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    FUNDAMENTALS OF

    NURSING

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    Florence NIGHTINGALE(1820-1910) Lady with the Lamp Considered the founder of modernnursing

    NURSING

    THEORISTS

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    INTERPERSONAL PROCESS4 Phases (NURSE-CLIENT RELATIONSHIP) ORIENTATION

    IDENTIFICATION--Identify difficultiesand amount of needed help EXPLOITATION/EXPLANATION-nurse

    utilizes available resources towardgoal of maximum health RESOLUTION/TERMINATION-goals

    met

    HILDEGARD PEPLAU(1952)

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

    HENDERSON

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    21 CLIENT NEEDS

    ABDELLAH

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    10.To facilitate the maintenance of regulatorymechanisms and functions

    11.To facilitate the maintenance of sensory function

    12.To identify and accept positive and negativeexpressions, feelings and reactions

    13.Top identify and accept the interrelatedness ofemotions and organic illness

    14.To facilitate the maintenance of effective verbaland nonverbal communication

    15.To promote the development of productiveinterpersonal relationship

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    16.To facilitate progress towardachievement of personal spiritual goals

    17.To create and maintain a therapeutic

    environment18.To facilitate awareness of self as anindividual with varying physical,emotionaland developmental needs

    19.To accept the optimum possible goals inlight of physical and emotional limitations

    20.To use community resources as an aid inresolving problems arising from illness

    21.To understand the role of social problemsas influencing factors in the cause of illness.

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    CONCEPTUALIZED THEDYNAMIC NURSE PATIENT

    RELATIONSHIPFocuses on how the clientadapts to illness and howactual or potential stresscan affect the ability to

    adapt.

    IDA JEAN ORLANDO(1961)

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    COINED NURSING

    PROCESSCORE, CURE, CARE

    CORE: THERAPEUTIC USE OF SELF CURE: DISEASE & TREATMENT AS BASED ON

    DOCTORs Order CARE: Nurturance of the BODY

    HALL

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    Nursing care isnecessary only if the

    client is unstable tofulfill biologic,

    psychologic,developmental or social needs.

    JOHNSON

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    SCIENCE OF UNITARYHUMAN BEING

    THE INDIVIDUAL IS MORETHAN and DIFFERENT

    FROM THE SUM OF ITSPARTS,DITINCTIVE

    PROPERTIES OF THE

    ROGERS

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    DESCRIBED NURSING AS AHELPING PROFESSION THATASSISTS INDIVIDUALS AND

    GROUPS TO ATTAIN ,MAINTAINAND RESTORE HEALTH.

    3 DYNAMIC INTERACTINGSYSTEMS: PERSONAL,INTERPERSONAL, SOCIAL FORM

    THE BASIS FOR NURSE CLIENT

    KING

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    HEALTH CARE SYSTEMMODEL-Nursing is a

    unique professionconcerned with all the

    variables affecting anindividuals response

    to stress.

    NEUMAN

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    TRANSCULTURALNURSING MODEL

    AVOCATED NURSINGCARE THROUGH

    SCIENTIFIC ANDHUMANISTIC ANDSPECIFIC CULTURALCARING PROCESSES

    LEININGER

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    ADAPTATION MODEL

    HELP CLIENT TO ADAPTTO CHANGES IN

    PHYSIOLOGIC NEEDS,SELF-CONCEPT, ROLEFXN, INTERDEPENDENT

    RELATIONS

    ROY

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    HUMAN CARING MODEL Believed that a person

    is a valued being to becared for, respected,nurtured, understood

    and assisted, a fullyfunctional integratedself.

    JEAN WATSON

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    THEORY ON THEDEVELOPMENT OF

    VIRTUES-the unifyingstrength of a good man.MORAL DEVELOPMENT

    CONTINUES THROUGHOUTLIFEEGO STRENGTH VIRTUE/GOODMAN

    NURSES ACT AS ROLE

    ERICKSON

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    CENTRAL CARINGCARING IS CENTRAL IN

    NURSING, CREATINGPOSSIBILITIES FORCOPING & CONNECTINGWITH OTHERS

    BENNER

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    PHYSIOLOGICSAFETY AND SECURITYLOVE AND BELONGINGNESS

    The need to love and need tobe lovedSELF-ESTEEM

    Self-worth, Self-identity, BodyImage

    SELF-ACTUALIZATION Need to learn

    Need to be self-fulfilled

    MASLOWS HIERARCHY OFNEEDS

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    Organized andsystematic-composed of

    6 sequential andinterrelated stepsHumanistic-individualized,involving the aspects of

    human dignity

    NURSING PROCESS

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    Collecting, validating,organizing and recording

    data about clients healthstatus to establish database.

    Collection of Data Subjective Ob ective

    ASSESSMENT

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    Methods

    Interview Observation-use of senses

    PE

    Sources Primary Secondary

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    The clinical act of identifyingthe problem.Analysis of assessment infoand derive meaning from this

    analysisFormat: P-problem R-related factors/Etiology

    S-signs and symptomsOR.

    P-problem E-etiology S-si ns and s m toms

    DIAGNOSING

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    Refers to formulating anddocumenting measurable, realisticgoals

    PURPOSESTo provide individualized care Promote client participation

    To plan care that is realistic andmeasurableTo allow involvement of supportpeople

    OUTCOME IDENTIFICATION

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    4. Planning Determiningbeforehand the strategies and

    course of action beforeimplementation

    PURPOSES: to identify the clients goals andappropriate nursing intervention

    to direct client care activities to promote continuity of care to direct activities to be carried out

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    5. Implementation putting thenursing care plan into action

    a. Reassessing to ensureprompt attention to

    emerging problemb. Set priorities

    c. Perform nursing interventiond. Record action

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    6. Evaluation assessing the

    clients response to nursingintervention

    PURPOSE:

    -to appraise the extent towhich goals and outcome

    criteria of nursing care hasbeen achieved

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    Law-rules that regulate socialconduct in a formallyprescribed and legally binding

    manner.Rights- PrivilegesResponsibilities- ObligationsGrievance-DisputeStare Decicis-to stand by

    things decided.

    JURISPRUDENCE

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    Public/Criminal laws-Actionsagainst safety and welfare of thepublic

    Felony-Serious Misdemeanor-Less serious

    Civil/Private laws Contracts Torts-Wrong doing againstperson/property

    Unintentional

    Intentional

    CLASSIFICATION

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    INTENTIONAL TORT

    Assault or battery Invasion of privacy

    Defamation(Libel/Slander) Malpractice andnegligence

    False Imprisonment

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    NOT instituted forconvenience

    False ImprisonmentAlternative measure first

    Remove Q2hFor safetyNeeds Doctors order.

    RESTRAINTS

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    PHYSICALEXAMINATION

    INDIVIDUAL ASSESSMENT OF EACH BODYSYSTEM, USUALLY CONDUCTED IN ACEPHALO-CAUDAL MANNER

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

    INSPECTION

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    PALMS & FINGER PADS:TEXTURE, CONSISTENCY &

    FORMDORSUM OR BACK OFHAND: TEMPERATURE

    BONY PROMINENCES OFTHE PALM: VIBRATION

    PALPATION

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    HEAD TO TOE ASSESSMENT

    REVIEW OF SYSTEMS

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    SEMI-FOWLERS FOR GASTRIC FEEDING TOREDUCE REFLUX

    HIGH FOWLERS FOR EATING, NGT INSERTION ANDSUCTIONING, PROMOTES GOODCHEST EXPANSION

    SUPINE FOR VERTEBRAL INJURIESDORSAL RECUMBENT

    FOR ABDOMINAL EXAM

    CLIENT POSITIONS

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    PRONE SMALL PILLOW JUST BELOW DIAPHRAGM,SUPPORTS LUMBAR CURVE, FACILITATESBREATHING

    SIMS FOR RECTAL EXAM

    KNEE-CHEST/ GENUPECTORAL CLIENT PRONE, ARMS FLEXED ON SIDES,KNEE-CHEST FLEXION. FOR VAGINAL/RECTAL EXAM

    LITHOTOMY HAVE CLIENT VOID PRIOR TO. FOR PELVICEXAM

    VITAL SIGNS

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    TEMPERATURE

    VITAL SIGNS

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    HEAT LOSS

    1. RADIATION: no direct contact

    e.g. therapy2. CONDUCTION: direct contact

    e.g. TSB3. CONVECTION: air Currents

    e.g. electric fan fan

    4. EVAPORATION: liquid to gase.g. skin sweat

    f

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    Patterns of Fever:

    1. Remittent: Remains high

    (fever fluctuates but neverreturn to normal)

    2. Intermittent: International!

    (fever fluctuates b/w normal &above normal)

    3. Relapsing: fever fluctuates,normalizes for days, feveragain!

    4. Constant: >38C

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    PULSE

    RESPIRATION

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    RESPIRATIONIncreased RR: stress,smoking, anemia,>altitude; Amphetamine,

    CoccaineDecreased RR: acute

    pain in chest/abdomen,brain damage; narcotics,

    anesthesia, P tt f B thi

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    Patterns of Breathing1. CHEYNE-STOKES: HV-

    Apnea normal in kids & elderly whenasleep; heart failure, uremia,brain damage

    2. BIOTs: Shallow breath-

    Apnea3. KUSSMAULs: deep,regular, rapid

    4. ORTHOPNEA: DOB supine

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    BP t ki !!!

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    BP taking!!! 1. 5 min rest, within 30 min no

    coffee 2. Supine/sitting: arm at heartlevel, 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.

    Disappearance of sound (Diastole)

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    Permission obtained from apatient to perform a specific testor procedure.Agreed uponFacts knownExplainedRisk and chances understood

    INFORMED CONSENT

    LEAVELL AND CLARKS

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    PRIMARY-To encourage optimal healthand to increase the personsresistance to illness. To stopsomething 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

    LEAVELL AND CLARKSLEVELS OF PREVENTION

    SECONDARY Health maintenance

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    SECONDARY-Health maintenance.Seeks to identify specific illnessesor 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 35yo)

    GLAUCOMA & HYPERTENSIVESCREENING

    DISABILITY LIMITATIONS: Adequate tx

    T ti

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    Tertiary Restoration and Rehabilitation

    Occurs after a disease ordisability has occurred andthe recovery process has

    begun, assisting the client inobtaining an optimal healthstatus.

    CVA therapyCardiac Rehabilitation foraddiction or MI

    Blood Glucose Monitoring for

    STAGES OF INFECTIOUS

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    Incubation Period= exposure to 1stS/S

    Prodromal Period= Symptoms thatmay be the 1st indication of theonset of the disease

    Stage of Illness= Manifesting S/S

    Convalescence=the stage to

    recovery after the disease

    STAGES OF INFECTIOUSPROCESS

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    CONTACT TRANSMISSION DIRECT CONTACT-person to person INDIRECT CONTACT-Fomites,

    dressing, needle, instrumentsDROPLET TRANSMISSIONVEHICLE TRANSMISSION- water,

    bloodAIRBORNE TRANSMISSIONVECTORBORNE TRASMISSION

    MODE OF TRANSMISSION

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    The quality of beinginsusceptible or unaffectedby a particular disease orcondition.

    IMMUNITY

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    Natural Immunity Immunity that is notacquired through previous

    contact with a infectious agent but is largelygeneticallydetermined.

    Inherent

    TYPES

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    AcquiredA.Passive immunity-a state of temporary

    partial insusceptibility to an infectious agentthat has been induced by IV or IM

    administration of preformed antibodies.

    B Active Immunity

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    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 ofantibodies against antigens of microorganisms or theirproducts.

    2)Cellular Immunity-The central position in defense (Band T cells).

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    Antibodies are produced by anothersource. NATURAL-MOTHER to FETUS via placenta ARTIFICIAL-immune serum(Ab) injected to person

    PASSIVE IMMUNIZATION

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    HandwashingCleaningDisinfectionSterilizationUse of barriersIsolation systemsSurgical Asepsis

    ASEPTIC PRACTICES

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    The single most important infection controlpractice.

    Effectiveness is greatly influenced byadequate friction and thoroughness of

    surface cleaned.Wash hands under running water,soap and

    friction for 15 to 30 sec. on each hand.

    HANDWASHING

    METHODS OF

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    STEAM AUTOCLAVE,NONTOXIC,SPOROCIDALGAS 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

    METHODS OFSTERILIZATION

    RADIATION-Penetrates deeply into the objects

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

    BOILING WATER

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    Caps and shoe coveringsMasksGlovesPrivate roomsWaterproof disposable bags for linen ands

    trashControl of airflow

    Goggles and face shield

    USE OF BARRIERS

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    NEVER TOUCH WITHBARE HANDS ANYTHING

    THAT IS WET COMINGFROM A BODY SURFACE

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    DEFINITION OF TERMS:1. Medication substance

    administered for diagnosis,

    cure, treatment, relief orprevention of disease

    2. Chemical name describes

    the constituents of the drug3. Brand name the name

    given by the manufacturer.

    Medication Administration

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    TYPES OF DOCTORS ORDER

    1. Standing order carried outuntil specified period of timeor until it is discontinued by

    another order2. Single order

    3. Stat order

    4. PRN

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    Effects of drug

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    1. Therapeutic

    2. Side effect or secondary effect3. Drug allergy4. Anaphylactic reaction5. Drug tolerance

    6. Drug abuse7. Drug dependence8. Addiction9. habituation

    Effects of drug

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    ASSOCIATED WITH AGING THAT

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    1. Altered memory

    2. Less acute vision

    3. Decrease renal function4. Slower GI absorption

    5. Increase proportion of fat to lean body

    mass leading to toxicity6. Decreased liver function

    ASSOCIATED WITH AGING THATINFLUENCE MEDICATIONADMINISTRATION ANDEFFECTIVENESS

    ADMINISTERING

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    1. Right drug

    2. Right dose

    3. Right route4. Right patient

    5. Right recording

    6. Right approach7. Right patient

    ADMINISTERINGMEDICATION

    Routes of Drug

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    1. Oral2. Sublingual

    3. Topical

    a. dermatologicb. ophthalmic

    c. otic

    d. nasal

    e. inhalation

    f. vaginal

    gAdministration

    4 Rectal

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    4. Rectal

    5. Parenteral

    a. Intradermal Dermal layer underneath theepidermis.

    The sites are the inner, lower arm,

    upper chest and back, and beneaththe scapula

    Indicated for allergy, and tuberculintesting

    Needle gauge 25,26,27. size 3/8,5/8 inches

    10-15 degree angle , bevel up

    Do not massage the site of injection

    B. Subcutaneous

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    For vaccines , preoperativemedications, narcotics, insulin,

    heparin. Sites: outer aspect of upperarm, anterior aspect of the

    thigh, abdomen Small doses are injected Rotate sites

    Needle gauge and size same asID 45 degree angle

    For obese, 90degree angle C. Intramuscular

    N dl l th 1 i h 1 t 2 i h t h

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    Needle length 1 inch,1 to 2 inches to reachmuscle 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

    do not massage

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    2. Circulatory overload

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    yresults from administration

    of excessive volume of IVfluidsAssessment:

    -headache-Flushed skin-increased BP

    -weight gain-syncope-pulmonary edema

    - INTERVENTION:

    Sl i f i KVO

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    1. Slow infusion to KVO2. High-Fowlers position

    3. Bronchodilator

    3. Drug Overload the patient receives anexcessive amount of fluid containing

    drugs.Assessment:-dizziness-Shock

    -FaintingNSG INTERVENTION:-Slow infusion to KVO. Notify the

    physician

    4. Superficial Thrombophlebitis it isd f i i i i

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    due to overuse of a vein irritatingsolutions or drugs, clot formation,

    large bore catheters.Assessment:- Pain along the course of vein- Vein may feel hard and cordlike- Edema and redness at needinsertion site

    - Arm feels warmer than the other

    armINTERVENTION:-Change IV site every 72 hours.

    -Use large vein

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    Vitamins

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    Water soluble1.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, appetiteand weight loss, disturbed nerve function, wasting

    of limbs, edema and heart failure.

    Vitamins

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    5 Vit B6 (Pyridoxine)

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

    Deficiency:

    6. Vit.B9 (Folic acid) Sources: green leafyvegetable, liver, eggs

    Deficiency:

    Fat Soluble VitaminsVitamin A (Retinol) good eyesight

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    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)- calciumabsorption.

    Sources-dairy products,salmon, sardines Deficiency-

    Rickets-Soft, pliable bone, muscle pain,Spinal curvature

    Osteomalacia-Loss of calcification of boneresulting to softening of the bone.

    3 Vitamin E ( Tocopherol) for

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    3. Vitamin E ( Tocopherol) formaintenance of healthy skin and

    good eyesight. Sources vegetable oils, leafyvegetables, peanuts

    Deficiency-anemia, skin lesion

    4.Vit K(Menadione) for bloodclotting.

    Sources-green leafy vegetable,egg yolk.

    Deficiency-bleeding

    Minerals

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    Minerals

    1.Calcium-

    bone and teeth formation- Muscular contraction- Blood coagulation- Neurotransmission- Catalyst for biologic reactionSources-milk and dairy products, nuts,tofu.

    Deficiency- retarded growth, rickets,osteomalacia and tetany.

    2. Potassium F and E balance,

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    ,Hypokalemia

    -Manifested as apathy, muscular

    weakness, confusionHyperkalemia- weakening in cardiac

    contraction, poor respiration, numbness ofextremities

    Sources-fruits

    3. Sodium responsible for fluid balance.

    i lli

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    Hyponatremia causes swelling

    Hypernatremia- crenation

    4. Iron The most abundant trace element inthe body necessary for hemoglobin formation.

    Sources-pork liver, lean meat

    Deficiency- anemia

    Excess hemosiderosis-Abnormal deposition ofIron to different tissues.

    5. Iodine for normal synthesis of thyroxine.

    S f d ilk

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    Sources- seafoods, milk, eggs

    Deficiency-goiter, cretenism, myxedema

    Bowel and Bladder Elimination

    1 Defecation expulsion of feces from the

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    1. Defecation expulsion of feces from therectum

    STOOL ASSESSMENTA. Color

    B. Odor

    C. Amount

    D. ConsistencyE. Shape

    F. Frequency

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    Common elimination problems1.Constipation-passage of small, dry, hard

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    p p g , y,stool or the passage of no stool for aperiod of time.

    2.Fecal impaction- mass collection ofhardened feces in the folds of therectum. The stool is lodged or stucked inthe rectum

    3. Diarrhea frequent evacuation of waterystool

    4. Flatulence excessive gas in the

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    intestine. Due to swallowed air, bacterialaction in the large intestine.

    5. Fecal incontinence involuntaryelimination of bowel contents associatedwith neurologic, mental and emotional

    impairment.

    Urinary Elimination

    *Anatomy

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    *Anatomy

    1. Kidney

    2. Ureter3. Urinary bladder

    4. Urethra

    Micturition the act of expelling urine from

    the bladder.Initiated by parasympatheticnervous system.

    Characteristics

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    1. Color amber or straw

    2. Odor aromatic

    3. Transparency clear

    4. pH 4.6 8

    5. Specific Gravity 1.010 1.025

    Altered Urinary Frequency

    Frequency

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    1. Frequency

    2. Nocturia

    3. Urgency4. Dysuria

    5. Hesitancy

    6. Enuresis

    7. Urinary Incontinence

    8. Retention

    Activity, mobility and exercise*Immobility

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    1.Musculoskeletal System-atrophy

    -disuse osteoporosis-dimineralization-contracture2.Cardiovascular System

    -orthostatic hypotension-thrombus formation-embolus-thrombophlebitis

    3.Respiratory

    -atelectasis

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    -atelectasis

    -pneumonia

    -respiratory acidosis

    4. Urinary

    -UTI- Urinary stasis- Calculi- Incontinence

    5. Integumentary

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    -loss of skin turgor

    -decubitus ulcer reddened areas or ulcer in

    the skin occuring over bony prominences

    Causes:

    a. Pressure

    b. Friction

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    BED SORE

    Stages of Decubitus Ulcer

    Stage I : Erythema

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    Stage I : Erythema

    Stage II: Involves epidermis and or dermis.

    Presence of abrasion or blister or shallowcrater.

    Stage III: Full thickness skin loss involvingdamage or necrosis of subcutaneous tissue

    that may extend through the fascia.Stage IV: Full thickness skin loss all the wayto muscle and bone.

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    Safe EnvironmentCharacteristics:

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    Adequate lighting Neat and clean Safe equipment Noise level is comfortable Cleanliness

    Medication Temperature of the environment

    Factors that affect peoples protection

    1 Age

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    1. Age

    2. Orientation and LOC

    3. Emotion4. Injury or illness

    5. Sensory or communication impairment

    6. Safety awareness

    Injuries

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    1.Fall

    2.Burns

    3.Chemical trauma

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    PAIN

    PainA sensation of physical or mental hurt or

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    - A sensation of physical or mental hurt orsuffering that causes distress or agony

    Factors Influencing the pain experience1. Age2. Sex3. Cultural background

    4. Psychological5. Previous experience6. Knowledge or understanding

    Stages of Pain

    A ti ti b i ith th ti f

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    1. Activation begins with the perception ofpain.

    2. Rebound the pain experience is intense butbrief.

    3. Adaptation

    Classification of Pain

    1 Cutaneous

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    1. Cutaneous

    2. Somatic

    3. Visceral4. Referred perceived at an area other than the

    site of injury.

    5. Intractable

    6. Phantom

    7. Radiating- felt at the source and extends thesurrounding tissue.

    8.

    Intermittent

    SLEEP=state of lesser perception & reaction to the

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    environment.

    RETICULAR ACTIVATING SYSTEM (RAS)

    =WAKEFULNESS: catecholamine release (E)

    =SLEEPINESS: serotonin release

    Stages of Sleep

    1. NREM: body restoration2. REM: >brains processes

    A. NREMStage 1: Lightest sleep, 10 min,

    dil k

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    readily awakensStage 2: Sound sleep, easily

    arousable, VS decrease

    Stage 3: Deep sleep, musclesrelaxed, diff to arouse

    Stage 4: Deepest sleep, most relaxed,sleepwalking, enuresis, night

    terrorsB. REM: Paradoxic, vivid, full color

    dreams, 90 min

    SLEEP DISORDERSNarcolepsy: > daytime sleepiness

    l dd l k

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    *Cataplexy: sudden muscle weakness

    *Hypnagogic: dreams undistinguishable fromreality

    Somnambulism: sleep walking

    Soliloquy: sleep talking

    Sleep Terrors: sudden waking, but with no dreamrecall

    Bruxism: teeth grinding

    Enuresis: bed-wetting

    OXYGENATION

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    VENTILATION: BREATHINGDIFFUSION: O2 MOVES FROM ALVEOLI TO

    RBCPERFUSION: RBCS MOVE INTO CIRCULATION

    OXYGENATION

    THORACENTESIS

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    NEEDLE INSERTION THRU CHEST WALL FORASPIRATION OF PLEURAL FF FLUID ORINSTILLATION OF MEDS

    EXPLAIN PROCEDURE & INSTRUCT CLIENTNOT TO COUGH OR MOVE SUDDENLY

    CHECK FOR PNEUMOTHORAX

    O C S S

    CARDIAC CATHETERIZATION

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    R-SIDED: ANTECUBITAL VEINR HEART--PULMONARY ARTERYL-SIDED: BRACHIAL OR FEMORAL ARTERY

    AORTALEFT VENTRICLE

    PRE-TEST: CHECK FOR ALLERGIES; NPO 8-12HOURS PRIOR, NO ANTICOAGULANTS AT LEAST3 DAYS PRIOR

    FEELING OF WARMTH OR FLUTTERING ISCOMMON AS CATHETER PASSES

    POST-TEST: CHECK CIRCULATION IN AFFECTEDEXTREMITY (PULSES, COLOR, SENSATION),SANDBAG OR PRESSURE DRESSING OVERPUNCTURE SITE.

    BRONCHIAL LAVAGE/STEAM INHALATION

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    LIQUIFIES AND MOBILIZES SECRETIONS;MEDIUM FOR AEROSOLBRONCHODILATORS & MUCOLYTICEXPECTORANTS

    COVER CHEST WITH TOWEL AND PLACESPOUT 12-18 IN. AWAY TO PREVENTBURNS. STEAM FOR 15-20 MINUTES.

    THEN DEEP BREATHING AND COUGHINGTO MOBILIZE SECRETIONS

    STEAM INHALATION

    CHEST PHYSIOTHERAPY

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    PERFORM AC TO AVOID ASPIRATIONSEMI-FOWLERS POSITIONGIVE BRONCHODILATORS 20 MIN PRIOR

    *POSTURAL DRAINAGE: CAREFUL POSITIONINGALLOWS SECRETIONS TO FLOW BY GRAVITYFROM SMALLER AIRWAYS INTO LARGERAIRWAYS

    *PERCUSSION: CLAPPING WITH CUPPED HANDSON CHEST WALL FOR 3-5 MIN TO DISLODGESECRETIONS

    *VIBRATION: WITH HANDS PRESSED FLAT ONCHEST, UPPER ARM & SHOULDERS

    TRACHEOSTOMY

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    SURGICAL CREATION OF A STOMA, OPENINGINTO THE TRACHEA THROUGH THEOVERLYING SKIN FOR RELIEF OF UPPERAIRWAY OBSTRUCTION OR ACCESS FOR

    MECHANICAL VENTILATION

    NGT INSERTION

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    PLACE PT IN HIGH-FOWLERS

    NURSE ON SIDE OF NOSTRIL FOR INSERTION.MEASURE TUBE LENGTH BY NOSE-EARLOBE-XIPHOID (NEX). ADD 20-30 cm FOR DUODENALPLACEMENT. LUBRICATE TUBE.

    HYPEREXTEND NECK, INSERT TUBE THRUNOSTRILS TOWARDS BACK OF THROAT WHILEROTATING TUBE 180. FLEX NECK ONCE TUBE INOROPHARYNX & ASK CLIENT TO SWALLOW.

    CLIENT SITTING OR HIGH FOWLERS POSITION

    NGT FEEDING

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    CLIENT SITTING OR HIGH-FOWLERS POSITION(PREVENTS ASPIRATION)

    CHECK FOR RESIDUAL FEEDING >150 ml:INFORM DR

    WITH FEEDING BAG OR SYRINGE ELEVATED 12INCHES. ELEVATION ALLOWS EMPTYING BY

    GRAVITY TO PREVENT ABDOMINALDISCOMFORT, REFLUX AND VOMITING

    FOLLOW WITH WATER TO CLEAR TUBE. CLAMPTUBE BEFORE ALL THE WATER IS INSTILLED TO

    PREVENT AIR BUBBLES (FLATULENCE)

    PARENTERAL NUTRITION

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    FOR CLIENTS WHO ARE UNABLE TO DIGESTOR ABSORB ENTERAL NUTRITION: GIOBSTRUCTION, ILEUS, SURGERY, TRAUMA

    REQUIRES MONITORING OF GLUCOSE,

    ELECTROLYTES, LIPIDS, PROTEINS

    PARENTERAL NUTRITION

    CLEAR LIQUID: BROTH, COFFEE, TEA,DIET PROGRESSION

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    Q , , , FRUIT JUICES, GELATIN, POPSICLE

    FULL LIQUID: ALL JUICES/ SHAKE, PUREED VEGGIES, CUSTARD, COOKED CEREALPUREE: PUREED MEAT/FRUITS, SCRAMBLED EGG, MASHED POTATOES

    MECHANICAL SOFT: GROUND OR FINELY FLAKEDMEAT/ FISH, CHEESE, RICE, POTATOES,HOTCAKES, LIGHT BREAD, SOUP

    SOFT: TENDER MEAT, SOFT FRESH FRUIT, CAKE,

    COOKIES (NO NUTS)

    BOWEL ELIMINATION

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    FECES MOVES INTO RECTUM RELAXINGINTERNAL ANAL SPHINCTER THENEXTERNAL ANAL SPHINCTER RELAXES TOEXPEL FECES. IF NOT, LEVATOR ANIMUSCLES, HELP KEEP SPHINCTER CLOSED.

    VALSALVA: FORCEFUL EXPIRATION THRU ACLOSED GLOTTIS. IT FACILITATESDEFECATION BY INCREASINGINTRAABDOMINAL PRESSURE.

    FECALYSIS

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    1 INCH (FORMED); 15-30 ml (LIQUID)COLOR: YELLOW-BROWN RT STERCOBILINODOR: 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

    BULK FORMER= SAFEST. PSYLLIUM (METAMUCIL).TAKE WITH WATER TO PREVENT IMPACTION

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    STOOL SOFTENER= Na DOCUSSATE.

    OSMOTIC AGENT= ABSORBS WATER.LACTULOSE: GIVE BEFOREBREAKFAST OR BEDTIME.

    MILK OF MAGNESIA: LOWERDOSES ACT AS ANTACID

    LUBRICANTS= MINERAL OIL. GIVE UPRIGHT: NOTWITH MEALS!CHEMICAL IRRITANTS= > PERISTALSIS

    BISACODYL (DULCOLAX): GIVE ac, WAIT 1 HOUR

    BEFORE MILK OR ANTACID.SENA (SENOKOT): GIVE hs, DISCOLORS URINECASTOL OIL= TAKE WITH SODA

    SKIN CARE/HYGIENEBED BATH

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    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-chest-abdomen-legs-feet-back-buttocks-perineum

    *Extremities: long firm strokes (D-P)*Back: P-D

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    ORAL CAVITY CARECheilosis: lip cracking (Vit B12 def)

    D t l C i t th di i t ti (b

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    Dental Caries: teeth disintegration (browndiscoloration) lactic & pyruvic acid(product of bacterial action on CHO)

    Gingivitis

    Glossitis

    Parotitis/MumpsPeriodontitis

    Stomatitis

    Tartar: visible hard deposit of plaque(bacteria, saliva, EC on teeth enamel)

    EYES, EARS, NOSE CARE

    Hyperopia: Farsightedness; ray of light focusBEHIND retina

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    BEHIND retinaMyopia: Near; IN FRONT retina

    Presbyopia: impaired near vision DT

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    p *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 withwarm NSS!

    EARS CARE*moist washcloth, ear canal straightening

    *Impacted cerumen: instill H2O2 1-2 drops/ear 3x/d

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    Impacted cerumen: instill H2O2 1-2 drops/ear 3x/dfor 3d. Irrigate with 250 ml WARM water!

    (hot/cold: NV)

    NOSE CARE

    *gentle blowing thru open nostrils

    *soften crusted secretion with NSS

    BED MAKINGBed Types:

    1 Unoccupied Bed

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    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

    Grieving and Death

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    Loss- actual or potential situation in whichvalued object, person changed so that it is nolonger perceived as valuable.Bereavement is a subjective response to aloss through death.

    Grief-total response of emotional experience ofthe loss and is manifested in thoughts,feelingsand behaviorMourning- behavioral process through which

    grief is eventually resolved or altered.

    g

    Stages of Grieving

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    DenialAnger

    BargainingDepressionAcceptance

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    Signs of impending clinicaldeath

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    Loss of muscle toneSlowing of circulationChanges in vital signsSensory impairment

    death

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    THANKS