we Fundamentals of Nursing NS IN “Theory - set of concepis fo explana phenomenon, Paradigm - pattern ‘4 Metaparadigms of Nuning ‘Person Mos! important because knowing the clent wil make your nung care individualized, holstc, ethical, ond humane. = Heath Environment © Nusing Concepts of Man + Manso bio-psychosoctal and spitval being who sin Constant contact withthe environment. + Maniecon open system in constant interaction with a changing ervirorment ‘+ Man's c unified whole composed of pars, which ore interdependent and intenelaied wiih each other. 1+ Manis composed of parts, which are greater thon and ferent rom the sum of all hs pats. 'o Senaly saying, you cannot remove | systern fom 1+ Monis composed of subsystems and suprasystems 'o_ Subsyslern (within) Example: biological, ‘p8ychological, emotiona. ‘© Suprasystem (outside) Exomple: For, cornmurtty, popuiation Florence Nightingale + Act of ullzing the environment of ine patient fo ass rim inhisrecovery. Siter Calista Roy "+ Theorelica system of knowledge thal presciibes o process ‘of analysis ond action related to the core of the ll person. Martha Rogers ‘+ Nestingis @ humanistic science dedicated to the Compassionate coneein with mainicining and promoting healin ond preventingilness and cating for and renabittaaing the sick and disabled, ‘© Levelsof prevention = Paimary= Health promotion and disease prevention + Secondary Treatment, curative + TertioryRehabittation Dorothea Orem (Sef-ccre ond Sol-care deficit theory) ‘+ Helping or asisting sence 1o persons who are whaly or orlly dependent, when they, ei parents onc quoxcfans, brother acu responsible for their care are no longer able lo gve orsypenise thelr core, 0 Le.—completely assisted, partly assisted, ond sel-ossited [ANA (American Nurses Association) ‘+ Nusing|s the protection, promotion, and optimization of health and abies, prevention of ness and iriury Aleviotion of stering through the diagnosis and ‘advocacy in he core of individuals, femnies, commurilis, ‘and populations (2003). ‘Abraham Masiow’s Hierarchy of needs + Seloctuaiztion > Sorestoem + love end belongingness + [Link] Security © Being Hoe fom ham or danger © 2 forms: Physical fel fee tom physical hom) dnd Psychological oft explong he procedue ohne paiont) + Physologie (potty) © Iralthe need ce within he physiologic level igh Ponty noocs life Irveatering neecs) Away, Breathing, Creulaton Medium prorty needs (Heit teotering needs) SiminaFon, nuliion, Comfort low Prony needs ~ [Person's developmentol needs) Florence Nightingale + Environment meory 3 May 12, 1830~ August 13,1910 + Enviicrmental saritafon ‘idegard Peplau = Paychodynomic Theory of Nursing + Inferpersonal Process + Phases of Nuse patient rlationshi ‘L. Ofieniation (cfent seeks) 2. Identification independence, dependence) 3. Exploiigfon (accept service of nuse) 4. Resolution ‘Virginia Henderson © 14Fundamental needs of the person Faye Abdeliah + Typology of 21 Nursing problems + Potient-centered opproach © The client's needs ore the boss of the nursing pprobiems yet Hat + 3C's 1. Cove therapeutic use of se) ~ Patent 2. Core [nursing function) - Nuss 3. Cute [medical - Doctor Jean Watson ‘Human Caring Theory = Caiingis aninnate choractotisic of every rune. + 1oCcraiive factors da Jean Oando-Pelletior + Dynamic Nurse Patient Relationship Mode! 4 Nussing Process Theory ‘0 Nuising 68 @ process invalvedin interacting with cillindvidul to meet cn immediate need. + Fourractices Basic to Nusing 19 Observation, reporting, recording, and actons ‘Madeleine Leininger Transcultural Theory of Nursing ‘Myra Levine + 4Piincipies of Conservation 1. Conservation of energy 2. Conservation of siuctural ntegity of the body 3. Conservation of petsond integity 4. Conservation of social integrityFundamentals of Nursing Sister Calista Roy ‘+ Adaptation Mode! ‘+ Individuals cope ttrough biophysical social adoptation + -Amode of edopiation ‘© Role function, interdependence, physiological, sel-concep! Dorothea '* Sef-core and Selt-care Deficit Theory + Urivorsalselt-care requirement (nutition, oxygenation), ‘developmental selt-care requirement (devetopmental tasks) health cate deviation self-care requirement + 3Nuning systems: wholly compensatory partly ‘compensatory, supportive-educative compensatory Dorothy Johnson ‘+ Behaviorat ystems Theory “+ Man's composed of subsystems and these systems exst in dynamic stobily. Marthe Rogers ‘+ Science of Unitary Human Being + Unitarymanis an energy fieidin consiant interaction with the environment. Imogene King ‘© GoalAttainment Theory 1 ecacting systems fromework Nusses purposefuly interac! with the potent and mutually sel he god, explore, ond agee to means to achieve the gods. Betty Neuman ‘© Total Person Mode! 1 3types of stressor: inta-petsonad, extra personal, injerpersondl + Primary, secondary, tetiony levels of prevention The g00 of nung sto asst indivi families and groups inetloning and maintaining a maxima level of foi wellness by puposefu interventions Pore ‘© Theory of Human Beconting 2 emphasizes now individual chose and bear responstily for pattems of persona health Paticia Benner = Novice - Expert Theory Stoge |: Novice Stage 2: Advance beginner Slage 3: Competent [23 years) Slage 4: Proficient [35 yess) Slage 5: Expert = Sills coquiston | Joyce Travelbee "= Human fo Human Relationship, Emestein Weldenbach ‘© Clinical Nusing: A Hetping Art Nola Pender ‘= Health Promotion Mode! FUPINO NURSING THEORISTS Carmencita Abaguin ‘Chaiman of Board of Nursing PREPARE ME intervention P-pretence whichin RE~reminsce theropy P-proyer Re - relaxation ‘ME-medication 7. Caroline Agravante ‘+ The CASAGRA Transformative Leadership model + 5C’sforTrarsfomafond leadership: creative, coring, ctiica,, contemplative, colegia Carmela Divinagracio + COMPOSURE Behovio: for wellness + Competence + Presence of Prayer, Open mindedness, mulation, Understonding, Respect, Relaxation, Empathy ‘Mie Delia Vanes + Concepivol model on Core Competency Development ‘Ma. ma Bustamante = Th effecs ofthe Nussng Self-Esteem Enhancement {NuSe] Program fo he Sel- Esteem of Fpino Abused. Women 1 Letty Kuan Reliement ond Role Discontinuity St. Bfeabeth of Hungary -Patroness of nurses 51. Catherine of Siena ~The 1 lady withthe lamp Ciara Barton - Fourcler of American Red Cross Fabiola - Wealthy Matron who donated het wed fo build a hospital the Christion world [Link] - Founder ofthe fist organized school of nursing Rose Nicole! - Helped establish the fist schoo! of pursing in the Philippines Lon Wold - Founder of Public Health Nusing Hi PENT Intutive = Practiced during the prerislorc, nusing was untought, rendered by the mothers (Dy inition. isthe woman who ‘smote caring) = Qulof love, sickness caused by black spits, [Link], Irstinct + Shamans, spots, fils ‘Tephinng ~boting a hoe info « seulwithout cnethesia to release ov spits *Eaypiians — oft of embciming, anatomy and physoloay ‘Moses ~ Father of Servation,asepss, oft of creumeision China ~ malefiol medica book of phamacoioay Babylonians ~ Bil of Righls, Code of Homimurabi (made by King Hammura which include freedom to refuse recimeni), mecicct fee ‘india ShushurutU Ist of function of the nurse — combination of masseur, caregiverFundamentals of Nursin: "Romans Fabia arich mavon who conlibuledirer home To serve os fist hospital Apprentice = Known as the ‘on the job irining’ period, under the supenision of amore expetienced person but yet there is 190 formal education, = Expetienced (IFrough tial and enor) nurte teaches new ‘Yoluntees ruses who Usually come from religious orders “= Nursing the sick and wounded ftom the wars = Chatles Dickens—novel "Martin Chuziewit" about Sairy ‘Gump and Be'sy Prog [exempitication of ruses inthe Datk Pefiod of Nursing) = Pastor Theodore Flecner (Protestant) — fis training schoo! for Nursing, “Deaconess School of Nuring”, 6 months rogram al Keserswerih,Gemany Educated Florence Nightingale School of Nusing + Fist theory author, fist nusezesearcher *_Ladywith'a Lamp/ Mother of Modem Nusing 2 Smonths of study fom Kaiserswerth + Developed her own kairing "Nighlingsies System of Nursing Education” whichis implementedin St. Thomas Hospital in vonon + Correlate theory and practice, updates, continuing edication, research, self-supporting nuting schoo! {separate from hospital) ~ Changedimage of nusing,revolutonized practice + Profestonalzed os a nusing + Noles of Nusing: What itis, What Ils not, Notes on. Hospitals [Nursing asa profession Is not as old as mankind but nuning as an act ef i ce ‘Modem using practice Anastacia Giron Tupas = Grand lody of Phiipine Nusing 2 Founded PNA FHioria Aguinaldo - Development of Red Cross Loreto Tupas — Florence Nighfingale of filo Melchora Aquino ~ Tendang Sora HISTORY OF NURSING IN THE PHILIPPINES > Frsthospitol— Hospital de Rect de Moria (1577) } 1878 ~ San Lazaro Hospital, Inromuros— leprosy and mental hess Hospital de San Gail -Crinese General Hospital ‘Alping sogigiid ond alping namamanay ~ fist volunteer ustes who served as apprentice in ne fist hospitas > 1878— Escuela de Pracicantes (UST) ~ Fis! schoo for Nuting |shortived) > 1908~lollo Mision Hospiel Schoo for Nusing = $month ring, no bocrd exam (NON-EXISTENT) Mission Hospital (1901) ~ sil exient 1907 - PGH Hospital, St Lukes Hospital, St Paul Hospital [Normal Hallin PNU i used at ircning ground ~ Some insiuction (central school idea) for & moni then go back fohosolal > Act2493 (1915) - Mecical act which included Sec 7&8 ‘ebou! nursing practice which mandated registration and ‘examination > Act 2608 (1919) Fist rue poring law + Board of Examiner for Nuss (BEN) 1 Doelerand 2 Nuses + 1920-Fis! board excrinaion + Ama Dulgent = fist Board exom fopnoicher > GN Progam Graduate Nurse) —1 year > AMler World Worl, BE degree for four years wos given by Ust (1946) Manogeri, leaching and superon poston. Eau fo Master's deoree. RABI? -BEN's compote of 8SN 1966-—Meser's degree needed RA 6136 con acme inravenous meds as ong as Physician volaion of profesional outonomy, id not Imaleriize but irstead ruse preporec medication ond {oclor aciiristered unl 1992bu i had confi! wih he Giug cdmiristation principle of “ocmiister what you Prepare" > 19605 Syear curicuum > 1976~ayear curicuum: GN program was phased out, practicing GNs must go back fo year lo ean a BSN Gogree but they won't take boord excm anymore since they cre Gteody icersed > 1960" ovetlopping of dand 5 year curicuum graduates > RATI64 1992) raring for uses by ANSAP, signed by ‘Cory Aauino, vad only offer 2monis > RA9I73 [2002|-Now Nurse Pracice Ac! SE LNESS Healt — Define as the merely he cosence or presence of dsease ‘of rfimily. WHO dofined heatthis a state of complete physical, mente, and socal wel- being ond not just merely the absence of Disabilly/Disoaso > symptoms > Sions > Awareness > Education > Growin > High level welness ‘Dunn's High Level Wellness Grid = Healthviness Continuum + health axs "Fovorabie/Untavorable environment” ‘Quadiants: 1. High Ievelwelnessin a favorcble envionment 2. Emergent Fighleveksin Level Wetnessin an unfavorable environment 3. Poor Healhin on Unfavorable Envrorment 4. Poothealihin favorable ervzonment ‘Schumann's Slages of tiness Behaviors Symptom experience ‘Assumption of sick fle Medical core contact Dependent cient ole Convalescence/ Rehabitiction ‘Opporite of health ness, not disease STRESS "© Oigorisms reacts os a unified whele 2 Fabicot ite Models of sss Response Based Mode! (Setye} anon specific response of the body fo any demand made upon it Tronsoction-based Mode! indice perceptual tesporse rooted in psychdlogica anc cognitive process Slimulus Bosed Model = Distubing or spive charocteristics within the environment ‘Adaptation Model “Anwioly provoking stimulus — Feople experience crsialy cndincieased stress when they ore Unprepated fo cope with stessfulsivations cnisis = sequitvium, not merely psychological but physiologic os well (shock) = spontaneous resolution is 6 weeks + gieving process: 4 years ‘stressor = lateral ining = extemal /extinsc + Developmental/ Maturatond 2 Stuatones Exstress—helptl stress Distress —harmfu o heal Body adop's fo the changes nthe envrorment whichleads fo Homeostasis |Watle: 8, Connon) (Cloud Bemaid - caled homeostasis os “therapeutic miieu" ‘Adaptation - change to meintain integily of the environment ‘Models of Adapation Biobogical/Physiological - GAS and LAS; compensatory physical ‘changes Emotional/Psychologica’- Involves a change in attitudes oF behavior Socio-cultur~ changes in he person's behavior in accordance ‘with noms, conventions and belies of various groups. Technological volves the use of modem technology Pinciples of Homeostatic Mechanisms ~ Automatic, seltreguictory Compersatory 1 Negofive feedback excep! for utetine contraction dung bor = Hostinits ‘One physiologic eroris corrected by severe homecstatic, mechorisens STRESS RESPONSE Lazarus stress Response Theory General Adaptation Syndrome (GAS) ~@ physiological response iso systemic response Local Adaptation Synckome (LAS) - Only apart of the body ‘General Adaptation Syndrome Stages ‘Alar ‘Awareness of stressor Increase in vital signs = Mobiization of defense + Decreased body ressionce 2 Increased hormane level + Resslonce = Repel of stessor: overcome: + Adaptation 2 Noimatization of hormone levels and vita signs + Inereasein body ressiance 2 Going back to pre-sress state + Bhousion = Unable fo overcome stressor Decreased energy evel = Breakdownin Feedback mecharism 7 Organylssue damage; decreased phipiclogicat function + Exaggeratonot ‘General Adaptation Response ‘Sympathoacreno-medullary Response (SAMA) ‘actvafon of sympathetic sysiom welch simulated ackenat medulla = Release of epineptyine and norepinephine —> inc. physiological activites = Sympathetic simulation (inc. HR, RR, BP, visuo perception, mefabotsm — glycogendlysi in ver, dec. Gi, GU) = Propandio inderal bronchocorsticten ‘Adrenocortical Response ‘anterior pititory gland >Adreno corlicoliopic hormone > adtenat cortex {l) release of aldosterone > kidneys > Increase No. reabsorption {2} telease of corisol > fats & CHON cotabalism > glucoseFundamentals of Nursin: Neurohypophyseal Response Posterior pituitary gland release (i). Antidivtetic hormone * kidneys > ine. Na, H20 {ecbsorpfon > dec. wine out nc Blood volume, ne: (2) Ine. oxytocin (aidsin ejacuiation/sperm motity) > uterine contraction Methods to decrease shess: = Progressive relaxclion - muscle tension + Benton felaxotion methed ~ cing the ight, music Yoga, meditaton Venton of feeings Local Adaptation Syndrome Inflammatory Response “Alinfections cause on inflammatory response "Not al fisve damage resus fo inflammation Ilemmation can heal spontoneousy as ong as the body can manage | Vascular tage (1), Vasocorsticfon which iil (trorsion!) (2), Release of chemical mediotors— kinins ‘2. Bradykinin -ros! potent vosodiotor/ universal [pein simul, ine. chemical actly 3 warmth [color redness (ubor) b. Prostagiondin . [9) Copillary permecbilty > sweling {tumor pain (duo), temporary loss of funcon (function aeso} injury and contain domoge 1. Cellular stage 1) Neutrophils -bands and segmentersin cfferenfal count: fist one fo arive. elevated, it suggests acule infection [2) tymphoeytes, Monocyes, ot Macrophages suggests Cchroric infection, (3) Eosinophis~ alergy (4). Bosophis- heating 1 exuding Types of Exudate ‘Serous- plasma (watery) ‘Sanguinousthemorages — blood Serosaguinous— pink Pus-purdeni/ suppurative Catorhal-mucin Fibrin bers -Roiinous \V. Reparative Phagocytos ingestion of foreign substances, ‘Macrophages > Monocytes (Chemotaxis - movement of substances fo @ chemical sgnct Heging methods: ‘© Cold comptes: fr fis hous then wam compress afer + Nutlion ond fiidintoke ‘Types of wound healing Primary Intention — Wound edges are well oppromated [closed ‘minimal tise domage Le. sugicaly created wound; this con be ‘dene with stitches, soples. etc. Secondary Intention - Wound edges are not well approximated, ‘moderale fo extensive fssue damoge and edges can'tbe brought fogether ie. Decubiius Ucer Tefay infention -"Deloted pimay inlenton’suluing or cosng of the woundis delayed .e. due fo poor citcuation in the area ‘MURSING PROCESS ‘A= Assessment D -Diegnoss P-Plonring |-Implementotion E-Evaivaion ‘Anvoverlapping of process can be noted since itis eyche ASSESSMENT Types = iol osessment = Problem focused assessment Emergency assessment + Time-lopsed assessment Data Collection = fis! slep in assessment ‘+ Pimary/ Secondary + Object (overy/ Subjective (covert) Methods of Gathering Dota Inleniew "> Thetapeulic andnon-commurication 2 Health history (© Medical history - isease focused (physiological) © Nuting history -needs, psychosocial cimersion, spitiua ospects + Petsonal space © Inimote Space ~1 foot © Personal Space - 1 4-4 feet © Sociol Spoce= 4-12 feet © Public Space ~ 12-15feet ‘Observation = Use of serses fo gather dato + nical eye ~ comes with practice and experience Examination ‘+ nspecton, Poipation, Percussion, Auscultafon [generai) + lespection, auscultation, Percussion, Palpation ebdomina)} Stepsin assessment Colecton of data Validation of date rgonization of date CColegoting ot dentfying pattems of data Making fluences crimpressions of data. ape Atfer data collection, synthesis, analysis and vasation are performed DIAGNOSIS Problem + efology +defiring symptoms SGuided by the NANDA Knowledge deficit—kulang so kaispan Knowedge deficiency - kuiang sa koolaman (preferred) Salf-core defi ~ acceptable Types of Nursing Diagnosis + Actual + Risk or/ Potential for + Wellness -readiness ond enhancement/ achieve higher level of functioning + Synetome = "syndrome"Fundamentals of Nursing 7 unclear posible/probable Phoilizaton of Nusing Diagnoss ‘© Airway, breathing, cieuaion PLANNING ‘© Short Range = _longRange ‘thst be SUART Specie, Measabe, Aftinable, Reo Tine (Clasify as dependent, interdependent, and collaborative IMPLEMENTATION. + Reatiesi he patent sll neds intervention + Delemine it younsedasistonce 2 Conyoutinlaverton,eneve to! wehave background 2 Document hrocess of implementing Rocssess chen! Determine nuses' needs for asislonce implementingrutsng nienentone Supenting tne Celogated care Documenting rursng actives EVALUATION Purposes of evaluation Determine the: = Client's progress or lack of progress + Overall quality of care provided = Promote nussing accountability Guidelines for evaluation = Systemic process = Ongoing basis = Revision of the plan of care when needed = Involve the client, significant others, and other members of the health team = Must be documented Process russe Stucture -syster (Outcome -patient DOCUMENTATION or CHARTING STAT-now ‘Ad li ~ 03 desred PRN ~ Knee Chest postion/ Geno:pectoral postion/ Jack Knife postion Rectal exom, dysmenothea. Kracske —inveried V Uthotofomy-~ stimaps Tendelentburg - too! up; head down Reverse trendelenburg— head up, foot down ‘Modilled trendelenburg - only 1 leg up for shock: L vey MCNAP - training to perfom internal examination Chest + Pectus excovaium - funnel chest (congenital: Compression of heaat and breathing = Pactus corinatum - pigeon chest— deformity fr rckets (Vit D deficiency|; AP ciometer decreased Posture + Kyphosis 2 Lotdoss Scotosisloteral CCopliry ref est= 1-2seconcs 2 Ielerc sclera 2 Cyanosis-late son of oxygen deprivation = Miligo + Eythema * Pdior Nail Beds = Clubbing Beyond 160 degree due fo dec. oxygenFundamentals of Nursin: ~_ Kellonyehia “Spoon shaped nl due To ron daiciancy cnemio + Onycholysis/Oncolsis separation of nal + Poronyctia~ severe inflammation of na + Ungusincartatus-ingrown toenail PALPATION + Ught indentation haif nine) ‘© Fonlanels, budges, pues mph nodes, thyroid, symmelty, neck veins, edema IEIs aform of palpation ‘Chest expansion must be symmetical Tete fremitus- sound that is paipable = Increase in consolidation, pneumorio 2 Decrease in pneumothorax Thell~ palpable mum Edema ~ on dependent area and may occur inlegs + PittingiNonsiting ‘Anasarca - generalized edema Peiiorbital edema about the eye PERCUSSION ~ Touch endheaiing Tuning Fork Weber's test/Laterotzation fest ~ conduction hearing 1 Rhine's Test -one-cir conduction Indtect Patpation = lexor iting *Pleximeter-Recelving Sounds = Dul-orgon 1 Flatones, muscles 2 Tympany-codoment 2 Resonant lungs 1 Hyperresonance ~ abnoimal {emphysema} ‘above It hyper resonant, below itis hyporesonant Past ofthe Stethoscope Diaphragm - righ picned: lng sounds Bellow pitched: heat souncs ‘Adventtious breath sounds no ebnormal sounds ‘Respivaton Sounds Normal Breath Sounds Vesicular ~ Soft intensity, low pitched * TSonware Peipheral lung, base of the lung ronchovesicuor ~ Moderate intenily, moderate pitch i315 Between scoputce lateral fo the stemum Bronchial High pitch, loud hash sounds ~ HS 2 Anterioty over the trachea ‘Advenions Breath Sounds Wheeze ~ Continucts,Pigh-pitched, squeciry musical sounds = norrowed aiway; esha, brenchils crackles ales) ~ Fine, shot, inlemupted cracking sounds = Rbbing hain smal ciways:reined secretions; ‘Gurgles [honch] - Continuovs, low pilched, couse, guging, harsh sounds with moaning / noting quatty = rubbing hr in wide alway Friction rub - Superficial gzaling or creaking sounds Vocal flactie| emifus ~ Fain percepible vibration felt through the ches! woll when tne client specks Stidor -noisy reatting Stertor~larynged spasm ‘Cardiac Sounds = SPICLMCL ot the PM 2 Lileft—PUmoric valve +m. Aotic valve NPH-Nimeciote Human roi ‘Glorguar = rapic Rowel Sounds *~ Nommoactve: 5:30 bowel sounds per minute Wall 3-5 mins betore concluding that bowel sounds are absent = Hyperactive - Borboryamus Poratytic leus - paras after surgery Voice Transmitted Sounds : ~ say "E" but hears "A" 1 Whispered Pertodoquy— whisper but we hear itloudly, secondary fo consolation + Vocal emits Shiting dulines lo check for ascites LABORATORY EXAMS. = Property collect the specimen 1 Giveinstuctions corectly inalysis Color: Amber, tea-colosed (bilory d/o}, urobilinogen ‘Odor: Aromatic/ Arimoniocal (decomposed utine) pi: Aciic ~ does no! favor boclerial growth Spectic gravity: 1.050-1.025, If elevated urine is Concentrated, suspect dehydraton Phosphates/Urates Nomal ‘Giycosirla ~ Diabetes [BS is more than 200mg) Hematuria — Stones, BPH, rend dlsecses, UT! Abuminemia - proteinin une, eccampsa Pyro —Utl (CYfindusia ~ cast in urine (stones) Fist voided Utne. mid-stteam to clean the ureth fist Stetle specmen Indweling catheter — waitin he end of the catheter for 30 rrins + Indweling catheler— aspirate from 1Omi syringe + Wee bag [*) sine Culture & Sensistvity Test = Exact microbe 7 Resiti final oniy oer 57 days < Some collection process but less amount = Ideciis catheterized cath (Chemical Tests for Urine ee Cinitest way to determine sugarin une (glycosuia) 7 Benedict's lest used Benedict's ution hen heat 10 check for potency: must remain bive; if not bive, discard = NOBOUNG 19 Thenadd 3-10 deps of une then heat Negative resus Negative: Ble +1-Green 42: Yellow.aeons Fundamentals of Nursing 333 renee ot Red eo ane DieGteS Bore mocks + Heat and Acetic Acid Test - fest of albuminuita vie into 3 parts then add 2/3 une, then 1/3 acetic acid © Tubid/Cloudy- postive © Nollie se no microscope uments ‘© Done mostyin the community, NO BOUNG ‘Quantitative Vine Exam ~ 24-hour Urine Collection HCG, unary omfase, inary Colecholomines, uincry creatinine, urine ofburin, corticosteroids ‘© épm order, scar urine on 6pm, start on 60pm ‘2 Whole amount of urine, need no} be micsiream © Preterve nice caid storage © Leeway of 15-39mrins: ge! une after deassine os long es no! too for = fractional Une Collection -shotter span: ime determined by doctor Fecaiysis ‘Color of stools nftuenced by slercobiin Choy colored = achote stool bilary ack obstucton Hematochedo = red =lower Gi bleeding Melena = blood= upper Gi bleeding Steotorines = fat = gal bladder rpobier Fou smeling indole and skatole Softftomed ‘Deod bacteta, bers, amorphous phosphates normal Live bactera~ conormal Aller | hour he stool canno! be used for fecal Collec! abnormal iackzng feces. not the one which is well fermed ‘tool Cutie and senstvly = Determining exact microorganism Rest aso final ofter 5-7 days 1 state container ‘Gulae Test * Occult blood test Nomeot, high colored food, ron preparation. Vit. Cin det = Sdaysoceult blood sample sputom Exam =" Donan ecly morring snce secretions cready pooled Sputim C &S- may gve oral Fygiene fo remove mouth ocieria + Acid Fost Bacil-3 consecutive days Sputum Cytology - cancer cel *Eeinophl determination fo determine allergic reaction 1 unconscious, suction maybe done: mucus ltap ‘lood Examinations FASTING © Tihyoeride(1-12hous), BUN [68 hous), HOA, LDL, FES, Total Protein, Albumin Globulin aon, ic acta NON FASTING. © Creo, Na, [Link], C8G [bul pre meas) css before mes jon Blood vases ~ prick athe aide snc Thoracentesls ‘ospration of pleut fd ttrouch need 2 orfropneic postion + informed consent 1 Rid 70°89 inintercostal posterior dary line 2 Air-23,34 in inlercostals 1 Needs chest xvay 2 Positoned lying on unatfected side Thoracostomy o Bretum fo negative pressure ‘Abdominal Paracentesis ern aspuation of peitoned fkidin ascites Serm-itingsiting position Void before procedure 2 May be tneropeutic ox agnostic 2 Watch out fornypovolemio Lumbar Puncture/ Top 273, L413, socrachnoid space 2 Paras ik low 1 Fela posifon ~ widens the angle ofthe lumbor spine 1 So20mm=nomal CSF pressure Prepare test kibes since every tes! requires © diferent tesl tube = {bol fest tibet ond seat wilh appropriate cover: not wih cotton -_Kenthochromic - hemctyaed blood: yellowish dscoioration 1 Flat on bed offer procedure (68 hou) to prevent spinol headache Diagnostic Exams Visualization proceckxes Endoscopy © dee! visualization: ighted insiument + XRay-gronhy ‘0. Conifcindicoted in pregnant women due fo feratogeric effect + Transformed ‘©. Ulltasound/ sonogram ectroencephalography (EEC) w "Shampoo hak Before and after procedure 2 Sedative musi be withheld 1 Detemining seine disorders Bectrocardiography (ECG) lectromyogram (EMG) = wasive [Phase 2-inserion of neecle into muscle ing ‘Cisleel implont and pace moksr 2 Some oxlno implonts/prosthess re alowed 2 Assess for cloustophobic 2 Needs consent since ils expensive 2 With contrast in special procedures 2 NPO=t0 avoid axpiraton in case of untowardreaction Computed Tomography Scan = Lesonmustbe bigger + Dyeond NPOr Fundamentals of Nursin ‘osthon Emission Tomography Rachoaclive alucose (fluotine) + Cancer cells have strong affinity for lucore; detect concer stes of metastasis ‘Muciear Medicine Thyroid Scan Nocile/iumor on thyroid For abdominal scans laxative, (castor ol/ Ducolax) and NPO may be necessary ‘Opthaimescopy = Optholmoscope + Usedin determining cataract + Dim the igh and focus ight af opthaimoscope inthe eve + Fundoscopy may be determined Otorcopy = Oloscope * AcannUalsinsertedin the exlesnal auctory canal No need for written consent = 3y/o above up & back = 3y/o below — down & back Rhinoscopy = Rhinoscope: Hyperextend the neck Endoscope “Can be used for sxgery biopsy Praryngescopy Bronchoscopy Longyngoscopy Esophogogastoduedenoscopy Anoscopy Procioscopy ~rectum Sigmoidescopy Coloscopy- ars tolleum © Cleansing enema unit cleor Remove dentures Remove gourefiex by local anesthetic agant and check ‘90 reflex - _ Rerume food only when gag reflexis present + Consent and NPO + Uretrroscopy 1 Gjstoscopy - blader, wrtlen consent, cystocyss set Up {Continuous low of ster water wrich also exis) = Colpotcopy- vagal examination, needs vagina! specuum © Sfirodkar Iying the cen so that miscariage is evoided: incompetent cervix Ros veBectromagnefc tadaton photography 2 Xrgy but without contrast medium 2 ChestxRay © Not dofiive of 18 = Mammography 0 Examination of breast Scout Fim of Aodomen KUB Upper Gi sevies Esophagus, slomach, duodenen *Batlum swalow (dye) oultine the Glsystem, flavored, hos Constpating effect —ine. uid = Useslaxatve, NPO —— Enema fo evacuale Balm To preven fecal impaction | Lower Gi Series ‘Batu enema COuttine of colon Laxative and cleansing enema untlitis leon Fink phospotoda [ord cleansing enema) Evocuale barium through enema to prevent fecal impaction Excretory Vrogiaphy = Inkavenous Pyelography rere iypague.. made from iodine substance; check for allergy for seafoods Laxative + NPO (Given through IV port and the aay sees is made [Assesses kidney s coil to ler [Astesses presence of stones ifreverse, retrograde pyelogrephy + Ora Cholecystography © lapandic acid (Telepaque) -foken every 5-10 manu inferva: 6 tablets © low fatmed tne day before the exam © Laxative + NPO Ltratound/ sonogram = US Bain 2 SHeart (20 ECHO, Echocardiography) © Regugtation o Senos = UStungs = USBreast/ Sonomamogram ‘9. Needs irencuicer = US Abdomen © Colon laxative, NFO © Kicney—KUB © PeNic Ulra:ound chink 68 glasses to have 0 fut blodder: do not alow to void 2 Gallbladder ulrasound = Ransvaginal Utresound 2 Wil oulfne falopion tube, uterus and ovaries © consent + Tansrectol Utrasound 0 Consent ‘© Emply the bladder for comfort and good vevalzation | © Visudization of ulens/ prostate Types of Bed = Closed-in anticipation for an admission + Open 5 Pos-Op/ sugicai/ Anesthetic/ Heater bed Ocewpied Finciple of Bed-making sre oy Mechanics Bec fom knees, wide bose of eppor ey loose, donot nen touch uno 2 Do otet ne lnenfaino groune 1 Rismowe se arbes tnt Remove wines o have aes valve so Vopaneet exces ineninfoo! par hom shoct-enceusinanin head pot canons cown nN Semove wth fee am fistin changing gown 1 bomwih [Link] mG THE CUENTFundamentals of Nursing = OO E00 TSESVENT STORY TARING rg exana WAL sions DOCUMENT oe Cie complaint ory found on acnision he DISCHARGE OF PATIENT 7 oe may be agra! mecical acvice [DAMA] butiineeds doctor's order : ee = heaihirsvcion + Illegal detention (false imprtsonment) VITALSIGNS Children ~ Respirctory Rale, PUse Rate, Temperature * Blood Pressure con ako be obicinedin chicren TEMPERATURE ‘Types of Temperature Cove temp. ~ more important; can't be affected by envirorment Surface lemp. mote imporiontin chicken since hypothaloms not Yel developed Poikiothermia - temp & some with environment: newborn, Homeothermia ctferent wih he environment Factors that affect Body Temperature 1. Age 2. Owdelion- temps tigher progesterone 3. Activity ine. BMR 4 Environment Temperature conversion CF mutply 18+ 32 FC subtoct 32/ 18 ‘Methods of foking body temperature ret Oral conitcnctcated in brcin damage, ments ines, felarded, problem with nose and mouth, jooth extraction, ‘Conktopion in nose and mouth, altered LOC, dyspnea, seiaes,7 y/o below ‘© 2minsunder the tongue = Reclal—contreindicoled in imperforate anus, rectal polyps hischprung’s cseose, cfarthea, increase ICP, Cadac dseose may couse vagal simulation) © Not sale since fan cause rectal raurna © Imin Axlioy —3mies {ympanic- external eax. contraindicatedin otis, cor sxagery: most occuote = Temporal Scanner done in temporal; most corwerient Temperature canbe checked every 30 mins snce hypothclomus ‘canonly fuctuate the femperature every 30 mins Spot Vill Sions— HR, RR, BP Thermepociier—for crying babies Paste sip Tnemometer Amitemp Alterations in body temperature yperpyresia: 41" degrees + Pyresiar 375 38° degrees + ‘Onset / Chil phase: up HR, up RR, shivering, cold skin. cessation of sweating 7 Course / Plateau phase: cbsence of chs, eats warm, OP RRR, tit + Abatement phase: flshed skin, sweating, reduced shivering ‘Average: 36-38 degrees Hypothermio: 38’ degrees below Death: 34° degrees of Fever Mlemilfent - fuctuates fom febdie fo afebrle Remitlent~ febrile, lemperatse fluctuation s minimal Relapsing — fluctuates in days Constant / Conlinuous- febile, lemperatre fluctuation is wide (+2) Heat stroke - depletion of uid, hypothelamus does not equate Hypothermia induced (surgery), exiteme temperaluxe using interventions Fees chiled - provide extra blonkels Fees wom remove excess blankets; loosen cotting ‘Adequate nutifion and fluids Reduce physica actly Oral hygiene Topld Sponge Bath - increase heat loss (conduction, convection, evaporation} Unexpected situation and Associated Interventions During rectal lemperalure assessment, the patient reports feeling joded or passer out > Remove the thermometer immediately. Quickly asses the patient's BP and HR. Notify Dhysicion. Donol attempt fo fake cnother recial temperature on Irispatient PULSE Tempo Carold—cacdac arrest ‘Apical Brocriol Raciol—thumb site Femoral Popitedt ‘Affected by the folowing: ‘Age ~ the younger, the faster Acthity Shes Drugs Inereaxe - ontichotinergc, sympathomimetic Decrease ~cordac dycosde vyRone Palpation Pattem of Beat (Rhythm) "Regular (60 100b6mp} + Imeguler(exinythmia) "[Link] puse ~ 1,2, sappear © Tigeminal puse - 1, 2,3, dseppear Pub strength = pulse volume +1 collopsble. ready +2-notmal +3-ful +4=ful, Bounding CConigan puse/ Wateshammer pulse ~ttready ond with fa ‘expansion followed bysudden collapse.4 Fundamentals of Nursing =e Apical (PMI) . eet parte : ye Setar aee wena ees beter ere EEE wren ieereeeeee rons Saar icrians Sanita che You cannot palpate a pulse > Use « poricble ulrasound Doppler to ‘235055 the pulse. If this isc change in assessment orif you cannot Direct - venous pressue, CVP, invasive, culdown (5- Vammg) Indrect © Palpatory © Ausultatory Pu pressure — 40mmHo Pulse deficit systoke-clastofc} ‘Mean Aero Presse ((20*3]/0) {ind the pute sing an ultrasound Doppler, nolity the physicion. RESPIRATION Normal: 16:20 bpm Three processes Venilation- the breathing in ond breathing out + Ihiact CNS 2 Gearaiway Infect thoracic cavity Compliance and recoil ea pituzon Srovemernt of ures fom Fiche olower concenroon choote the higher +” Adequate eancentaton f esses Sources otros? Assessment 1 Romans fave high P reading Pension’ crectaton othe onygenaled ood tothe cterert F "Fadiocut ograrow fier is PO Bree > Insufficient rest before the assessment Inhalation | epation = 1 seconds 3 Repeaingrecsionmen! oo quickly Boot /exration 210 Sseconds > Detoingeut oo omy te fen 2h > Assessing immediately offer a meal or while client smokes ‘orhas pan ‘iterations in retin Fetters ‘Rate . eh Low BP reading Tochypnoa fast breath © "adder cuff too wide Dodypres-sowedrecming > Dafting cut oo auch oreo. obrence of beating 3 Rmabove te level of he hect 3 Fatue fo centty aucuttory op Fupnea —nermal breathing ‘anythin Bors shalow breathing with periocs of apnec XYGENATI ‘Cheyne strokes ~ deep breathing with apne Keaeuts. deep, ropid beating wih rexpitatory acidosis 10 Respiratory Modalities bow off excess carbon codes) Volume ‘Abdominal (dlaphragmatic) and purse-p breathing ‘etn /Figh Fowlers postion Siow Geep breath hold for a count of 3 then slowly exhale ‘yperventiation-leads fo respiratory aktosis : ‘Hyppoventilaion —leads to respiratory acidosis ‘rough mouth ond pused ip +S" 10 sow deep breaihs every 2hours on waking hours Ease of offot Dyspnea - dticuly of breathing Coughing exercise Crhopnea- dffculy of breathing within supine positon Upright postion {best poston for his orthopnetc postion) + Contraindleated: pos! brain, spinal or eye surgery atypned -Diffeuly of beating whi in siting position : Trepopned - ease whenin delving positon yperpnea Inc. aie and depth ofrespation [81000 PRESSURE Factors Affecting Blood pressure Incentive: = Age. Gender : 1 Aetity, exerci, sess + Time of he day Korotkoft sounds Phase I ~sharp tapping (sytoic) Phase 2— suiting oF woosting sound Phase 3 thump softer nan the topping in phase Phase 4— softer blowing muffled sound hal fodes fond = cstoc) a Phase 5~slerce Tote two dow deep breaths on the thtd breath, hold for ‘Gow seconds, cough ice witnoutinhding inbetween May spint sutgeal incisions Every 2 hours while awake splometty ‘Rrectiing device that provides visual feadbock that Gnesurages patient fo susan deep voluntary breathing ‘and menimum inspication, 1Olimes every fo 2 hours Chest Physiotherapy Postural rlnage Percussion VibrationFundamentals of Nursing Posiforing > percuision > vibralon®> removal of secretions bby coughing or suction © Contraindications: + ICP more than 20mg, head and neck uy, ‘octive hemohage, recent spinal surgery, active ‘hemoptysis, pumonary edema, confused or envious patients rb fracture Postural Drainage + When = morning, at bedtime, 30 minutes 1 hour before or 1-2hours otter meat Each position = assumed for 10~ 15 minutes * Entice treatment shoud lost ony for 30 minutes Percussion ‘+ Rhythmical force provided by clapping the nurse's ‘cupped honds agains! the cients thorax. + Overcffected segment for L-2minutes ‘+ Perfor by conirocting al the muscies in the nuse's upper textemiies fo couse vibration while apphng pressure fo the clen'’s chest wal © One hand over the other suctioning ‘Maintain patent oiway. Promole adequate exchange of O2end CO2 2 supuute for effective cougting 2 Aduter 1218 + Chi Fret0 2 infontser 58 Length ‘+ Flom fp of nose fo eatobe (Sin) Notopharyngeal = Séinches 2 Crophanngea!= 34inches 2 Narottocheal= 89 inches Et=lenth of £T+ 1 inch + _Tracheostomy=lengih of trachea + } om suctioning + Duxation of suction: §-10 seconds 1 infermitfent suetoring upon withckawal using rotating motion + Morepeat: 1-2 mins interval + Umit etoning inc told of Sminutes Unexpected Situations and Associated interventions Patfent vomils during suefoning > If patient gags or becomes rnauteated, remove the eatheter I has probably enleved the ‘esophagus inadverlenily fhe patien! needs to be suctioned ‘egahn sucfon catheter because is probebly contaminated. Secrefion oppearo be stomach content > Ask the pation! to fexlend the neck sigh. This helps fo prevent the tube from passing Into the esophags Eplstoxs noted with continued suctioning > Nott the physician and hicipate the need for anasd impel Speelol consideration: > Gen witha doctor's order > Careful and continuous assessment fo evaluate the need fer andi effect on the patient TNO srs Salaly precuaTons NO SMOKNG” ond at he door ‘Natal Cannula (approx. 20-40% of oxygen) lWmin = 26% g A a Prcrty ning Interventions: 2 Schock frequently thal both prongs ce inthe patent's ‘0 Encourage the patient fo breathe rough the nose, with mouth closed. 0 Maybe limited to no mote than 2.L/min fo potent with erroric ng disease, Face mask Spi face mesk (apo P40) = 1oL/min= 60% Ponty nursing inferventfons: © Monitor patent frequently fo check the placement of the mosh 2 Supper patient if claustrophobia @ concern. Secure physician's order fo replace mask with nasal cannula ding med! fone Poti rebreatner mask (approx. 60-60%), Potty nursing interventions: Set Rowe rate 0 that mask remains hwoutrieds ful duting inspiration © Keep reservar bag fee of tists or kirks, Norrebeather mask > Oui = 80-100% Pioty nursing interventions: © Maintain flow rate so reservok bag colapses onty sighty ding inspiration. © Check that valved and rubber flaps ate functtoning property open during expiraton and closed ding innataten) © Morilor Sa02 with puse oximeter. Venturi mask most accurate and precise oxygen concentration, 2% Toumin = 50% ‘oxygen Tent Unexpected Stations and Associated intervenitons Child refuses fo stay In the fent > Parent may play games in the tent ‘with child, Alternative methods of O2 delivery may need to be Cconsidevedif child stl refuses to stayin ent. {fs diicut to malntaln an 02 level above 40% in the tent > Ensure tha! the flap is closed and edges of tent are tucked under bionkel. ‘Check 02 delvery Unio ensure that rate has not been changed. Patient was confined on 02 delivered by nasal canuia but now is ceyanolic, and the pulte oximeler reading is less than 5% > Check 1020 thal 02 tubing sill comectod fo the flow meter.7 qe Fundamentals of Nursing ‘pocorner cyano or point becorres hen doting, patent begins brecte though he mouth > Temoetalyplce ne neil coreianer he meh does ro} to switch’ try reading, you may need fo obtain an order Ichihe patent io mask wre dospng. Inhalation | ‘Moist inhotation ~ Steam inhdlation = yy inhalation ~ Metered dose inhaer for 10 seconds wth 5 mines interval owoter Child has 70-90 percent water ‘AGU has 50-70 percent waier ‘Males have more water than females since they have more adipose ‘Atifcial Airways Oropharyngeal away ‘+ Prevenis fongue from feling back agcis! the posteror Iinches; 15 ~ 20min. se of spacer hold breath pharynx ‘+ Meosurement: fom opering of the mouth fo the eer [back ‘angle of the jaw) + Check forloose teeth, food and dentures Unexpected sivations ond Associated ierentont Oe pollen! ewakent Remove ho ord away She longue bialg beck no he posterior phan, Cousin replay dees > Puen diposote Goves Sraronore crc). Make ste dovey somos! yop Tor patlen ° Potent rvomis 0 on airway is inserted > Riek poaten poten! onto Fe de lo proven! expration [Nasopharyngeal Away / Nasal Trumpets 2 indications Clenched leet, eriaiged longue, need for frequent nasal suctioning 1+ Meceutement: fom ine rag of fre eer fo the nests pls ‘one inch + Proper Kerication for exsyinsertion Endorachea! 1 ncicatons: route formecharical ventilation, easy access fer secretion emova) crifclalcinway 0 relieve mechanical anvay abstuction. 1+ Cate for patients wit: © [Link] leas! every 24-48 hours 5 Depth andlengih during insertion shouc be mantaines Level oF tube: gumine / itetine -Maantoin cut pressure of 2-25 mmiig (© Check fps for cracks and ittion ‘Unexpected stations and Associated interventions 2 Patlen is accidentaly extubated during svetfoning > Remain withthe patent. nstuct Cssstont fo nolfy physician. Asiess patents vital sigrs, cbilly fo breathe without assistance and O2 sclurction. 8e ready fo administer osisled breaths with a bag vave mask or aomiister 02. ‘Aniiopate need for rentubation. © Oxygen sation decreases er scoring > Hyperonygensie patent! coe © Patent develops signs of infelerance to sucfoning: O2 saturation level decreases and remains low after hyperoxygenating, patent bradycardia > Stop suctioning. Avsculate lung Sounds, Corsiger mpperventicing patent with monval resuscitation device. Remoin with Potent. Patent is accidentally extuboted during fope ‘5 Remain with the potent. instruct {ssstont fo nolily physicion, Assess patent's vito gps, ily fo breathe without ossstance ond O2 {ouiclon, Be ready fo cdminister sisted breaths ‘with @ bag valve mask or admirister 02. [nlicpate need for reinibation. Patient is bing on ET Obtain abite block. wih the help of an ausor, place the bite Block ‘round the ET orin patent's mouth. ‘9 Lung sounds are greater on one side > Check the depth ofthe [Link] he fube hos been ‘edvanced, the lung sounds wil appear greater Srone side on which he fube is Further down, Remove the fope ondmove tube s0 frat tis ploced propery Thacheostomy To maintain patent ciway ond prevent infection of respiratory kect Care of patient wih tracheostomy. "2 Slerle tachrique: ocule phase ©. Clean techrique: home care © Ist 2ehours: tracheostomy care every 4 hours © Preven! ospraton Unexpected situations ond Associated Interventions Patient coughs hard enough fo dislodge racheostomy > Keep ipare tracheostomy and ‘oblrator al he bedside. Insert cbturctorinio Iracheostomy Ube ond inser racheostomy into stoma. Remove obturator. Secure tes ond ‘uscullate lung sounds, Pulse Oxymety Purpose: meaaue erleral blood O2by extemal sensor rowinvasive) Placement (0. Adu usually on the finger © Pedia: vivally on the big toe (© Other ies: earlobes, nose, hand ond feet ‘NUTRITION Pinciplet in he Promotion of Good Nutition The body requites food to: ‘© Provide energy for oigan function. movement, ‘ond work 12 Provide row metetas for enayme function, ‘growth, replacement of call and repat. The process of cigeston, absppon, and metabolism work fogether to provide al body cells with energy and ulient ‘Man's energy requtement vary and isintuenced by mony foctots: ge, body se, octvity, eccupation, climate, sleep, phypiclogleal skoss, pathological disorders, ifesyo, ‘ond genderFundamentals of Nursins Foods ore desciibed accorcing to he Gana of Inet nulionls "Nutrient dersity ~ the proportion of essential nutes 10 the number ofHloccores MMactonuttens- Give off colts oe + Fatsokce emir it A, vd Mrcnutet No css rs dno + Woter sabe lorin vit ©. 2 988,89, ond B12 Colo (kcal) rit of energy [Link] cmount ofa! ‘eauied oie he lomperaieo hgh watr fo SS Sources: (CHO- 4 coloties/om: fist fo be burned FATS 9 coloties/om;slored at actpose tksue CHON- 4 calories/gmn: meat Aecoho) 7 caleries/am Vitamins = Fot soluble - ADEK + _ Water soluble -8 complex, C ‘Macromineral ~ 100 mg or more ‘Microminerals~Less than 100mg; Zinc, ron. jodne “Potato —highestinpotossum ‘The fp of the banana has the highest amount of potassimn lodine - prevent cretrism Tine ~to improve appetite Iron -costect anemia Hypeniiominoss increase in ilomins intake; occuss commonly in Fal sokble No hypenvitaminoss in water soluble since is easly eliminated in wine COvenweight - increase in macronutients; may progress to obese ‘Marosmus na = edorie manutiion 1 German facie, infercestals and suocostal rtioctions Kwathiorkor moon face, Globular abdomen edemme 2 proleiamanuttion m vt skin, and gums etal ee , Deedee rich! bindednos)- 81" sot = Severe: keratomalacia (Ineversible) we ‘cotter (et ceming om hes ut eth octal inane calcu endprosphons cosrpon Betcency kets Seve’ Oreos Gr ingges = ger aun 5 knoarbnesgenuvagan & Peekseaakm nontors goove) S Spnatcotomty & skied gown Youcen store calcu 991 yea Vit frocophero) + Anfioident: remove free ractcals 1 ‘Amount should net go 400 unis Becouseif it exceect I ‘becomes prooxidan! + Enhances RBC maluration 2 Deficiency: anemia irk (Menacione} = Antshemonogic = Deficiency: hemorhagé, bleeding ‘Kaesselbach's plexss prone fo epistonis '8 Vitamins ~ Metabolim since these have enzymatic actvily vita! (Thi 1 i ctcloncy Betbe Werrcke-KosckoftSyncrome 2 Edemainwel Bei-bert vit 2 (Ribofiavin) = Deficiencies: Aboflovinoss, chelsis © Anguorstomaliis - mouth fissures Vo enc: Polar Duley san, coe! colt its Pantothenic Acta) ‘Keeps integity of hair Deficiency: dopecia Vit 8 (Pridoxin) =) Deficiency: Neus vitBi2 (Cyanocobatamin) + Befition: pernicious anemia, nevis tc (Ascorbic) ne, dbsorbfion of ion 1 Deficiency :scury- easy bruising, gums, petfolicuor lesion, hemorthoge Types of Diet Reguior = Hat al essentis no estictons = Nospecial detnesded Clear quis ses see-through foods" Ike broth, tea, srined juices, gelatin = Recovery from surgery or very Fal quid SO clear quid pus mile products. eggs Tronstion from clear to reguor ciet Soft diet =" Soft consistency ond mild spice Difeutly swallowing ‘Mechanicaly soft a Reguiar ciel but chopped or ground = Difficulty chewing ‘Blond = chemically and mecharicaly non sfimuating, no spicy food = Ulcers or cots Low resicve ce No bulky foods, apples or nus, be, foods having skins ant seeds = Recld cieose High calorie = High protein, vitomin and fat = Manourshed Low cotorie se Decreased fat, no whole mil, cream, eggs, complex CHO = Obete Diabetic =" Balance of protein, CHO and fat = _ insulfood imbolence High protein 2 Meat, sh, ik, cheese, poully, eggs = Tasue repair ond undenweight Low fat = Litle butler, cream, whole mik or eggs = Gallbladder, iver orheat csease«4 Fundamentals of Nursing Tow choeterr 2 Ute meat or chese = _ Need decrease ftin Low sodium Stintoke = No sit added dung coo = _ Heat ortend deease Nutitonal Problems 1. Aniropometic Measurement ©. BMI=kgimo 1 Underweight below 18 iL Nomat= tee ii Overweight 24 above 2. lochemical Asta laborion exc 3. Clinical trad 4 Biola ietoy ©. Food habits ‘Anorexia - re eating Bulimia binge-purge syndrome: ‘Management: + Hygiene: + smal frequent feeding Serve attractively Parenteral Nuttion > Nonfunetional Gr > Exlendedbowel rest > Preoperative TFN Enteral Nutition > Concer 5 Neurological and Muscular disorder 5 Gostroinestinal cores > Resplitory falue with prolongedintieation Nasogastic Tube Feeding/ Levine's Tube Postion: sting 3 Head: nypetextensl and sghly flexed 1 Bsertont NEx (ip of Ine nose ~Eatlobe — Xyphoid Process) pH gastic content: 4—6 + Contimaton: By xxay ca wage + Postion: siting 2 Gastne ospirate:>1 000m — withhold feeding: pul bock the rescue + ifwith medication ond isnot gostic rant: 20:30ee fushing > meds > feecing > 20-20ce Rusring tevage 2 To emgate the stomach in case of gasrc bleeding, food pasoring oringeston:if corosive substance: do not Ingate 5 Postion:siting 2 Gostic axprate: dscord + Amount of nigoing solution: 750mL— 1k Unexpected Stvations and Associated Interventions Tube found not fo be Inthe slomach or intestine > Replace the hbe © Paifent complains of nausea afer tube feeding > Ensure thal the head of the bed remains elevated end that suction equiement sal bedside; Check medication 1ecord force any antemelicss ordered. © When attempting fo aspirate contents, the nurse notes that ube ls clogged > Try using worm water anc gentle presire lo remove The clog Never use asiiet To unclog the tubes: Tube may have fo be replaced. Gastrostomy / Jejunostomy Feeding Long farm ruional support, more than 6 - Bweeks Place in Figh fowier’s postion ‘Check Ihe patency ofthe lube: Pour 15-30ec of water ‘Check the patency ofthe lube: Pour [Link] of water (Check fo resiud feeding Hold oseplo-syinge 3-6 inches above ostomy feeding Frequenly esess forskin breakdown Unexpected Sivations and Associated Interventions “Co stostomy lube fs leaking large amount of drainage > ‘Check terion of the tube: Apply gentle presse fo Nbe Gils presing the extemal bumper closer tothe skint Roe hos an intemal balloon holcng itn place, check to make sure ino! the baloon inflated property. ‘Gun htotion around the insertion site > Stop The leokage, fs prescribed previously ond apply askin barrier Ste oppears erythematous and patient compiains of pain Gtihe se > Notify physicen, patient coud Be developing Cells ot the site. French Iscectly proportional o se Gauge i inversely proportional fo se ‘tniravenous Hyperalimentation/ TPN ‘Kobiven Wateh ou for gycosuria one blood sugar Maynecessais insulin [erge need since iis conta rovte Monitor for complications EUMINATION ‘URINE EUMINATION 1200 1$00ee/doy Normal outpul: SOmiipour Urge fo urinate: 300-500 Poliacure - frequent, scanty une Urgency urge but unproductive of uinate Retention -stmulale uinafon, runing water, worm water over petneur, warm compress, and straight calheterization catheterization Indication: > Decompresion > Insitaon > tigation > Specimen collection Une measurement: Resldual urine: Houty tine output Promotion of heaing of GUT Catheter size + Childien: Fr 8-10 + Female adil: Fr 14-16; Fr 12fer young gi + Made odul: Fr 1618 Postion Femole: dorsal ecumbent Male: supine with Highs sightly abducted Length of insertion ‘Anchor Female: 23 nhes (5~7-5em) Mate: 7:9 inches (17-225 em) Femole:innes thigh Made: Top of thigh or lower abdomen Unexpected stations and Associated InterventionsFundamentals of Nursin: =a in restr gloves and cate set; Once new cao ees + tee cemepnc the balloon ~ Siop inflation of bx fies soutoe from the balloon, eee stake rigtion per er etn) “Forialoton of meccaters or le Clsed stem frterniton'orcontanuy oe For ose whan geri S4g31/ “Foc conofmeccasors promot horecsoss tuning o oo debs ‘*NEVER INFLATE THE BALLOON UNLESS URINE FLOWS “*Ifinsertedin vagina, keep in place but insert another one Cotheter can be placed in ane month as long as no signs of infection Condom Catheter- must be secured through abel Fides' Maneuver — appication of pressure in he bladder to stimulate ine BOWEL ELMINATION ‘Assessment Inspection ~ Auscultation- Percuston - Poipatc ‘approach + Bowel sound [4 quacronts) © Active every 5:20 seconds © Hypocctive= I per minute Hyperactive — every aseconds Absent None heard in 36 minutos + Fecalyis aninch of formed stool, 15-30 ml of laxid stoo! 1 Fecal occult blood testing / Guios test Fecal Elmination Problems Diarheo watery stool; ORESOL; bonane rice apple Constipaiion herd stools: laxative; Pltum (buk-oxers). Castor ol {(Glinitont) Tenesmus urge fo bul unproductive o soo! Fecal impaction constipation and seepage of watery stools 2 Nosnema 2 Digta/Manual extacton with doctor's order 1 Monitor for wages smuation stop il signs are noted Euctation/ Belching = Bxputon of gases through mouth Fialulence/Typanim = Aveid gas forming foods: cautiower, cola 2 Caminaiive enema ~erpel aks [Rectal {ube insertion inverledin anus then placedin walle or 20min f need fo be repeated walt for 2-3 mins. foprevent and sprincter damage Types of taxatves Uk forming — Increases fkid, gaseous or solid buk (Mefamuci, Cirucet Emolent / Soo Sottener— Sottens and delays dying of feces (Colece} “Simulant [fant - kilales /sinciotes [Dulcolax Senokot, Castor ol Lubricant -Lubricates (Mineral OM) Saline / Osmotic Draws wolerinio intestine [Epsom sats, Mik of ‘Mogresio) nema Types CClearsing Enema + Pir to chagnostc test, surgery 2 Incares of conslpation and impaction 2 Binerbe: High enema [12-18in] of Low enema (12IP.) ‘caminotive Enema * Toexpelfiatus 2 @-80mi of hic Retention Enema t Soluton relcined for 1-3 hours Genome, anibiotic enema, cnithelminhic enema, ruiiive enema Returfiow Enema > Toexpel faivs 2 Allemating flow rectum cof 100-200mL of flid in end out of the eG Fr 22-30 2 Chic: Fr 12-18 ‘Conect Volume Adult 750~ 1,000 mt 2 Adolescent: 500~750 mL. 1 Sehootaged: 300 500m. + Toddler: 250~ 360mL font: 150~ 280mt Length of Insertion AQUI Sanches 2 child: 23inches ¢nfent:1~ Ts incbes ‘Commonly Used Enema Solutions Hypertonic - Drews water into colon (Sodium phosphate solution) Hypotonic —Ditlends colon, simulates, softens (Top water) Igolonie -Distend colon, simuales, softens [Normal sane) Soop suds -Ifates mucosa, dslends colon (3-Smt soap fo IL of woter) Ol- Lubricate: feces (Mineral olve, cottonseed) Unexpected Situations and Associated interventions 0 Soluion does not flow into the rectum -> Reposition rectal tube, ifsotuion wl sill not flow, remove 1UbS ‘ond check fox any fecal contents © Patient cannot rain enema solvfon for adequate ‘amount of ime > Palen! neecs lo be placed on ‘bedpanin ine supine positon © Paent canno! folesate large amouns of enema solution > Amount and engin of edimivisraion may have fo be modified’ ne paten! begins io complain of pain ‘© Palien! complains of severe cramping with Introduction of enema solution > Lower sotution container and check temperature and flaw rate; F the solutlonis 100 cotd, er loo fa, severe cramping may occur. Colostomy > S20 of stoma willbe stabilized within 6.8 woeks > Biuent Foulsmeling ondinitating fo the skin = ileostomy (Guidelines for Ostomy Care.r Fundamentals of Nursin; Teep pater orfos of oaan or om appliance frequently. ete: ety + epect stoma Hecueaty + Hemel ok ft, enc mast al et indeales cyonoss or decreases creschon . fete the se of he stoma inne bv cep skin rou he peo {Kegpstnacand re pettonel anadeenonty Unexpected Situations and Associated Interventions © Peristomal skins excotiated or nilated > Moke sure ‘applionce i no! cut foo large: Assess for presence of {urge snrfectorIhrcupy dears noe ly kin borier; Allow fo dry completely, Reappl soe fy completely, Reappy (© Patient continues fo notice odor > Check system for ‘any lecks or poor adhesion Thoroughly emply pouch MEDICATIONS Parenteral intradermal = Gouge 25-25 + Insert only the bevel: zero to 15 degree onde = Epidermal = Sensiiviy test subcutaneous = Stelchif fo pinchif thin 1 Adipose layer ofthe buttocks, ms 1 Best ste is cbdomen, below the umbilicus! 2 Gauge 22-25, 5/8inch inserted 1 iflong need, insert 5/8 shor 90 degree Inramusculor re Must be sity 90 percent 2 etSinch 2 Gauge 22:28 Brack technique = Deep IM 1 Prevent leakage of solution fo tse NO INSERTION IN GLUTEUS MAXIMUS, BUTON MINIMUS AND MEDIUS Intravenous IV Push ~ check bockfiow, if none do not insert IVintusion pump —for more accurate crip Solusef~ chamber up fo 100cc; microsel calibration ‘Opthaimie solution lower conjunctiva ste; 1-2 crops ot maximum Rectal Suppository - go beyond the onal sphincter Inhaler ~ may use spacer [DO NOT USE INHALER IN STEROIDS TO PREVENT MOUTH SORES! HEAT AND COLD AFPUCATION > Dono! prolong more than 20 mins. because of rebound Heat Varodiiation Increase copilary permecbilly Increase celkéor metabolism increose inflammation Sedative effect Vosoconstition Decrease copilary pemmecbilly Decrease celuiarmetabotsm > Decrease ntammaron > Localanesthelic effect Inflammation ~ fist 24houss = cold then heat Poin cold: to block neve Dyyheat [Hot water bogs temperalixe: 110-125 degrees F = Disposable ho! pocks 1 looriamp / gooseneck lamp / heat crade ‘0 Bulb = 25 watts © Dislonce = 12-24inches Dry cold appfcation = ieecap 2 Compress + After 15 mins Tepid Sponge Bath Do antetor ist 1 Use T washcloths ‘Sie Bath = immersion of 110-115 degrees Fahrenheit 1 enol eemove rectal pack, remove rectal dressing | may have cerebral hypoxia - put ice cap on forehead WOUND MANAGEMENT [No gauze cause it can sick o kin ‘Cenfer fo outer when cleaning Jackson Fratt = keep innegatve pressure; remove drainage 1 inheod ju, canhave JP but not on negative pressure since It con interfere with ICP HYGIENIC MEASURES Perineal core Female: Dorsal recumbent; front fo back Male: Supine; crcucr + one stroke, one direction ral Core = Bashing suicuor lechnique 2 Lemon gycerine swab, mineral ot (Oral hygiene for unconscious = supine, head tuned to one side = aniseptic solution Bed Bath = Woler temperate: 3-46C oF 110-115 1 Ams: Long, fem stokes, distal to proximal 1 breasts: Female circular: Mote - Longitudinal EXERCISE AND ACTIVITY ‘Active-asttive - one side help the affected side, 'sotonie - jogging; change inlength mucle Tension no change inlength Aerobic - exceed oxygen needs ‘Anerobie - does no! exceed oxygenneeds ‘Massages Effeurage - smooth, long giding stroke Petrssage - lorge pinch of skin; "kneading Tapotement ~side of each hand, sharp hacking movementFundamentals of Nursin: immobilly Thrombus formation 2 Edema = Constipation + Urinary stasis stones- calcul + Altophy = Disuse syndrome + Trochanter rol fo prevent external rotation of femur Pressure Ulcer = Decubitts uicer/ bed sore = Prone in bony surfaces = 1 =non blanchable erythema + 2-openiesion + [Link] fat exposed + exposed mucles and bones Dressing = Tronsparent batier 2 Gauencl used + To absorb exudates + Hydrocolloid steer Rest - Stote of calmness: elaxation without emotional siess oF freedom from anety. Sleep - slate of consciousness inwhich the individual's perception ‘end reaction fo the environment are decreased Physiology of Sleep Reficuler Activating System (RAS) ~ responsible in keeping you woke and alert Bulbor Synchronizing Region (BSR) ~ causes sleep types of Sleep REM Qon-Rapid Eye Moverent/ deep, rest seep / slow-wave sleep) . eee) Jer ight: crows: relaxed, eyes ol ftom sce-toside; lasting otew mins Ses Infant seep: body processes slow further (decrease PR/RR) t yon cre sists about 10-20 mins, este domination othe PNS-ctcul fo crouse; nol shxbed by Sergbay simul snoting, muscles Totaly relaxed Sage IW dallo seep deep [Link] sleep [REM (Rapid Eye Movement) Where most dreams take place. > Biainishighyy active, hence, paradoxical sleep ‘Common Sleep Disorders insomnia - warm bath, massage, milk (kyptophan), medication Poresomnia ~ periods of woking up while asleep Somabulsm - seep walking: lock the door Soliloquy - seep tok Nofcurnal enuresis (right/Diuml enucesismoming) ~ Bed wel, place doper Bruxism — anxiety; ginding of teeth Hypersomnia = excessive sleep: may have hypothyroid, DKA Narcolepsy ~ uncontrolled desite to sleep: ampethamine - taken fier breakfast, cnorexiant PAIN = Subjective 5 May have psychogeric pain as well + Acute —less thon 6 montis + Chrorie mere than é months + Iniractable ~no! reseved Wong and Baker Scale ~ 1-10raling Phantom pain = pain from amputated smb Gate theory of Pain Substenta getotinoso Poin threshold - Maybe psychological/ physiological (o Heat ond cold © Imagery and distraction DEATH Thanantology - study of death “stages of Gileving by Kubler Ross Post-mortem care molust be pronounced deed by physician igor Marts sitfening ‘Alger Mortis ~ change in temperature liver Mortis color change