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

Anatomy and Physiology Notes: Gastrointestinal-Hepatobillary System

This is an outlined lecture note on the Anatomy and Physiology of theGastrointestinal-Hepatobillary System. Some information are so compressed that some concepts are not explained in detail. If it is your first time to meet such information please refer to your textbook for further explanation of the concept. This review material requires a student to have a prior knowledge and good foundation of the subject matter for this only emphasizes important/ key information deemed important in understanding advanced concept in Pathophysiology and Medical Surgical Nursing.

Functions of the gastrointestinal system
- Process food substances.
- Absorb the products of digestion into the blood.
- Excrete unabsorbed materials.
- Provide an environment for microorganisms to synthesize nutrients, such as vitamin K.

 Mouth
- Contains the lips, cheeks, palate, tongue, teeth, salivary glands, muscles, and maxillary bones
- Saliva contains the amylase enzyme (ptyalin) that aids in digestion.

Esophagus
- Collapsible muscular tube about 10 inches long
- Carries food from the pharynx to the stomach


The stomach
- Contains the cardia, fundus, the body, and the pylorus
- Mucous glands are located in the mucosa and prevent autodigestion by providing an alkaline protective covering.
- The lower esophageal (cardiac) sphincter prevents reflux of gastric contents into the esophagus.
- The pyloric sphincter regulates the rate of stomach emptying into the small intestine.
- Hydrochloric acid kills microorganisms, breaks food into small particles, and provides a chemical environment that facilitates gastric enzyme activation.
- Pepsin is the chief coenzyme of gastric juice, which converts proteins into proteases and peptones.
- Intrinsic factor is necessary for the absorption of vitamin B12.
- Gastrin controls gastric acidity.

Small intestine
- The duodenum contains the openings of the bile and pancreatic ducts.
- The jejunum is about 8 feet long.
- The ileum is about 12 feet long.
- The small intestine terminates in the cecum.

Pancreatic intestinal juice enzymes
- Amylase digests starch to maltose.
- Maltase reduces maltose to monosaccharide glucose.
-  Lactase splits lactose into galactose and glucose.
- Sucrase reduces sucrose to fructose and glucose.
- Nucleases split nucleic acids to nucleotides.
-. Enterokinase activates trypsinogen to trypsin.


Large intestine
- About 5 feet long
- Absorbs water and eliminates wastes
- Intestinal bacteria play a vital role in the synthesis of some B vitamins and vitamin K.
- Colon: Includes the ascending, transverse, descending, and sigmoid colons and rectum
- The ileocecal valve prevents contents of the large intestine from entering the ileum.
- The anal sphincters control the anal canal.

Peritoneum: Lines the abdominal cavity and forms the mesentery that supports
the intestines and blood supply

Liver
-The largest gland in the body, weighing 3 to 4 lb.
-Contains Kupffer's cells, which remove bacteria in the portal venous blood
- Removes excess glucose and amino acids from the portal blood
- Synthesizes glucose, amino acids, and fats
- Aids in the digestion of fats, carbohydrates, and proteins
- Stores and filters blood (200 to 400 mL of blood stored)
- Stores vitamins A, D, and B and iron
- The liver secretes bile to emulsify fats (500 to 1000 mL of bile/day).
 Hepatic ducts
a. Deliver bile to the gallbladder via the cystic duct and to the
duodenum via the common bile duct.
b. The common bile duct opens into the duodenum, with the pancreatic duct at the ampulla of Vater.
c. The sphincter prevents the reflux of intestinal contents into the
common bile duct and pancreatic duct.

Gallbladder
-Stores and concentrates bile and contracts to force bile into the duodenum during the digestion of fats
- The cystic duct joins the hepatic duct to form the common bile duct.
- The sphincter of Oddi is located at the entrance to the duodenum.
- The presence of fatty materials in the duodenum stimulates the liberation of cholecystokinin, which causes contraction of the gallbladder and relaxation of the sphincter of Oddi.

Pancreas
Exocrine gland
- Secretes sodium bicarbonate to neutralize the acidity of the stomach contents that enter the duodenum
-. Pancreatic juices contain enzymes for digesting carbohydrates, fats, and proteins.
Endocrine gland
- Secretes glucagon to raise blood glucose levels and secretes somatostatin to exert a hypoglycemic effect
- The islets of Langerhans secrete insulin.
- Insulin is secreted into the bloodstream and is important for carbohydrate metabolism.

“If at first you don't succeed, try, try again. Then quit. No use being a damn fool about it.”  -WC Fields

Anatomy and Physiology Notes: Endocrine System

This is an outlined lecture note on the Anatomy and Physiology of the Endocrine System. Some information are so compressed that some concepts are not explained in detail. If it is your first time to meet such information please refer to your textbook for further explanation of the concept. This review material requires a student to have a prior knowledge and good foundation of the subject matter for this only emphasizes important/ key information deemed important in understanding advanced concept in Pathophysiology and Medical Surgical Nursing.


Functions of Endocrine Glands
- Maintenance and regulation of vital functions
- Response to stress and injury
- Growth and development
- Energy metabolism
- Reproduction
- Fluid, electrolyte, and acid-base balance

Hypothalamus 
- Portion of the diencephalon of the brain, forming the floor and part of the lateral wall of the third ventricle
- Activates, controls, and integrates the peripheral autonomic nervous system, endocrine processes, and many somatic functions, such as body temperature, sleep, and appetite

Pituitary gland 
- The master gland; located at the base of the brain 2. Influenced by the hypothalamus; directly affects the function of the other endocrine glands
- Promotes growth of body tissue, influences water absorption by the kidney, and controls sexual development and function

Adrenal gland
- One adrenal gland is on top of each kidney.
- Regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein metabolism; influences the development of sexual characteristics; and sustains the fight-or-flight response
 Adrenal cortex
- The cortex is the outer shell of the adrenal gland.
-. The cortex synthesizes glucocorticoids and mineralocorticoids and secretes small amounts of sex hormones
Adrenal medulla
- The medulla is the inner core of the adrenal gland.
- The medulla works as part of the sympathetic nervous system and produces epinephrine and norepinephrine.

Thyroid gland
- Located in the anterior part of the neck
- Controls the rate of body metabolism and growth and produces thyroxine (T4), triiodothyronine (T3), and thyrocalcitonin

Parathyroid glands
- Located on the thyroid gland
- Control calcium and phosphorus metabolism; produce parathyroid hormone

Pancreas
- Located posteriorly to the stomach
- Influences carbohydrate metabolism, indirectly influences fat and protein metabolism, and produces insulin and glucagon

Ovaries and testes
-The ovaries are located in the pelvic cavity and produce estrogen and progesterone.
-The testes are located in the scrotum, control the development of the secondary sex characteristics, and produce testosterone.

Negative feedback loop
-Regulates hormone secretion by the hypothalamus and pituitary gland
-Increased amounts of target gland hormones in the bloodstream decrease secretion of the same hormone and other hormones that stimulate its release.

“Success is getting what you want, happiness is wanting what you get” -Kinsela

Human Immunodeficiency Virus / Acquired immunodeficiency syndrome Lecture Notes

This is a Medical Surgical Nursing lecture note on AIDS/HIV in outlined format. Information and concepts are compressed to provide a quick review of the topic. Some information are so compressed that some concepts are not expounded in detail. If it is your first time to meet such information please refer to your textbook for further explanation of the concept. This review material requires a student to have a prior knowledge and good foundation of the subject matter for this only emphasizes important/ key information deemed important in understanding concepts in Pathophysiology and Medical Surgical Nursing.

Acquired immunodeficiency syndrome (AIDS)

•  AIDS is a viral disease caused by human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy
•  The syndrome is manifested clinically by opportunistic infection and unusual neoplasms.
• AIDS is considered a chronic illness.
• The disease has a long incubation period, sometimes 10 years or longer.
• Manifestations may not appear until late in the infection.

High-risk groups
Heterosexual or homosexual contact with high-risk individuals
Intravenous drug abusers
Persons receiving blood products
Health care workers
Babies born to infected mothers

Assessment
Malaise, fever, anorexia, weight loss, influenza-like symptoms
Lymphadenopathy for at least 3 months
Leukopenia
Diarrhea
Fatigue
Night sweats
Presence of opportunistic infections
Protozoal infections (Pneumocystis jiroveci pneumonia, major source of mortality)
Neoplasms (Kaposi's sarcoma, purplish-red lesions of internal organs and skin, B-cell non-Hodgkin's lymphoma, cervical cancer)
Fungal infections (candidiasis, histoplasmosis)
Viral infections (cytomegalovirus, herpes simplex)
Bacterial infections

Interventions
1. Provide respiratory support.
2. Administer oxygen and respiratory treatments as prescribed.
3. Provide psychosocial support as needed.
4. Maintain fluid and electrolyte balance.
5. Monitor for signs of infection.
6. Prevent the spread of infection.
7. Initiate standard precautions.
8. Provide comfort as necessary.
9. Provide meticulous skin care.
10. Provide adequate nutritional support as prescribed.

"Success is not final, failure is not fatal: it is the courage to continue that counts"

Nursing Leader: Sanger and Breckinridge

This is a series of post regarding notable nursing leaders who have given many contribution to nursing and their influence uplifted the nursing profession.


Nursing Leaders
Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable contributions both to nursing's history and to women's history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory  development.

Sanger (1879-1966)
Margaret Biggins Sanger, a public health nurse in New York, has had a lasting impact on women's health care. Imprisoned for opening the first birth control information clinic in America, she is considered the founder of Planned Parenthood. Her experience with the large number of unwanted pregnancies among the working poor was instrumental in addressing this problem.

Breckinridge (1881-1965)
After World War I, Mary Breckinridge, a notable pioneer nurse, established the Frontier Nursing Service (FNS). In 1918, she worked with the American Committee for Devastated France, distributing food, clothing, and supplies to rural villages and taking care of sick children. In 1921, Breckinridge returned to the United States with plans to provide health care to the people of rural America. In 1925, Breckinridge and two other nurses began the FNS in Leslie County, Kentucky. Within this organization, Breckinridge started one of the first midwifery training schools in the United States.

Nursing Leader: Lavinia Dock

This is a series of post regarding notable nursing leaders who have given many contribution to nursing and their influence uplifted the nursing profession.


Nursing Leaders
Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable contributions both to nursing's history and to women's history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory  development.


Dock (1858-1956)
Lavinia L. Dock was a feminist, prolific writer, political activist, suffragette, and friend- of Wald. She participated in protest movements for women's rights that resulted in the 1920 passage of the 19th Amendment to the U.S. Constitution, which granted women the right to vote. In addition, Dock campaigned for legislation to allow nurses rather than physicians to control their profession. In 1893, Dock, with the assistance of Mary Adelaide Nutting and Isabel Hampton Robb, founded the American Society of Superintendents of Training Schools for Nurses of the United States and Canada, a precursor to the current National League for Nursing.

Biography

 Lavinia Dock was born in Harrisburg, Pennsylvania in 1858. She graduated from the Bellevue Training School for Nurses in 1886. In 1889 she helped in the disaster relief effort following the devastating flood in Johnstown, Pennsylvania. In 1890 she became Isabel Hampton's assistant superintendent at the Johns Hopkins Hospital Training School for Nurses, where she was in charge of instruction . The same year, her textbook Materia Medica for Nurses which quickly became a standard in Nursing curriculum was published. She spoke at the Columbian Exposition at the World's Fair in Chicago in 1893. In 1907, along with Mary Adelaide Nutting she wrote the illustrated A History of Nursing. She went on to write more books on the history of nursing, including A Short History of Nursing with Isabel M. Stewart in 1920, and History of American Red Cross Nursing with Sarah E. Pickett in 1922. She was a member of the Nurses' Settlement in New York, Secretary of the American Federation of Nurses and of the International Council of Nurses. She was also a member of the National Women's Party which campaigned for the equal rights amendment introduced in 1923. She served as secretary for the International Council of Nurses from 1899 to 1922. From 1900 to 1923 she was a contributing editor for the American Journal of Nursing's "Foreign Department". She was made an honorary member of the Johns Hopkins Nurses' Alumnae Association at its founding in 1892. In 1976 she was inducted into the American Nurses Association Hall of Fame.

Nursing Leader: Lillian Wald

This is a series of post regarding notable nursing leaders who have given many contribution to nursing and their influence uplifted the nursing profession.


Nursing Leaders
Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable contributions both to nursing's history and to women's history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory  development


Wald (1867-1940)
Lillian Wald (Figure 1-13 •) is considered the founder of public health nursing. Wald and Mary Brewster were the first to offer trained nursing services to the poor in the New York slums. Their home among the poor on the upper floor of a tenement, called the Henry Street Settlement and Visiting Nurse Service,provided nursing services, social services, and organized educational and cultural activities. Soon after the founding of the

Lillian Wald invented public health nursing in 1893, making this year the field's centennial. One of nursing's visionaries, Wald secured reforms in health, industry, education, recreation, and housing. This historical inquiry examines three of Wald's critical experiments, each of which illuminates the past of public health nursing and its contemporary dilemmas: invention of public health nursing itself, establishment of a nationwide system of insurance payments for home-based care, and creation of a national public health nursing service.

Lllian Wald was born into a comfortable Jewish family in 1867, but chose to work in the tenements of New York City. She coined the phrase “public health nursing” and is considered to be the founder of that profession.

Lillian was educated at a private boarding school. She had graduated from a two-year nursing program and was taking classes at the Women’s Medical College when she became involved in organizing a class in home nursing for poor immigrants on New York’s Lower East Side. Lillian, distressed by the conditions in the multi-story walk-up, cold-water flats, moved to the neighborhood and, along with her classmate and colleague Mary Brewster, volunteered her services as a visiting nurse. With the aid of a couple of wealthy patrons, the operation quickly grew in size. The Henry Street Settlement (otherwise known as the VNS, or Visiting Nurse Service) grew from 2 nurses in 1893 to 27 in 1906, and to 92 in 1913.

The nurses educated the tenement residents about infection control, disease transmission, and personal hygiene. They stressed the importance of preventative care, but also provided acute and long-term care for the ill. They received fees based on the patient’s ability to pay. The organization also eventually incorporated housing, employment, and educational assistance and recreational programs as well. In 1912, Wald helped found the National Organization for Public Health Nursing, which would set professional standards and share information. She served as its first president.

Her other accomplishments included:
• Persuading President Theodore Roosevelt to create a Federal Children’s Bureau to protect children from abuse, especially exploitation such as improper child labor.
• Lobbying for health inspections of the workplace to protect workers from unsafe conditions and encouraging employers to have nursing or medical professionals on-site.
• Convincing the New York Board of Education to hire its first nurse, which lead to the standard practice within in the U.S. of having a nurse on duty at schools.
• Persuading Columbia University to appoint the first professor of nursing in the country, and initiating a series of lectures for prospective nurses at Columbia’s Teachers College. This became the basis a few years later for the University’s Department of Nursing and Health and caused nursing education to shift away from solely hospital-taught training to university courses augmented by hospital fieldwork.

Wald wrote two books about her experiences, The House on Henry Street, and Windows on Henry Street. She died in Westport, Connecticut, on September 1, 1940. Wald’s legacy is seen in the lasting good of her many accomplishments in the areas of public health and social services, not the least of which is her founding of the VNS. The New York Visiting Nurse Service continued to grow and thrive, increasing to 3,000 employees, with the number of people served annually now totaling 700,000. The original VNS is still a model for the 13,000 visiting nurse groups which exist today.

Wald said, “Nursing is love in action, and there is no finer manifestation of it than the care of the poor and disabled in their own homes.”

Summary
Wald coined the term "public health nurse" in 1893 for nurses who worked outside hospitals in poor and middle-class communities. Specializing in both preventative care and the preservation of health, these nurses responded to referrals from physicians and patients, and received fees based on the patient's ability to pay. In response to growing demand from all sides, Wald helped to initiate a series of lectures to educate prospective nurses at Columbia University's Teachers College in 1899. Students attended classes at Columbia and received their field training at Henry Street. This series led to the formation of the University's Department of Nursing and Health in 1910. By 1912, public health nurses—sometimes called visiting or district nurses—had begun to have significant impact. Wald and her colleagues in the public health movement recognized the need for the establishment of professional standards for public health nurses. Like other professional organizations, the National Organization of Public Health Nurses (NOPHN) was designed to set professional standards, share techniques and protect the reputations of its members. Wald was elected as the organization's first president.

Nursing Leader: Mary Mahoney

This is a series of post regarding notable nursing leaders who have given many contribution to nursing and their influence uplifted the nursing profession.


Nursing Leaders
Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable contributions both to nursing's history and to women's history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory  development


Mahoney (1845-1926)
Mary Mahoney  was the first African American professional nurse. She graduated from the New England Hospital for Women and Children in 1879. She constantly worked for the acceptance of African Americans in nursing and for the promotion of equal opportunities (Donahue, 1996, p. 271). The American Nurses Association (2006b) gives a Mary Mahoney Award biennially in recognition of significant contributions in
interracial relationships.

Nursing Leader: Clara Barton

This is a series of post regarding notable nursing leaders who have given many contribution to nursing and their influence uplifted the nursing profession.


Nursing Leaders
Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable contributions both to nursing's history and to women's history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory  development.



Barton (1812-1912)
Clara Barton (Figure 1-10 • ) was a schoolteacher who volunteered as a nurse during the American Civil War. Her responsibility was to organize the nursing services. Barton is noted for her role in establishing the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Treaty of Geneva (Geneva Convention). It was Barton who persuaded Congress in 1882 to ratify this
treaty so that the Red Cross could perform humanitarian efforts in time of peace.


More About Clara Barton ( From American Red Cross)
Clarissa Harlowe Barton, Clara, as she wished to be called, is one of the most honored women in American history. She began teaching school at a time when most teachers were men and she was among the first women to gain employment in the federal government. Barton risked her life to bring supplies and support to soldiers in the field during the Civil War. At age 60, she founded the American Red Cross in 1881 and led it for the next 23 years. Her understanding of the needs of people in distress and the ways in which she could provide help to them guided her throughout her life. By the force of her personal example, she opened paths to the new field of volunteer service. Her intense devotion to serving others resulted in enough achievements to fill several ordinary lifetimes


Inspired by her experiences in Europe, Barton corresponded with Red Cross officials in Switzerland after her return to the United States. They recognized her leadership abilities for including this country in the global Red Cross network and for influencing the United States government to sign the Geneva Treaty. Armed with a letter from the head of the International Committee of the Red Cross, Barton took her appeal to President Rutherford B. Hayes in 1877, but he looked on the treaty as a possible “entangling alliance” and rejected it. His successor, President James Garfield, was supportive and seemed ready to sign it when he was assassinated. Finally, Garfield’s successor, Chester Arthur, signed the treaty in 1882 and a few days later the Senate ratified it.

In 1881—with the signing of the treaty in sight—Barton and a group of supporters formed the American Association of the Red Cross as a District of Columbia corporation. Reincorporated as The American National Red Cross in 1893, the organization was given charters by Congress in 1900 and in 1905. The 1905 charter and its amendments provide the basis for today’s American Red Cross and the close working relationship between the organization and the federal government.

The American Red Cross, with Barton at its head, was largely devoted to disaster relief for the first 20 years of its existence. The Red Cross flag flew officially for the first time in this country in 1881 when Barton issued a public appeal for funds and clothing to aid victims of a devastating forest fire in Michigan. In 1884, she chartered steamers to carry needed supplies up and down the Ohio and Mississippi rivers to assist flood victims. In 1889, she and 50 volunteers rode the first train into Johnstown, Pennsylvania, to help the survivors of a dam break that caused over 2,000 deaths.

In 1892, she organized assistance for Russians suffering from famine by shipping them 500 railroad cars of Iowa cornmeal and flour. After a hurricane and tidal wave left over 5,000 dead on the Sea Islands of South Carolina in 1893, Barton’s Red Cross labored for 10 months helping the predominantly African-American population recover and reestablish their agricultural economy. In 1896, Barton directed relief operations on behalf of victims of unrest in Turkey and Armenia, the sole woman and only Red Cross advocate the Turkish government allowed to intervene. During her last relief operation, in 1900, Barton distributed over $120,000 in financial assistance and supplies to survivors of the hurricane and tidal wave that struck Galveston, Texas, and caused more than 6,000 deaths.

Although Henry Dunant had suggested in 1864 that Red Cross societies provide disaster relief as well as wartime services, Barton became its strongest advocate in the years that followed. During the Third International Red Cross Conference in Geneva in 1884, the American Red Cross proposed an amendment to the Geneva Treaty calling for expansion of Red Cross relief to include victims of natural disasters. Although some national societies were dubious, the resolution passed and became known as the “American Amendment” to the Geneva Treaty of 1864. Because of work like this in support of the global Red Cross network, several countries honored Barton with decorations, such as the German Iron Cross for her relief work in the Franco-Prussian War and the Silver Cross of Imperial Russia for the supplies provided during the famine of 1892.

The American Red Cross moved in a new direction near the end of Barton’s tenure as head of the organization when we delivered supplies and services to Cuba during the Spanish-American War. Recipients of Red Cross aid included members of the American armed forces, prisoners of war, and Cuban refugees. This was the first time that the American Red Cross provided assistance to American armed forces and civilians during wartime.

Nursing Leader: Florence Nightingale

This is a series of post regarding notable nursing leaders who have given many contribution to nursing and their influence uplifted the nursing profession.

Nursing Leaders

Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable contributions both to nursing's history and to women's history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory  development.

Nightingale (1820-1910)

Florence Nightingale's contributions to nursing are well documented. Her achievements in improving the standards for the care of war casualties in the Crimea earned her the title "Lady with the Lamp." Her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished political nurse: She was the first nurse to exert political pressure on government. Through her contributions to nursing education—perhaps her greatest achievement—she is also recognized as nursing's first scientist-theorist for her work Notes on Nursing: What It Is, and What It Is Not (1860/1969).

She was born to a wealthy and intellectual family. She believed she was "called by God to help others . . . [and] to improve the well-being of mankind" (Schuyler, 1992, p. 4). She was determined to become a nurse

in spite of opposition from her family and the restrictive societal code for affluent young English women. As a well-traveled young woman of the day, she visited Kaiserswerth in 1847, where she received 3 months' training in nursing. In 1853 she studied in Paris with the Sisters of Charity, after which she returned to England to assume the position of superintendent of a charity hospital for ill governesses.

When she returned to England from the Crimea, a grateful English public gave Nightingale an honorarium of £4500. She later used this money to develop the Nightingale Training School for Nurses, which opened in 1860. The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse-training programs.

Nightingale's vision of nursing, which included public health and health promotion roles for nurses, was only partially addressed in the early days of nursing. The focus tended to be  on developing the profession within hospitals.

Historical Background of Nursing 1

This post pertains to the historical background of the nursing profession-on how nursing evolved from a mere responsibility of women before to an evolving discipline. From a being a job of slaves during the dzrk period in Europe to being a noble job today. 

The contemporary nursing is far different from nursing as it was practiced years ago, and it is expected to continue evolving during the 21st century. To comprehend present-day nursing and at the same time prepare for the future, one must understand not only past events but also contemporary nursing practice and the sociological and historical factors that affect it.

HISTORICAL PERSPECTIVES
Nursing has undergone dramatic change in response to societal needs and influences. A look at nursing's beginnings reveals its continuing struggle for autonomy and professionalization. In recent decades, a renewed interest in nursing history has produced a growing amount of related literature. This section highlights only selected aspects of events that have influenced nursing practice. Recurring themes of women's roles and status, religious (Christian) values, war, societal attitudes, and visionary nursing leadership have influenced nursing practice in the past. Many of these factors still exert their influence today.

Women's Roles
Traditional female roles of wife, mother, daughter, and sister have always included the care and nurturing of other family members. From the beginning of time, women have cared for infants and children; thus, nursing could be said to have, its roots in "the home." Additionally, women, who in general occupied a subservient and dependent role, were called on to care for others in the community who were ill. Generally, the care provided was related to physical maintenance and comfort. Thus, the traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting.

Religion
Religion has also played a significant role in the development of nursing. Although many of the world's religions encourage benevolence, it was the Christian value of "love thy neighbor as thyself' and Christ's parable of the Good Samaritan that had a significant impact on the development of Western nursing. During the third and fourth centuries, several wealthy matrons of the Roman Empire, such as Fabiola, converted to Christianity and used their wealth to provide houses of care and healing (the forerunner of hospitals) for the poor, the sick, and the homeless. Women were not, however, the sole providers of nursing services.

The Crusades saw the formation of several orders of knights, including the Knights of Saint John of Jerusalem (also known as the Knights Hospitalers), the Teutonic Knights, and the Knights of Saint Lazarus . These brothers in arms provided nursing care to their sick and injured comrades. These orders also built hospitals, the organization and management of which set a standard for the administration of hospitals throughout Europe at that time. The Knights of Saint Lazarus dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions.

The deaconess groups, which had their origins in the Roman Empire of the third and fourth centuries, were suppressed during the Middle Ages by the Western churches. However, these groups of nursing providers resurfaced occasionally throughout the centuries, most notably in 1836 when Theodore Fliedner reinstituted
the Order of Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany. Florence Nightingale received her "training" in nursing at the Kaiserswerth School.

Early religious values, such as self-denial, spiritual calling, and devotion to duty and hard work, have dominated nursing throughout its history. Nurses' commitment to these values often resulted in exploitation and few monetary rewards. For some time, nurses themselves believed it was inappropriate to
expect economic gain from their "calling."

War
Throughout history, wars have accentuated the need for nurses. During the Crimean War (1854-1856), the inadequacy of care given to soldiers led to a public outcry in Great Britain. The role Florence Nightingale played in addressing this problem is well known. She was asked by Sir Sidney Herbert of the British War
Department to recruit a contingent of female nurses to provide care to the sick and injured in the Crimea. Nightingale and her nurses transformed the military hospitals by setting up sanitation practices, such as hand washing and washing clothing regularly. Nightingale is credited with performing miracles; the mortality rate in the Barrack Hospital in Turkey, for example, was reduced from 42% to 2%..

During the American Civil War (1861-1865), several nurses emerged who were notable for their contributions to a country torn by internal strife. Harriet Tubman and Sojourner Truth  provided care and safety to slaves fleeing to the North on the Underground Railroad. Mother Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Noted authors Walt Whitman and Louisa May Alcott volunteered as nurses to give care to injured soldiers in military hospitals. Another woman leader who provided nursing care during the Civil War was Dorothea Dix . She became the Union's Superintendent of Female Nurses responsible for recruiting nurses and supervising the nursing care of all women nurses working in the army hospitals.

The arrival of World War I resulted in American, British, and French women rushing to volunteer their nursing services. These nurses endured harsh environments and treated injuries not seen before. *A monument, entitled "The Spirit of Nursing," stands in Arlington National Cemetery . It honors the nurses who served in the U.S. Armed Services in World War I, many of whom are buried in Section 21 which is also called the "Nurses Section" (Military District of Washington, n.d.). Progress in health care occurred during World War I, particularly in the field of surgery. For example, there were advancements in the use of
anesthetic agents, infection control, blood typing, and prosthetics.

World War II casualties created an acute shortage of caregivers, and the Cadet Nurse Corps was established in response to a marked shortage of nurses (Figure 1-6 •). Also at that time, auxiliary health care workers became prominent. "Practical" nurses, aides, and technicians provided much of the actual nursing
care under the instruction and supervision of better prepared nurses. Medical specialties also arose at that time to meet the needs of hospitalized clients.

During the Vietnam War, approximately 90% of the 11,000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nursing school. This made them the youngest group of medical personnel ever to serve in wartime (Vietnam Women's Memorial Foundation, n.d.). Near the Vietnam Veterans Memorial ("The Wall") stands the Vietnam Women's Memorial . This monument was established to "honor the women who served and also for the families who
lost loved ones during the war . . . to let them know about the women who provided comfort, care and a human touch for those who were suffering and dying" (Vietnam Women's Memorial Foundation, n.d.).

Societal Attitudes
Society's attitudes about nurses and nursing have significantly influenced professional nursing.

Before the mid-1800s, nursing was without organization, education, or social status; the prevailing attitude was that a woman's place was in the home and that no respectable woman should have a career. The role for the Victorian middle-class woman was that of wife and mother, and any education she obtained was for the purpose of making her a pleasant companion to her husband and a responsible mother to her children. Nurses in hospitals during this period were poorly educated; some were even incarcerated criminals. Society's attitudes about nursing during this period are reflected in the writings of Charles Dickens. In his book Martin Chuzzlewit (1896), Dickens reflected his attitude toward nurses through his character Sairy Gamp. She "cared" for the sick by neglecting them, stealing from them, and physically abusing them (Donahue, 1996, p. 192). This literary portrayal of nurses greatly influenced the negative image and attitude toward nurses up to contemporary times.

In contrast, the guardian angel or angel of mercy image arose in the latter part of the 19th century, largely because of the work of Florence Nightingale during the Crimean War. After Nightingale brought respectability to the nursing profession, nurses were viewed as noble, compassionate, moral, religious, dedicated, and self-sacrificing.

Another image arising in the early 19th century that has affected subsequent generations of nurses and the public and other professionals working with nurses is the image of doctor's handmaiden. This image evolved when women had yet to obtain the right to vote, when family structures were largely paternalistic, and when the medical profession portrayed increasing use of scientific knowledge that, at that time, was viewed as a male domain. Since that time, several images of nursing have been portrayed. The heroine portrayal evolved
from nurses' acts of bravery in World War II and their contributions in fighting poliomyelitis—in particular, the work of the Australian nurse Elizabeth Kenney. Other, images in the late 1900s include the nurse as sex object, surrogate mother, tyrannical mother, and body expert.

During the past few decades, the nursing profession has taken steps to improve the image of the nurse. In the early 1990s, the Tri-Council for Nursing (the American Association of Colleges of Nursing, the American Nurses Association, the American Organization of Nurse Executives, and the National League for Nursing) initiated a national effort (titled "Nurses of America") to improve the image of nursing. More recently, the
Johnson & Johnson corporation contributed $20 million in 2002 to launch a "Campaign for Nursing's Future" to promote nursing as a positive career choice (Anonymous, 2003; Fitzpatrick, 2002). In addition, nursing schools and hospitals are targeting men in their recruitment efforts (Meyers, 2003).

“Success is most often achieved by those who don't know that failure is inevitable.” 

- Coco Chanel

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

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.