FUNDAMENTA LS OF NURSING

Click to edit Master subtitle style

8/14/12

 Florence

NURSING THEORISTS

NIGHTINGALE (1820-1910)
Lady with the Lamp Considered the founder of modern nursing

8/14/12

HILDEGARD PEPLAU (1952)

INTERPERSONAL PROCESS

4 Phases (NURSE-CLIENT RELATIONSHIP) ORIENTATION

IDENTIFICATION--Identify difficulties and amount of needed help EXPLOITATION/EXPLANATION-nurse utilizes available resources toward goal of maximum health RESOLUTION/TERMINATION-goals met
8/14/12

HENDERSON
14

BREATH EAT & DRINK ELIMINATE POSTURE SLEEP DRESS TEMPERATURE HYGIENE COMMUNICATE WORSHIP WORK PLAY LEARN AVOID DANGER

BASIC HUMAN NEEDS

8/14/12

ABDELLAH
21

CLIENT NEEDS

8/14/12

Holistic delivery of health care to meet the social,physical,creative,emotional,and spiritual needs of the client and family. 1.Promote good hygiene and physical comfort 2.Promote optimal activity,exercise,rest,sleep 3.To promote safety. 4.To maintain good body mechanics and prevent and correct deformities 5.To facilitate maintenance of a supply of O2 to all body cells 6.To facilitate maintenance of nutrition 7.To facilitate maintenance of elimination 8.To facilitate maintenance of F and E balance 9.To recognize the physiologic responses of the body to disease condition.

8/14/12

10.To facilitate the maintenance of regulatory mechanisms and functions 11.To facilitate the maintenance of sensory function 12.To identify and accept positive and negative expressions, feelings and reactions 13.Top identify and accept the interrelatedness of emotions and organic illness 14.To facilitate the maintenance of effective verbal and nonverbal communication 15.To promote the development of productive interpersonal relationship

8/14/12

16.To facilitate progress toward achievement of personal spiritual goals 17.To create and maintain a therapeutic environment 18.To facilitate awareness of self as an individual with varying physical,emotional and developmental needs 19.To accept the optimum possible goals in light of physical and emotional limitations 20.To use community resources as an aid in resolving problems arising from illness 21.To understand the role of social problems as influencing factors in the cause of illness.
8/14/12

IDA JEAN ORLANDO (1961) CONCEPTUALIZED THE DYNAMIC NURSE PATIENT RELATIONSHIP Focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt.
8/14/12

HALL
COINED

NURSING PROCESS CORE, CURE, CARE

CORE: THERAPEUTIC USE OF SELF CURE: DISEASE & TREATMENT AS BASED ON DOCTORs Order CARE: Nurturance of the BODY
8/14/12

JOHNSON
Nursing

care is necessary only if the client is unstable to fulfill biologic, psychologic,developmen tal or social needs.
8/14/12

ROGERS
SCIENCE

OF UNITARY HUMAN BEING INDIVIDUAL IS MORE THAN and DIFFERENT FROM THE SUM OF ITS PARTS,DITINCTIVE PROPERTIES OF THE
8/14/12

THE

KING
DESCRIBED

NURSING AS A HELPING PROFESSION THAT ASSISTS INDIVIDUALS AND GROUPS TO ATTAIN ,MAINTAIN AND RESTORE HEALTH. DYNAMIC INTERACTING SYSTEMS: PERSONAL, INTERPERSONAL, SOCIAL FORM THE BASIS FOR NURSE CLIENT 8/14/12

NEUMAN
HEALTH

CARE SYSTEM MODEL-Nursing is a unique profession concerned with all the variables affecting an individuals response to stress.
8/14/12

LEININGER
TRANSCULTURAL

NURSING MODEL

AVOCATED

NURSING CARE THROUGH SCIENTIFIC AND HUMANISTIC AND SPECIFIC CULTURAL CARING PROCESSES 8/14/12

ROY
ADAPTATION

MODEL

HELP CLIENT TO ADAPT TO CHANGES IN PHYSIOLOGIC NEEDS, SELF-CONCEPT, ROLE FXN, INTERDEPENDENT 8/14/12 RELATIONS

JEAN WATSON
HUMAN

CARING MODEL

Believed that a person is a valued being to be cared for, respected, nurtured, understood and assisted, a fully functional integrated self.
8/14/12

ERICKSON
THEORY ON THE DEVELOPMENT OF VIRTUES-the unifying strength of a good man. MORAL DEVELOPMENT CONTINUES THROUGHOUT LIFE
NURSES

EGO STRENGTH VIRTUE/GOOD MAN

8/14/12 ACT AS ROLE

BENNER
CENTRAL

CARING CARING IS CENTRAL IN NURSING, CREATING POSSIBILITIES FOR COPING & CONNECTING WITH OTHERS
8/14/12

MASLOWS HIERARCHY OF NEEDS PHYSIOLOGIC SAFETY AND SECURITY LOVE AND BELONGINGNESS

SELF-ESTEEM

The need to love and need to be loved

SELF-ACTUALIZATION

Self-worth, Self-identity, Body Image

Need to learn Need to be self-fulfilled

8/14/12

NURSING PROCESS

Organized and systematic-composed of 6 sequential and interrelated steps Humanisticindividualized, involving the aspects of human dignity

8/14/12

ASSESSMENT
Collecting,

validating, organizing and recording data about clients health status to establish data base.
Subjective Objective

Collection

of Data
8/14/12

Methods

Interview Observation-use of senses PE

Sources

Primary Secondary

8/14/12

DIAGNOSING
The clinical act of identifying the problem. Analysis of assessment info and derive meaning from this analysis Format:

OR.

P-problem R-related factors/Etiology S-signs and symptoms P-problem E-etiology S-signs and symptoms

8/14/12

OUTCOME IDENTIFICATION
Refers

to formulating and documenting measurable, realistic goals PURPOSES

To provide individualized care

Promote client participation To plan care that is realistic and measurable To allow involvement of support people
8/14/12

4. Planning Determining beforehand the strategies and course of action before implementation PURPOSES:

to identify the clients goals and appropriate nursing intervention to direct client care activities to promote continuity of care to direct activities to be carried out
8/14/12

Implementation putting the nursing care plan into action a. Reassessing to ensure prompt attention to emerging problem b. Set priorities c. Perform nursing intervention d. Record action
5.
8/14/12

6. Evaluation assessing the clients response to nursing intervention PURPOSE: -to appraise the extent to which goals and outcome criteria of nursing care has been achieved
8/14/12

JURISPRUDENCE
Law-rules

that regulate social conduct in a formally prescribed and legally binding manner. Rights- Privileges Responsibilities- Obligations Grievance-Dispute Stare Decicis-to stand by things decided.
8/14/12

CLASSIFICATION

Public/Criminal laws-Actions against safety and welfare of the public

Felony-Serious Misdemeanor-Less serious

Civil/Private

laws

Contracts Torts-Wrong doing against person/property Unintentional Intentional

8/14/12

 INTENTIONAL

TORT

Assault or battery Invasion of privacy Defamation (Libel/Slander) Malpractice and negligence False Imprisonment

8/14/12

RESTRAINTS
NOT

instituted for convenience False Imprisonment Alternative measure first Remove Q2h For safety Needs Doctors order.
8/14/12

INCIDENT REPORT
Statement of facts and patients physical response from unexpected occurrence that could affect the client. Complete sequence within 24 hours
Telephone

orders-Repeat order and let the AP sign within 24 h. 8/14/12

PHYSICAL

EXAMINATION

INDIVIDUAL ASSESSMENT OF EACH BODY SYSTEM, USUALLY CONDUCTED IN A CEPHALO-CAUDAL MANNER

8/14/12

INSPECTION
OBSERVE

AREA FOR SIZE, SHAPE, SYMMETRY, POSITION & ABNORMALITIES.

8/14/12

PALPATION
PALMS

& FINGER PADS: TEXTURE, CONSISTENCY & FORM DORSUM OR BACK OF HAND: TEMPERATURE BONY PROMINENCES OF THE PALM: VIBRATION
8/14/12

PERCUSSION
TAPPING THE BODY USING FINGERTIPS, PRODUCING VIBRATIONS TYMPANY: DRUM-LIKE, HIGH PITCH (ENCLOSED AIR SPACE) RESONANCE: HOLLOW, LOW PITCH (NORMAL LUNG) HYPERRESONANCE: VERY LOW BOOMING (EMPHYSEMA) DULLNESS: HIGH PITCH, THUD-LIKE (LIVER) 8/14/12 FLATNESS: SOFT & FLAT (MUSCLE)

AUSCULTATION
BELL:

LOW PITCH (HEART & KOROTKOFF SOUNDS) DIAPHRAGM: HIGH PITCH (BOWEL & LUNG SOUNDS) HEART SOUNDS:

S1: MITRAL VALVE CLOSURE (Ventricular) S2:AORTIC VALVE CLOSURE (Ventricular) S3: RAPID VENTRICULAR FILLING (Atrium) S4: ATRIAL CONTRACTION (then repolarization)

MURMURS:

TURBULENT BLOOD 8/14/12 FLOW FROM STENOSIS/

ADVENTITIOUS LUNG SOUNDS

CRACKLES: BUBBLING SOUNDS RT DISRUPTED PASSAGE OF AIR IN ALVEOLI (FROM LUNG SECRETIONS) AS IN PNEUMONIA RONCHI: LOUD, LOW-PITCH RUMBLING RT FLUID IN THE LARGER AIRWAY WHEEZES: HIGH-PITCH, SQUEAKY. STRIDOR: HARSH, HIGH-PITCHED RT UPPER AIRWAY OBSTRUCTION FRICTION RUB: DRY, GRATING SOUND BEST HEARD ON INSPIRATION RT RUBBING OF VISCERAL OVER PARIETAL 8/14/12 PLEURA WHEN INFLAMED

REVIEW OF SYSTEMS

HEAD TO TOE ASSESSMENT

8/14/12

CLIENT POSITIONS

SEMI-FOWLERS

HIGH

FOR GASTRIC FEEDING TO REDUCE REFLUX FOR EATING, NGT INSERTION AND SUCTIONING, PROMOTES GOOD CHEST EXPANSION FOR VERTEBRAL INJURIES FOR ABDOMINAL EXAM

FOWLERS

SUPINE

DORSAL

RECUMBENT

8/14/12

PRONE

SMALL PILLOW JUST BELOW DIAPHRAGM, SUPPORTS LUMBAR CURVE, FACILITATES BREATHING FOR RECTAL EXAM

SIMS

KNEE-CHEST/

GENUPECTORAL

CLIENT PRONE, ARMS FLEXED ON SIDES, KNEE-CHEST FLEXION. FOR VAGINAL/ RECTAL EXAM HAVE CLIENT VOID PRIOR TO. FOR PELVIC EXAM
8/14/12

LITHOTOMY

VITAL SIGNS

TEMPERATURE

8/14/12

LOSS 1. RADIATION: no direct contact e.g. therapy 2. CONDUCTION: direct contact e.g. TSB 3. CONVECTION: air Currents e.g. electric fan fan 4. EVAPORATION: liquid to gas e.g. skin sweat
8/14/12

HEAT

of Fever: 1. Remittent: Remains high (fever fluctuates but never return to normal) 2. Intermittent: International! (fever fluctuates b/w normal & above normal) 3. Relapsing: fever fluctuates, normalizes for days, fever again! 4. Constant: >38C 8/14/12

Patterns

 PULSE

8/14/12

RESPIRATION Increased

RR: stress, smoking, anemia, >altitude; Amphetamine, Coccaine Decreased RR: acute pain in chest/abdomen, brain damage; narcotics, anesthesia,
8/14/12

Patterns

of Breathing 1. CHEYNE-STOKES: HVApnea

normal in kids & elderly when asleep; heart failure, uremia, brain damage

2.

BIOTs: Shallow breathApnea 3. KUSSMAUL s: deep, regular, rapid 8/14/12 4. ORTHOPNEA: DOB supine

BLOOD

PRESSURE

8/14/12

BP

taking!!!

1. 5 min rest, within 30 min no coffee 2. Supine/sitting: arm at heart level, PALM UP! 3. Cuff width 40% of limbs circum; bladder encircle 2/3 of arm 4. BP cuff 1 inch above antecubital 5. Determine palpatory BP before auscultatory BP 6. Bell: 1st Korotkoff (Systole) 7. Deflate slowly: 2-3 mmHg/sec. 8/14/12 Disappearance of sound (Diastole)

INFORMED CONSENT
Permission

obtained from a patient to perform a specific test or procedure. Agreed upon Facts known Explained Risk and chances understood
8/14/12

LEAVELL AND CLARKS LEVELS OF PREVENTION

PRIMARY-To encourage optimal health and to increase the persons resistance to illness. To stop something from ever happening.

Quit Smoking Avoid /limit alcohol Eat well-balanced diet Complete immunization programs GOOD NUTRITION, SAFE SEX, EXERCISE PROTECTION FROM ACCIDENTS (HELMET), HYGIENE
8/14/12

SECONDARY-Health maintenance. Seeks to identify specific illnesses or conditions a earlier stage.

Sputum exam for TB MONTHLY SELF-EXAM (BREAST, TESTICLE, SKIN, MOUTH) ANNUAL PAP SMEAR (STARTING 18 yo), MAMMOGRAM (STARTING 40 yo IF hr & 50 yo IF LOW RISK) ANNUAL DIGITAL RECTAL EXAM (MALES >50 yo) ANNUAL PHYSICAL EXAM (STARTING 35 yo) GLAUCOMA & HYPERTENSIVE SCREENING DISABILITY LIMITATIONS: Adequate tx 8/14/12

 Tertiary

Restoration and Rehabilitation Occurs after a disease or disability has occurred and the recovery process has begun, assisting the client in obtaining an optimal health status.
CVA therapy Cardiac Rehabilitation for addiction or MI Blood Glucose Monitoring for 8/14/12

STAGES OF INFECTIOUS PROCESS

Incubation Period= exposure to 1st S/S Prodromal Period= Symptoms that may be the 1st indication of the onset of the disease Stage of Illness= Manifesting S/S Convalescence=the stage to recovery after the disease 8/14/12

MODE OF TRANSMISSION

CONTACT TRANSMISSION

DROPLET

TRANSMISSION VEHICLE TRANSMISSION- water, blood AIRBORNE TRANSMISSION VECTORBORNE TRASMISSION

8/14/12

DIRECT CONTACT-person to person INDIRECT CONTACT-Fomites, dressing, needle, instruments

IMMUNITY
The

quality of being insusceptible or unaffected by a particular disease or condition.

8/14/12

TYPES

Natural Immunity

Immunity that is not acquired through previous contact with a infectious agent but is largely genetically determined. Inherent

8/14/12

 Acquired A.Passive

immunity-a state of temporary partial insusceptibility to an infectious agent that has been induced by IV or IM administration of preformed antibodies.

8/14/12

 B.Active

Immunity

A state of resistance built up in an individual following effective contact with foreign antigens (toxoid). 1)Humoral Immunity-Results from active production of antibodies against antigens of microorganisms or their products. 2)Cellular Immunity-The central position in defense (B and T cells).

8/14/12

IMMUNIZATION
ACTIVE

NATURAL-Ab formed in the presence of active infection in the body. ARTIFICIAL-antigens are administered to stimulate antibody production.

8/14/12

PASSIVE IMMUNIZATION
Antibodies

source.

are produced by another

NATURAL-MOTHER to FETUS via placenta ARTIFICIAL-immune serum(Ab) injected to person

8/14/12

ASEPTIC PRACTICES
Handwashing Cleaning Disinfection Sterilization Use

of barriers Isolation systems Surgical Asepsis

8/14/12

HANDWASHING
The

single most important infection control practice. Effectiveness is greatly influenced by adequate friction and thoroughness of surface cleaned. Wash hands under running water,soap and friction for 15 to 30 sec. on each hand.

8/14/12

METHODS OF STERILIZATION
STEAM

AUTOCLAVE,NON TOXIC,SPOROCIDAL GAS STERILIZATION-Ethylene Oxide

Can penetrate plastic ,rubber.cotton,BP apparatus,catheters Sterilization is expensive and takes 2 to 5 hours to accomplish Ethylene oxide is toxic to humans

8/14/12

 RADIATION-Penetrates

deeply into the objects CHEMICALS-Effective Disinfectants

Attacks all types of Microorganisms,work with water Do NOT destroy articles Example is Chlorine

BOILING

WATER

8/14/12

USE OF BARRIERS
Caps and shoe coverings Masks Gloves Private rooms Waterproof disposable bags for linen ands trash Control of airflow Goggles and face shield

8/14/12

TOUCH WITH BARE HANDS ANYTHING THAT IS WET COMING FROM A BODY SURFACE

NEVER

8/14/12

Medication Administration
DEFINITION OF TERMS: 1. Medication substance administered for diagnosis, cure, treatment, relief or prevention of disease 2. Chemical name describes the constituents of the drug 3. Brand name the name given by the manufacturer.
8/14/12

TYPES OF DOCTORS ORDER 1. Standing order carried out until specified period of time or until it is discontinued by another order 2. Single order 3. Stat order 4. PRN
8/14/12

Parts of Doctors Legal Order

1. 2. 3. 4. 5. 6. 7.

Name of Patient Date and Time Name of Drug Dose of drug Route of administration Time of frequency Signature of physician
8/14/12

Effects of drug
1. 2. 3. 4. 5. 6. 7. 8. 9.

Therapeutic Side effect or secondary effect Drug allergy Anaphylactic reaction Drug tolerance Drug abuse Drug dependence Addiction habituation

8/14/12

Therapeutic action of drugs 1. Palliative 2. Curative 3. Supportive 4. Chemotherapeutic

8/14/12

PHYSIOLOGIC CHANGES ASSOCIATED WITH AGING THAT INFLUENCE MEDICATION ADMINISTRATION AND EFFECTIVENESS 1. Altered memory 2. Less acute vision 3. Decrease renal function 4. Slower GI absorption 5. Increase proportion of fat to lean body mass leading to toxicity 6. Decreased liver function
8/14/12

PRINCIPLES IN ADMINISTERING MEDICATION

1. 2. 3. 4. 5. 6. 7.

Right Right Right Right Right Right Right

drug dose route patient recording approach patient

8/14/12

Routes of Drug Administration

1. 2. 3.

Oral Sublingual Topical a. dermatologic b. ophthalmic c. otic d. nasal e. inhalation f. vaginal

8/14/12

4. Rectal 5. Parenteral a. Intradermal

Dermal layer underneath the epidermis. The sites are the inner, lower arm, upper chest and back, and beneath the scapula Indicated for allergy, and tuberculin testing Needle gauge 25,26,27. size 3/8,5/8 inches 10-15 degree angle , bevel up Do not massage the site of injection 8/14/12

B. Subcutaneous

For vaccines , preoperative medications, narcotics, insulin, heparin.

Sites: outer aspect of upper arm, anterior aspect of the thigh, abdomen Small doses are injected Rotate sites Needle gauge and size same as ID 45 degree angle For obese, 90degree angle 8/14/12

C. Intramuscular

Needle length 1 inch,1 to 2 inches to reach muscle layer Needle gauge: 20,21,22,23

a. Dorsogluteal - uses gluteus medius muscle POSITION : Prone or side-lying AREA: Upper,outer quadrant of buttocks b. Vastus lateralis for infants POSITION: back lying or sitting position c. Deltoid Site - not always used. IM Z-track technique parenteral iron preparation. retract the skin laterally, inject the medication slowly. hold the retraction of skin until the needle is withdrawn 8/14/12 do not massage

D. Intravenous

Direct IV push or infusion

Most rapid route of absorption Can be used with clients with GI problems

TYPES OF IV FLUIDS 1. Isotonic ex: D5W, 0.9Nacl 2. Hypotonic ex: 0.3Nacl, Plain LR 8/14/12

Complications of IV infusion
Infiltration the needle is out of vein and fluids accumulate in the SC Assessment: -Pain -Swelling -Pallor -Decreased or stopped IV flow -no back flow 8/14/12
1.

2. Circulatory overload results from administration of excessive volume of IV fluids Assessment: -headache -Flushed skin -increased BP -weight gain -syncope -pulmonary edema
8/14/12

INTERVENTION: 1. Slow infusion to KVO 2. High-Fowlers position 3. Bronchodilator 3. Drug Overload the patient receives an excessive amount of fluid containing drugs. Assessment: -dizziness -Shock -Fainting NSG INTERVENTION: -Slow infusion to KVO. Notify the physician
8/14/12

4. Superficial Thrombophlebitis it is due to overuse of a vein irritating solutions or drugs, clot formation, large bore catheters. Assessment: - Pain along the course of vein - Vein may feel hard and cordlike - Edema and redness at need insertion site - Arm feels warmer than the other arm INTERVENTION: -Change IV site every 72 hours. -Use large vein 8/14/12

5. Air embolism Assessment : - Chest, shoulder, backpain. -Hypotension -Dyspnea -Cyanosis -Tachycardia -LOC INTERVENTION -Do not allow IV bottle to run dry -Prime IV tubing before starting infusion
8/14/12

6. Nerve damage results from tying the arm too tightly to the splint Assessment: -numbness INTERVENTION: -Massage area -Do ROM -Instruct client to do open and close hands several times each hour.
8/14/12

Vitamins
Water

soluble

1.Ascorbic acid
for better absorption of iron

for smooth epithelium/Defenses Sources broccoli, guava, cabbage Deficiency scurvy (weakness , anemia, edema, spongy gums, loosening of teeth) 2. Thiamine (Vitamin B1)
Deficiency beriberi fatigue, diarrhea, appetite and weight loss, disturbed nerve function, wasting of limbs, edema and heart failure. 8/14/12

3. Vitamin b2-(Riboflavin)

Sources- milk, dairy products

Deficiency skin lesions, glossitis.

Sources-kidney, liver

4.Vitamin b3 (Niacin)

Deficiency-Pellagra, Dermatitis
8/14/12

5.Vit.B6 (Pyridoxine)
Sources: Chicken,Peanuts Deficiency:

6. Vit.B9 (Folic acid)

Sources: green leafy vegetable, liver, eggs Deficiency:

8/14/12

Fat Soluble Vitamins 1. Vitamin A (Retinol)-good eyesight; Maintenance of good epithelium

Sources-liver, fish liver oil Deficiency-night blindess, Xeropthalmia-dry lusterless cornea

2. Vitamin D (Ergocalciferol)- calcium absorption.

Sources-dairy products,salmon, sardines Deficiency Rickets-Soft, pliable bone, muscle pain, Spinal curvature Osteomalacia-Loss of calcification of bone resulting to softening of the bone.
8/14/12

3. Vitamin E ( Tocopherol) for maintenance of healthy skin and good eyesight.

Sources vegetable oils, leafy vegetables, peanuts Deficiency-anemia, skin lesion

4.Vit K(Menadione) for blood clotting.

Sources-green leafy vegetable, egg yolk. Deficiency-bleeding

8/14/12

Minerals 1.Calcium - bone and teeth formation - Muscular contraction - Blood coagulation - Neurotransmission - Catalyst for biologic reaction Sources-milk and dairy products, nuts, tofu. Deficiency- retarded growth, rickets, osteomalacia and tetany.

8/14/12

2. Potassium F and E balance, Hypokalemia -Manifested as apathy, muscular weakness, confusion Hyperkalemia- weakening in cardiac contraction, poor respiration, numbness of extremities Sources-fruits

8/14/12

3. Sodium responsible for fluid balance. Hyponatremia causes swelling Hypernatremia- crenation 4. Iron The most abundant trace element in the body necessary for hemoglobin formation. Sources-pork liver, lean meat Deficiency- anemia Excess hemosiderosis-Abnormal deposition of Iron to different tissues.

8/14/12

5. Iodine for normal synthesis of thyroxine. Sources- seafoods, milk, eggs Deficiency-goiter, cretenism, myxedema

8/14/12

Bowel and Bladder Elimination 1. Defecation expulsion of feces from the rectum STOOL ASSESSMENT A. Color B. Odor C. Amount D. Consistency E. Shape F. Frequency

8/14/12

Alteration on the Characteristic of stool 1. Acholic 2. Hematochezia 3. Melena 4. Steatorrhea

8/14/12

Common elimination problems 1.Constipation-passage of small, dry, hard stool or the passage of no stool for a period of time. 2.Fecal impaction- mass collection of hardened feces in the folds of the rectum. The stool is lodged or stucked in the rectum 3. Diarrhea frequent evacuation of watery stool

8/14/12

4. Flatulence excessive gas in the intestine. Due to swallowed air, bacterial action in the large intestine. 5. Fecal incontinence involuntary elimination of bowel contents associated with neurologic, mental and emotional impairment.

8/14/12

Urinary Elimination *Anatomy 1. Kidney 2. Ureter 3. Urinary bladder 4. Urethra Micturition the act of expelling urine from the bladder.Initiated by parasympathetic nervous system.

8/14/12

 1. 2. 3. 4. 5.

Characteristics Color amber or straw Odor aromatic Transparency clear pH 4.6 8 Specific Gravity 1.010 1.025

8/14/12

Altered Urinary Frequency 1. Frequency 2. Nocturia 3. Urgency 4. Dysuria 5. Hesitancy 6. Enuresis 7. Urinary Incontinence 8. Retention

8/14/12

Activity, mobility and exercise *Immobility 1.Musculoskeletal System -atrophy -disuse osteoporosis -dimineralization -contracture 2.Cardiovascular System -orthostatic hypotension -thrombus formation -embolus -thrombophlebitis

8/14/12

3.Respiratory -atelectasis -pneumonia -respiratory acidosis 4. Urinary -UTI - Urinary stasis - Calculi - Incontinence

8/14/12

5. Integumentary -loss of skin turgor -decubitus ulcer reddened areas or ulcer in the skin occuring over bony prominences Causes: a. Pressure b. Friction

8/14/12

BED SORE
8/14/12

Stages of Decubitus Ulcer Stage I : Erythema Stage II: Involves epidermis and or dermis. Presence of abrasion or blister or shallow crater. Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend through the fascia. Stage IV: Full thickness skin loss all the way to muscle and bone.

8/14/12

8/14/12

SAFETY and PROTECTI ON

8/14/12

Safe Environment Characteristics: Adequate lighting Neat and clean Safe equipment Noise level is comfortable Cleanliness Medication Temperature of the environment

8/14/12

Factors that affect peoples protection 1. Age 2. Orientation and LOC 3. Emotion 4. Injury or illness 5. Sensory or communication impairment 6. Safety awareness

8/14/12

Injuries 1.Fall 2.Burns 3.Chemical trauma

8/14/12

PAIN
8/14/12

Pain A sensation of physical or mental hurt or suffering that causes distress or agony Factors Influencing the pain experience 1. Age 2. Sex 3. Cultural background 4. Psychological 5. Previous experience 6. Knowledge or understanding

8/14/12

Stages of Pain 1. Activation begins with the perception of pain. 2. Rebound the pain experience is intense but brief. 3. Adaptation

8/14/12

Classification of Pain 1. Cutaneous 2. Somatic 3. Visceral 4. Referred perceived at an area other than the site of injury. 5. Intractable 6. Phantom 7. Radiating- felt at the source and extends the surrounding tissue. 8. Intermittent

8/14/12

SLEEP =state of lesser perception & reaction to the environment. RETICULAR ACTIVATING SYSTEM (RAS) =WAKEFULNESS: catecholamine release (E) =SLEEPINESS: serotonin release Stages of Sleep 1. NREM: body restoration 2. REM: >brains processes

8/14/12

A.

NREM Stage 1: Lightest sleep, 10 min, readily awakens Stage 2: Sound sleep, easily arousable, VS decrease Stage 3: Deep sleep, muscles relaxed, diff to arouse Stage 4: Deepest sleep, most relaxed, sleepwalking, enuresis, night terrors

B. REM: Paradoxic, vivid, full color dreams, 90 min

8/14/12

SLEEP DISORDERS Narcolepsy: > daytime sleepiness *Cataplexy: sudden muscle weakness *Hypnagogic: dreams undistinguishable from reality Somnambulism: sleep walking Soliloquy: sleep talking Sleep Terrors: sudden waking, but with no dream recall Bruxism: teeth grinding Enuresis: bed-wetting

8/14/12

OXYGENATION
VENTILATION:

BREATHING DIFFUSION: O2 MOVES FROM ALVEOLI TO RBC PERFUSION: RBCS MOVE INTO CIRCULATION

8/14/12

THORACENTESIS
NEEDLE

INSERTION THRU CHEST WALL FOR ASPIRATION OF PLEURAL FF FLUID OR INSTILLATION OF MEDS EXPLAIN PROCEDURE & INSTRUCT CLIENT NOT TO COUGH OR MOVE SUDDENLY CHECK FOR PNEUMOTHORAX

8/14/12

CARDIAC CATHETERIZATION
R-SIDED: ANTECUBITAL VEINR HEART-PULMONARY ARTERY L-SIDED: BRACHIAL OR FEMORAL ARTERY AORTALEFT VENTRICLE PRE-TEST: CHECK FOR ALLERGIES; NPO 8-12 HOURS PRIOR, NO ANTICOAGULANTS AT LEAST 3 DAYS PRIOR FEELING OF WARMTH OR FLUTTERING IS COMMON AS CATHETER PASSES POST-TEST: CHECK CIRCULATION IN AFFECTED EXTREMITY (PULSES, COLOR, SENSATION), SANDBAG OR PRESSURE DRESSING OVER PUNCTURE SITE.

8/14/12

BRONCHIAL LAVAGE/ STEAM INHALATION

LIQUIFIES

AND MOBILIZES SECRETIONS; MEDIUM FOR AEROSOL BRONCHODILATORS & MUCOLYTIC EXPECTORANTS COVER CHEST WITH TOWEL AND PLACE SPOUT 12-18 IN. AWAY TO PREVENT BURNS. STEAM FOR 15-20 MINUTES. THEN DEEP BREATHING AND COUGHING TO MOBILIZE SECRETIONS

8/14/12

CHEST PHYSIOTHERAPY
PERFORM

AC TO AVOID ASPIRATION SEMI-FOWLERS POSITION GIVE BRONCHODILATORS 20 MIN PRIOR *POSTURAL DRAINAGE: CAREFUL POSITIONING ALLOWS SECRETIONS TO FLOW BY GRAVITY FROM SMALLER AIRWAYS INTO LARGER AIRWAYS *PERCUSSION: CLAPPING WITH CUPPED HANDS ON CHEST WALL FOR 3-5 MIN TO DISLODGE SECRETIONS *VIBRATION: WITH HANDS PRESSED FLAT ON CHEST, UPPER ARM & SHOULDERS
8/14/12

TRACHEOSTOMY
SURGICAL

CREATION OF A STOMA, OPENING INTO THE TRACHEA THROUGH THE OVERLYING SKIN FOR RELIEF OF UPPER AIRWAY OBSTRUCTION OR ACCESS FOR MECHANICAL VENTILATION

8/14/12

NGT INSERTION
PLACE

PT IN HIGH-FOWLERS NURSE ON SIDE OF NOSTRIL FOR INSERTION. MEASURE TUBE LENGTH BY NOSE-EARLOBEXIPHOID (NEX). ADD 20-30 cm FOR DUODENAL PLACEMENT. LUBRICATE TUBE. HYPEREXTEND NECK, INSERT TUBE THRU NOSTRILS TOWARDS BACK OF THROAT WHILE ROTATING TUBE 180. FLEX NECK ONCE TUBE IN OROPHARYNX & ASK CLIENT TO SWALLOW.

8/14/12

NGT FEEDING
CLIENT

SITTING OR HIGH-FOWLERS POSITION (PREVENTS ASPIRATION) CHECK FOR RESIDUAL FEEDING >150 ml: INFORM DR WITH FEEDING BAG OR SYRINGE ELEVATED 12 INCHES. ELEVATION ALLOWS EMPTYING BY GRAVITY TO PREVENT ABDOMINAL DISCOMFORT, REFLUX AND VOMITING FOLLOW WITH WATER TO CLEAR TUBE. CLAMP TUBE BEFORE ALL THE WATER IS INSTILLED TO PREVENT AIR BUBBLES (FLATULENCE)

8/14/12

PARENTERAL NUTRITION
FOR

CLIENTS WHO ARE UNABLE TO DIGEST OR ABSORB ENTERAL NUTRITION: GI OBSTRUCTION, ILEUS, SURGERY, TRAUMA REQUIRES MONITORING OF GLUCOSE, ELECTROLYTES, LIPIDS, PROTEINS

8/14/12

 CLEAR

LIQUID: BROTH, COFFEE, TEA, FRUIT JUICES, GELATIN, POPSICLE FULL LIQUID: ALL JUICES/ SHAKE, PUREED VEGGIES, CUSTARD, COOKED CEREAL PUREE: PUREED MEAT/FRUITS, SCRAMBLED EGG, MASHED POTATOES MECHANICAL SOFT: GROUND OR FINELY FLAKED MEAT/ FISH, CHEESE, RICE, POTATOES, HOTCAKES, LIGHT BREAD, SOUP SOFT: TENDER MEAT, SOFT FRESH FRUIT, CAKE, COOKIES (NO NUTS)

DIET PROGRESSION

8/14/12

BOWEL ELIMINATION
FECES

MOVES INTO RECTUM RELAXING INTERNAL ANAL SPHINCTER THEN EXTERNAL ANAL SPHINCTER RELAXES TO EXPEL FECES. IF NOT, LEVATOR ANI MUSCLES, HELP KEEP SPHINCTER CLOSED. VALSALVA: FORCEFUL EXPIRATION THRU A CLOSED GLOTTIS. IT FACILITATES DEFECATION BY INCREASING INTRAABDOMINAL PRESSURE.

8/14/12

FECALYSIS
1

INCH (FORMED); 15-30 ml (LIQUID) COLOR: YELLOW-BROWN RT STERCOBILIN ODOR: PUNGENT RT INDOLE & SKATOLE FREQUENCY: 1-3x/DAY (INFANT) CONSISTENCY: SOFT BUT FORMED, SHAPE REFLECTS RECTAL DIAMETER. *RAPID TRANSIT TIME: LESS WATER REABSORBEDLIQUID STOOL *SLOW OR DELAYED: MORE ABSORPTION HARD & DRY STOOLS
8/14/12

LAXATIVES
BULK FORMER= SAFEST. PSYLLIUM (METAMUCIL). TAKE WITH WATER TO PREVENT IMPACTION STOOL SOFTENER= Na DOCUSSATE. OSMOTIC AGENT= ABSORBS WATER. LACTULOSE: GIVE BEFORE BREAKFAST OR BEDTIME. MILK OF MAGNESIA: LOWER DOSES ACT AS ANTACID LUBRICANTS= MINERAL OIL. GIVE UPRIGHT: NOT WITH MEALS! CHEMICAL IRRITANTS= > PERISTALSIS BISACODYL (DULCOLAX): GIVE ac, WAIT 1 HOUR BEFORE MILK OR ANTACID. SENA (SENOKOT): GIVE hs, DISCOLORS URINE CASTOL OIL= TAKE WITH SODA

8/14/12

 SKIN

CARE/HYGIENE BED BATH *cover with top sheet up to shoulder level. *To avoid chills: close windows; warm water; expose, wash & dry 1 body part at a time: eyes, face, ears, neck-forearms-distal arms-hands-chestabdomen-legs-feet-back-buttocks-perineum *Extremities: long firm strokes (D-P) *Back: P-D

8/14/12

PERINEAL-GENITAL CARE *Drape, Dorsal Recumbent *Female: anterior-posterior *Male: firm strokes circular motion Glans penis tip-Shaft! *uncircumscised: retract, smegma X

8/14/12

ORAL CAVITY CARE Cheilosis: lip cracking (Vit B12 def) Dental Caries: teeth disintegration (brown discoloration) lactic & pyruvic acid (product of bacterial action on CHO) Gingivitis Glossitis Parotitis/Mumps Periodontitis Stomatitis Tartar: visible hard deposit of plaque (bacteria, saliva, EC on teeth enamel)

8/14/12

EYES, EARS, NOSE CARE Hyperopia: Farsightedness; ray of light focus BEHIND retina Myopia: Near; IN FRONT retina Presbyopia: impaired near vision DT <lens elasticity (aging) Astigmatism: blurred vision uneven curvature of lens or cornea (causing light to focus on diff points) Retinopathy: retinal vessel changes (hemorrhage, exudates, narrowing) Strabismus: cross-eyes Cataract: lens opacity blocks light Glaucoma: optic atrophy (disc cupping &visual field loss) with IOP

8/14/12

Clean with WATER!, clean cloth inner-outer canthus Contact lens: Pseudomonas/Staph *daily wear: removed overnight & not worn >10-14 hr/day *extended wear: worn not >6 consecutive nights without cleaning Artificial Eyes: Depress lower eyelid to remove eye, hold it between thumb & index, clean with warm NSS!

8/14/12

EARS CARE *moist washcloth, ear canal straightening *Impacted cerumen: instill H2O2 1-2 drops/ear 3x/d for 3d. Irrigate with 250 ml WARM water! (hot/cold: NV) NOSE CARE *gentle blowing thru open nostrils *soften crusted secretion with NSS

8/14/12

BED MAKING Bed Types: 1. Unoccupied Bed *Open: top cover (folded back) *Closed: Top sheet (spread up) 2. Occupied Bed: bed made c pt BiRD TaBa Po! Bottom, Rubber, Draw, Top, Blanket, Pillow case

8/14/12

Grieving and Death

Loss- actual or potential situation in which valued object, person changed so that it is no longer perceived as valuable. Bereavement is a subjective response to a loss through death. Grief-total response of emotional experience of the loss and is manifested in thoughts,feelings and behavior Mourning- behavioral process through which grief is eventually resolved or altered.

8/14/12

Stages of Grieving
Denial Anger Bargaining Depression Acceptance

8/14/12

Symptoms of Grief
Repeated somatic distress Tightness in the chest SOB Sighing Loss of muscular power Intense subjective distress

8/14/12

Signs of impending clinical death

Loss

of muscle tone Slowing of circulation Changes in vital signs Sensory impairment

8/14/12

THANKS
8/14/12