FUNDA

• Nursing Process


  The process of intentional higher level thinking to define a client's problem, examine the evidence-based practice in caring for the client and make choices in the delivery of care
• Clinical reasoning


  The application of critical thinking to the clinical situation
• Use of Critical Thinking Skills

  • Nurses use knowledge from other subjects and fields
  • Nurses deal with change in stressful environments
  • Nurse make important decisions
  • Critical thinking guides nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect
• Approaches to problem solving


  • Intuition
  • Clinical judgment
  • Use of scientific basis
  • Use of nursing process
• Intuition


  A problem-solving approach that relies on a nurse's inner sense. It is a legitimate aspect of a nursing judgment in the implementation of care
• Clinical judgment in nursing

  A decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client's care
• Use of scientific basis

  Involves asking questions from resource persons, reading about information and evidence, and figuring out conclusions. All of these actions are the basis for the scientific method
• Nursing Process


  A systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. It includes the client's perceived needs, health problems, related experiences, health practices, values and lifestyles. It is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
• Characteristics of the Nursing Process

  • Cyclic and dynamic
  • Client-centered
  • Universally applicable
  • Focus on problem-solving
  • Presence of interpersonal collaboration
  • Use of critical-thinking
• Nursing Process Activities


  • Nursing Health History taking
  • Physical Assessment
  • Physicians history and physical assessment
  • Laboratory Results & other diagnostic tests results
• Components of a Nursing Health History

  • Biographic data
  • Reason for visit/Chief complaint
  • History of present Illness
  • Past Health History
  • Family History
  • Review of systems
  • Lifestyle
  • Social data
  • Psychological data
  • Pattern of health care
• Cues


  Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure
• Inferences


  The nurse interpretation or conclusion based on the cues
• Nurses record all data collected about the client's health status in a factual manner, not as interpreted by the nurse
• Record subjective data in client's word; restating in other words what client says might change its original meaning
• 1. DAR chart


  A common tool nurses may use to track patients' health information. Nurses can monitor patient data and evaluate their treatment progress in an organized way
• Nursing Interventions


  A comprehensive standardized classification of interventions that nurses perform. When selecting an intervention 6 factors should be considered: the desired patient outcome, characteristics of the Nursing Diagnosis, research base for the intervention, feasibility for performing the intervention, acceptability to the patient, and compatibility of the nurse
• Hygiene


  The science of health and its maintenance
• Types of hygienic care

  • Early morning care
  • Morning care
  • Hours of sleep or PM care
  • As needed or PRN care
• Early morning care


  • Serving a urinal or bedpan to the confined to bed clients, washing the face and hands and giving oral care
• Morning care


  • Provision of breakfast, providing elimination needs, bath/shower, perineal care, back massages, and oral, nail and hair care and making the clients bed
• Hours of sleep or PM care

  • Care provision before patients retire at night. It involves provision of elimination needs, washing face and hands, giving oral care and giving back rub/ massage
• As needed or PRN care


  • Required as needed by the patient
• Factors influencing individual hygienic purposes

  • Culture
  • Religion
  • Environment
  • Developmental level
  • Health and energy
  • Personal preferences
• Hospital Bed Components


  • Overbed Table and Bedside Table
• Procedures in Bedmaking


  1. Stripping the Bed

  2. Making a Closed Bed and Open Bed

  3. Making an Occupied Bed
• Personal hygiene


  Includes oral hygiene, bathing, eliminating, shaving, brushing, and styling hair
• Types of Bed Bath

  • Hot Sitz bath
  • Tepid Sponge Bath: to reduce the body temperature to normal
• Bed Bath Procedure


  1. Promote independence and participation

  2. Check the chart for client's diagnosis, activity orders, positioning or movement or any orders specific to hygiene

  3. Assess client's condition

  4. Determine whether or not you will need any assistance and also what client's supplies and equipment are present

  5. Gather all the needed supplies and equipment then bring preparations to client's room

  6. Identify and explain the procedure to the client

  7. Adjust room temperature and ventilation

  8. Wash hands and wear gloves

  9. Raise the bed to working height

  10. Bring client toward side closest to you

  11. Lower the side rails close to you and assist client in assuming comfortable position

  12. Loosen top cover at the foot of bed

  13. Adjust bed to fowler's position or semi-fowler's

  14. Remove the client's gown or pajamas while maintaining privacy

  15. Remove pillow

  16. Rectangular method or triangular method

  17. Wash, rinse and dry well forehead, cheeks, nose, neck and ears
• Angular method


  Immerse mitt in water and wring thoroughly. Mitt retains water and heat better than loosely held washcloth, keeps cold edges from brushing against client and prevents splashing.
• Procedure and Rationale


  1. 17. With wet wash cloth (no soap), wipe the farther eye from inner to outer canthus using different section of mitt for each eye. Dry eye thoroughly but gently. Repeat with nearest client's eye. Soap irritates eyes. Use separate sections of mitt reduces infection transmission. Bathing the eye from inner to outer canthus prevents secretions from entering nosocomial duct. Pressure can cause internal injury.

  2. 18. Wash, rinse and dry well forehead, cheeks, nose, neck and ears. Avoid soap on the face if the client prefers. Soap tends to dry face more quickly and maybe avoided as a personal preference.

  3. 19. (In the attached video, the nurse cleanses first the arm nearest to her and allows the hand to soak in the basin filled with water) Expose the farthest arm to be cleansed then place the towel lengthwise under it. Using firm long strokes, wet, soap, rinse and dry the arm. Strokes should be from distal to proximal. Towel prevents soiling of bed. Washing the far side first eliminates contamination a clean area once it is washed. Gentle friction stimulates circulation. Excess moisture causes skin maceration.
• Procedure and Rationale


  1. 20. Place basin on the towel. Immerse client's hand in water. Soap, rinse and dry the hand. If nails are dirty, perform nail care. Soaking softens the cuticle and calluses of hand and loosens debris beneath nails.

  2. 21. Raise the arm and expose axilla. Gently support the arm while thoroughly washing the axilla. Rinse and Dry. Place deodorant to control odor.

  3. 22. Replace water. Perform steps 19, 20 and 21 to the nearest arm.

  4. 23. Spread the towel across the client's chest and abdomen. Lower the bath blanket down to the client's umbilicus/pubic area or as the bath towel can reach. Wash, soap, rinse, dry the chest and abdomen, giving special attention to the skinfold under breasts. Keep the chest and abdomen covered with a towel between the wash and rinse. Apply powder, if desired. Spreading the towel across the client's chest will avoid unnecessary exposure and chilling. Secretions and dirt collect easily in areas of tight skin folds.
• Procedure and Rationale


  1. 24. To clean the lower extremities, cover the upper extremities with the bath blanket and expose the leg farthest to you. Flex client's leg by positioning your arm under leg while grasping client's heel. Place the bath towel under leg, covering also the perineal area. Prevent soiling of linen. Support of joint and extremity during lifting prevents strain on musculoskeletal structure.

  2. 25. Wash, soap, rinse and dry from the ankle to the knee then the knee to the thigh. Place the foot into the basin. Soap, rinse and dry. Soaking softens calluses and rough skin. Use the same bath towel for lining and drying

  3. 26. Place water in the basin , soak the foot, clean, soap and rinse. Remove basin and cover with towel. Dry properly and apply lotion, if desired. Cover with bath blanket after removing the basin.

  4. 27. Obtain fresh, warm water. Water may become dirty or cold.

  5. 28. Repeat steps 24, 25 and 26 to the nearest extremity.
• Procedure and Rationale


  1. 29. Assist the client to side lying position facing away from you, and place the bath towel lengthwise, to cover the back and lumbar area after washing.

  2. 30. Wash, soap, rinse and dry the back, buttocks, paying particular attention to the gluteal folds. Avoid undue exposure of the client.

  3. 31. Assist the client to supine position, and determine whether the client can wash the genital area independently. If able, the client can finish the bath or if unconscious you finish the bath.

  4. 32. Help the client to put on a clean gown. Replace bath blanket to top sheet and allow the client to comb hair.

  5. 33. Perform after care.

  6. 34. Document.
• Oral Care for Conscious Client

  1. Explain the procedure.

  2. Gather all supplies needed. Be sure to place these in a tray with lining. 2.1 Towel, 2.2 Mouthwash, 2.3 Toothbrush and toothpaste, 2.4 Dental floss, 2.5 Lip balm, 2.6 Two cups for water and mouthwash solution, 2.7 Kidney Basin

  3. Close door and/or place screen

  4. Wash hands and wear clean disposable gloves.

  5. Assist the client a comfortable sitting position (Fowler's position).

  6. Inspect oral cavity for cavities or any dental problems

  7. Place towel over the client's chess.

  8. Put kidney basin in hand and assist the client.

  9. Assist the client to brush teeth and tongue.

  10. 10. Give to the client a glass of water and allow to rinse oral cavity. Ask the client to void contents into the kidney basin you are now holding.

  11. 11. If desired, give an enough amount of mouthwash, gargle and void into the kidney basin.

  12. 12. Ask the client to wipe mouth and around it.

  13. 13. Confirm the condition of client's teeth, gums and tongue. Apply lubricant to lips.

  14. 14. Rinse and dry toothbrush thoroughly. Return to its proper place for personal belongings.

  15. 15. Discard dirt properly.

  16. 16. Remove gloves and wash hands.

  17. 17. Document the care.

  18. 18. Report any findings.
• Procedure


  1. Check client's identification and condition.

  2. Explain the purpose and procedure to the client.

  3. Wash hands and wear clean disposable gloves.

  4. Prepare needed supplies, (all supplies listed previously plus a gauze-padded tongue depressor or forceps with rolled gauze). 4.1 Prepare sodium bicarbonate solution (3 pinches plus 2/3 water in gallipot). 4.2 Soak all the gauze-padded tongue depressor into the solution.

  5. Close the curtain or door to the room. Put screen.

  6. Keep the client in side lying position. Place enough pillows for extremities.

  7. Place disposable pad or towel covering the neck and chest area.

  8. Place kidney basin over the towel or pad.

  9. Inspect oral cavity for ulcers, bleeding, swelling, cavities and dental caries.

  10. 10. Clean oral surfaces. Ask the client to open the mouth and insert the padded tongue depressor gently from the angle of mouth towards the back molar area.

  11. 11. Clean the client's teeth from incisors to molars using up and down movements from gums to crown. Clean oral cavity also from proximal to distal, outer to inner parts using cotton ball attached to a forceps for each stroke.

  12. 12. Discard used cotton ball into the kidney basin.

  13. 13. Clean tongue from inner to outer aspect.

  14. 14. Rinse oral cavity 14.1 Provide tap water to gargle mouth and position kidney basin. 14.2 If client cannot gargle by him/herself rinse the areas using moistened CB. 14.3 Assist to discard the month contents by suctioning any excess fluid.

  15. 15. Confirm the condition of client's teeth, gums, mucosa and tongue

  16. 16. Wipe and apply lubricant or lip balm.

  17. 17. Reposition client comfortably

  18. 18. Replace all supplies in proper place

  19. 19. Discard dirt properly. Remove gloves and wash hands.

  20. 20. Document and report for any abnormal findings.
• Procedure


  1. Explain the procedure to the client and obtain consent.

  2. Prepare the equipment and supplies needed to be use. A tray containing: 2.1 Sterile Cotton Balls, 2.2 Thumb forceps, 2.3 Sterile gallipot or bowl, 2.4 Kidney basin, 2.5 Towel, 2.6 Sterile 0.9 Saline solution

  3. Wash hands.

  4. Adjust the bed to the comfortable working position of the nurse.

  5. Place rubber sheet or protective pad.

  6. Take two cotton balls dip in sterile saline solution and squeeze them. Clean the eye from inner canthus to outer canthus in a straight single stroke. Ensure to use new CB each time. Dry. Repeat the procedure until all the discharges has been removed.

  7. Repeat number 7 with the opposite eye.

  8. Make the client comfortable. Discard used supplies and materials. Wash hands.

  9. Record the procedure in the nurses record.
• Procedure


  1. Preparation of Client 1.1 Instruct the client the proper way to clean the outer ear, avoiding use of sharp objects such as hairpins, pen covers etc. 1.2 Encourage older clients to regular hearing checks.

  2. Obtain consent and explain procedure to client. Wash hands and gather materials. A tray containing the following: 2.1 Cotton pledget and CB, 2.2 Mineral oil, 2.3 Washcloth, 2.4 Basin with warm water

  3. Assess and listen for the client's ear complaints and allergies.

  4. Clean external ear using squeezed CB soaked with warm water. If dried debris is present, use CB soaked with mineral oil, squeeze. Clean thoroughly. Do these procedures in the opposite ear.

  5. Clean the internal canal using the cotton applicator gently and carefully not touching the ear drum. Do these procedures in the opposite ear.

  6. Evaluate, perform after care and document.
• Procedure


  1. Obtain consent. Explain the procedure to the client. Wash hands. Gather materials. A tray containing: 1.1 Cotton, 1.2 Normal Saline or warm water in gallipot, 1.3 Face towel

  2. Bring materials to bedside. Adjust the bed to the comfortable position. Place the client's head well supported with titled head.

  3. Remove the nasal secretions of the client by using CB with water or NSS.

  4. Ensure a new cotton balls is used each time, repeat the procedure until all the secretions has been removed.

  5. Once the nose have been cleaned and dried out, make the client comfortable.

  6. Discard waste. Wash hands and document.
• FINGERNAILS


  1. Perform handwashing.

  2. Gather all require supplies and equipment. 2.1 Nail cutter, nail file, wooden stick, 2.2 Gallipot with water for cotton, 2.3 Kidney basin, 2.4 Face Towel, 2.5 Hand Towel, 2.6 Protective pad, 2.7 Plastic basin for soaking the hand / foot, 2.8 Soap with soap dish

  3. Check client's identification. Explain procedure to the client. Bring preparation to the client's room.

  4. Assist the client to a sit