Fundamental of Nursing 4 Finals

8/12/2019 Fundamental of Nursing 4 Finals

1/12

- Fundamental of nursing-

# Activity and Exercise

In nursing assessment, if we sow redness in the skin "we've take the right action" Body Mechanics :Is the utilization of correct muscles to complete a task safely and

efficiently, without undue (unnecessary) strain on any muscle or joint.

Principles of good body mechanics:Maintain a stable center of gravity:

1-Keep your center of gravity low.

2-Keep your back straight.

3-Bend at the Knees and hips.

we do the logrolling for spinal injured patients. Effects of immobility:Individuals who have inactive lifestyles due to illness or injury

are at risk for many problems that can affect major body systems.- Musculoskeletal System:

1-Disuse (neglect) osteoporosis :Without the stress of weight-bearing activity, the

bones are depleted chiefly of calcium. Regardless of the amount of calcium in

patient diet.

2-Muscles atrophy: Muscles atrophy losing most of their strength and normal

function.

3-Contractures:It is irreversible except by surgical intervention such as foot drop,

wrist drop, and external hip rotation.

4-Stiffness and pain in the joints:Without movement, the collagen tissues at the

joint become permanently immobile.

- Cardiovascular System :

1-Postural Hypotension:Is common result of immobilization.

# Spirituality

Spirituality : is anything that pertains to a persons relationship with a nonmateriallife force or higher power.

# Self concepts

Self- concept :Is ones mental image of oneself. Self-Knowledge:the knowledge that one has about oneself, including, insights into

ones abilities, nature, and limitation.

Self-expectation :what one expects of oneself; may be a realistic or unrealisticexpectation.

Social Self:How a person is perceived by others and society. Personal Identity: is the conscious senseof individuality And uniqueness that is

continually evolving throughout life. People often view their identity in terms of


2/12

name, sex, age, race, ethnic, and other situational characteristics e.g. marital status

and education. It also includes beliefs and values.

Nursing Management :Guidelines for conducting a psychosocial assessment include the following:

1-Create a quiet, private environment.

2-Minimize interruptions if possible.

3-Maintain appropriate eye contact.

4- Sit at eye level with the client.

5- Demonstrate an interest in the clients concerns.

6-Indicate acceptance of the client by not criticizing, or demonstrating shock.

7-Ask open-ended questions to encourage the client to talk.

8-Avoid asking more personal questions than are actually needed.

9-Maintain confidentiality

# Sensory Perception

Sensory reception:is the process of receiving stimuli or data. These stimuli areeither external or internal to the body.

External Stimuli:are visual (sight), auditory (hearing), olfactory (smell), tactile(touch), and gustatory (taste).

Internal stimuli :1- Kinesthetic :(refers to awareness of the position and movement of body parts,

for example, a person walking is aware).

2- Stereognosis:( the ability to perceive and understand an object through touch byits size, shape for example, a person holding a tennis ball is aware of its size, round

shape, and soft surface without seeing it.

3- it.Visceral:refers to any large organ within the body (a person aware of them e.g.

a full stomach).

Sensory perception :involves the conscious organization and translation of the dataor stimuli into meaningful information.


3/12

States of Awareness:

# Oxygenation

Factors affect the rate of oxygen transport from the lungs to the tissues :1-Cardiac output.

2-Number erythrocytes and blood hematocrit.

3-Exercise.

Hypoventilation: that is inadequate alveolar ventilation, can lead to hypoxia, whichmay occur because of diseases of the respiratory muscles, drugs, or anesthesia.

Hyperventilation: Cyanosis : bluish discoloration of the skin, nail beds, and mucous membranes, due

to reduced hemoglobin-oxygen saturation.

Orthopnea:is the inability to breath except in an upright or standing position. Diagnosing: The following diagnostic for clients with oxygenation Problems :

1-Ineffective Airway Clearance: inability to clear secretions

2-Ineffective Breathing Pattern: Inspiration and /or expiration that dose not provide

adequate ventilation.

Oxygen Delivery Systems :1-Nasal Cannula : Delivers a low concentration of oxygen (24% to 45%).

2-Face Mask : This system provides concentrations of oxygen as high as 40-60%.

Airway and ventilation adjunct :How to relieve the airway obstruction:

1-HEAD TILT AND CHIN LIFT (in case of there isn't trauma in head)

2-JAW THRUST (in case of there is trauma in head)

Pulmonary function test :To major lung volume and capacity.

State Description

Full

consciousness

Alert, oriented to time, place, person, understands verbal

and written words.

Disoriented Not oriented to time, place, or person.

ConfusedReduced awareness, poor memory, misinterprets stimuli,

impaired judgment.

Somnolent Extreme drowsiness but will respond to stimuli.

Semicomatose Can be aroused by extreme or repeated stimuli.

Coma Will not respond to verbal stimuli.


4/12

# Skin Integrity and Wound areas

What we mean by intact skin?Intact skin refers to the presence of normal skin andskin layers uninterrupted by wounds.

Types of Wounds :- Wounds can be described according to how they are acquired, and the degree of

wound contamination :

1-Clean wounds.

2-Contaminated wounds.

3-Dirty or infected wounds.

- Classifying wounds by depth :

1-Partial thickness

2-Full thickness

Wounds are classified by depth, that is, the tissue layers involved in the wound :Type Cause Description & Characteristics

IncisionSharp instrument (e.g. Knife or

scalpel)Open wound; deep or shallow

Contusion Blow from a blunt instrument

C losed wound, skin appears

ecchymotic

LacerationTissues torn apart, often from

accidents (e.g. with machinery)Open wound, edges are jagged

Penetrating wound

Penetration of the skin and the

underlying tissues, (e.g. from a

bullet or metal fragmants)

Open wound

Pressure Ulcers:Os any lesion caused by unrelieved pressure (a compressingdownward force on a body area) that results in damage to underlying tissue.

Etiology of Pressure Ulcers :Pressure ulcers due to localized ischemia, a deficiencyin the blood supply to the tissue. The tissues is compressed between two surfaces,

usually the surface of the bed and the bony skeleton. When blood cannot reach the

tissue, the cells are deprived of oxygen and nutrients, the waste products of

metabolism accumulate in the cells, and the tissue consequently dies. Prolonged,

unrelieved pressure also damages the small blood vessels.


5/12

Bony Prominences :1- Occiput

2-Ear3- Scapula

4- Spinous Process

5-Shoulder6- Elbow

7- Iliac Crest

8- Sacrum/Coccyx

9- Ischial Tuberosity

10- Trochanter

11- Knee

12- Malleolus

13-Heel14- Toe

Risk Factors for Pressure Ulcers :1-Friction and Shearing: Friction is a force acting parallel to the skin surface. For

example, sheets rubbing against skin create friction. Shearing force is a combination

of friction and pressure.

2-Immobility:Paralysis, extreme weakness, pain, or any cause of decreased activity

can hinder a persons ability to change positions independently and relieve the

pressure.

3-Inadequate Nutrition.

4- Fecal and Urinary Incontinence.

5- Decreased Mental Status.

6- Excessive Body Heat.

7-Advanced Age.8- Chronic Medical Conditions.

Pressure ulcers are classified according to the extent of tissue damage :

1- Stage l: Skin is intact with

an area of nonblanching

erythema. This is usually

over a bony prominence.


6/12

2- Stage ll: Partial-thickness skin loss with loss of the epidermis and some of the

dermis. It appears as a shallow ulcer with a red-pink color. No slough or necrotic

tissue is present in the base. It may also appear as an enclosed or open serum-filled

blister.

3- Stage lll: Full-thickness loss of skin with the epidermis and dermis gone and

damage to or necrosis of subcutaneous tissues. Damage extends down to but not

through the underlying fascia. Subcutaneous fat may be visible, but muscle, tendon,

or bone is not seen. Slough may be present but does not hinder estimation of the

extent of tissue loss. Tunneling or undermining may be present.

4- Stage lV: Full-thickness loss of skin with extensive destruction, tissue necrosis, and

damage to bone, muscle, or other supporting structures that are exposed.


7/12

Preventing Pressure Ulcers :1- Skin Hygiene.

2-Pressure Relieving & Supportive Devices.3-Maintain Skin Integrity.4-Patient Education.5-Support Services.6-Training of Caregivers.7-Providing good Nutrition.8-Avoid Skin Trauma.

Laboratory Data :1-A decreased leukocyte.2-A hemoglobin level below normal.3-Serum protein.4-Albumin below 3.5 g/dL.5-Wound cultures.6-Sensitivity studies.

# Urinary elimination

Nocturia:Is voiding two or more times at night. Dysuria:It is means voiding that is either painful or difficult. Definitions of NANDA Diagnosis:

- Functional Urinary Incontinence:inability of usually continent person to reach

toilet in time to avoid unintentional loss of urine.

# Loss, Grieving and Death

Loss:is an actual or potential situation in which something that is valued is changedor no longer available e.g. loss of body image, a significant other, a sense of well

being, a job, illness and hospitalization.

Types of loss :1-Actual Loss: can be recognized by others.

2-Perceived Loss: is experienced by one person but cannot be verified by others. It

is psychologic losses. For example a woman who leaves her work (employment) to

care for her children at home may perceive a loss

Sources of loss :- Familiar environment:Separation fro an environment and people who provide

security can result in a sense of loss such as a 6-year-old who move away to another

school.


8/12

Stages of Grieving, Client Responses and Nursing Implication :Stage Behavioral Responses Nursing Implication

Denial

Refuses to believe that loss is

happening. Is unready to deal

with practical problems, as

prosthesis after the loss of a leg.

Verbally support client but

do not reinforce denial . Do

not share in client denial.

# Asepsis

Asepsis:Is the freedom from disease-causing microorganisms Basic types of asepsis:

1-Medical asepsis

2-Surgical asepsisor sterile techniqueMedical asepsis Surgical asepsis(sterile technique)

1- includes all practices intended toconfine a specific microorganism

to a specific areal.

2- In medical a sepsis objects arereferred to as clean, which meansthe a absence of almost all

microorganisms, or dirty (solid,

contaminated).

1- Refers to those practices thatkeep an area or object free of all

microorganisms and spores (

microscopic dormant structures

formed by some pathogens that

are very hardly and often survive

common cleaning techniques).

2- Surgical asepsis is used for allprocedures involving the sterile

areas of the body.

Infection:is an invasion of body tissue by microorganisms and their growth there:such a microorganism is called an infectious agent (virus, bacteria and fungi) .

Nosocomial infections:-Any infection causing illness that wasn't present or in its incubation period when

the subject entered hospital or received treatment in outpatient clinic.

-type of infection is also known as a hospital-acquired infection ( or more

generically healthcare- associated infections.

-Infections are considered nosocomial if they first appear 48 hours or more after

hospital admission or within 30days after discharge.

# Fecal elimination

Meconium:is the first fecal material passed up to 24 hr. after birth. It is black, tarry,odorless, and sticky.


9/12

Sufficient bulk (fiber) in the diet to provide fecal volume. Diagnostic Procedures :Such as visualization of the colon (colonoscopy, or

sigmoidoscopy) the client restricted from ingesting food or fluid, and may be given a

cleansing enema prior to the examination.

# Medication

Patient who has infection in his\her eye, must lay on the same side of the infectiouseye.

Absorption:is the process by which a drug is transferred from its site of entry intothe body to the bloodstream.

Parenteral medication :Defined as other than through the alimentary or respiratorytract; that is by needle.

Intramuscular injection (IM) :location of IM injection in the upper outer quarter ofthe buttock.

# Circulation

Cardiac output (CO):is the amount of blood pumped by the ventricles in 1 minute. Preload:Is the degree to which muscle fibers in the ventricle are stretched at the

end of the relaxation period (diastole).

Afterload:Is the resistance against which the heart must pump to eject the bloodinto the circulation.

Anemia happens if there is a decrease in the number of RBCs or blood hemoglobin. Factors Affecting Cardiovascular Function :

- Modifiable Risk Factors :

1-Elevated serum lipid level.2-Hypertension.3-Cigarette smoking.4-Diabetes.5-Obesity.6- Lack of physical exercise.

The function of the heart as a pump (Decreased Cardiac Output):- Myocardiac Infarction (MI) :If large portion of the heart muscle is affected.Signs and symptoms of MI :

1-Chest pain, substernal and/or radiating to the left arm, Jaw.2-Nausea3-Shortness of breath4-Diaphoresis

Heart Failure :- Causes:

1-Heart failure usually occurs because of myocardial infarction.2-Also may result from chronic overwork of the heart, such as in client withuncontrolled hypertensoin or extensive arteriosclerosis.


10/12

3-In left-sided heart failure, the vessels of the pulmonary system becomecongested or engorged with blood. This may cause fluid to escape into the alveoli

and interfere with gas exchange (Pulmonary edema).

- Signs of heart failure may include the following:

1-Pulmonary congestion.2-Increased heart rate.3-Prepheral vasoconstriction, cold pale extremities.4-Distended neck veins.5-Shortness of breath.6-Increase respiratory rate.

#Dosage Calculation Important Abbreviations :

*cc - cubic centimeter

*ggram

*mgmilligram

*ugmicrogram

*gttdrop/1ml

*IMintramuscular

*IVintravenous

*IVPintravenous push

*tab. = tablet

* / = per

Equivalents :* 1g = 1000 mg

*1mg = 1000 microgram (ug or mcg)

*1L = 1000 ml

Examples :

350 mg =0.35g

0.061g =16g

500ml =0.5L

In every order there are 4 main questions:1-What is the order?2-What is on hand?3-Do you need any equivalents?4-Where are you going? (or what are you being asked to give?

First formula :Desired dose

Dose to administer =------------------- X Quantity on handDose on hand


11/12

Example :

* The doctor orders a patient to receive Daypro 1200mg am and pm. The stock

supply is 600mg/tab. How many tablets will the patient receive for the correct

dose?

desire dose = 1200 mgDose on hand = 600 mg\tab.

Quantity on hand =1 tab.

Second formula : "Calculating Intravenous Flow Rates"

Example :* A client on an infusion pump is to receive 500 ml. of RL. in 12 hours. What is the

flow rate in ml. per hour?

Volume to be deliver = 500 mlDuration = 12hours

Thered formula : "Manual Intravenous Flow Rates"

Example :* A physician order 4000 mL of D5W. (Dextrose water) IV. Over 36 hours period.If

the IV. Set will deliver 15 gtt/mL., then how many drops must be administered per

minute?

Volume of fluid = 4000 mL

Delivery time = 36 hr.

Desired dose

Dose to administer =------------------- X Quantity on hand

Dose on hand

1200

Dose to administer =------------------- X 1 = 2 tab.

600

amount of fluid

Volume to be delivered per hour = ------------------------

total time

amount of fluid

Volume to be delivered per hour = ------------------------

total time

500 ml

= ------------- = 42 ml\hr

12 h

Volume of Fluid X Drop rate of IV. Set(Drop factor

Drops/min = ---------------------------------------------------------------------

Delivary Time in Hours X 60 min /hr


12/12

Drop rat (drop factor) = 15 gtt./mL

Volume of Fluid X Drop rate of IV. Set(Drop factor

Drops/min = ---------------------------------------------------------------------

Delivary Time in Hours X 60 min /hr

4000 mL X 15

= -----------------------

36 hr. X 60 min

500

= --------

18

= 28 drops\min

.^^):

)(:D

~

Fundamental of Nursing 4 Finals

Documents

Transcript of Fundamental of Nursing 4 Finals