Medical Surgical Nursing Case Study: Gastrointestinal System 1

A 37-year-old executive returns to your clinic for follow-up of recurrent upper abdominal pain. He initially presented 3 weeks ago, complaining of an increase in frequency and severity of burning epigastric pain, which he has experienced occasionally for more than 2 years. Now the pain occurs three or four times per
week, usually when he has an empty stomach, and it often awakens him at night. The pain usually is relieved within minutes by food or over-the-counter antacids, but then recurs within 2 to 3 hours. He admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine
and eating a lot of take-out foods. His medical history and review of systems were otherwise unremarkable, and, other than the antacids, he takes no medications. His physical examination was normal, including stool guaiac that was negative for occult blood. You advised a change in diet and started him on a proton-pump
inhibitor. His symptoms resolved completely with the diet changes and daily use of the medication. Results of laboratory tests performed at his first visit show no anemia, but his serum Helicobacter pylori antibody test was positive.

What is your diagnosis?

What is your next step

Medical Surgical Nursing Case Study: Cardiovascular System 1

A 72-year-old man presents to the clinic complaining of several weeks of worsening exertional dyspnea. Previously, he had been able to work in his garden and mow the lawn, but now he feels short of breath after walking 100 feet. He does not have chest pain when he walks, although in the past he has experienced episodes of retrosternal chest pressure with strenuous exertion. Once recently he had felt lightheaded, as if he were about to faint while climbing a flight of stairs, but the symptom passed after he sat down. He has been having some difficulty sleeping at night and has to prop himself up with two pillows. Occasionally, he wakes up at night feeling quite short of breath, which is relieved within minutes by sitting upright and dangling his legs over the bed. His feet have become swollen, especially by the end of the day. He denies any significant medical history, takes no medications, and prides himself on the fact that he has not seen a doctor in years. He does not smoke or drink alcohol.

On physical examination, he is afebrile, with a heart rate of 86 bpm, blood pressure of 115/92 mm Hg, and respiratory rate of 16 breaths per minute. Examination of the head and neck reveals pink mucosa without pallor, a normal thyroid gland, and distended neck veins. Bibasilar inspiratory crackles are heard on examination. On cardiac examination, his heart rhythm is regular with a normal S1 and a second heart sound that splits during expiration, an S4 at the apex, a nondisplaced apical impulse, and a late-peaking systolic murmur at the right-upper sternal border that radiates to his carotids. The carotid upstrokes have diminished amplitude.

What is the most likely diagnosis?

What test would confirm the diagnosis?

Carbohydrates

Carbohydrates 1
Carbohydrates are made of carbon, hydrogen, and oxygen atoms. Many different monosaccharides, or simple sugars, can combine into polysaccharides, or complex carbohydrates. Even though they have a bad reputation among some diet plans, carbohydrates perform many essential functions for cells. In this chapter, I present the basic structure of carbohydrates and explain their importance to cells.

CH2O: Structure of Carbohydrates
In recent years, due to the comeback of the low- carb diet, carbohydrates have gotten a bad rap. Some people have started thinking that proteins are good, and carbohydrates are bad. However, the idea that carbohydrates aren’t good for you is overly simplified. After all, carbohydrates are an essential component of your cells. What can make a difference is the type of carbohydrates you eat. Carbohydrates are organic molecules composed of carbon, hydrogen, and oxygen. The two main types of carbohydrates are as follows:

Monosaccharides are also called simple sugars. (Most diets recommend that you avoid eating too much of this type of carbohydrate.) Glucose is a monosaccharide that is usually available to your cells.

Polysaccharides are also called complex carbohydrates. (Fiber is an example of a complex carbohydrate that is a recommended part of your daily nutrition.)

Keeping it simple: Monosaccharides
Monosaccharides, or simple sugars, are single sugars. (“Mono” means “one” and “sacchar” means sugar.) Many monosaccharides have the generic formula CH2O: For every one carbon atom they have, they have two hydrogen atoms and one oxygen atom. Two monosaccharides that may be familiar to you are glucose (see Figure 5-1A) and fructose (a sugar found in fruit and also in high-fructose corn syrup).

All monosaccharides have certain features in common:

 A backbone of 3, 4, 5, 6, or 7 carbons. Sugars are categorized based on the number of carbons: In order of the numbers, they are called trioses, tetroses, pentoses, hexoses, and heptoses. For example, glucose is a hexose, or 6-carbon sugar.

Hydroxyl groups (–OH) attached to every carbon but one. The hydroxyl groups make sugars polar, which is why they dissolve easily in water.

 One double-bonded oxygen attached to the carbon backbone. An oxygen double-bonded to a carbon is called a carbonyl group. If the carbonyl group is located at the end of a monosaccharide, the sugar is an aldose. If the carbonyl group is located within the carbon backbone, the sugar is a ketose. Glucose is an aldose because its carbonyl group is at the end of the carbon backbone.

 Of the four groups of macromolecules (carbohydrates, proteins, nucleic acids, and lipids), carbohydrates have the greatest number of hydroxyl groups (–OH) attached to their carbon atoms. When you’re trying to distinguish between the four types of macromolecules, a structure with hydroxyl groups attached to almost every carbon is probably a carbohydrate.

Two monosaccharides can have the same numbers of carbon, hydrogen, and oxygen atoms and yet have very different properties. When two monosaccharides have the same atoms, but those atoms are arranged differently, the sugars are isomers of each other (“iso” means same). For example, if the hydroxyl group (–OH) and hydrogen atom (–H) attached to the fourth carbon from the top in glucose (see Figure 5-1A) were swapped with each other, the sugar would be converted to galactose. Glucose and galactose are almost identical, except for that one change in the arrangement of the atoms, and yet they behave very differently in cells.



 The way the atoms are bonded together is very important in the structure and function of sugars. Isomers are made from exactly the same atoms, but their atoms are arranged differently.

In the watery environment of the cell, monosaccharides convert into ringshaped structures. A bond forms between two atoms in the backbone of the sugar, causing the sugar to bend around to form the ring. As an example, compare the linear structure of glucose shown in Figure 5-1A with the ring structure shown in Figure 5-1B.

Making it complex: Polysaccharides
Polysaccharides, or complex carbohydrates, are polymers (see Chapter 4) of monosaccharides. (“Poly” means many, and “sacchar” means sugar, so a polysaccharide is “many sugars” strung together.) To make polysaccharides, monosaccharides are joined together by condensation reactions (see Chapter 4). During condensation, a water molecule is removed as a bond is formed between an atom in the growing polysaccharide chain and an atom in
the monosaccharide that is being added to the chain (see Figure 5-1B). The bonds between monosaccharides are called glycosidic linkages.

Polysaccharides are classified based on the number of monosaccharides in the chain:

 Disaccharides are chains of two monosaccharides. Sucrose (see Figure
5-1B), or table sugar, is a disaccharide that is probably very familiar to you. Another disaccharide you probably know about is lactose, the sugar
found in milk.

 Oligosaccharides are short chains of monosaccharides (see Figure 5-1C). Oligosaccharides are part of receptors in the plasma membranes of your cells.

 Polysaccharides are long chains of monosaccharides (see Figure 5-1D). Starch and cellulose, both shown in Figure 5-2, are two polysaccharides that you probably eat every day. Starch is found in bread, potatoes, rice, and pasta; cellulose is referred to as fiber in your diet.



Many cell types produce polysaccharides. Starch and cellulose, which are made by plants, are both polymers of glucose. Glycogen, made by animal cells, is also a polymer of glucose. Chitin, found in the shells of crustaceans and insects, is a polymer of a nitrogen-containing monosaccharide called N-acetylglucosamine. Peptidoglycan, the polysaccharide found in bacterial cell walls (see Chapter 2), is a polymer of two alternating monosaccharides, N-acetylglucosamine and N-acetylmuramic acid.

Polysaccharides can also be different based on how their monosaccharides are strung together. Starch, cellulose, and glycogen are all made entirely of glucose, yet they behave very differently in the body. Starch and glycogen are easily broken down in the human digestive system. Cellulose, or fiber, can’t be broken down at all by humans. Instead, it passes right through your digestive system and exits as part of your wastes.

The difference between starch, cellulose, and glycogen isn’t what they’re made of, but rather in the bonds between the glucose molecules:
 The glucose molecules in starch are joined with a bond called a α–1,4–glycosidic linkage.
 The glucose molecules in cellulose are joined with a β–1,4–glycosidic linkage.
 At approximately every tenth glucose molecule, a branch is joined to the main backbone of glycogen by an α–1,6–glycosidic linkage. Thus, glycogen molecules are highly branched.

The reason humans can digest starch and glycogen, but not cellulose, is that human enzymes can break down some glycosidic linkages, but not others. Human enzymes break down α –1,4–glycosidic linkages and α –1,6–glycosidic linkages, but not β –1,4–glycosidic linkages. Together, starch, cellulose, and glycogen demonstrate how important different types of glycosidic linkages can be to polysaccharide structure and function.

 The type of glycosidic linkage between monosaccharides is very important in determining structure and function of polysaccharides.

Functions of Carbohydrates
Carbohydrates are probably most famous for their role in providing energy to bodies (and, of course, cells), but they perform many other important functions for cells as well:

 Carbohydrates are an important energy source for cells. The monosaccharide glucose is a rapidly used energy source for almost all cells on planet Earth. In addition, many cell types store matter and energy for later use in the form of polysaccharides. Plants, algae, and bacteria store energy in starch, and animals and bacteria store energy in glycogen.
 Carbohydrates are important structural molecules for cells. Polysaccharides are the major components of the cell walls of plants, algae, fungi, and bacteria. The cell walls of plants and algae contain cellulose, the cell walls of fungi contain chitin, and the cell walls of bacteria contain peptidoglycan.

 Carbohydrates are important markers of cellular identity. The surfaces of cells are marked with glycoproteins, molecules of protein that have an attached sugar. Different cells have different glycoproteins on their surface, marking the cells with their identity. In your body, liver cells are marked as liver cells, heart cells are marked as heart cells, nerve cells are marked as nerve cells, and so on.

 Carbohydrates are important extracellular molecules. Polysaccharides are a major component of the sticky matrix that surrounds cells. They help bacteria stick to surfaces

Pre-Board Exam Drill

SITUATION 1: A patient just arrived in the Oncology unit from the Post Anesthesia Care Unit (PACU) following a Left Modified Radical Mastectomy because of Inflammatory Breast Cancer (IBC). She has a pressure dressing over the surgical site and two drains. Assessment shows her vital signs are stable, fully awake and claims that pain is under control. Fortune is the nurse assigned to the patient.
1. From the following data obtained from the chart by Fortune, which is NOT a risk factor which could have predisposed the patient to breast cancer:
a. Age – 55
b. Height 5’2”, weight 160 lbs.
c. Menarche at age 13
d. Mother died of colon cancer
2. Fortune read a literature which says that by the time Inflammatory Breast Cancer (IBC) is diagnosed, 50% - 75% have palpable auxiliary nodes; as many as 30% have gross distant metastasis; and as few as 30% of patients have an underlying breast mass. Which of the following is the APPROPRIATE interpretation of this research findings.
a. Auxiliary nodes were palpated on 20 out of 30 women positive for IBC3
b. Out of the 20 women who were positive for IBC, only 5 have metastasis
c. If there were 10 women diagnosed with IBC, 3 have positive lymph nodes
d. Breast mass was identified on 8 out of 30 women positive for IBC
3. Fortune recognizes that adjuvant chemotherapy for breast cancer may include any of the following EXCEPT:
a. Monoclonal antibody
b. Antibiotics
c. Proton inhibitors – this is a drug for ulcer
d. Antiestrogen – tamoxifen

4. Fortune understands that when the antineoplastic  agent leaks through the peripheral vascular access during chemotherapy procedure, which of the following is expected to be done FIRST?
a. Refer to the physician
b. Stop the chemotherapy infusion
c. Cleanse site with saline solution
d. Call another nurse to check the intravenous site

5. A clinical trial is currently being undertaken to test treatments for Inflammatory Breast Cancer (IBC). The research team leader wishes to include the patient as a participant in the study. As a patient advocate, which of the following will Fortune do FIRST?
a. Obtain informed consent from the patient
b. Explain to the patient the scope of the clinical trial
c. Inquire from the team leader benefits for the patient
d. Read more related literatures
SITUATION 2: During a staff meeting in the Intensive Care Unit, the nurse manager reported a list of procedures that need to be reviewed and updated. One of these procedures is the precautionary measures related to ventilator associated pneumonia.- on mechanical ventilation through an endotracheal or tracheostomy tube for at least 48 hours
6. While brainstorming, the group mentioned the use of evidence-based techniques. Which of the following statements given by the members of the group reflect evidence-based methods?
a. “Let us ask opinions of experts”
b. “The experiences of the nurses must be obtained”
c. “Review of related literature will be very helpful”
d. “We must agree on a common procedure”
7. The nurse manager assigned a group to develop a project intended to improve the existing procedure related to the prevention of ventilator associated pneumonia among ICU patients. A first team leader was selected by the group. Which of the following will the team leader do FIRST?
a. Tell the group to state their objectives
b. Formulate a list of desired outcomes
c. Set a target
d. State actions to be done by each member of the group
8. Which of the following definitions best describes pneumonia?
 A. Inflammation of the large airways
B. Severe infection of the bronchioles
C. Inflammation of the pulmonary parenchyma
D. accumulation of fluids in the lungs
9. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?
        A. Fluid volume deficit
        B. Decreased tissue perfusion.
        C. Impaired gas exchange.
        D. Risk for infection

10. What action should the nurse take in assisting Mr. Ramos in doing deep breathing and coughing exercise?
A. Recognize that the patient is too sick to cough at this time
B. Splint the patient’s chest while he coughs
C. Turn Mr. Ramos to the unaffected side and ask him to cough
D. Encourage her to cough and then give her pain medication as ordered
11. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and  replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be
         A. placing her in a trendeleburg position
         B. putting several warm blankets on her
         C. monitoring her hourly urine output
         D. assessing her VS especially her RR

12. Ana's postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?
         A. Put the client in modified Trendelenberg's position.
         B. Administer oxygen at 100
         C. Monitor urine output every hour.
         D. Administer Demerol 50mg IM q4h

13. When assessing Luther for hypovolemic shock, which of the following data indicates that he is in IRREVERSIBLE stage of shock?
a. Restless, anxious and confused
b. Anuria
c. Skin, cool, pale and moist- compensatory stage
d. Pulse rapid and weak – reversible stage
14. The physician ordered colloid solution such as Dextran 40. During the infusion, Luther complained of dyspnea. Upon auscultation, you noted wheezes. Which of the following will you do FIRST?
a. Discontinue the infusion
b. Place Luther on a Fowler’s position..
c. Decrease infusion rate
d. Call the attending physician

15. Luther’s central venous pressure is monitored every hour. When you measure the CVP using a water manometer, you are expected to observe which of the following to ensure accuracy of CVP measurement?
a. Maintain the client on a Fowler’s position
b. Use a one way stopcock to regulate flow of IV fluids to the water manometer
c. Immobilize client’s right arm
d. Keep the zero point of the manometer in level with the client’s right atrium
SITUATION 4: You are caring for Warren, 58 years old, who is diagnosed with Laryngeal cancer
16. Warren, who is scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx, asks you, “How will I talk after the surgery?” as his nurse your BEST response will be:
a. “You will breathe through a permanent opening in your neck, but you will not be able to communicate orally”
b. “You won’t be able to talk right after surgery, but you will be able to speak again once the tracheostomy tube is removed”
c. “You will have a permanent opening in your neck, and you will need to have rehabilitation for some type of voice restoration”
d. “You won’t be able to speak as you used to but there are artificial voice devices that will give you the ability to speak normally”
17. Warren returns from surgery with a tracheostomy tube after a total laryngectomy and radical neck dissection. In caring for Warren during the first 24 hours after surgery, your PRIORITY nursing action is to:
a. Avoid changing tracheostomy ties
b. Monitor for bleeding around stoma
c. Assess the airway patency and breath sounds
d. Clean the inner cannula every 8 hours
18. After doing assessment, one of the nursing diagnosis you identified is “Body image disturbance related to loss of control of personal care.” To evaluate effectiveness of your interventions, the expected outcome for the problem that Warren should demonstrate is that he:
a. Lets his wife provide hygiene and stoma care
b. Wears clothing that minimizes the disfigurement caused by surgery
c. Asks that only family members be allowed to visit
d. Learns to remove and clean the laryngectomy tube independently
19. Warren is scheduled to start radiation therapy. You have just taught Warren all about radiation therapy. Which of the following statements by Warren would indicate that your teaching has been EFFECTIVE?
a. “I can use lotions to moisturize the skin on my throat”
b. “I will need to buy a water bottle to carry with me”
c. “I need to use alcohol-based mouthwashes to help clean oral ulcers”
d. “I may experience diarrhea, I may have diarrhea until radiation is complete”
20. After completing the discharge instructions for Warren, you  determine that ADDITIONAL instruction is needed when he says:
a. “I can participate in most of my prior fitness activities except swimming”
b. “I should wear a Medic Alert Bracelet that identifies me as a neck breather”
c. “I must keep the stoma covered with a loose sterile dressing at all times”
d. “I need to eat nutritious meals even though I can’t smell or taste very well”

Anatomy and Physiology Quiz

I. Fluid and Electrolyte and Acid – Base Balance

1. Approximately 60% of the weight of a typical adult consists of fluid. Body fluid is located in two fluid compartments namely what?
a. Intracellular and intravascular
b. Extracellular and intracellular
c. Intracellular and interstitial
d. Extravascular and intracellular

2. When two different solutions are separated by a membrane that is impermeable to the dissolved substances, fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. This diffusion of water caused by a fluid concentration gradient is known as what?
a. Diffusion
b. Filtration
c. Osmosis
d. Active Transportation

3. Hydrostatic pressure in the capillaries tends to filter fluid out of the intravascular compartment into the interstitial fluid. Movement of water and solutes occurs from an area of high hydrostatic pressure to an area of low hydrostatic pressure is known as what?
a. Diffusion
b. Filtration
c. Osmosis
d. Active Transport

4. A patient presented the following signs and symptoms: confusion, muscle cramps and weakness,  dry skin, ↑pulse,  ↓ BP. The patient’s lab result shows ↓ serum and urine sodium and  ↓ urine specific gravity. The doctor told you that the patient is exhibiting hyponatremia. Hyponatremia is having a serum sodium below what? (Smeltzer 2012)
a. 145 mEq/L
b. 108 mEq/L
c. 96.5 mEq/L
d. 135 mEq/L

5. A patient with congestive heart failure is given oral potassium supplements to avoid digoxin toxicity. As a nurse you are aware that the normal serum level for potassium is what? (Smeltzer 2012)
a. 135-145 mEq/L
b. 3.5-5.0 mEq/L
c. 8.5-10.5 mg/dL
d. 1.8-2.7 mg/dL

Evaluate the following arterial blood gas values

6. pH: 7.5   PaCO2: 31   HCO3 : 26

7. pH: 7.38  PaCO2: 32  HCO3: 19

8. pH: 7.24  PaCO2: 60  HCO3: 32

9. pH: 7.41  PaCO2: 30  HCO3 18

10. pH: 7.5  PaCO2: 42  HCO3: 33

II. Respiratory System

11. Resting respiration is the result of cyclic excitation of the respiratory muscles by the phrenic nerve. The rhythm of breathing is controlled by respiratory centers in the brain. The inspiratory and expiratory center is located in the?
a. Medulla Oblongata
b. Hypothalamus
c. Pons
d. Cerebellum

12. The _____ center in the lower pons stimulates the inspiratory medullary center to promote deep, prolonged inspirations.
a. Pneumotaxic
b. Apneustic
c. Chemotaxic
d. Physiotaxic

13. A term that correspond the amount of air inhaled and exhaled with each breath.
a. Residual Volume
b. Inspiratory Reserve Volume
c. Expiratory Reserve Volume
d. Tidal Volume
14. It is the volume of air in the lungs after maximum inhalation
a. Vital Capacity
b. Inspiratory Capacity
c. Functional Residual Capacity
d. Total Lung Capacity

15. The volume of air remaining in the lungs after a normal expiration .
a. Vital Capacity
b. Inspiratory Capacity
c. Functional Residual Capacity
d. Total Lung Capacity

III.  Cardiovascular System

16. It is the ability of the heart to initiate electrical impulse.
a. Excitability
b. Automaticity
c. Conductivity
d. Permeability

17. It is called as the primary pace maker of the heart which fires 60 to 100 impulse per minute
a. SA Node
b. AV Node
c. Bundle of His
d. Purkinje Fibers

18. The ___  coordinates the incoming electrical impulses from the atria and after a slight delay, allowing the atria time to contract and complete ventricular filling then relays the impulse to the ventricles.
a. SA Node
b. AV Node
c. Bundle of His
d. Purkinje Fibers

19. This heart sound is created by the closure of the tricuspid and bicuspid valve
a. S1
b. S2
c. S3
d. S4

20. This heart sound is created b the closure of the pulmonic and aortic valves
a. S1
b. S2
c. S3
d. S4

Fundamentals Lecture 1: Development of Nursing

Nursing, like every discipline, evolved from its primitive form to a developing branch of professional discipline. In this Fundamentals of Nursing Lecture, we will tackle on key happenings that led to the evolution of nursing as a science and an art. 

This lecture note is in an outline form to compliment your classroom discussion. This are compiled notes of the author. Care is taken in synthesizing the compiled notes.

Early times

Nursing was untaught and instinctive

Performed out of compassion for others and desire to help others

Beliefs and Practices of Prehistoric Man

Nursing was a function that belonged to women taking care of the children, the sick and the aged.

Believed that illness causes the invasion of evil spirit through the use of black magic or voodoo.

Believed that medicine man was called shaman or witch doctor having the power to heal using white magic.

They also practiced “trephining” or drilling a hole in the skull with a rock or stone without anesthesia as a last resort to drive evil spirits from the body.

Contributions to Medicine and Nursing

Babylonia

o Code of Hammurabi  provided laws that covered every facet of Babylonian life including medical practice and recommended specific doctors for each disease and gave each patient the right to choose between the use of charms, medications or surgical procedures.

Egypt

o Introduced the art of embalming

o Developed the ability to make keen observation and left a record of 250 recognized diseases

o Slaves and patient’s families nursed the sick

Israel

o Moses was recognized as the “Father of Sanitation” and wrote in Old Testament which:

Emphasized the practice of hospitality to strangers and acts of charity

o Promulgated laws of control on the spread of communicable disease and the ritual of circumcision of the male child

 o Referred to nurses as midwives, wet nurses or child’s nurses whose acts were compassionate and tender

China

o Believed that in using girl’s clothes for male babies keep evils away from them

o Prohibited the dissection of dead human body as a worship to ancestors

o They gave the world knowledge of material medica (pharmacology)

India

o Men of medicine built hospitals, practiced an intuitive form of asepsis and were proficient in the practice of medicine and surgery

o Sushurutu made a list of function and qualifications of nurses. This was the first reference to nurse’s taking care of the patient’s.

Ancient Greece

o Nursing was the task of untrained slave

o Introduced caduceus, the insignia of medical profession today

o Hippocrates was given the title of “Father of Scientific Medicine”. He made major advances in medicine by rejecting the belief that diseases had supernatural causes. He also developed assessment standards for clients, established overall medical standards, recognized a need for nurses.

Rome

o The Romans attempted to maintain vigorous health, because illness was a sign of weakness

o Care of the ill was left to the slaves or Greek physicians. Both groups were looked upon as inferior by Roman society.

o Fabiola made her home the first hospital in the Christian world through the help of Marcella and Paula

Period of Apprentice Nursing

• Also called the period of “on the job” training.
• Nursing care was performed without any formal education and by people who were directed by more experienced nurses
• Religious orders of the Christian church were responsible for the development of this kind of nursing.
• Founding of religious nursing orders to 1836 when Kaiserwerth Institute for the training of Deaconesses in Germany was established

Crusades

• Military religious orders established hospitals staffed with men
• Knights of Lazarus was founded and primarily for the nursing care of lepers in Jerusalem after the Christians had conquered the city.

Rise of Secular Orders

• Religious taboos and social restrictions influenced nursing at the time of the Religious Nursing orders
• Hospitals were poorly ventilated and the beds were filthy
• There was overcrowding of patients: 3 or 4 patients regardless of diagnosis or whether dead or alive, may have shared one bed. 
• Practice of environmental sanitation and asepsis were non-existent
• Older nuns prayed with and took good care of the sick, while younger nuns washed soiled linens, usually in the rivers.
• St. Catherine of Siena. The first “Lady with a Lamp”. She was a hospital nurse, prophetess, researcher and a reformer of society and the church.
• In 16th century, hospitals were established for the care of the sick where hospitals were gloomy, cheerless, airless and unsanitary. People entered hospitals only under compulsion or as a last resort.

Dark Period of Nursing

(17th to 19th century)

• There were no provisions for the sick, no one to care for the sick
• Nursing became the work of the least desirable of women---women who took bribes from patients, who stole the patient’s food and who used alcohol as a tranquilizer.
• They worked seven days a week slept in cubbyhole near the hospital ward or patient and ate scraps of food when they could find them.

Period of Educated Nursing

(From June 15, 1869 when Florence Nightingale School of Nursing was opened until World War II)

• The development of nursing during this period was strongly influenced by trends resulting from wars, from an arousal of social consciousness, from the emancipation of women and from the increased educational opportunities offered to women
• Popularization of the philosophy of the Nightingale System

o Importance of nursing education

o Hospital affiliation

o Nurses teaching students

o Health teaching as critical responsibility

o Enforced written physician orders

o Expansion in no. of schools to North America

o Specialization developed

Period of Contemporary Nursing

(Period after World War II up to present)

• Scientific and technological developments as well as social changes mark this period
• Establishment of WHO
• Use of atomic/nuclear energy for medical diagnosis and treatment
• Utilization of computers
• Use of sophisticated equipment for diagnosis and therapy
• Health is perceived as a fundamental human rightNursing involvement in community health is greatly intensified
• Development of the expanded role of nurses
• Professionalization of nursing

NCLEX-RN DRILL: MEDICAL SURGICAL CARDIOVASCULAR C

Medical Surgical Nursing is a very broad area in the field of Nursing for it tackles the management of different client condition. Books in Medical Surgical Nursing are usually divided according to the Organ System of the Human Body. The Cardiovascular System is one of the most difficult areas to study and to master since any deviation in this system will affect every organ system. Mastery is needed to be able to answer board type questions pertaining to Cardiovascualr System.



1. A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse discriminate pain caused by a noncardiac problem?
1. “Can you describe the pain to me?”
2. “Have you ever had this pain before?”
3. “Does the pain get worse when you breathe in?”
4. “Can you rate the pain on a scale of 1 to 10, with 10 being the worst?”

2. A client is admitted to an emergency room with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows: at 11 am, pulse (P), 92 beats/min, respiratory rate (RR), 24 breaths/min, blood pressure (BP), 140/88 mm Hg; 11:15 am, P, 96 beats/min, RR, 26 breaths/min, BP, 128/82 mm Hg; 11:30 am, P, 104 beats/min, RR, 28 breaths/min, BP, 104/68 mm Hg; 11:45 am, P, 118 beats/min, RR, 32 breaths/min, BP, 88/58 mm Hg. The nurse should alert the physician because these changes are most consistent with which of the following complications?
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm

3. A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities?
1. Strict bed rest for 24 hours after transfer
2. Bathroom privileges and self-care activities
3. Ad lib activities because the client is monitored
4. Unsupervised hallway ambulation with distances under 200 feet

4. A client admitted to the hospital with chest pain and history of type II diabetes mellitus is scheduled for cardiac catheterization. Which of the following medications would need to be held for 48 hours before and after the procedure?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)

5. A client is in sinus bradycardia with a heart rate of 45 beats/min, complains of dizziness, and has a blood pressure of 82/60 mmHg. Which of the following should the nurse anticipate will be prescribed?
1. Defibrillate the client.
2. Administer digoxin (Lanoxin).
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing.

6. A nurse notes bilateral 12 edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next?
1. Order daily weights starting on the following morning.
2. Review the intake and output records for the last 2 days.
3. Request a sodium restriction of 1 g/day from the physician
4. Change the time of diuretic administration from morning to evening.

7. A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure?
1. Atrial fibrillation
2. Nutritional anemia
3. Peptic ulcer disease
4. Recent upper respiratory infection

8. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds?
1. Stridor
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds

9. A client who has developed severe pulmonary edema would most likely exhibit which of the following?
1. Mild anxiety
2. Slight anxiety
3. Extreme anxiety
4. Moderate anxiety

10. A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), the nurse should review which laboratory result?
1. Sodium level
2. Digoxin level
3. Creatinine level
4. Potassium level

NCLEX-RN DRILL: MEDICAL SURGICAL CARDIOVASCULAR B

Medical Surgical Nursing is a very broad area in the field of Nursing for it tackles the management of different client condition. Books in Medical Surgical Nursing are usually divided according to the Organ System of the Human Body. The Cardiovascular System is one of the most difficult areas to study and to master since any deviation in this system will affect every organ system. Mastery is needed to be able to answer board type questions pertaining to Cardiovascualr System.

1. The nurse realizes that more teaching is needed when the client on a cardiac low-cholesterol diet makes which choice from the menu?
a. Stewed chicken, green beans, and noodles
b. Liver and onions, salad with ranch dressing, and milk
c. Ham and bean soup, salad with vinaigrette dressing, and cornbread
d. Pork roast, brown rice, and beets

2. When taking a client’s medical history, which are the precipitating factors for myocardial infarction?
(Select all that apply.)
a. Hypothyroidism
b. Cigarette smoking
c. Hyperlipidemia
d. Rheumatic fever
e. Elevated serum iron level
f. High density lipids 40 mg
g. Using oral contraceptives

3. When the nurse performs an admission assessment on a client, the nurse notes that the client has xanthomas present on both eyelids. The laboratory value that the nurse would want to check based on this assessment finding is
a. triglyceride level
b. homocystine level
c. cardiac enzymes—CPK-MB, troponin, and myoglobin
d. cholesterol panel

4. A client presents to the clinic with the following symptoms: a burning sensation in the lower extremities, thickened toe nails, and pain in legs when walking. The nurse would assess the client for which additional factor consistent with Burger’s disease (thromboangitis obliterans)?
a. Bounding peripheral pulses
b. Rubor when the extremities are elevated
c. Intolerance to heat
d. Symptoms triggered by stress

5. A goal for a client with arteriosclerosis obliterans is to increase arterial blood supply to the extremities. Which of the following nursing interventions would be appropriate for this goal?
a. Elevate the extremities above the level of the heart for 15 minutes four times a day.
b. Have client perform Buerger-Allen exercises four times a day.
c. Maintain client on bed rest with legs in a neutral position.
d. Position client in high-Fowler’s position with legs straight.

6. Which of the following assessment findings are consistent with the diagnosis of venous stasis?
a. Absent or diminished peripheral pulses
b. Hair loss on the extremity
c. Moist ulcers around the malleolus
d. Edema of the extremity
e. Coolness of the extremity
f. Leathery quality of the extremity
g. Pallor of the extremity

7. A client is returned to the unit after having a repair of an abdominal aortic aneurysm. The nurse should place the client in which of the following positions?
a. High-Fowler’s
b. Sims
c. Semi-Fowler’s
d. Flat

8. The nurse is giving a client low molecular weight heparin, enoxaparin. The correct nursing interventions when administering this medication include all of the following except
a. using a TB syringe
b. injecting the medicine using Z-track method
c. not rubbing the site postinjection
d. administering the medicine in the anterolateral abdominal wall

9. In order to prevent the postoperative complication of thrombophlebitis in a client who has had mitral valve replacement, the nurse would have the client engage in which of the following activities?
a. Perform dorsiflexion of the feet several times every hour while awake
b. Cough and take deep breaths every hour while awake
c. Sit up in a chair for several hours during the afternoon
d. Eat a high-fiber, high-calorie diet

10. The nurse is caring for a client who has just arrived on the unit following a cardiac catheterization. Which of the following assessments would be most immediate?
a. Heart and lung sounds
b. Pain at the catheter insertion site
c. Pulses distal to the insertion site
d. Urine output

11. A client comes into the ER complaining of “his heart racing.” Cardiac monitor shows atrial tachycardia with a ventricular rate of 190 bpm. The nurse anticipates that the physician will order adenosine (Adenocard) to be given. Prior to giving the medication the nurse should do which of the following?
a. Determine when the client last ate
b. Ask the laboratory to draw serum BUN and creatinine levels
c. Ask the client if he/she has a history of asthma
d. Have the client sign a consent

12. Metoprolol tartrate (Lopressor) is ordered for a client who has had a myocardial infarction. The nurse would expect which therapeutic result from administration of this drug?
a. Increased urinary output
b. Decreased coronary artery spasms
c. Increased cardiac output
d. Decreased resting heart rate

13. A client’s cardiac monitor strip shows the following: HR 42/min, rhythm regular, PRI 0.16 seconds, QRS 0.06 seconds. The client is experiencing dizziness, nausea, and chest pain rated as 3 on a scale of 1–10 with 10 being the worst pain. The drug of choice to treat this dysrhythmia is
a. Lidocaine (Xylocaine)
b. Adenosine (Adenocard)
c. Atropine sulfate
d. Epinephrine (Adrenalin)

14. A client is admitted to the ER with new onset atrial fibrillation with a ventricular response of 110/min. The nurse would anticipate which of the following treatment options to be ordered. (Select all that apply.)
a. Defibrillation
b. Start oxygen at 2–4 lpm
c. Anticoagulant therapy
d. Medicate with beta blocker
e. Start Lidocaine drip
f. Atrial pacing

15. The nurse is assessing a newborn infant who is exhibiting the following signs and symptoms: elevated blood pressure, bounding brachial pulses, diminished pedal pulses, elevated Jugular venous distention (JVD), and cardiac murmur. Based on the assessment, the nurse would suspect that the client may have which of the following conditions?
a. Congestive heart failure
b. Coarctation of the aorta
c. Mitral valve prolapse
d. Transposition of the great vessels

16. The nurse has assessed a client and has determined that the client is exhibiting signs and symptoms of left heart failure. Identify which of the following are indicative of left heart failure.
a. Tachypnea, loss of appetite, ST elevation on the ECG
b. Hemoptysis, cogwheel murmur, midsternal chest pain
c. Ascites, oliguria, fatigue
d. Orthopnea, bibasilar crackles, gallop rhythm

17. The nurse is providing nutritional counseling for a client who is receiving a loop diuretic. Which meal plan would be most appropriate for this client?
a. Raisin bran cereal, tomato juice, whole grain toast
b. Boiled chicken, green beans, tossed salad
c. Vegetable soup, low-salt crackers, skim milk
d. Poached fish, beets, macaroni and cheese

18. The nurse is reading a 6-second cardiac rhythm strip and notes 9 QRS complexes in it. The client’s heart rate is
a. 54
b. 63
c. 81
d. 90

19. A client has been diagnosed with pericardial effusion. The nurse would prepare the client for which of the following procedures?
a. Myotomy
b. Pericardiectomy
c. Pericardiostomy
d. Dynamic cardiomyoplasty

20. Which instruction would be inappropriate to give a client following coronary artery bypass graft surgery?
a. No driving for 6–8 weeks
b. Avoid smoking or tobacco use for 4–6 weeks
c. No heavy lifting for 6–8 weeks
d. Can resume sexual intercourse in 3–4 weeks

NCLEX-RN DRILL: MEDICAL SURGICAL CARDIOVASCULAR A

Medical Surgical Nursing is a very broad area in the field of Nursing for it tackles the management of different client condition. Books in Medical Surgical Nursing are usually divided according to the Organ System of the Human Body. The Cardiovascular System is one of the most difficult areas to study and to master since any deviation in this system will affect every organ system. Mastery is needed to be able to answer board type questions pertaining to Cardiovascualr System.

1. A client with hypertension has an order for furosemide. Which lab finding should be reported to the physician?
A. Phosphorus 2.5 mEq/L
B. Potassium 1.8 mEq/L
C. Calcium 9.4 mg/dl
D. Magnesium 2.4 mEq/L

2. A client is admitted with a diagnosis of heart block. The nurse is aware that the pacemaker of the heart is the:
A. AV node
B. Purkinje fibers
C. SA node
D. Bundle of His

3. A client is being treated with nitroprusside (Nitropress). The nurse is aware that this medication:
A. Should be protected from light
B. Is a non–potassium-sparing diuretic
C. Causes vasoconstriction
D. Decreases circulation to the extremities

4. A client being treated with lisinopril (Zestril) develops a hacking cough. The nurse should tell the client to:
A. Take half the dose to control the problem
B. Take cough medication to control the problem
C. Stop the medication
D. Report the problem to the doctor

5. An elderly client taking digitalis develops constipation. The nurse is aware that constipation in a client taking digitalis might:
A. Develop an elevated digitalis level
B. Have a decrease in the digitalis levels
C. Have alterations in sodium levels
D. Develop tachycardia

6. The client is suspected of having had a myocardium infarction. Which diagnostic finding is most significant?
A. LDH
B. Troponin
C. Creatinine
D. AST

7. A client with an internally implanted defibrillator should be taught to:
A. Avoid driving a car
B. Avoid eating food cooked in a microwave
C. Refrain from using a cellular phone
D. Report swelling at the site

8. A client is scheduled for a cardiac catheterization. Following the procedure, the nurse should:
A. Assess for allergy to iodine
B. Check pulses proximal to the site
C. Assess the urinary output
D. Check to ensure that the client has a consent form signed

9. A client with Buerger’s disease complains of pain in the lower extremities. The nurse is aware that Buerger’s disease is also called:
A. Pheochromocytoma
B. Intermittent claudication
C. Kawasaki disease
D. Thromboangiitis obliterans

10. A client with an abdominal aneurysm frequently complains of:
A. A headache
B. Shortness of breath only during sleep
C. Lower back pain
D. Difficulty voiding

Health Assessment Lecture: Respiratory System D

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

Thoracic Percussion

Percussion sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. The nurse uses percussion to determine whether underlying tissues are filled with air, fluid, or solid material. Percussion also is used to estimate the size and location of certain structures within the thorax (eg, diaphragm, heart, liver).

Percussion usually begins with the posterior thorax. Ideally, the patient is in a sitting position with the head flexed forward and the arms crossed on the lap. This position separates the scapulae widely and exposes more lung area for assessment. The nurse percusses across each shoulder top, locating the 5-cm width

of resonance overlying the lung apices. Then the nurse proceeds down the posterior thorax, percussing symmetric areas at 5- to 6-cm (2- to 2.5-inch) intervals. The middle finger is positioned parallel to the ribs in the intercostal space; the finger is placed firmly against the chest wall before striking it with the middle finger of the opposite hand. Bony structures (scapulae or ribs) are not percussed.

Percussion over the anterior chest is performed with the patient in an upright position with shoulders arched backward and arms at the side. The nurse begins in the supraclavicular area and proceeds downward, from one intercostal space to the next. In the female patient, it may be necessary to displace the breasts for an adequate examination. Dullness noted to the left of the sternum between the third and fifth intercostal spaces is a normal finding because it is the location of the heart. Similarly, there is a normal span of liver dullness in the right thorax from the fifth intercostal space to the right costal margin at the midclavicular line. The anterior and lateral thorax is examined with the patient in a supine position. If the patient cannot sit up, percussion of the posterior thorax is performed with the patient positioned on the side. Dullness over the lung occurs when air-filled lung tissue is replaced by fluid or solid tissue. 

DIAPHRAGMATIC EXCURSION

The normal resonance of the lung stops at the diaphragm. The position of the diaphragm is different during inspiration than during expiration. To assess the position and motion of the diaphragm, the nurse instructs the patient to take a deep breath and hold it while the maximal descent of the diaphragm is percussed. The point at which the percussion note at the midscapular line changes from resonance to dullness is marked with a pen. The patient is then instructed to exhale fully and hold it while the nurse again percusses downward to the dullness of the diaphragm. This point is also marked. The distance between the two markings indicates

the range of motion of the diaphragm. Maximal excursion of the diaphragm may be as much as 8 to 10 cm (3 to 4 inches) in healthy, tall young men, but for most people it is usually 5 to 7 cm (2 to 2.75 inches). 

Normally, the diaphragm is about 2 cm (0.75 inches) higher on the right because of the position of the heart and the liver above and below the left and right segments of the diaphragm, respectively. Decreased diaphragmatic excursion may occur with pleural effusion and emphysema. An increase in intra-abdominal pressure, as in pregnancy or ascites, may account for a diaphragm that is positioned high in the thorax.

Health Assessment Lecture: Respiratory System C

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

Thoracic Palpation

The nurse palpates the thorax for tenderness, masses, lesions, respiratory excursion, and vocal fremitus. If the patient has reported an area of pain or if lesions are apparent, the nurse performs direct palpation with the fingertips (for skin lesions and subcutaneous masses) or with the ball of the hand (for deeper masses or

generalized flank or rib discomfort).

RESPIRATORY EXCURSION

Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. The nurse assesses the patient for range and symmetry of excursion. The patient is instructed to inhale deeply while the movement of the nurse’s thumbs (placed along the costal margin on the anterior chest wall) during inspiration and expiration is observed. This movement is normally symmetric. 

Posterior assessment is performed by placing the thumbs adjacent to the spinal column at the level of the tenth rib. The hands lightly grasp the lateral rib cage. Sliding the thumbs medially about 2.5 cm (1 inch) raises a small skinfold between the thumbs. The patient is instructed to take a full inspiration and to exhale fully. The nurse observes for normal flattening of the skinfold and feels the symmetric movement of the thorax.

Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction.

TACTILE FREMITUS

Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. This is especially true of consonant sounds. The detection of the resulting vibration on the chest wall by touch is called tactile fremitus.

Normal fremitus is widely varied. It is influenced by the thickness of the chest wall, especially if that thickness is muscular. However, the increase in subcutaneous tissue associated with obesity may also affect fremitus. Lower-pitched sounds travel better through the normal lung and produce greater vibration of the chest wall. Thus, fremitus is more pronounced in men than in women because of the deeper male voice. 

Normally, fremitus is most pronounced where the large bronchi are closest to the chest wall and least palpable over the distant lung fields. Therefore, it is most palpable in the upper thorax, anteriorly and posteriorly. The patient is asked to repeat “ninety-nine” or “one, two, three,” or “eee, eee, eee” as the nurse’s hands move down the patient’s thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared . Bony areas are not tested.

Air does not conduct sound well but a solid substance such as tissue does, provided that it has elasticity and is not compressed. Thus, an increase in solid tissue per unit volume of lung will enhance fremitus; an increase in air per unit volume of lung will impede sound. Patients with emphysema, which results in the rupture of alveoli and trapping of air, exhibit almost no tactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased tactile fremitus over that lobe. Air in the pleural space will not conduct sound.

Health Assessment Lecture: Respiratory System B

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING

Thorax

Inspection of the thorax provides information about the musculoskeletal structure, the patient’s nutritional status, and the respiratory system. The nurse observes the skin over the thorax for color and turgor and for evidence of loss of subcutaneous tissue. It is important to note asymmetry, if present. When findings are

recorded or reported, anatomic landmarks are used as points of reference

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CHEST CONFIGURATION

Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1 2. However, there are four main deformities of the chest associated with respiratory disease that alter this relationship: barrel chest, funnel chest (pectus excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis.

Barrel Chest. Barrel chest occurs as a result of overinflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The appearance of the patient with advanced emphysema is thus quite characteristic and often allows the observer to detect its presence easily, even from a distance.

Funnel Chest (Pectus Excavatum). Funnel chest occurs when there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfan’s syndrome.

Pigeon Chest (Pectus Carinatum). A pigeon chest occurs as a result of displacement of the sternum. There is an increase in the anteroposterior diameter. This may occur with rickets, Marfan’s syndrome, or severe kyphoscoliosis.

Kyphoscoliosis. A kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.

BREATHING PATTERNS AND RESPIRATORY RATES

Observing the rate and depth of respiration is a simple but important aspect of assessment. The normal adult who is resting comfortably takes 12 to 18 breaths per minute. Except for occasional sighs, respirations are regular in depth and rhythm. This normal pattern is described as eupnea. 

Bradypnea, also called slow breathing, is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea, or rapid breathing, is commonly seen in patients with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, and rib fracture.  Shallow, irregular breathing is referred to as hypoventilation. An increase in depth of respirations is called hyperpnea. 

An increase in both rate and depth that results in a lowered arterial PCO2 level is referred to as hyperventilation. With rapid breathing, inspiration and expiration are nearly equal in duration. Hyperventilation that is marked by an increase in rate and depth, associated with severe acidosis of diabetic or renal origin, is called Kussmaul’s respiration.

Apnea describes varying periods of cessation of breathing. If sustained, apnea is life-threatening.

Cheyne-Stokes respiration is characterized by alternating episodes of apnea (cessation of breathing) and periods of deep breathing. Deep respirations become increasingly shallow, followed by apnea that may last approximately 20 seconds. The cycle repeats after each apneic period. The duration of the period of apnea may vary and may progressively lengthen; therefore, it is timed and reported. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced, tumor, trauma).

Biot’s respirations, or cluster breathing, are cycles of breaths that vary in depth and have varying periods of apnea. Biot’s respirations are seen with some central nervous system disorders.

Certain patterns of respiration are characteristic of specific disease states. Respiratory rhythms and their deviation from normal are important observations that the nurse reports and documents. The rate and depth of different patterns of respiration are presented

In thin people, it is quite normal to note a slight retraction of the intercostal spaces during quiet breathing. Bulging during expiration implies obstruction of expiratory airflow, as in emphysema. Marked retraction on inspiration, particularly if asymmetric, implies blockage of a branch of the respiratory tree. Asymmetric bulging of the intercostal spaces, on one side or the other, is created by an increase in pressure within the hemithorax. This may be a result of air trapped under pressure within the pleural cavity where it does not normally appear (pneumothorax) or the pressure of fluid within the pleural space (pleural effusion).

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Nursing Theory Lecture 15: Myra Estrin Levine

Myra Estrin Levine

(1973)

Conservation Model

Conservation Model
• Believes nursing intervention is a conservation activity, with conservation of energy as a primary concern, four conservation principles of nursing: conservation of client energy, conservation of structured integrity, conservation of personal integrity, conservation of social integrity.
• Described the Four Conversation Principles. She advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of the individual. The four conservation principles are as follows:
1. Conservation of energy. The human body functions by utilizing energy. The human body needs energy producing input (food, oxygen, fluids) to allow energy utilization output.
2. Conservation of Structural Integrity. The human body has physical boundaries (skin and mucous membrane) that must be maintained to facilitate health and prevent harmful agents from entering the body.
3. Conservation of Personal Integrity. The nursing interventions are based on the conservation of the individual client’s personality. Every individual has sense of identity, self worth and self esteem, which must be preserved and enhanced by nurses.
4. Conservation of Social integrity. The social integrity of the client reflects the family and the community in which the client functions. Health care institutions may separate individuals from their family. It is important for nurses to consider the individual in the context of the family.

Metaparadigm

Person
• A holistic being

Environment
• Broadly, includes all the individual’s experiences

Health
• The maintenance of the client’s unity and integrity

Nursing
• A discipline rooted in the organic dependency of the individual human being on his or her relationship with others

Nursing Theory Lecture 14: Martha Rogers

Martha Rogers

(1970)

Science of Unitary Man

Science of Unitary Man
• Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is concerned with the nature and direction of human development.
• Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the Individual and redirect human and environmental patterns or organization to achieve maximum health.
• 5 basic assumptions:
1. The human being is a unified whole, possessing individual integrity and manifesting characteristics that are more than and different from the sum of parts.
2. The individual and the environment are continuously exchanging matter and energy with each other.
3. The life processes of human beings evolve irreversibly and unidirectionally along a space-time continuum 4. Patterns identify human being and reflect their innovative wholeness.
5. The individual is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion.

Metaparadigm

Person
• Unitary man, a four-dimensional energy field.

Environment
• Encompasses all that is outside any given human field. Person exchanging matter and energy.

Health
• Not specifically addressed, but emerges out of interaction between human and environment, moves forward, and maximizes human potential.

Nursing
• A learned profession that is both science and art. The professional practice of nursing is creative and imaginative and exists to serve people.

Nursing Theory Lecture 13: Madeleine Leininger

Madeleine Leininger

(1978, 1984)

Transcultural Care Theory and Ethnonursing

Transcultural Care Theory and Ethnonursing
• Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition.
• Nursing is a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death.
• Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness caring practices, beliefs and values with the goal to provide meaningful and efficacious nursing care services to people according to their cultural values and health-illness context.
• Focuses on the fact that different cultures have different caring behaviors and different health and illness values, beliefs, and patterns of behaviors.
• Awareness of the differences allows the nurse to design culture-specific nursing interventions.

Nursing Theory Lecture 12: Lydia Hall

Lydia Hall

(1964)

Core, Care and Cure Model

Core, Care and Cure Model
• The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment (cure) and body (care).
• Introduced the model of Nursing: What Is It? Focusing on the notion that centers around three components of Care, Core and Cure.
• Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing related to the physician’s orders. Core and cure are shared with the other health care providers.
• The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core.

Metaparadigm

Person
• Client is composed of body, pathology, and person. People set their own goals and are capable of learning and growing.

Environment
• Should facilitate achievement of the client’s personal goals.

Health
• Development of a mature self-identity that assists in the conscious selection of actions that facilitate growth.

Nursing
• Caring is the nurse’s primary function. Professional nursing is most important during the recuperative period.

Nursing Theory Lecture 11: Joyce Travelbee

Joyce Travelbee 

(1966, 1971) 

Interpersonal Aspects of Nursing 

 

Interpersonal Aspects of Nursing 

• She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing individual or family in preventing or coping with illness, regaining health finding meaning in illness, or maintaining maximal degree of health.

• She further viewed that interpersonal process is a human-to-human relationship formed during illness and “experience of suffering”

• She believed that a person is a unique, irreplaceable individual who is in a continuous process of becoming, evolving and changing.

Metaparadigm 

Person 

• A unique, irreplaceable individual who is in a continuous process of becoming, evolving, and changing.

Environment 

• Not defined

Health 

• Heath includes the individual’s perceptions of health and the absence of disease.

Nursing 

• An interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary, to find meaning in these experiences.

Nursing Theory 10: Jean Watson

Jean Watson 

(1979) 

The Philosophy and Science of Caring 

 The Philosophy and Science of Caring
• Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health.
• Nursing is a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human care transactions
• She defined caring as a nurturing way or responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the person as what he/she may become in a caring environment

Carative Factors:
1. The formation of a humanistic-altruistic system of values
2. Instillation of faith-hope
3. The cultivation of sensitivity to one’s self and others
4. The development of a helping- trust relationship
5. The promotion and acceptance of the expression of positive and negative feelings.
6. The systemic use of the scientific problem-solving method for decision making
7. The promotion of interpersonal teaching-learning
8. The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritual environment
9. Assistance with the gratification of human needs
10. The allowance for existential phenomenological forces

Metaparadigm

Person
• A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, integrated self

Environment 
• Social environment, caring and the culture of caring affect health

Health 
• Physical, mental, and social wellness

Nursing 
• A human science of people and human health; illness experiences that are mediated by professional, personal, scientific, aesthetic, and ethical human care transactions.

Nursing Theory Lecture 9: Imogene King

Imogene King 

(1971, 1981) 

Goal Attainment Theory 

 

Goal Attainment Theory 

• Nursing process is defined as dynamic interpersonal process between nurse, client and health care system.

• Postulated the Goal Attainment Theory. She described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. If is this not possible, nurses help individuals die with dignity.

• In addition, King viewed nursing as an interaction process between client and nurse whereby during perceiving, setting goals, and acting on them transactions occurred and goals are achieved.

Metaparadigm 

Person 

• Biopsychosocial being

Environment 

• Internal and external environment continually interacts to assist in adjustments to change.

Health 

• A dynamic life experience with continued goal attainment and adjustment to stressors.

Nursing 

• Perceiving, thinking, relating, judging, and acting with an individual who comes to a nursing situations

Nursing Theory Lecture 8: Hildegard Peplau

Hildegard Peplau 

(1951) 

Interpersonal Relations Theory 

Interpersonal Relations Theory 
• Defined Nursing: “An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.
• Nursing is a “maturing force and an educative instrument”
• Identified 4 phases of the Nurse - Patient relationship:

1. Orientation - individual/family has a “felt need” and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase.

2. Identification - where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance.

3. Exploitation - the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services.

4. Resolution - where patient’s needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.


Metaparadigm 

Person 
• An organism striving to reduce tension generated by needs

Environment 
• The interpersonal process is always included, and psychodynamic milieu receives attention, with emphasis on the client’s culture and mores.

Health 
• Ongoing human process that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living.

Nursing 
• Interpersonal therapeutic process that “functions cooperatively with others human processes that make health possible for individuals in communities. Nursing is an educative instrument, a maturing force that aims to promote forward movement of personality.