- • Explain nursing process
- • Ethical issues in nursing
- • Acid-base imbalance
- • Nutrition and vitamins
- • Laboratory values
- • Positions
- • Drug calculation
The era of modern nursing commences with the work of Florence Nightingale in the Crimean war (1854–1856). She was born in Italy in 1820. She was the second daughter of wealthy English parents. In 1851, Nightingale entered the Deaconess school in Kaiserswerth. She was 31 years old and her family and friends were strongly opposed to her becoming a nurse. After her graduation in 1853, she became superintendent of charity hospital for the government.
In 1854, the Crimean war began. Her dedicated service both during the day and at night, when she and some other nurses made their rounds carrying oil lamps, created a public image of the lady with the lamp. In time, the ‘Nightingale lamp’ or the “Lamp of learning” became a symbol of nursing and nursing education. Todays, many schools of nursing display a model of the lamp or a picture of Florence Nightingale carrying a lamp.
In 1860, Nightingale opened the first nursing school outside a hospital. The nursing course was 1 year in length and included both classroom and clinical experience, a major innovation at that time.
Modern nursing is a dynamic, therapeutic and education process in meeting the health needs of the individuals, the family and the community. Nursing is one of the health professions which functions in conjunction with other health care agencies in assisting individuals, families and communities to achieve and maintain desirable standards of health.
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge and to do this in such a way as to help him gain independence as rapidly as possible.”
“Nursing is the protection, promotion and optimizing of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals, families, communities and population.”
—The American Nurses Association, 2003
Profession has been defined as an occupation that requires extensive education or a calling that requires special knowledge, skill and preparation. A profession is generally distinguished from other kinds of occupations by:
- Its requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed.
- An orientation of the individual toward service, either to a community or to an organization.
- Ongoing research
- Professional organization
A process is a series of steps that is used to perform any activity to meet the desired outcome. Nursing process is a five step process for providing professional and quality nursing care to the patients.
Steps in Nursing Process
Assessment is the first step in nursing process. In this phase the nurse assess the condition of the patient by collecting data from the patients or relatives. The data is collected by variety of means such as personal interview, physical examination, health history, family history, and so on. There are two types of data, subjective data and objective data. Subjective data are data from patient's point of view or verbal report, e.g. I have fever. Objective data are observable and measurable data, what the nurse observes, e.g. monitoring temperature to assess the severity of fever.
Diagnosis is the second step in nursing process. In this phase the nurse makes a judgment about the potential or actual problems based on the assessment findings. Multiple diagnosis are sometimes made for a single patient, among that we have to pick the most priority one first. After analyzing the collected data (high temperature), we will come to the conclusion that patient is having fever. The diagnosis is a critical step as it is used to determine the course of treatment.
Planning is the third step in nursing process. Once a patient and nurse agree on the diagnosis, a plan of action can be developed. If multiple diagnosis need to be addressed, the head nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. After selecting the diagnosis (fever) nurse plan the actions to reduce the fever such as cold sponge, medications, fluids, diets, etc.
Implementation is also called as working phase. The nurse works through the desired plan. This plan is specific for each person and focus on the achievable outcome. Implementation can take place over the course of hours, days, weeks or even months. After planning the activities for the desired diagnosis (fever) nurse implement the plan such as administering medications, health education, fluids, etc.
Evaluation is the last step of nursing process. Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine the goals for patient wellness has been met. The possible patient outcomes are generally described under three terms: patient's condition improved (fever decreased), patient's condition stabilized and patient's condition deteriorated, died or discharged.
ISSUES IN NURSING
Ethics are the rules or principles that govern right conduct and are designed to protect the rights of human beings.
A code of ethics is a set of ethical principles that are accepted by all members of a profession.
ICN Code of Ethics for Nurses
In 1953 ICN adopted its first code of ethics for nurses and was revised in 2000. The four principle elements contained within the ICN code involve standards related to nurses and people, practice, profession and co-workers.
ICN recommended that nurses have four fundamental responsibilities, i.e. to promote health, to prevent illness, to restore health and to alleviating suffering. And also inherent in nursing is respect for human rights, like right to life, to dignity and to be treated with respect. And the care should not be restricted by age, sex, color, creed, culture or nationality.
Nurses and People
The nurse's primary responsibility is to those people who require nursing care. The nurse in providing care promotes an environment in the values, customs and spiritual beliefs of the individual are respected. The nurse holds in confidence personal information and uses judgment in sharing this information.
Nurses and Practice
The nurse carries personal responsibility for nursing practice and for maintaining competence by continual learning. The nurse maintains the highest standard of nursing care possible within the reality of a specific situation.
Nurses and Co-workers
The nurse maintains a cooperative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard the individual when his care is endangered by a co-worker or any person.
Nurses and the Profession
The nurses play a major role in determining and implementing desirable standards of nursing practice. The nursing is active in developing a core of professional knowledge. The nurse acting through the professional organizations participates in establishing and maintaining equitable social and economic working conditions in nursing.
Key Principles of Ethics in Healthcare System
- Autonomy: The right of self-determination, independence and freedom. Right to health care decision.
- Justice: Obligation to be fair with all people.
- Fidelity: Obligation of an individual to be faithful to the commitment made to himself and to others. It is the main support of accountability.
- Veracity: The duty to tell the truth.
- Beneficence: Doing good for the client. What exactly is good for one person may not be the same for others.
- Maleficence: Maleficence is the requirement that health care providers do no harm to their client either intentionally or unintentionally.
Common Ethical Issues
- Physician assisted suicide (PAS)
- Do not resuscitate order (DNR)
- Refuse to treat by nurses
- Refusal of treatment by patient
- Genetic research
- Legal: Established by or founded upon law or official or accepted rules.
- Law: It means a body of rules to guide human action.
Legal Liability in Nursing
Statutory Law is created by elected legislative bodies such as state or provincial legislatures, the U.S. Congress, administrative bodies such as state boards of nursing or the Canadian Parliament.
Common Law is created by judicial decisions made in courts when cases are decided.
Criminal Law is concerned with relationships between individuals and governments and with acts that threaten society and its order. Misuse of controlled substances is an example of criminal conduct for nurses. A crime is an offense against society that violates a law. Criminal acts are prosecutes in the criminal justice system. A felony is a crime of a serious nature that usually carries a penalty of imprisonment or death.
Civil Law is concerned with the relationships among people and the protection of a person's rights. Although violations of civil law might cause harm to an individual or property, society as a whole is usually not affected. For example, defamatory statements made about an individual might lead to interpersonal problems, but they do not threaten society as a whole.
- Invasion of privacy
- Defamation of character
Torts: A tort is a civil wrong committed against a person or property. Torts may be subtle and difficult to define; they may be classified as intentional or unintentional. Unintentional torts include negligence. Malpractice is one example of an unintentional tort or negligence. Intentional torts are willful acts that violate another`s rights. Examples are assault, battery and defamation, invasion of privacy, false imprisonment and fraud.
Assaults: Assault is any willful attempt or threat to harm another, coupled with the ability to actually harm the other person. The victim believes harm will come as a result of the threat. Assault may be subtle; for example, a nurse might attempt to coerce a client into taking a drug he or she does not wish to take. A more blatant example might involve a nurse handing an uncooperative client in the emergency room, e.g. “If you don't take off those filthy clothes, I am going to rip them off you!” and moves toward the client, a claim of assault could be made.
Battery: Battery is any intentional touching of another's body or anything the person is touching or holding without consent. Injury is not a requirement. There have been instances of battery of confined clients by personnel in mental institutions.
Invasion of privacy: Clients have claims for invasion of privacy when their private affairs, with which the public has no concern, have been publicized. A client is entitled to confidential health care. All aspects of care should be free from unwanted publicity or exposure to public scrutiny.
Defamation of character: Defamation of character is the holding up of a person to ridicule, scorn or contempt within the community. There are two types of defamation: slander and libel. For example, if a nurse tells a client that his physician is incompetent; the nurse could be held liable for slander. If the nurse writes such a comment, the charge would be libel. The important issues in a claim of defamation of character are whether the information was shared with third persons (other than the client) and if harm has been done to the reputation of the plaintiff (legal short hand).
Negligence: Negligence is conduct that falls below the standard of care. It is established by law for the protection of others against unreasonable risk of harm and it is characterized chiefly by inadvertence, thoughtlessness or inattention.
If nurses give care that does not meet appropriate standards, they may be held liable for negligence. Negligence may involve carelessness, such as failing to check a client's arm band and then administering the wrong drug. Another example of negligence may be administering a medication even when it has been documented that the client has an allergy to that medication. For example:
- Intravenous therapy errors resulting in infiltrations or phlebitis.
- Burns to clients
- Falls resulting in injury to clients.
- Failure to use aseptic technique where required.
Malpractice: Malpractice is one type of negligence. It is defined as professional misconduct, unreasonable lack of skill or fidelity in professional duties, evil practice or illegal or immoral conduct. In a malpractice law- suit against a nurse, the following criteria must be established.
- The nurse (defendant) owned a duty to the client (plaintiff).
- The nurse did not carry out that duty.
- The client was injured.
- The client's injury was a result of the nurse's failure to carry out his or her duty.
There are mainly four acid-base imbalances.
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
- Metabolic alkalosis
Respiratory – Opposite direction
Metabolic – Equal direction
- Pulmonary edema
- Pulmonary embolism
- CNS depressants
- Brain trauma
- Mechanical ventilation
Nursing care: Limit oxygen
- Diabetic ketoacidosis and DM
- Severe diarrhea
- Renal failure
- Renal insufficiency
- High fat diet
- Excessive ingestion of acetyl salicylate acid (aspirin)
- Insufficient metabolism of carbohydrate
Nursing care: Administer sodium bicarbonate
- Excessive vomiting
- GI suction
- Infusion of sodium bicarbonate
- Massive transfusion of whole blood
Nursing care: Administer chloride
The energy sources are carbohydrates, fats and protein. Carbohydrates are the base of food pyramid and fats are the top of food pyramid.
Potatoes, whole grains, citrus fruits, berries, water melon, nuts and legumes, cereals, dried fruits, bread, banana and green leafy vegetables.
Eggs, milk, yogurt, fish and sea foods, soya, nuts, meats, chicken, etc.
Indications of High-Protein Diet
- Mild to moderate liver diseases
- Cystic fibrosis
- Under nutrition
- Nephrotic syndrome
Indications of Low-Protein Diet
- Liver failure
- Kidney failure
Beef, poultry, butter, cream, milk, cheese, etc.
Total Parenteral Nutrition
Total Parenteral Nutrition (TPN) is feeding the patient intravenously; nutrients are infused directly into the veins through a central line catheter.
The contents are hypertonic solutions, amino acids, vitamins, lipids, etc.
- Monitor RBS every 4 hours.
- Monitor for any complications (Hyperglycemia, Hypertension, Infection).
- Fat emulsions (lipids) contain egg yolk; phospholipids should not be given to client with egg allergies.
- Insulin and heparin may be added in the TPN solution.
- When TPN disconnects, never discontinue abruptly, it will cause hypoglycemia. So, the flow rate should be decreased gradually.
- Do not write on a plastic IV bag with a marking pen as the ink may be absorbed into the solution. So use a label and place the label on to the bag.
There are two categories:
- Fat-soluble vitamins (A, D, E, K)
- It is also called as retinol.
- Rich sources are fish liver oil, animal fat, egg yolk, liver, dark green leafy vegetables and milk.
- Deficiency will leads to blindness.
- It is also called as thiamine.
- Rich sources are cereals, pulses, nuts, green vegetables, yeast, egg and meat.
- Deficiency will leads to beri-beri.
- It is also called as riboflavin.
- Rich sources are yeast, grains, green leafy vegetables, pulses, egg, liver and milk.
- Deficiency will lead to sore throat, glossitis and cheilosis.
- It is also called as nicotinic acid.
- Rich sources are meat, grains, liver, fish, cheese and pulses.
- Deficiency will lead to pellagra.
- It is also called as pyridoxine.
- Rich sources are yeast, liver, egg yolk, peas and soybean.
- Deficiency will leads to changes to skin, nervous system and erythropoiesis.
- It is also known as ascorbic acid.
- Rich sources are citrus fruits, fresh vegetables, tomato, potato, green chillies and cabbage.
- Deficiency will leads to scurvy.
- It is also called as calciferol (D2) or cholecalciferol (D3).
- Rich sources are fish liver oil, egg yolk, butter, milk, milk and milk products and sunlight.
- Deficiency will leads to rickets and Osteomalacia.
- It is also called as Tocopherol.
- Rich sources are germ oil, cereals, nuts, egg yolk and green leafy vegetables such as spinach.
- Deficiency of vitamin E produces sterility in animals and Hemolysis.
- It is also called antioxidant and beauty vitamin.
- It is also called as Phylloquinone or coagulation vitamin.
- Rich sources are dark green leafy vegetables.
- Also produced by the normal flora of intestine.
- Deficiency will leads to bleeding disorders.
- Rich sources are sardines, milk and milk products.
- Deficiency will leads to osteoporosis and rickets.
- Rich sources are milk, cheese and egg.
- Deficiency will leads to rickets.
- Rich sources are milk, cheese, legumes, etc.
- Deficiency will leads to renal problem and tremor in alcoholics.
- Rich sources are milk, fish, poultry, etc.
- It is a constituent of keratin in skin.
- Rich sources are liver organ meat, poultry and dark green leafy vegetables.
- Deficiency will leads to anemia.
- Rich sources are iodized salt e.g. sea foods.
- Rich sources are orange, banana, dry fruits and fresh fruits.
- Deficiency will lead to muscle cramps, arrhythmias.
Types of Diet on the Basis of Consumption
Clear Liquid Diet
- Not nutritionally adequate
- Foods included are water, apple juice, frozen ice, carbonated beverages.
Full Liquid Diet
- Can be nutritionally adequate
- Used as a transition between clear liquid and soft diet.
- Foods included are clear liquid plus, milk and milk products, fruit juices, cooked and stained foods.
- Used as a transition between full liquid diet and regular diet.
- Foods allowed are full liquid diet plus foods low in fiber, cooked vegetables, boiled eggs and meats.
- Diet promotes wound healing, healing of gastric ulcer.
- Foods allowed are soft diet without spices, low residual diet.
Normal CSF volume
Normal CSF pressure
50–175 mm H2O (6–13 mm Hg)
Normal CSF glucose
Normal CSF protein
5–15 mm Hg
10–21 mm Hg
4–10 cmH2O (3–8 mm Hg)
Normal RBC count
4.5–6.2 million cells/microliter
Serum bilirubin Total
< 1.5 mg/dL
Serum bilirubin direct
< 130 mg/dL
< 200 mg/dL
Serum uric acid
Fasting blood sugar
< 140 mg/dL
Blood urea Nitrogen
0.2–5.4 micro IU/L
Serum Thyroxine (T4)
Serum Triiodothyronine (T3)
Normal serum lithium
Prone or side line position
Right sided position
Side line position
Sitting position before and after meals
Supine position for half hour after meals
Cyanotic heart disease
High Fowler's position
Knee chest position
Prevent hip contractures
Side line position
Left lateral position
Lateral recumbent position
Abdominal Aneurysm surgery
Semi-Fowler's position in case of rupture
High Fowler's position
Congestive cardiac failure
High Fowler's position
Semi-Fowler's for supratentorial
Flat for infratentorial
Elevate the head
Elevate the head
Elevate the head of bed
Leaning forward to prevent aspiration
Elevate with pillow, the extremity of affected side
Right side lying
Total parenteral nutrition
Elevate the legs
Same-sided position is given for pneumonectomy, liver biopsy, myringotomy, retinal detachment
CALCULATIONS AND PROBLEMS
1 drain = 60 grains
1 ounce = 30 mL
1 liter = 1000 mL
1 grain = 60 mgm
1 pint = 500 mL
1 kg = 2.2 lbs
1 mgm =1000 mcg
1 teaspoon = 4–5 mL
1 teaspoon = 60 drop
1 mL = 16 drop
1 inch = 2.5 cm
qd = everyday
qod = every other day
d = daily
bid = twice a day
tid = three times a day
qid = four times a day
q4h = every 4 hrs
q6h = every 6 hrs
q8h = every 8 hrs
q4–6h = every 4–6 hrs
prn = as needed
C = (F – 32) × 5/9 (For converting Fahrenheit to Celsius)
F = (C × 9/5) + 32 (For converting Degree to Fahrenheit)
Child's dose = [(Age of child/(Age of child + 12)] × Average adult dose
A 10 year old girl/60 Lbs with 300 mg Average adult dose is given for the girl. Calculate the child's pediatric dose.
Age of child = 10 years
Average Adult dose = 300 mg
Child's pediatric dose
Child's dose = [(Age of child/(Age of child + 12)] × Average adult dose
= [10/(10 + 12)] × 300 mg
= (10/22) × 300 mg
= (0.45454545454) × 300 mg
= 136.363636364 mg
Child dose = (weight in pounds/150) × adult dose.
Clark's rule uses Weight in lbs, NEVER in kg.
11-year-old girl/70 lbs, adult dose is 500 mg
500 mg × (70 ÷ 150) = Child's dose
500 mg × (.47) = Child's dose
500 mg × .47 = 235 mg
Pulse pressure = Systolic BP–Diastolic BP
MAP (mean arterial pressure) = [(Systolic BP + 2 (Diastolic BP)]/3
Cerebral perfusion Pressure (CPP) = MAP–ICP
Drops per minute = (order dose/overdose) × drop factor
- The drop factor is the number of drops contained in 1 milliliter.
- Macrodrip tubing administers a larger drop and may be used for 10 gtts/mL, 15 gtts/mL or 20 gtts/mL.
- Microdrip tubing administers 60 gtts/mL
Problems and Solutions
- Prepare 250 cc of 4% solution of boric acid.(4% solution means 4 gms of boric acid in 100 cc) 4:100 = X: 250100X = 1000 (cross multiplication)X = 1000/100 = 10
- A child is to receive dexona (dexamethasone) intravenously at the ordered dosage of 7.6 mg. The drug concentration in the vial is 4 mg/mL. Which of the following amounts should the nurse administer?4 mg: 1 mL = 7.6 mg: XmL4 X = 7.6 × 1X = 7.6/4 = 1.9 mL
- Choral hydrate 1000 mg has been ordered. It is available in a syrup containing 0.5 g/5 mL. How many milliliters should the nurse give?0.5 g = 500 mg1000 mg/X mL = 500 mg/5 mLX = (1000 × 5)/500 = 10 mL
- The client is prescribed Dynapar 15 mg IM. The nurse has a 1 mL preloaded syringe of Dynapar labeled 30 mg/mL. How many milliliters of medication should the nurse administer?30 mg/1 mL = 15 mg/X mLX = (15/30) = 0.5 mL
- A client has been diagnosed with acute prostatitis. The physician order 1 gm of chloramphenicol every 4 hours. The pharmacy has 250 mg capsules available. How many capsules should the nurse administer every 4 hours?1 gm = 1000 mg250 mg: 1 capsule = 1000 mg: X mL250 × X = 1000 × 1X = 1000/250 = 4 capsules
- A client is admitted with dehydration and oliguria. The physician order 1000 mL of 5% dextrose IV to be infused within 8 hour period. The IV set delivers 15 gtt/mL. The nurse should regulate the flow rate so, it delivers how many drops of fluid per minute?Order dose = 1000 mLOver time = 8 hoursDrop factor = 15Flow rate = (order/over) × drop factor= (1000/8 × 60) × 15= 30 gtt/minute
- A nurse is assessing a client with brain injury. What is a client's cerebral perfusion pressure (CPP) when the blood pressure (BP) is 90/50 mm Hg and the intracranial pressure (ICP) 21?CPP = MAP–ICPMAP = (systolic + (2 × diastolic))/3MAP = (90 + 100)/3 = 63.3CPP = MAP–ICPCPP = 63.3-21 = 42.3 mm Hg
- The doctor order cholecalciferol 600000 units IM has been ordered. The nurse have available 1 mL prefilled syringe labeled 600000 units/mL. How many milliliters should the nurse administer?600000 units/1mL = 600000/X mLX = 600000/600000 = 1 mL