Foundations of Nursing SN Nanjunde Gowda
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1Foundations of Nursing2
3Foundations of Nursing
SN Nanjunde Gowda MSc (N) DPN Professor Medical Surgical Nursing Principal Dayananda Sagar Nursing College Bheemanahalli, Bengaluru–Mysore Main Road Ramanagar Taluk, Bidadi, Hobli Bengaluru Rural District Karnataka, India
4
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Foundations of Nursing
© 2010, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2010
9788184489798
Typeset at JPBMP typesetting unit
Printed at
5
The more credit you give away,
the more will come back to you.
The more you help others,
the more they will want to help you.
Brian Tracy6
7Advisors
Mary K Harmina msc (n) phd
Former Dean
Nizwa Nursing Institute
Ministry of Health
Sultanate of Oman
Cairo, Egypt
Nagarajaiah msc (n) phd
Department of Nursing
National Institute of Mental
Health and Neuro Sciences (NIMHANS),
Bengaluru, Karnataka, India
General Secretary
Indian Society of Psychiatric Nurses
Bengaluru, Karnataka, India
Rabecca Samson msc (n) phd
Graduate Midwife Program
Adelaide, South Australia
Nizwa Nursing Institute
Ministry of Health
Sultanate of Oman
Cairo, Egypt8
9Reviewers 11Foreword
The challenge of becoming a nurse has always been a considerable one. The work is often difficult emotionally and at times extremely hard physically. Over the years, nursing evolved through many forms and in recent years, it has become technically-based and scientifically challenging.
Human beings are goal-directed creatures constantly striving for meaning, significances and purpose. We all need a role for something to work towards, to give us a sense of value and control. The author of this book has used his clinical teaching and management expertise to bring out the contemporary and innovative thoughts practised in Indian hospitals and at the Department of Nursing, Ministry of Health, Sultanate of Oman, Cairo, Egypt. However, to implement the standard practices, author observed that how to get new innovative thoughts into mind and how to get the old ones out.
This book could also be called as The Nursing Insight and it is in plain English. The most enduring principles of nursing are presented with such vivid examples that there are no excuses for any one not to understand nursing.
I recommend this book to be used for BSc Nursing as well as general nursing students and should be on the book-shelf of every students and practicing nurse today.
I congratulate the author who has brought together the most important ideas from the old and new nursing principles under one cover Foundations of Nursing.
BN Muninarayanappa
Registrar
Karnataka State Nursing Council
Karnataka, India12
13Preface
It gives me immense pleasure and satisfaction to introduce the first edition of Foundations of Nursing to nursing community. In offering this title I remain grateful to readers, specially nursing teachers, who supported my books that is Basic Principles and Practice of Nursing, Fundamentals of Nursing for General Nursing and Midewifery, Intravenous Therapy for Nurses, Perioperative Nursing Manual and Clinical Nursing Diary.
The future of nursing promises dynamic and continuous changes, nurses of tomorrow need a broad knowledge base from which to provide care. The role of the nurse includes assuming the lead in preserving nursing practice and demonstrating its contribution to the health care of individual.
Foundations of Nursing is developed to prepare today's students for the challenges of tomorrow. This textbook is designed for students beginning all types of professional nursing programs. The comprehensive coverage provides fundamentals of nursing concepts, skills and techniques of nursing practice and a firm foundation for more advanced areas of study.
My sincere thought, if the nursing teachers, students and other health care personnel apply the scientific principles which are described in this book, they will be getting immense satisfaction. I sincerely welcome constructive criticism from readers that will help me to enrich my knowledge to contribute more to the profession.
The development of this book resulted from the combined effort of many talented professionals. I acknowledge their dedication, skill and professionalism. I am very proud to be associated with such fine individuals.
SN Nanjunde Gowda14
15Acknowledgments
A special acknowledgment to all our colleagues, for their cooperation and encouragement, I have received throughout the completion of this work.
My heartfelt thanks and gratitude to all reviewers for their valuable suggestions and technical inputs. When I requested to review this book, every reviewers devoted their valuable time, encouraged me and discussed each of its technical point, as to how each scientific principles enhance the client care.
My sincere appreciation also goes to my Fellow teachers and to all my students who have encouraged and participated in photographs and inspired in making this book possible.
My warmest appreciation goes to M/s Jaypee Brothers Medical Publishers, New Delhi, for sharing my vision for this book and giving me the chance to turn vision into reality.
Above all, I am thankful to almighty GOD for bestowing his bountiful grace for the successful completion of this book.16
21Abbreviations
When multiple meanings are possible, consider the context
A
abd
: Abdomen
ABG
: Arterial Blood Gases
ac
: Before Meals
A&E
: Accident and Emergency
ACLS
: Advanced Cardiac Life Support
ACTH
: Adreno Cortico Trophic Hormone
ADLs
: Activities of Daily Living
AF
: Anterior Fontanel
alb
: Albumin
alk phos
: Alkaline Phosphatase
Am
: Morning
amp
: Ampoule
appt
: Appointment
ARF
: Acute Renal Failure
Asst.
: Assistant/Assist
B
BBB
: Bundle Branch Block
BCG
: Bacilla Calmette Guerin (Immunization Shot)
b.i.d.
: Twice a Day
BM
: Bowel Movement
BP
: Blood Pressure
BPH
: Benign Prostatic Hypertrophy
BUN
: Blood Urea Nitrogen
C
C
: Centigrade
c
: With
Ca
: Calcium
cal
: Calorie
cap
: Capsule
CAT
: Computerized Axial Tomography
CBC
: Complete Blood Count
cc
: Cubic Centimeter
C/C
: Chief Complaint
CCU
: Coronary Care Unit
CHD
: Congestive Heart Disease
CHF
: Congestive Heart Failure
CHO
: Carbohydrade
chol
: Cholesterol
Cl
: Chloride
cm
: Centimeter
CNS
: Central Nervous System
c/o
: Complaint of
CO2
: Carbone Dioxide
cont
: Continue/continued
COPD
: Chronic Obstructive Pulmonary Disease
CPR
: Cardio Pulmonary Resuscitation
C & S
: Culture and Sensitivity
CSF
: Cerebro Spinal Fluid
CTG
: Cardio Toco Graph
CVA
: Cardio Vascular Accident
CVS
: Cardio Vascular System
C X-ray
: Chest X-ray
D
D & C
: Dilatation and Curettement
DIC
: Dissemintate Intravascular Coagulation
dl
: Deciliter
DM
: Diabetes Mellitus
DOB
: Date of Birth
E
ECG/EKG
: Electro Cardio Graphy
ECHO
: Echocardiogram
E. Coli
: Escherichia coli
EEG
: Electro Encephalo Gram
ENT
: Ear, Nose, Throat
e.g.
: For example
ESR
: Erythrocyte Sedimentation Rate
ETT
: Endo Tracheal Tube
F
F
: Fahrenheit
FBO
: Foreign Body Obstruction
FBS
: Fasting Blood Sugar
FHR
: Fetal Heart Rate
fl oz.
: Fluid ounce
FSH
: Follicle Stimulating Hormone
G
GB
: Gall Bladder
GI
: Gastro Intestinal
gm
: Gram
Gravida
: Number of Pregnancies
GU
: Genito Urinary
Gynae
: Gynaecology
H
Hb/Hgb
: Hemoglobin
Hct
: Haematocrit
Hr
: Hour
h. s.
: Hours Sleeping/At bed time
ht
: Height
I
ICF
: Intra Cellular Fluid
ICU
: Intensive Care Unit
I&D
: Incision and Drainage
IM
: Intra Muscular
INH
: Iso Nicotimic Acid Hydrazide
I&O
: Intake and Output
IPPD
: Intermittent Positive Pressure Breathing
IRDS
: Infant Respiratory Distress Syndrome
IUCD
: Intrauterine Contraceptive Device
IV
: Intravenous
IVP
: Intravenous Pyelogram
J
J
: Jugular Venous Distension
K
K
: Potassium
KCl
: Potassium chloride
kg
: Kilogram
KUB
: Kidney Ureter Bladder
22
L
LAMA
: Leave Against Medical Advice
Lt
: Left
Lab
: Laboratory
lb
: Pounds
LE
: Lupus Erythematous
LMP
: Last Menstrual Period
LP
: Lumbar Puncture
M
m2
: Square Meters
mcg
: Microgram
MCH
: Maternal Child Health
mEq
: Milli-equivalent
mg
: Milligrams
Mg
: Magnesium
MI
: Myocardial infarction
Min
: Minute
mm
: Millimeter
mcg
: Microgram
ml
: Milliliter
N
Na
: Sodium
NaCl
: Sodium Chloride
No
: Number
Noct
: Night
NPH
: Neutral Protamine Hagedorn (Insulin)
NPO
: Nothing Per Oral
NS
: Nervous System
O
O2
: Oxygen
Obs/gynae
: Obstetrics and Gynaecology
OD
: Right Eye (Oculus Desxter)
Oint
: Ointment
OPD
: Out-Patient Department
OT
: Left Eye
OU
: Both Eye
oz
: Ounce
P
P
: Pulse
para
: Number of Children
pc
: After Meals
PEEP
: Positive Enol Expiratory Pressure
paeds
: Paediatrics
pH
: Hydrogen Ion Concentration
pm
: Evening
PO
: Per Oral
Post-Op
: Post-Operative
Pre-Op
: Pre-Operative
S
s
: Without
SCBU
: Special Care Baby Unit
sec
: Second
SCPK
: Serum Creatinine Phospho Kinase
SGOT
: Serum Glutamic Oxalocetic Transminase
SGPT
: Serum Glutamic Oxalocetic Transminase
SC
: Sub Cutaneous
staph
: Staphylococcus
supp
: Suppository
Surg
: Surgery
Susp
: Suspension
syr
: Syrup
T
T
: Temperature
TB
: Tuberculosis
tab
: Tablet
tbsp
: Tablespoon
t.i.d.
: Three Times a Day
TPN
: Total Parenteral Nutrition
TSH
: Thyroid Stimulating Hormone
turp
: Trans Urethral Resection Prostatectomy
U
URTI
: Upper Respiratory Tract Infection
US
: Ultra Sound
UTI
: Urinary Tract Infection
V
vag
: Vaginal
VD
: Venereal Disease
VDRL
: Veneral Disease Research Lab
vit
: Vitamin
W
WBC
: White Blood Cell
wt
: Weight
23
Selected Abbreviations Used for Specific Descriptions
ASCVD
Arteriosclerotic cardiovascular disease
ASHD
Arteriosclerotic heart disease
BE
Barium enema
CMS
Circulation movement sensation
CNS
Central Nervous System or Clinical Nurse Specialist
GYN
Gynecology
H2O2
Hydrogen peroxide
HA
Hyperalimentation or headache
HCVD
Hyperalimentation cardiovascular disease
HEENT
Head, ear, eye, nose, throat
HVO
Hypertensive vascular disease
1CU
Intensive care unit
LLE
Left lower extremity
LLQ
Left lower quadrant
LOC
Level of consciousness; laxatives of choice
IMP
Last menstrual period
LUE
Left upper extremity
LUQ
Left upper quadrant
Neuro
Neurology; neurosurgery
NS
Normal saline
NWB
Non-weight bearing
OPO
Outpatient department
ORIF
Open reduction internal fixation
Ortho
Orthopedics
OT
Occupational therapy
PAR
Postanesthesia room
DJD
Degenerative joint disease
DOE
Dyspnea on exertion
DT's
Delerium tremens
DsW
5% dextrose in water.
FUO
Dever of unknown orgin
GB
Gallbladder
Gl
Gastrointestinal
PE
Physical examination
PERRLA
Pupils equal, round, and react to light and accommodation
PID
Pelvic inflammatory disease
PI
Present illness
PM&R
Physical medicine and rehabilitation
Psych.
Psychology; psychiatric
PT
Physical therapy
RL
or LR Ringer's lactate; lactated Ringer's
RLE
Right lower extremity
RR
Recovery room
RUE
Right upper extremity
RUQ
Right upper quadrant
Rx
Prescription
STSG
Split-thickness skin graft
Surg
Surgery, surgical
THR;TJR
Total hip replacement; Total joint replacement
URI
Upper respiratory infection
VD
Venereal disease
WNWD
Well-nourished, well-developed
24
Descriptive Terms Commonly Used in Charting
Concerning
Factor to be charted
Suggested Terminology
Abdomen
1. Large and extends outward
1. Enlarged, protruding
2. Hard, boardlike
2. Hard, rigid
3. Soft, flabby, flat
3. Relax, flaccid, flat
4. Hurts when touched
4. Tender
5. Appears swollen, rounded
5. Distended
6. Filled with gas or air
6. Tympanite
Amounts
1. Large amount
1. Profuse, copious, excessive
2. Moderate
2. Moderate
3. Small
3. Scanty, slight, small
Appearance
1. Thin and undernourished
1. Emaciated
2. Fat, greatly overweight
2. Obese
3. Seems very sick
3. Acutely ill
4. Not very sick
4. Not acutely ill
Appetite
1. Loss of appetite
1. Anorexia
2. Craving of certain foods
2. Parorexia
3. Eats only small amount
3. Appetite fair
Arm
1. Shoulder to elbow
1. Upper arm or arm
2. Elbow to wrist
2. Forearm
3. Appears puffy or swollen
3. Edematous
4. Artificial arm
4. Prosthesis
Attitude
1. Not interested in surroundings
1. Indifferent
2. Has “don't care” attitude
2. Apathetic
3. Does not believe anything
3. Suspicious, distrustful
4. Quarrelsome, disagreeable
4. Belligerent, quarrelsome
5. Afraid, worried
5. Anxious, fearful, apprehensive
6. Sad
6. Depressed, moody
Back Area
1. Upper back
1. Interscapular, shoulder
2. Low back
2. Lumbar region
3. End of spine
3. Sacral region
4. Gluteal area
4. Buttocks
5. Hump back
5. Kyphosis
6. Sway back
6. Lordosis
Belch
1. Belching
1. Eructation
Bleeding
1. Very little
1. Oozing
2. Nose bleed
2. Epistaxis
3. Blood in vomitus
3. Haematemesis
4. Blood in urine
4. Hematuria
5. Spitting of blood
5. Hemoptysis
6. Presence of blood in stool
6. Melena
Breathing
1. Act of breathing
1. Respiration
2. Act of inhaling
2. Inspiration
3. Act of exhaling
3. Expiration
4. Difficult breathing
4. Dyspnea
5. Short period when breath ceases.
5. Apnea
6. Inability to breathe when lying
6. Orthpnea
7. Rapid breathing
7. Hyperpnea
8. Increasing dyspnea with apnea
8. Cheyne-stokes respiration
Consciousness
1. Fully conscious, aware
1. Alert, full conscious
2. Only partly conscious
2. Semi-comatose
3. Unconsious, cannot be aroused.
3. Comatose
25
Concerning
Factor to be charted
Suggested Terminology
Cough
1. Coughs all the time
1. Continuous cough
2. Coughing over long period of time.
2. Persistent cough
3. Cough up materials
3. Productive cough
4. Occurs in paroxysms or attacks.
4. Paroxysmal cough
Defecation
1. Bowel movement
1. Defecation
2. Formed, yet soft stool
2. Soft-formed stool
3. Formed with hardened feces
3. Hard-formed stool,
4. Tinged with blood
4. Blood tinged stool, melena
5. Looks like tear
5. Tarry
6. Watery
6. Diarrhea
Dizziness
1. Dizziness
1. Vertigo
Drainage
1. Containing pus
1. Purulent
2. Bloody
2. Sanguineous
3. Consists of feces
3. Fecal
4. Tough, thick
4. Tenacious
Ears
1. Wax in the ears
1. Cerumen
2. Ringing in the ears
2. Tinnitis aurium
3. Abnormal in shape
3. Deformed
Emesis
1. induced by patient
1. Induced
2. Ejected to a few feet distant
2. Projectile
Eye
1. Yellow in color
1. Jaundice
2. Puffy, swollen
2. Edematous
3. Drooping of lids
3. Ptosis of lids
4. Motionless, not moving
4. Fixed
5. Unusual sensitivity to light
5. Photophobia
6. Double vision
6. Diplopia
7. Abnormal protrusion of eyeball.
7. Exophthalmos
8. Near-sightedness
8. Myopia
9. Far-sightedness
9. Hyperopia
10. See objects indistinctly
10. Blurred vision
11. Sty on eyelid
11. Hordeolum
Faint
1. Fainting
1. Syncope
Head
1. Forehead
1. Frontal
2. Region over temple
2. Temporal
3. Back of head
3. Occipital
4. Base of skull
4. Basilar
Hives
1. Hives
1. Urticaria
2. Itching
2. Pruritis
Legs
1. Thigh to knee
1. Upper leg
2. Knee to ankle
2. Lower leg
Menstruation
1. Painful
1. Dysmenorrhea
2. Total absence of
2. Amenorrhea
3. Profuse or prolonged flow
3. Menorrhagia
4. Occurring between periods
4. Metrorrhagia
5. Cessation of
5. Menopause
Pain
1. Great pain
1. Severe
2. Comes in seizures
2. Paroxysmal, spasmodic
3. Spreads to distant area
3. Radiating
4. Started all at one
4. Sudden onset
26
Concerning
Factor to be charted
Suggested Terminology
Paralysis
1. Of the muscles of the face
1. Facial
2. Of the legs
2. Paraplegia
3. Of one side of the body
3. Hemiplegia
4. Of a single limb
4. Monoplegia
5. Total (four limbs)
5. Quadriplegia
Pulse
1. Number of beats per minute
1. Rate
2. Regularity
2. Rhythm
3. Slow in rate
3. Bradycardia
4. Fast in rate
4. Tachycardia
5. Irregularity
5. Arrhythmias
Skin
1. Pink, hot
1. Flushed
2. Blue in color
2. Cyanotic
3. Very white
3. Extreme pallor, pale
4. Shines
4. Glossy
5. Raw surface
5. Excoriation
6. Yellow in color
6. Jaundice
7. Torn
7. Lacerated
8. Cold, moist
8. Clammy
9. Birthmark
9. Nevi
10. Wart
10. Verruca
11. Boil
11. Furuncle
12. Pimple
12. Papule
13. Blister
13. Vesicle
14. Pimple filled with pus
14. Pustule
15. Containing coloured area
15. Pigmented
16. Wet
16. Moist
17. Small ecchymosis
17. Petechiae
Speech
1. Not understandable
1. Incoherent
2. Meaningless, wandering
2. Rumbling
3. Words run together
3. Slurring
4. Difficulty in speaking
4. Dysphasia
5. Unable to speak
5. Aphonia
Symptoms
1. Observed only by patient
1. Subjective
2. Observed by other than patient
2. Objective
Throat
1. Difficulty in swallowing
1. Dysphagia
2. Inability to swallow
2. Aphagia
Urination
1. To urinate
1. Avoid, micturate
2. Total suppression of urine
2. Anuria
3. Urination at night
3. Nocturia
4. No control of urination
4. Involuntary, incontinent
5. Increased amount voided
5. Polyuria
6. Painful urination
6. Dysuria
7. Pus in urine
7. Pyuria
8. Blood in urine
8. Haematuria
9. Glucose in urine
9. Glycosuria
10. Albumen in urine
10. Albuminuria
11. Scantiness of urine
11. Oliguria
12. Stones in urine
12. Calculi
Weight
1. Overweight
1. Obese
2. Thin, underweight
2. Emaciated
27Introduction
This book in your hand endeavors to present both the traditional and modern concept on nursing for the benefit of students and scholars. Foundations of Nursing is the most important subject for the preparation of nursing students today. This is due to the fundamental concept and practice, emphasis is being put on the interplay of body, mind and spirit in nursing practice. The nurses must be aware of their role in building health by preventing disease and by caring those who are ill. The nurse cannot function efficiently without the knowledge of the basic principles and practice of nursing, this does not mean the fact of the theory alone, but the nurse needs to understand the skills that she can use in her daily learning for practice.
This book is prepared to facilitate easy comprehension and understanding. The facts have been presented in a tabulated or diagrammatic form for the BSc (Nursing and General Nursing) students. The nursing procedures are updated suitably for the present condition with reference to both national and international levels.
I have adopted a scientific approach in the treatment of the subject. This book is a guide to the students and a handbook for the staff.
This book is developed on the basis of the extensive experience in clinical practice and teaching. View of nursing today reflects what is going on in the real world, when I was given the responsibility as a clinical instructor and nursing staff development coordinator in Nizwa, Nursing Institute and Director General of Health Services, Ministry of Health, Sultanate of Oman, Cairo, Egypt, my job was oriented on clinical teaching of student and guiding nurses on clinical practice with the guidance of Dr Mary K Harmina, Former Dean, Nizwa Nursing Institute, Ministry of Health, Sultanate of Oman, Cairo, Egypt and her notes on nursing procedures and nursing task force made me to think and produce Foundations of Nursing in India.
My sincere thought is, if nursing (students, teachers, practitioner) personnel apply to the scientific principles, which is described in this book, for their day-to-day learning and practice can minimize the risk to the patient and provide quality care. I believe my effort of bringing out this book will give me an immense satisfaction.
I enjoy being a nurse. I believe that through nursing I have become a better person, it has certainly influenced the way I see the world. There are certain personal experiences which have been enriched by the fact that I am a nurse.