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Fundamentals of Nursing

Hildegard Peplaus Interpersonal Relations Theory


Defined Nursing: An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help. Nursing is a maturing force and an educative instrument Identified 4 phases of the Nurse Patient relationship:
Orientation individual/family has a felt need and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase. Identification where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance. Exploitation the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services. Resolution where patients needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

Faye Glenn Abdellahs Concept of Twenty One Nursing Problems


21 Nursing Problems
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. To maintain good hygiene. To promote optimal activity; exercise, rest and sleep. To promote safety. To maintain good body mechanics To facilitate the maintenance of a supply of oxygen To facilitate maintenance of nutrition To facilitate maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiologic response of the body to disease conditions To facilitate the maintenance of regulatory mechanisms and functions To facilitate the maintenance of sensory functions To identify and accept positive and negative expressions, feelings and reactions To identify and accept the interrelatedness of emotions and illness. To facilitate the maintenance of effective verbal and non-verbal communication To promote the development of productive interpersonal relationship To facilitate progress toward achievement of personal spiritual goals To create and maintain a therapeutic environment To facilitate awareness of self as an individual with varying needs. To accept the optimum possible goals To use community resources as an aid in resolving problems arising from illness. To understand the role of social problems as influencing factors

Dorothea Orems Self-Care Theory


Identified 3 related concepts:Self-care activities an Individual performs independently throughout life to promote and maintain personal wellbeing. Self-care deficit results when self-care agency (Individuals ability) is not adequate to meet the known self-care needs. Nursing System nursing interventions needed when Individual is unable to perform the necessary self-care activities:
Wholly compensatory nurse provides entire self-care for the client.
Example: care of a new born, care of client recovering from surgery in a postanesthesia care unit

Partial compensatory nurse and client perform care, client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently.
Example: Nurse can assist post operative client to ambulate, Nurse can bring a meal tray for client who can feed himself

Supportive-educative nurses actions are to help the client develop/learn their own self-care abilities through knowledge, support and encouragement.

Health
State of being well and using every power the individual possesses "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease" (WHO) "Health is not a condition, it is an adjustment. It is not a state, but a process. The process adapts the individual not only to our physical, but also our social, environments" (Presidents Commission) most individuals define health as the following:
being free of symptoms of disease and pain as much as possible being able to be active and able to do what they want or must do being in good spirits most of the time

Smiths Models of Health and Illness


clinical model narrowest interpretation; medically-oriented model
health is seen as freedom from disease illness is seen as the presence of disease

role performance model ability to perform work, that is fulfill societal roles, essential to the model; assumption of the model is that a persons most important role is their work role
health is seen as the ability to fulfill societal roles illness is seen as the inability to fulfill societal roles

Smiths Models of Health and Illness

adaptive model ability to adapt to the environment and interact with it to maximum advantage essential to the model
health is seen as adaptation illness is seen as a failure of adaptation, or maladaptation

eudaemonistic model most comprehensive, holistic, view of health; ability to become self-actualized essential to the model
health is actualization or realization of ones potential illness is seen as the failure to actualize or realize ones potential

Therapeutic Communication
Communication process that people use to exchange information. Verbal communication consists of words a person uses to speak to one or more listeners Context the environment in which the communication occurs and can include the time and physical, social, emotional and cultural environment. Nonverbal communication the behavior that accompanies verbal content such as body language, eye contact, facial expression, tone of voice, etc. Therapeutic communication an interpersonal interaction between the nurse and the client during which the nurse focuses on the clients specific needs to promote an effective exchange of information.

Goals of Therapeutic Communication:


Establish a nurse- client relationship. Identify the most important client concern at that moment. Assess the client's perception of the problem as it unfolds. Facilitate the client's expression of emotions. Teach the client and family necessary self- care skills. Recognize the client's needs. Implement interventions designed to address the client's needs. Guide the client toward identifying plan of action to a satisfying and socially acceptable resolution.

Privacy and Respecting Boundaries Privacy is desirable but not always possible. PROXEMICS the study of distance zones between people during communication. Therapeutic communication interaction is most comfortable when the nurse and the client are 3 to 6 feet apart. Touch Although touch can be comforting and therapeutic, ii is an invasion of intimate or personal space. Some clients with mental illness have difficulty understanding the concept of personal boundaries or when touch is or is not appropriate. When nurse is going to touch the client while performing nursing care, he or she must verbally prepare the client before starting the procedure.

Overview of the NURSING PROCESS

The Nursing process is the cornerstone of the Nursing profession. It is also synonymous to problem solving approach for discovers the healthcare and nursing needs of the patients.

Lydia Hall originates the term Nursing Process in 1955 It is an organized, systematic manner of providing goaloriented and humanistic care that is both efficient and effective. The Nursing Process is GOAL Oriented and humanistic approach

Prioritization
First level priority: are those that are emergent, life threatening, and needs immediate attention Examples : Airway problems, breathing problems, cardiac/circulation problems, signs (vital signs concerns).
Second level priority:are those requiring prompt intervention to forestall further deterioration. Immediate, after treatment for first level problems is initiated.

Prioritization
Example: Mental status change, Acute pain, Acute urinary elimination problems, Untreated medical problems requiring immediate attention (e.g., a diabetic who hasnt had insulin),Abnormal laboratory values, Risks of infection, safety, or security, (for the patient or for others).Mnemonic MAA-U-AR Third level priority: are those that are important to the patients health but can be addressed after more urgent health problems are addressed (later proprieties). Example: Health problems that do not fit into the above categories: problems with lack of knowledge, activity, rest, family coping.

Focus Charting
Focus Charting - is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action. COMPONENTS OF A FOCUS NOTE: Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events. Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. Response: Description of individual's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment.

FDAR
F: Hyperthermia D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla > flushed skin and warm to touched A: 9:00am > Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid > instructed SO to include in his diet foods rich in Vitamin C such as oranges > provided opportunity for patient to rest > due meds given R: 1:00pm > patient was able to rest > patient temperature decrease to T= 37.8 degree Celsius/axilla

Documentation
Documentation is the written or printed record of a clients care; its an essential nursing responsibility. It is the nurses responsibility that the record remains CONFIDENTIAL. Documentation allows continuity of care, gives a way to let other health care workers know what we have done, and is a legal documentation on the client.

6 purposes for documentation


Communication Legal documentation Financial billing/reimbursement Education Research Audit-monitoring/quality assurance

Documentation needs to be CC FLAT

5 Different Documentation Systems


Narrative- chronological account of clients care & response to care Problem-oriented- structure that emphasizes the clients identified problems and progress Charting by exception(CBE)- requires only deviations from baseline Problem-intervention-evaluation(PIE)organizes information according to the clients problems Electronic charting-newer method of documenting client care

Breath Sounds
Tracheal breath sounds are heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe.
Bronchial sounds are present over the large airways in the anterior chest near the second and third intercostal spaces; these sounds are more tubular and hollow-sounding than vesicular sounds, but not as harsh as tracheal breath sounds. Bronchial sounds are loud and high in pitch with a short pause between inspiration and expiration; expiratory sounds last longer than inspiratory sounds.

Breath Sounds
Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.
Vesicular sounds are soft, blowing, or rustling sounds normally heard throughout most of the lung fields. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.

Adventitious Breath Sounds


Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles are referred to as discontinuous sounds; they are intermittent, nonmusical and brief. Crackles may be heard on inspiration or expiration. The popping sounds produced are created when air is forced through respiratory passages that are narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation or infection of the small bronchi, bronchioles, and alveoli. Crackles that don't clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome (ARDS). Wheezes are sounds that are heard continuously during inspiration or expiration, or during both inspiration and expiration. They are caused by air moving through airways narrowed by constriction or swelling of airway or partial airway obstruction.
Wheezes that are relatively high pitched and have a shrill or squeaking quality may be referred to as sibilant rhonchi.They are often heard continuously through both inspiration and expiration and have a musical quality. These wheezes occur when airways are narrowed, such as may occur during an acute asthmatic attack. Wheezes that are lower-pitched sounds with a snoring or moaning quality may be referred to as sonorous rhonchi.Secretions in large airways, such as occurs with bronchitis, may produce these sounds; they may clear somewhat with coughing.

Pleural friction rubs are low-pitched, grating, or creaking sounds that occur when inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. To determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the patient to hold his breath briefly. If the rubbing sound continues, its a pericardial friction rub because the inflamed pericardial layers continue rubbing together with each heart beat - a pleural rub stops when breathing stops. Stridor refers to a high-pitched harsh sound heard during inspiration.. Stridor is caused by obstruction of the upper airway, is a sign of respiratory distress and thus requires immediate attention.

Cranial Nerves

Common Laboratory Values

Common Laboratory Values

Common Laboratory Values

Intravenous Fluids

Isotonic

Hypotonic

Hypertonic

Pap SMEAR
The Papanicolaou test (Pap smear) is a widely known cystologic test for early detection of c ervical cancer. The can also be used to detect cancerous cells of the breast, lung, stomach, and renal system. A physician or specifically trained nurse scrapes secretions from the patients cervic and spreads them on a slide, which is sent to the laboratory for cystologic analysis.

Pap SMEAR
Purpose of Pap Smear To detect malignant cells. To detect inflammatory changes in tissue. To assess response to chemotherapy and radiation therapy. To detect viral, fungal, and occasionally, parasitic invasions.
Patient Preparation Instruct the patient to avoid intercourse for 24 hours, douching for 48 hours, and vaginal creams or medication for 1 week. Just before the test, instruct the patient to empty her bladder. During the procedure, she might experience a slight discomfort but no pain from the speculum; however, she may feel some pain when the cervix is scraped. Explain the procedure takes only 5 to 10 minutes to perform. Instruct the patient to disrobe from the waist down and to drape herself. Ask her to lie on the examining table and to place her heels in the stirrups. Tell her to slide her buttocks to the edge of the table.

Pap SMEAR
Abnormal Results Cells with relatively large nuclei, only small amounts of cytoplasm, abnormal nuclear chromatin patterns, and marked variation in size, shape, and staining properties, with prominent nucleoli, suggest malignancy. Atypical but nonmalignant cells suggest a benign abnormality. Atypical cells may suggest dysplasia. Interfering Factors Douching within 24 hours of testing. Excessive use of lubricating jelly on the slide. Collection of specimen during menstruation Delay in fixing the specimens Consistency of specimen too thin or too thick. Precautions Preserve the slides immediately after the specimen is collected. Preserve the ThinPrep solution by immediately placing the lid back on the container, as exposure to air or light can cause distortion of cells.

Naso Gastric Tube

Z Track Method

Z Track Method
Z-track method ofintramuscular injection is used to administer drug in a large muscle that prevents the leakage of the medication into the layers of subcutaneous tissues. It is named Z-track because after the techniques of this medication administration are implemented a zigzag path is responsible for sealing the drug in the muscles.

Restraint
Restraint application is a technique of physically restricting a persons freedom of movement, physical activity or normal access to his body. A physical restraint is a piece of equipment or device that restricts a patients ability to move. It is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body.

Restraint
Types of Restraints Soft restraints. This type of physical restraint device is used to limit movement of patients who are confused, disoriented or combative. The main goal of using this restraint is to prevent the patient from injuring him or her self and/or others. Vest and Belt Restraints. In using this device full movement of arms and legs are permitted. This is used to prevent the patient from falling from bed or a chair. Limb Restraints. Patients who are removing supportive equipments such as I.V. lines, indwelling catheters, NGTs and etc. are placed on limb restraints. This device allows only slight limb motion. Mitts. This device prevents the patient from removing supportive equipment, scratching rashes or sores and injuring him or herself and/or others. 5. Body restraints. When patients become combative and hysterical they can be controlled by applying body restraints. This immobilizes almost all of the body. 6. Leather Restraints. This restraint is only used when soft restraints are not sufficient to control the patient and when sedation is either dangerous to the patient or ineffective.

Precautions of Restraint Application


Before applying restraints it is important to try other methods of promoting patient safety. Alternative methods that might be effective are reorientation of the patient to the physical surroundings, moving the patients room near to the staff members, teaching relaxation techniques in order to decrease anxiety and fear and decrease overstimulation. Documentation of any alternative method used is extremely important. Restraint application should be documented thoroughly.

Situations that Requires Restraint Application


Confused client tries to endanger him or herself Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective dressings. The client is at risk for falls. The client is suicidal. The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors. A child is unable to remain still during a minor surgical procedure.

Restraint Application Key Steps


Make sure that the restraints are correct size for the patients build and weight. Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or her from restraints. Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or others. Restraints used should be least restrictive to the patient. Obtain adequate assistance to manually restrain the patient. After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner and an order must be written for restraints. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for patients younger than 9 years old. The original order expires in 24 hours. Thus, the same order cannot be used the following day. To promote safety and ensure the patient is not harmed with restraint application, the patient should be assessed every 2 hours or according to the facility policy. In cases where the client consented to have his family informed of his care, the family should be notified of the use of restraints.

Blood Transfusion
Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions. Platelets, either HLA (human leukocyte antigen) matched or unmatched. Granulocytes ( basophils, eosinophils, and neutrophils ) Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors). Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation. Albumin, a plasma protein. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Blood Transfusion
Assessment Findings Clinical manifestations of transfusions complications vary depending on the precipitating factor. Signs and symptoms of hemolytic transfusion reaction include:
Fever Chills low back pain flank pain headache nausea flushing tachycardia tachypnea hypotension hemoglobinuria (cola-colored urine)

Blood Transfusion
Clinical signs and laboratory findings in delayed hemolytic reaction include:
fever mild jaundice gradual fall of hemoglobin positive Coombs test

Febrile non-hemolytic reaction is marked by:



Temperature rise during or shortly after transfusion Chills headache flushing anxiety
Rapid onset of high fever and chills vomiting diarrhea marked hypotension

Signs and symptoms of septic reaction include;

Blood Transfusion
Allergic reactions may produce:
hives generalized pruritus wheezing or anaphylaxis (rarely)

Signs and symptoms of circulatory overload include:


Dyspnea cough rales jugular vein distention

Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease. Characteristics of GVH disease include:
skin changes (e.g. erythema, ulcerations, scaling) edema hair loss hemolytic anemia

Exam Mode
1. A sudden redness of the skin is known as: a. Flush b. Cyanosis c. Jaundice d. Pallor 2. The term gavage indicates: a. Administration of a liquid feeding into the stomach b. Visual examination of the stomach c. Irrigation of the stomach with a solution d. A surgical opening through the abdomen to the stomach 3. A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action? a. Administer a sedative at bedtime, as ordered by the physician b. Ambulate the patient for 5 minutes before he retires c. Give the patient a glass of warm milk before bedtime d. Close the patient's door from 9pm to 7am

Exam Mode
4. Which of the following nursing theorists dveloped a conceptual model based on the belief that all persons strive to achieve self-care? a. Martha Rogers b. Dorothea Orem c. Florence Nightingale d. Cister Callista Roy
5. Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus? a. Martha Rogers b. Dorothea Orem c. Florence Nightingale d. Sister Callista Roy 6. Which of the following questions is most appropriate to ask when interviewing a potential candidate fo an RN position? a. What was your last nursing experience? b. Are you willing to do overtime on weekends? c. How many children do you have? d. Do you plan to get pregnant?

Exam Mode
7. If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the nurse? a. The private attending physician b. The nursing supervisor c. The hospital d. All of the above
8. Which of the following may be considered a patient's right? a. The right to euthanasia b. The right to refuse treatment c. The right to ignore hospital regulations d. The right to refuse to pay for what the patient considers to be inferior service. 9. If a patient sues a nurse for malpractice, the patient must be able to prove: a. Error, proximal cause, and lack of concern b. Error, injury and proximal cause c. Injury, error and assault d. Proximal cause, negligence and nurse error

Exam Mode
10. Which communication skills is most effective in dealing with covert communication? a. Validation b. Listening c. Evaluation d. Clarification 11. Which of the following qualities are relevant in documenting patient care? a. Accuracy and conciseness b. Thoroughness and currentness c. Organization d. All of the above 12. The usual sequence for assessing the bowel is: a. Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant b. Right lower lobe, right upper lobe, left upper lobe, left lower lobe c. Right hypochondriac, left hypochondriac and umbilical regions d. Rectum, pancreas, stomach and liver

Exam Mode
13. The nurse should take a rectal temperature of a patient who has: a. His arm in a cast b. Nasal packing c. External hemorrhoids d. Gastrostomy feeding tubes 14. Blood pressure measurement is an important part of the patient's data base. It is considered to be: a. The basis of the nursing diagnosis b. Objective data c. An indicator of the patient's well being d. Subjective data 15. Postural drainage to relieve respiratory congestion should take place: a. Before meals b. After meals c. At the nurse's convenience d. At the patient's convenience

Exam Mode
16. The correct site at which to verify a radial pulse measurement is the: a. Brachial artery b. Apex of the heart c. Temporal artery d. Inguinal site 17. S1 is heard best at the: a. 5th left intercoastal space along the midclavicular line b. 3rd intercoastal space to the left of the midclavicular line c. Second right intercoastal space at the sternal border d. Second left intercoastal space at the sternal border 18. The nurse's main priority when caring foar a patient with hemiplegia? a. Educating the patient b. Providing a safe environment c. Promoting a positive self-image c. Helping the patient accept the illness

Exam Mode
19. Constipation is a common problem for immobilized patients because of: a. Decreased peristalsis and positional discomfort b. An increased defacation reflex c. Decreased tightening of the anal sphincter d. Increased colon motility 20. Antiembolism stockings are used primarily to: a. Promote venous circulation b Provide external warmth c. Prevent dependent edema d. Hold foot dressings
21. To promote correct anatomic alignment in a supine patient, the nurse should: a. Place the patient's feet in dorsiflexion b. Place a pillow under the patient's knees c. Hyperextend the patient's neck d. Adduct the patient's shoulder

Exam Mode
22. An appropriate interdependent intervention to prevent thrombophebitis would be: a. Elevate the knee gatch of the bed b. Massage the legs vigorously c. Apply antiembolism stockings to both legs. d. Encourage the patient to sit with his knees crossed 23. The average daily amount of urine excreted by an adult is: a. 500 to 600 ml b. 800 to 1,400 ml c. 1,000 to 1,200 ml d. 1,500 to 2,000 ml

24. According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen? a. Activity b. Safety c. Love d. Self esteem
25. Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by: a. Croupette b. Nasal Cannula c. Nasal catheter d. Partial rebreathing mask

Exam Mode
26. Which element in the circular chain of infection can be eliminated by preserving skin integrity? A. Host B. Reservoir C. Mode of transmission D. Portal of entry 27.Which of the following will probably result in a break in sterile technique for respiratory isolation? A. Opening the patients window to the outside environment B. Turning on the patients room ventilator C. Opening the door of the patients room leading into the hospital corridor D. Failing to wear gloves when administering a bed bath
28.Which of the following patients is at greater risk for contracting an infection? A. A patient with leukopenia B. A patient receiving broad-spectrum antibiotics C. A postoperative patient who has undergone orthopedic surgery D. A newly diagnosed diabetic patient

29.Effective hand washing requires the use of: A. Soap or detergent to promote emulsification B. Hot water to destroy bacteria C. A disinfectant to increase surface tension D. All of the above

30.After routine patient contact, hand washing should last at least: A. 30 seconds B. 1 minuteC. 2 minute D. 3 minutes

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