal
o 3+ - Bounding
BLOOD PRESSURE
RESPIRATIONS
• Pressure exerted by blood as it flows through the
arteries
• Involves three processes:
o Ventilation: movement of air in and out of • Systolic pressure: BP as a result cg ventricular
the lungs contraction
§ Inhalation (inspiration) • Diastolic pressure: BP when ventricles are at rest
§ Exhalation (expiration) • Pulse pressure: difference between systolic and
o Diffusion- exchange of gases from higher diastolic pressure
pressure to an area of lower pressure. It • Hypertension- blood pressure that is persistently
occurs at the alveolocapillary membrane above normal
o Perfusion-availability and movement of the • Hypotension- blood pressure that is belch. Normal
blood for transport of gases. Nutrients and • Orthostatic Hypotension- blood pressure that falls
metabolic waste products when the client sits or stands
o Two types of Breathing • Determinants of BP
§ Costal (thoracic)- involves the o Pumping Action of the Heart- when the
external intercostal muscles and pumping action of the heart is weak, the BP
other accessory muscles decreases
§ Diaphragmatic (abdominal)- o Peripheral Vascular Resistance- peripheral
involves the contraction and resistance can increase BP
relaxation of the diaphragm o Blood Vessel Diameter – decreased blood
o Respiratory center vessel diameter (vasoconstriction) can
§ Medulla Oblongata- primary increase BP
respiratory center. CO2 is the o Blood Volume- when blood vol. decreases,
primary chemical stimuli for BP decreases
breathing o Blood Viscosity- BP increases when blood
§ Pons contains pneumotaxic center is viscous
that is responsible for rhythmic • Korotkoff’s Sound
quality of breathing, and apneustic
center that is responsible for deep o Phase 1: first faint, clear tapping or thumping
prolonged inspiration sounds are heard
§ Carotid and Aortic Bodies o Phase 2: heard sounds have a muffled,
contains peripheral chemoreceptors whooshing or swishing sound quality
that are sensitive to 02 and CO2 o Phase 3: sounds become crisper and more
level in the blood intense, softer thumping sound
o Assessing Respirations o Phase 4: sound become muffled and have a
§ Normal rate is 12-20 breaths/min soft, blowing quality
§ Depth is observed through the Phase 5: period of silence
movement of the chest and • CLASSIFICATION OF BLOOD PRESSURE
describe. as normal, deep or
shallow
§ Rhythm refers to the regularity of
the expirations and inspirations
§ Quality or character refers to
respiratory effort and sound of
breath
o Factors Affecting Respiratory Rate
§ Exercise
§ Stress
§ Environment
§ Increased altitude
§ Medications
• TERMINOLOGIES
• ASSESSING BLOOD PRESSURE
o Tachypnea- quick, shallow breaths
(>20cpm)

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• Ensure the equipment’s needed. Use appropriate a. Overview
size of BP cuff b. Integument
• Ensure that the client has rested. Allow 30 mins c. Head
to pass if the client had engaged to exercise, had d. Neck
smoked or ingested caffeine before taking BP e. Back
• Position the client in sitting or supine position f. Anterior Truck
• Position the arm at the level of the heart, left arm g. Abdomen
is preferably used h. Musculoskeletal system
• Wrap the cuff evenly around the upper arm, 1 i. Neurologic system
inch above the antecubital space j. Genitourinary system
• Determine palpatory BP first before auscultatory
BP B. Nursing Diagnosis (as a concept and process)

• Position the stethoscope appropriately

nd
• Inflate the cuff until sphygmomanometer reads 30 • 2 PHASE of nursing process
mmHG above the point where the brachial pulse
• The process, which results to a diagnostic
disappeared v Release the valve of the cuff at the
statement or nursing diagnosis. It is the clinical
rate of 2-3mmHG per second act of identifying problems.
• As the pressure falls, identify the manometer
• Purpose: to identify the client’s health care needs
reading at the Korotkoff’s phases
and to prepare diagnostic statement.
• Deflate the cuff rapidly and completely • Activities during diagnosing
• Wait 1-2 mins before making further o Organized cluster/group of data
determinations o Compare data with standards (norm)
• Errors in BP Assessment o Analyze data after comparing with standards
o False Low BP o Identifying gaps & inconsistencies in data
§ Bladder cuff to wide o Determine the client's health problems, risks,
§ Arm above level of the heart and strengths
o False High BP o Final output: Nursing Diagnosis statement
§ Bladder cuff too narrow • Nursing diagnosis is a statement of client's
§ Loose cuff potential or actual alteration of health status. It
§ Arm below the level of the uses the critical- thinking skills of analysis and
heart synthesis.
§ Arm unsupported • Basic 2-part statements
§ Insufficient rest o Problem (statement of the client's response)
o Etiology (factors contributing to or probable
d. Physical examination causes of the responses)
o The two parts are joined by the words
• Conducted from head to toes (cephalo-caudal "related to" (implies relationship) e.g.:
technique) Constipation related to prolonged laxative
• Determine the state of awareness of the client at the use
beginning of the physical examination e.g.: Ineffective breast feeding related to
breast engorgement
• The most important consideration during physical
examination is to prepare the client physical and • Basic 3-part statements (PES format)
psychologically o Problem
o Etiology
• Protect the client’s privacy during the entire
o Signs and symptoms (defining
procedure. Invasive procedures cause feelings of
o characteristics manifested by the client)
embarrassment
o e.g.: Situational low self-esteem related to
• Prepare the needed articles and equipment before the
rejection by husband as manifested by
start of the procedure to conserve time, effort, and
hypersensitivity to criticism; states "I don't
prevent
know if I can manage by myself" and rejects
• fatigue in the client positive feedback.
• One-part statements
o Consists of NANDA label only
5. Techniques in physical assessment e.g.: Rape-Trauma syndrome; Anticipatory
• Inspection: assessing the patient using the sense of grieving
sight • Collaborative problems
• Auscultation: listening to the body sounds with the o Suggested that all collaborative problems
use of stethoscope begin with diagnosing label “Potential
• Percussion: tapping the body parts to produce sound Complications”
o e.g.: Potential complications of head injury:
Increased intracranial pressure
• Purpose of NANDA
o To define, refine, and promote taxonomy
• Palpation: examining the body using the sense of (classification or system or set of categories
touch by using the fat pads of the fingers arranged on basis of a single principle or set
o Light (superficial) palpation should always of principles) of nursing diagnostic
precede by deep palpation terminology of general use to professional
o For light palpation, the nurse extends the nurses
dominant hand’s fingers parallel to the skin o Members
surface and presses gently while moving the § Staff nurses
hand in a circle § Clinical specialists
§ Faculty, directors of nursing
§ Deans, theorists, and researchers
• Types of Nursing Diagnosis
o Actual diagnosis
§ Client problem that is present at the
time of the nursing assessment
6. Sequence of physical examination

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(based on the presence of • Establishing client goals/desired outcomes
associated signs and symptoms) o Goals - broad statements about the client’s
§ eg: Ineffective breathing pattern; status
Anxiety o Desired outcomes - more specific,
o Risk nursing diagnosis observable criteria used to evaluate whether
§ Clinical judgment that a problem goals have been met
does not exist, but the presence of
risk factors indicates that a problem
• Components of Goal/Desired
is likely to develop unless nurses
Outcome Statements
intervene
o Subject
§ eg: Risk for Infection
o Verb
o Wellness diagnosis
o Condition or modifier
§ Describes human responses to
o Criterion of desired performance
levels of wellness in an individual,
• Guidelines for Writing Goals/Desired
family or community that have a
Outcomes
readiness for enhancement"
o Write in terms of client responses
§ eg: Readiness for enhanced
o Must be realistic
spiritual well -being; Readiness for
o Ensure compatibility with therapies
enhanced family coping
of other professionals
o Possible nursing diagnosis
o Derive from only one nursing
§ Evidence about a health problem is
diagnosis
incomplete or unclear ü eg:
o Use observable, measurable terms
Possible social isolation related to
o Make sure client considers goals
unknown etiology
important
• Syndrome diagnosis
§ Associated with a cluster of other
diagnoses • Selecting nursing interventions
eg: Risk for disuse syndrome;
Impaired physical mobility; Risk for o Actions nurse performs to achieve goals
infection; Impaired gas exchange o Focus on eliminating or reducing etiology of
• Planning (long-term, short-term, priority nursing diagnosis
setting, formulation of objectives) o Treat signs and symptoms and defining
o Deliberate, systematic, problem- solving characteristics
phase of nursing process o Interventions for risk nursing diagnoses
o Decide on nursing interventions should focus on reducing client’s risk factors
o Nurse responsible, but input from client o Types of Nursing Interventions
essential o Independent interventions
o The third phase of the nursing process, in § Activities nurses are
which the nurse and client develop client licensed to initiate (i.e.,
goals/desired outcomes and nursing physical care, ongoing
interventions to prevent, reduce, or alleviate assessment)
the client’s health problems. o Dependent interventions
o Begins with first client contact § Activities carried out under
o Continues until nurse-client relationship ends primary care provider’s
(discharge) orders or supervision, or
o Is multidisciplinary according to specified
• Types of Planning routines
o Initial Planning — done by the nurse who o Collaborative interventions
performs the admission assessment o Actions nurse carries out in collaboration with
o Ongoing Planning other health team members
§ Done by all nurses who work with o Reflect overlapping responsibilities of health
the client care team
§ Occurs at the beginning of a shift as o Criteria for Choosing Appropriate
the nurse plans the care to be given Interventions
that day o Safe and appropriate for the client’s
o Discharge Planning age, health, and condition
§ Process of anticipating and o Achievable with the resources
planning for needs after discharge, available
is a crucial part of comprehensive Congruent with the client’s values,
health care. beliefs, and culture
§ Begins at first client contact and o Congruent with other therapies
involves comprehensive & ongoing o Based on nursing knowledge and
assessment to obtain information experience or knowledge from
about client's ongoing needs. relevant sciences
• THE PLANNING PROCESS o Within established standards of
• Consists of following activities: care
• Setting priorities • Writing individualized nursing interventions
o Establishing a preferential sequence for on care plans
addressing nursing diagnoses and o Date when they are written Verb
interventions o Action verb
o High priority (life-threatening) o starts the interventions and
o Medium priority (health-threatening) must be precise
o Low priority (developmental needs) o Conditions
o Factors to Consider When Setting o Modifiers
Priorities o Time element
o Client’s health values and beliefs Client’s o How long or how often the
priorities nursing action is to occur
o Resources available to nurse and client
Urgency of the health problem Medical C. Intervention (collaborative, independent nursing
treatment plan interventions)

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BALLESTA, ERIKA B. BSN 4B. – RN, 2025
• Types of Nursing Interventions o Name of the person giving the
a. Independent interventions information
o Activities nurses are licensed to o Subject of information received
initiate (i.e., physical care, o Name and signature of the
ongoing assessment) receiver
b. Dependent interventions o Person receiving the
o Activities carried out under information should repeat it
primary care provider’s orders back to the sender to ensure
or supervision, or according to accuracy
specified routines • Telephone Orders
c. Collaborative interventions o Only RN’s may receive
o Actions nurse carries out in telephone orders.
collaboration with other health o Another RN should listen in
team members another telephone line to
o Reflect overlapping countercheck the details.
responsibilities of health care o Write the date and time the
team telephone order was received.
o Write the complete order and
D. Evaluation (formative, summative) read it back.
• The final phase of the nursing process, in which o Question primary care provider
the nurse determines the client’s progress toward about any order that is unusual
goal achievement and the effectiveness of the or contraindicated to client’s
nursing care plan. condition
• TYPES OF EVALUATION o The order should be
• On-going/Formative Evaluation countersigned by the physician
o Done during or immediately who made the order within the
after the intervention prescribed period of time (within
o Allows the nurse to decide and 24 hours)
make on-the-spot modification/s • Transfer Report
in an intervention o Done when transferring a client
• Intermittent Evaluation to other unit
o Done at a specified time & it
shows the extent of progress of
the patient
o Enables the nurse to correct
deficiencies and modify the
nursing care plan
• Terminal/Summative Evaluation
o Done at or immediately before
discharge
o Importance: It determines
whether the goals are met,
partially met or unmet
o When goals have been partially
met or when goals have not
been met, two conclusions may
be drawn:
o The care plan may need to be
revised, since the problem is
only partially resolved
o Or the care plan does not need
revision, because the client
merely needs more time to
achieve the previously
established goal(s)

E. Documentation of plan of care and reporting

• DOCUMENTATION: the nurse records client

data. Accurate documentation is essential and
should include all data collected about the client’s
health status. Data are recorded in a factual
manner and not interpreted by the nurse.
• REPORTING
• Takes place when two or more people share
information about client care, either face-face o
via telephone
• Types of Reporting
• Change-of-shifts report or endorsement
o For continuity of care of clients
by providing quick summary of
health care needs and details of
care to be given
o It is not merely reciting the
content or the KARDEX
• Telephone Reports
o Provide clear, accurate and
concise information:
o Date and time

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