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FUNDAMENTALS INNURSING
BY: NURSE_JHEN
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1. What vitamin is necessary for a patient suffering from pellagra?a. vitamin B1 c. vitamin B3b. vitamin B2 d. vitamin B6
2. According to the intentional torts, which of the following describesthe intentional touching of a person or something that person isholding or wearing, which is wrong in some way.a. assault c. domestic violenceb. battery d. false imprisonment
3. What stage of illness will the person belong if the client is
expectedly to gradually become independent and resume formerroles and duties?a. symptom experience c. assumption of sick roleb. dependent role d. recovery period
4. This is considered to be the 4th stage of grief and loss accordingto Kubler-Ross.
a. denial c. bargainingb. anger d. depression
5. According to Jean Piaget, in his theory of cognitive development,OBJECT PERMANENCE belongs to what level?a. Preoperational c. concreteb. Sensorimotor d. formal
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METAPARADIGMS INNURSING
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THEORIES OFNURSING
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FLORENCE NIGHTINGALE12 May182013 August1910
"The Lady with theLamp
Bplace: Florence, Italy Raised: England Educated:
Kaiserswerth,Germany founded byTheodore Fleidner
At 17 entered thecovenant
Crimean war
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St. Thomas Hospital School of Nursing,London June 15, 1860
Works: notes on nursing(1860) andnotes on hospital
1st theory of nursing
Environmental Model
Changing or manipulating theenvironment
The body can repair itself in anurturing environment
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FAYE GLENN
ABDELLAH born March 13,1919
nursing research
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nursing as an artand a science
Identified 21 nursing problems
nursing is a society
Works: Better Nursing CareThrough Nursing Research andPatient-Centered Approaches to
Nursing
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Abdellah's Typology of 21 Nursing Problems: To promote good hygiene and physical comfort To promote optimal activity, exercise, rest, and sleep To promote safety through prevention of accidents, injury, or other trauma and
through the prevention of the spread of infection
To maintain good body mechanics and prevent and correct deformities To facilitate the maintenance of a supply of oxygen to all body cells To facilitate the maintenance of nutrition of all body cells To facilitate the maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiologic responses of the body to disease conditions To facilitate the maintenance of regulatory mechanisms and functions
To facilitate the maintenance of sensory function To identify and accept positive and negative expressions, feelings, and reactions To identify and accept the interrelatedness of emotions and organic illness To facilitate the maintenance of effective verbal and nonverbal communication To promote the development of productive interpersonal relationships To facilitate progress toward achievement of personal spiritual goals To create and maintain a therapeutic environment To facilitate awareness of self as an individual with varying physical, emotional,
and developmental needs To accept the optimum possible goals in light of physical and emotional limitations To use community resources as an aid in resolving problems arising from illness To understand the role of social problems as influencing factors in the cause of
illness
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VIRGINIA AVENEL HENDERSON
(Nov. 30, 1897Mar. 19, 1996) first lady of
nursing
born in Kansas City,Missouri
graduated fromthe Army School
of Nursing,Washington
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14 basic needs assist clients to a peaceful death nursing as "assisting individuals to gain
independence in relation to the performance ofactivities contributing to health or its recovery"
Works: The Principles and Practice of Nursing
described the nurse's role as substitutive(doingfor the person), supplementary(helping theperson), or complementary(working with theperson), with the goal of helping the personbecome as independentas possible.
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DOROTHY E. JOHNSONBSN, MPH
1919 - 1999
"first four yeargeneric basic nursingprogram in the UnitedStates
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Behavioral system model
7 subsystems: ingestive, eliminative,affiliative, aggressive, dependence,achievement and sexual
patients health is dependent onnurses behavior
Works: One Conceptual Model of
Nursing
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IMOGENE KING Ed.D.
RN(1971, 1981) Goal attainment theory "General Systems
Framework" theory nursing as a
profession nurses help individuals
die with dignity interaction between
nurses and patients.
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King's Conceptual System:
Three Interacting Systems
Personal Systems InterpersonalSystems
Social Systems
perception interaction organization
self communication authority
growth &development
transaction status
body image role decision making
space stress
time
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MADELINE LEININGER PhD,LHD, DS, RN, CTN, FRCNA,
FAAN, LL
Transcultural nursing
model Nursing is a humanistic
and scientificmode ofhelping a client through
specific cultural caringprocess
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Works: Journal of Transcultural Nursing
The main goal of transcultural nursing is to provideculturally specific care
Transcultural Nursing focused upon differences and similarities among cultures
respect to human care, health, and illness based upon the people's cultural values, beliefs, andpractices, and
to use this knowledge to provide cultural specific orculturally congruent nursing care to people
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MYRA ESTRIN LEVINE
(1973) Supportive & Therapeutic Conservation model
4 Principles E
P
S
SWorks: Humanities in Nursing
B M N R N
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Betty M. Neuman, R.N.,B.S.N., M.S., Ph.D., PLC.,
FAAN
Born 1924 near Lowell,Ohio.
pioneer in the field ofnursing involvement incommunity mental health
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Health care systems model nurses help patients adjust to environmental
stressors Works: 'Model for teaching total person
approach to patient problems' in Nursing
Research Neuman Systems Model wholistic overview of the physiological,
psychological, sociocultural, and developmental
aspects of human beings
DOROTHEA ELIZABETH
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DOROTHEA ELIZABETHOREM
(1914June 22, 2007)
SELF CARE andSELF CAREDEFICIT THEORY
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Self care and Self care deficit theory
'the practice of activities that individuals initiate andperform on their own behalf in maintaining life, health,and well-being.'"
individuals can take responsibility for their health and
the health of others
3 nursing systems W P S
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HILDEGARD PEPLAU. EDd
(Sept 1, 1909 - Mar 17, 1999) _ Interpersonal Relations
in Nursing
emphasized the nurse-client relationshipasthe foundation ofnursing practice
Theory is the creationof a shared experience
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4 Phases of Nurse-Client
Relationship1. Orientation2.Identification
3.Exploitation4.Resolution
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DR. MARTHA ELIZABETHROGERS
1914 - 1994
Edited a journalcalled: NursingScience
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Science of Unitary Human Beings
man is an energy field in the environment Man has the capacity for abstraction and
imagery, language and though, sensationand emotion
Works: An Introduction to the TheoreticalBasis of Nursing(Rogers, 1970).
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SISTER CALLISTA ROY
RN, PhD, FAAN Bachelor of Arts with amajor in nursing at MountSt. Mary's College, in LosAngeles.
Nursings goal is topromote adaptation in fourmodes:physiologic, self-concept, role function, andindependence.
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Adaptation model man as a biopsychosocial system - The
person is an open, adaptive system whouses coping skills to deal with stressors sees the environment as "all conditions,
circumstances and influences thatsurround and affect the development andbehaviour of the person"
six-step nursing process which includes:assessment of behaviour, assessment ofstimuli, nursing diagnosis, goal setting,
intervention and evaluation.
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LYDIA ELOISE HALL
1906 - 1969 Nursing process Concept of CARE, CORE,
CURE Hall believed patients
should receive care ONLYfrom professional nurses Hall was not pleased with
the concept of teamnursing--she said that "anycareer that is definedaround the work that hasto be done, and how it isdivided to get it done, is a"trade" (rather than aprofession).
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According to the Care, Core, andCure" model, nurses work in threearenas: care (hands on bodily care),core (using the self in relationship tothe patient), and cure (applying
medical knowledge). three separate domains: the body
(care), the illness, (cure), and the
person (core).
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JEAN WATSON,
Phd, RN, AHN_BC, FAAN Born:West Virginia Educated:BSN,
University of
Colorado, 1964MS, University ofColorado, 1966PhD,University ofColorado, 1973
She is founder of theoriginal Center forHuman Caring inColorado
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Human caring model
Transpersonal caring
Included health promotion andtreatment of illness in nursing
Her latest book is Caring Science asSacred Science(2005)
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TEN CARATIVE FACTORS1. "The formation of a humanistic-altruistic system of values"(Watson, 1979). Thisfactor develops at an early age and involves a broad awareness of self.2. "The instillation of faith-hope"(Watson, 1979). An understanding of andsensitiviy to an individual's beliefs provides a sense of well-being for the client.
3. "The cultivation of sensitivity to one's self and to others"(Watson, 1979). Thisallows the nurse and the client to become increasingly sensitive, and thereforemore genuine.4. "The development of a helping-trust relationship"(Watson, 1979). Effectivecommunication techniques such as congruence aids in the creation of thisrelationship.5. "The promotion and acceptance of the expression of positive and negativefeelings"(Watson, 1979). This factor recognizes that the6. "The systematic use of the scientific problem-solving method for decisionmaking"(Watson, 1979). The problem-solving method is foundational to thepractice of nursing.7. "The promotion of interpersonal teaching-learning"(Watson, 1979). Theprovision of information empowers a client to make informed decisions abouthealth and healing.8. "The provision for supportive, protective, and (or) corrective mental, physical,sociocultural, and spiritual environment"(Watson, 1979). This factor encompassesinternal and external variables that the nurse is responsible for guiding.
9. "Assistance with the gratification of human needs"(Watson, 1979). Humanneeds include all acts of life, ranging from food to the need for achievement.10. "The allowance for existential-phenomenological forces" (Watson, 1979). Thenurse needs to view each person's reality through the individual's eyes.It was on Christine Donald's site
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ROSEMARIE RIZZO
PARSE, RN; PhD; FAAN Theory of humanbeing
Free choice of
personal meaning inrelating valuepriorities
Used terms such asrevealing-concealing,
enabling-limiting,connecting-separating
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BASIC HUMAN NEEDS
( Abraham Maslow)
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Maslows Characteristics of a
Self-Actualized Person1. realistic2. judges people correctly3. superior perception, is
more decisive
4. clear notion of what isright or wrong
5. usually accurate inpreceding future events
6. understands art, music,
politics, philosophy7. possesses humility,listens attentively
8. dedicated to work, task,duty, perception
CONCEPTS OF
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CONCEPTS OFHEALTH,WELLNESS AND
ILLNESS Health is a state of complete physical, mental andsocial well-being, and not just merely the absenceof disease of infirmity (WHO)
Wellness is well-being. It involves in engaging inattitudes and behaviors that enhance quality oflife and maximize personal potential
Illness is a state in which the person perceivesphysical, emotional, intellectual, social,developmental or spiritual functioning to bedecreased.
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MODELS OF HEALTH
AND ILLNESS
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HEALTH-ILLNESS
CONTINUUM (DUNN) describes the interaction of environmentwith well-being and illness
high-level wellness: towards optimum levelof functioning
if not going for OLOF, then the person istowards the illness continuum
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HEALTH BELIEF MODEL(Rosenstock and Becker)
individual perceptions andmodifying factors mayinfluence health beliefsand preventive health
behaviorindividual perceptions mayinclude: perceived threat,perceived susceptibility,perceived seriousness
modifying factors include:demographic variables(age, sex, race),sociophysilogic variables(peer group, clubs),structural variables (knowledge, contact)
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Concept Definition Application
PerceivedSusceptibility
One's opinion of chances ofgetting a condition
Define population(s) at risk, risklevels; personalize risk based
on a person's features orbehavior; heighten perceived
susceptibility if too low.
Perceived SeverityOne's opinion of how serious a
condition and itsconsequences are
Specify consequences of the riskand the condition
Perceived Benefits
One's belief in the efficacy ofthe advised action to
reduce risk or seriousnessof impact
Define action to take; how,where, when; clarify the
positive effects to beexpected.
Perceived BarriersOne's opinion of the tangible
and psychological costs ofthe advised action
Identify and reduce barriersthrough reassurance,incentives, assistance.
Cues to ActionStrategies to activate
"readiness"
Provide how-to information,promote awareness,
reminders.
Self-EfficacyConfidence in one's ability to
take actionProvide training, guidance in
performing action.
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FIVE STAGES OF ILLNESS
Symptomexperiences
When the person believes something iswrong; manifestations of signs and symptoms(they feel unwell or get a rash)
Assumption of
the sick role
When self-management fails, seeks
confirmation from family and friends oftenexcused from normal role expectations
Medical carecontact
When symptoms persist, seeks the advice ofa health professional (check- up)
Dependentclient role Becomes dependent on the professional forhelp with illness (admission to the hospital)
Recovery orrehabilitation
Client is expected to gradually becomeindependent and resume former roles andduties
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STRESS
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MODERN STRESSTHEORY
(HANS SELYE)
stress is a non-specific response ofthe body to any demand made upon it
A stressor is any stimulus that
produces stress and the disturbs thebodys equilibrium
FACTS OF STRESS
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FACTS OF STRESS:1. stress is not a nervous
energy2. man tends to adapt tostress
3. stress is not alwayssomething to be avoided
4. stress does not alwayslead to distress5. a single stress does not
cause a disease6. stress may lead to
another stress7. prolonged stress may
lead to exhaustion8. stress is always a part of
everyday life
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GENERAL ADAPTATION
SYNDROME (GAS) whenever a man responds to stress,
the whole body is involved
Regardless of the cause of stress,the same chain of physiologic eventsoccurs
The GAS is a result of the release ofadrenal hormones, with subsequentchanges in organ systems
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STAGES OF GAS: (ARE)
Stage of Alarm Stage ofResistance Stage ofExhaustion
person becomesaware of the
presence of threator danger
levels of resistanceare decreased
adaptive
mechanism aremobilized (fight orflight reaction)
characterized byadaptation
levels of resistanceare increased
person moves backto homeostasis
result fromprolonged exposure
to stress andadaptive
mechanisms can nolonger persist
unless other
adaptivemechanisms will bemobilized, death
may ensue
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LOCAL ADAPTATION
SYNDROME (LAS) man may respond to stress through a
particular body part or body organ
response is localized It is the reaction of one organ or one
part of the body
Example: inflammation
HEALTH PROMOTION
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HEALTH PROMOTION
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HEALTH PROMOTION
these are activities directed towards
increasing the level of well-being andself-actualization
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THREE LEVELS OF
PREVENTIONPrimaryPrevention
to encourage optimal health and to increase the persons resistance toillness
activities includes health promotion, health teachings
examples: quit smoking, exercise, immunizations, balanced diet, healthylifestyle, avoid alcohol intake, increase water intake, maintain idealbody
SecondaryPrevention
also known as health maintenance
activities include early diagnosis, detection and screening; prompttreatment
examples: PE, pap smear, clinical Breast Exam, sputum exam, stoolexam and rectal exam
TertiaryPrevention
to support the clients achievement of successful adaptation to known risks,optimal reconstitution and/or establishment of high-level wellness
examples: self-monitoring of blood glucose, physical therapy of a CVApatient, cardiac rehab after MI, self-management class for DM,speech therapy after laryngiectomy
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NURSING PROCESS
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NURSING PROCESS
Lydia Hall
G
O S
H
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CHARACTERISTICS OF
THE NURSING PROCESS1. problem oriented, it is comparable with scientificproblem-solving approach
2. goal oriented3. orderly, planned, step by step
4. open to accepting new information during its application,it is flexible to meet the unique needs of the client, groupor community
5. interpersonal it requires that the nurse communicatesdirectly and consistently with the client
6. permits creativity among nurses and clients in devising
ways to solve the health problems7. cyclical steps may overlap because they are interrelated8. universal
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ASSESSMENT collecting, validating, organizing and recordingdata about the clients health status
purpose: ______________
TYPES OF DATA: s -o -METHODS: 1. interview -
2. observation -
SOURCES: Primary Secondary
NURSING DIAGNOSIS
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NURSING DIAGNOSIS 4 parts _______: to identify the clients health care
needs and to prepare diagnostic statements PROBLEM: ETIOLOGY: SIGNS AND SYMPTOMS: SECONDARY FACTORS:
EXAMPLE:Altered Comfort: Pain related to presence of
incision site at the right lower quadrantsecondary to post appendectomy
TYPES OF NURSING
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TYPES OF NURSINGDIAGNOSIS
Actual Example: fluid volume deficit Risk
Example: risk for injury Potential
Example: potential for growth Wellness
Example: family pattern increased Syndrome
Example: altered community pattern
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PLANNING
Determining the strategies or course ofactions to be taken before implementationof nursing care
Purpose: to identify the clients goalsand appropriate nursing interventions
Should only have ONE GOAL but may have
MANY OBJECTIVES
Sh ld b SMART
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Should be SMART SPECIFIC: the goal should be directed to the
patient alone
MEASURABLE: use of action words likedemonstrate, verbalize, manifest, etc. ATTAINABLE: should be well stated in a way that
the goal is achievable REALISTIC: suited for the condition of the
specific patient and is applicable
TIME FRAMED: the time is set for the goal to beachievedEXAMPLE: (altered comfort: pain)At the end of my 8-hour shift, my patient will
verbalize increased level of comfort as evidenced by: Reduced pain scale of 3/10 from 6/10 with 0 as no
pain and 10 as most painful Participate in activities of daily living
Absence of guarding behavior, facial grimacing, andmoaning
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IMPLEMENTATION
Putting the nursing care plan intoaction
Purpose: to carry out plannednursing interventions to help theclient attain goals
h ld b i d i i
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Should be organized in itspresentation
INDEPENDENT: all nursing actions that needsNO doctors orders (vital signs, turning andpositioning, chest physiotherapy)
DEPENDENT: all nursing procedures thatNEEDS doctors orders (medications, special
procedures) INTERDEPENDENT: otherwise known asCOLLABORATIVE, in which other health teammembers are being tapped for the care(speech therapy, respiratory therapy, physical
therapy) REFERRAL: endorsed to the superior (NOD,head nurse, physician)
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EVALUATION
Assessing the clients response to nursinginterventions and then comparing theresponse to predetermined standards or
outcome criteria Purpose: to determine the extent of
which goals of nursing care have been
achieved
COMPONENTS OF A
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COMPONENTS OF ANURSING GOAL:
A. CONCLUSION STATEMENTS 1. GOAL MET 2. GOAL PARTIALLY MET 3. GOAL UNMET
B. JUSTIFICATIONS - written as as evidencedby EXAMPLE: Goal Met. Patient able to verbalize increased
level of comfort as evidenced by:
reduced pain scale cooperate in the ADL no more facial grimacing
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COMMUNICATION
TYPES OF COMMUNICATION:
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TYPES OF COMMUNICATION:
1. NONVERBAL actions or behaviors that communicate a
message without speaking facial expressions, body language, posture, hand gestures,use of space and territory
2. VERBAL transmission of a message using the spokenlanguage
3. THERAPEUTIC communication that pertains to treatmentand healing
important elements contributing to the establishment of thetherapeutic relationship are EMPATHY, ATTENDING,
OBSERVING, and LISTENING4. NON-THERAPEUTIC communication that is a barrier to
free
5. ACTIVE LISTENING attentiveness to the client in aphysical and psychological manner
ESSENTIAL COMPONENTS OF A
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ESSENTIAL COMPONENTS OF ATHERAPEUTIC COMMUNICATION
(ReGRET) RAPPORT IPR characterized by a spirit ofcooperation, confidence and harmony
TRUST a risk-taking process whereby a persons
situation and feeling of well-being depends on theactions of another RESPECT a relationship in which one considers
the other in high esteem or regard
EMPATHY
ability to try and understand what otherperson is feeling; Not actually feeling what the otherperson is feeling
GENUINENESS being as one appears, sincere andhonest
THERAPEUTIC COMMUNICATION
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TECHNIQUESListening Facing and leaning towards the client, using eye contact, relaxed
body posture
Broad opening Open-ended comments
Clarification Nurse communicates an understanding of the thought or feelingtone of the clients message back to him/her to offer another
perspective in the situation
Reflection Reflects back the feeling or thought
Confrontation Describes contraindications in the clients behavior or feeling
Giving information Provides facts and information
Seeking validation Asks to give feedback about the accuracy of the nurses
perceptions
Self-disclosure Occasionally and cautiously reveals something from her ownexperience
Silence To communicate presence and acceptance of the client
Summarizing Progress, evaluates, goals
NONTHERAPEUTIC
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NONTHERAPEUTICCOMMUNICATION
Changing thesubject
Nurse communicates an unwillingness to continue with theclients topic
Interrupting Nurse shows disrespect by breaking into an interferingwith his/her communication
Approving Nurse uses approval and disapproval to control the clientand his/her behavior
Moralizing Nurse passes judgment on the client
Social response Nurse uses superficial, social conversation that is not
client-centered
Belittling Nurse discounts the clients feelings and experiences asnot being valuable or worthwhile
Giving advice Nurse gives advice to the client
LEGAL ISSUES
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LEGAL ISSUES
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PRIVACY being apart from others for observation
INFORMED CONSENT the health care provider has theresponsibility to communicate pertinent information in a manner that
the client is able to understand role of the nurse: advocate
COMMITMENT the legal process by which the clients who havepsychiatric problems are brought to and confined in a secure areabecause their behaviors are so extreme and severe that they pose a
harm to themselves or to others CLIENT RIGHTS
clients retain all of the basic rights that every citizen has
clients also expect that the treatment will be individualized andcollaborative with no verbal or physical abuse
client rights include privacy, confidentiality, and expectation thattreatment will be appropriate to needs with client participation
HUMANE RESEARCH entails voluntary participation, informedconsent, and freedom to withdraw from the study at any time for anyreason, without penalty
LIABILITIES
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LIABILITIES MALPRACTICE incorrect treatment by a professional
that causes injury or harm NEGLIGENCE the commitment of an act that a
reasonable and prudent person would not have done INVASION OF PRIVACYviolation of another persons
rights to be left alone and free from unwarranted contact,
intrusion and publicity DEFAMATION OF CHARACTER any untrue
communication, written (libel) or spoken (slander) thatinjures the good name or reputation of another, or in anyway brings that person into disrepute
FALSE IMPRISONMENT the intentional, unjustified,nonconsensual detention or confinement of a client forany length of time.
RESPONDEAT SUPERIOR the employer is ultimatelyresponsible for the acts of its employees, and is thus liable
for damage to the third parties
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VITAL SIGNS
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TEMPERATURE
balance between the heat producedby the body and the heat lost from
the body body heat is primarily produced by
metabolism
the heat-regulating center is thehypothalamus
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2 TYPES:1. CORE deep tissues of the body2. SURFACE skin, SQ, fats
normal core body temperature isbetween 36.5 C 37.5 C
BASAL METABOLIC RATE the youngerthe person, the higher the BMR; theolder the person, the lower the BMR
PROCE NVOLVED
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PROCESS INVOLVED
IN THE HEAT LOSS1. RADIATION the transfer of heat from the
surface of one object to another without contactbetween the two objects
2. CONDUCTION transfer of heat from onesurface to another but with contact between thetwo objects
3. CONVECTION the dissipation of heat by aircurrents
4. EVAPORATION the continuous vaporization ofmoisture from the skin, oral mucous, heatrespiratory tract (insensible heat loss)
ALTERATIONS IN
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ALTERATIONS INBODY TEMPERATURE
FEBRILE from 37.5 C to 38 CHYPERTHERMIA from 38 C to
39.5 C Febrile and hyperthermia can be
relieved by TSB + antipyreticsPYREXIA from 39.5 C and aboveHYPERPYREXIA pyrexia +
convulsion Pyrexia and hyperpyrexia needs
IV antipyretics +anticonvulsants
Very high body temperature(41-42 C) cause irreversiblebrain cell damage
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TYPES OF FEVERa. INTERMITTENT temperature fluctuates
between periods of fever and periods ofnormal/subnormal temperature
b. REMITTENT temperature fluctuates within a
wide range over the 24-hour period but remainsabove normal range
c. RELAPSING the temperature iselevated for few days, alternated with
1 or 2 days of normal temperatured. CONSTANT body temperature
is consistently high
NURSING INTERVENTION
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NURSING INTERVENTIONOF CLIENTS WITH FEVER
1. monitor VS 2. assess skin color and temp skin flushing 3. monitor WBC NEUTROPHILS will increase f
due to bacterial infection
4. remove excess blankets 5. Provide adequate food and fluid replacement 6. measure I&O 7. promote rest
8. provide TSB prn 9. administer antipyretics
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PULSE A wave of blood created by
contraction of the left ventricle ofthe heart
The PR is regulated by the autonomicnervous system
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FACTS: 1. females have higher
PR after puberty 2. increase in
metabolic rate
increases PR 3. increase in bloodloss increases PR4. thready pulse weak and feeble pulse
5. bounding verystrong pulse
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PULSE SITES: temporal carotid apical
brachial radial femoral posterior tibial
pedal (dorsalis pedis) popliteal
ASSESSMENT OF THE
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ASSESSMENT OF THEPULSE:
A. RATE the normal pulse rates per minute are asfollows: Newborn: 80-180 bpm 1 year: 80-140 bpm 2 years: 80-130 bpm
6 years: 70-120 bpm 10 years: 50-90 bpm Adult: 60-100 bpmB. RHYTHM the pattern and intervals of beats.
Dysrhytmia is an irregular patternC. VOLUME (AMPLITUDE) the strength of the
pulse Words to use: strong or full, weak, feeble,
thready
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RESPIRATION PHYSIOLOGICAL PROCESSES
1. VENTILATION the movement of air in and outof the lungs
2. EXTERNAL RESPIRATION the exchange ofgases from the alveoli to the capillaries and viceversa
3. PERFUSION the transport of oxygen throughoxyhemoglobin throughout the body
4. INTERNAL RESPIRATION exhange of gasesfrom the capillaries to the tissue and vice versa
TYPES OF
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TYPES OFBREATHING:
COSTAL (THORACIC)involves movementof the chest
DIAPHRAGMATIC(ABDOMINAL)involves movementof the abdomen
RESPIRATORY
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RESPIRATORYCENTERS
A. MEDULLA OBLONGATA the primarycenter; in C3 or C4, where the diaphragmis innervated by the PHRENIC NERVE
B. PONS1. PNEUMOTAXIC CENTER: responsible forrhythmic quality of breathing (involuntarybreathing)
2. APNEUSTIC CENTER: responsible for deep,prolonged inspiration
ASSESSING
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ASSESSINGRESPIRATION
1. RATE: 16-20 cpm (adult)
2. DEPTH: observe the movement of thechest. Maybe normal, deep or shallow
3. RHYTHM: observe for regularity ofinhalations and exhalations
4. QUALITY OR CHARACTER: respiratory
effort and sound of breathing
RHYTHM OF RESPIRATION
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RHYTHM OF RESPIRATION(ALTERED BREATHING)
1. CHEYNE-STOKESwaxing and waning
Char: deep, shallow withtemporary apnea
Conditions: increase ICP,drug toxicity
2. BIOTS also known asCLUSTER RESPIRATION
Character: shallow breathsinterrupted by apnea
Condition: CNS disorders
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3. KUSSMAULShyperventilation
Character: tacypnea +metabolic acidosis;deep and rapidbreathing
Condition: DM 4. APNEUSTIC
prolonged gaspinginspiration followed by
a very shortexpiration
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BLOOD PRESSURE
Measure of the pressureexerted by the blood as itpulsates through the arteries
BP = cardiac output x strokevolume
TERMS:
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TERMS:1. SYSTOLIC PRESSURE pressure of the blood
as a result of contraction of the ventricles (110-140 mmHg)
2. DIASTOLIC PRESSURE pressure when theventricles are at rest (60-90 mmHg)
3. PULSE PRESSURE difference between thesystolic and diastolic pressures (normal is 30-40 mmHg)
4. HYPERTENSION abnormally high bloodpressure over 140 mmHg systolic and/or 90mmHg diastolic for at least two consecutivereadings
5. HYPOTENSION abnormally low bloodpressure, systolic pressure below 100 mmHg
FACTS:
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FACTS: increase peripheral
resistance increase BP decrease cardiac output
decreases BP decrease
compliance/elasticityincreases BP
increase hematocritincreases BP
BP is at lowest in themorning and highest inthe late afternoon
KOROTKOFF SOUNDnormal heart sounds
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LABORATORY EXAMSand DIAGNOSTIC
EXAMS
COMPUTED
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COMPUTEDTOMOGRAPHY (CT SCAN)
3-dimensional image INFORMED CONSENT No fasting required
(except for abdomen) Assess for allergic to
seafoods contrastmedium of iodine-basedwill be used
Should remain still Avoid driving immediately
after the exam
ULTRASOUND ( UTZ )
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ULTRASOUND ( UTZ )/ ULTRASONOGRAPHY
Use of ultrasonic waves(sound waves too high infrequency for a human earto detect)
No special preparationneeded or fasting If UTZ of ABD: let the
client void before theprocedure
If UTZ of KUB: let theclient drink water and notvoid till the procedure isdone
MAGNETIC RESONANCE
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MAGNETIC RESONANCEIMAGING (MRI)
Non-invasive test which usespowerful magnetic fields and radiofrequency pulses
No radiation involved Not for pregnant women, those with
metals in the body (artificialpacemakers, hip replacements,inserted metals after fracture)
Bone appears black in the MRIpaper
Remind that it is a noisy procedure
Assess for claustrophobia Keep still the whole procedure INFORMED CONSENT
CHEST X-RAY
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HES X Y Show the bony thorax and
structures Normal: right is slightly
higher than the left Costophrenic angle junction
between the rib cage and
diaphragm No special preparation No inform consent needed Non-invasive procedure
Keep still the wholeprocedure
POSITRON EMISSION
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POSITRON EMISSIONTOMOGRAPHY (PET)
Produces images ofmetabolic and physiologicfunction
Given strong doses ofradioactive tracers (radio-nuclides)
INFORMED CONSENT
Keep still the wholeprocedure
GASTROINTESTINAL
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GASTROINTESTINALSERIES (GI SERIES)
A. BARIUM ENEMA Examination of the patency
of the lower GI
NPO post NOC Give laxatives before theprocedure
Cleansing enema before Increase fluid intake after
the procedure
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BARIUM SWALLOW Examination of the
patency of the upperGI
Also known asESOPHAGOGRAM
Use of radiopaque whenviewed in thefluoroscope then
filmed Increase fluid intakeafter the procedure
INTRAVENOUS
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INTRAVENOUSPYELOGRAPHY
Radiopaque contrastmedium IV
Laxative given night
before NPO till procedure
is over
INFORMEDCONSENT
URINE ANALYSIS
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A. CLEAN CATCH, MIDSTREAM URINE for U/A and culture and sensitivity
The best time to collect urine specimenis EARLY MORNING, first void specimen
Provide sterile container Do perineal care before collection of
urine Discard the first flow of urine
Collect the midstream: 30-50 ml Send the specimen immediately to the
laboratory
24-HOUR URINE
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24 HOUR URINESPECIMEN
Discard first voided specimen
Collect all specimen thereafter until
same time the following day Soak specimen in a container with ice
Add preservative as ordered
C. SECOND-VOIDED
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C. SECOND VOIDEDURINE SPECIMEN
Discard the first voided specimen
Give water to drink
After few minutes, ask to void again,and collect the urine specimen
This is need for test for glucose in
urine
D. CATHETERIZED
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D. CATHETERIZEDURINE SPECIMEN
Clamp the catheter for 30minutes to 1hour
Cleanse the drainage port of the 2-wayfoley catheter with alcohol swab
Use sterile needle and syringe to aspirateurine specimen from the drainage port
DONTS: collect the urine specimenfrom the bag; detach the catheter from
the connecting tube
STOOL SPECIIMEN
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A. ROUTINE FECALYSIS Assess the gross appearance of stool and
presence of ova or parasites Secure sterile specimen container Instruct patient to defecate in the bedpan. If
desired, allow the patient to void first. Discardthe urine and wash the bedpan
Use tongue depressor to collect the stoolspecimen Collect one teaspoonful or 1 inch of well-formed
stool Label the specimen immediately to the laboratory.
Fresh, warm specimen helps detect ova andparasites
B STOOL CULTURE AND
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B. STOOL CULTURE ANDSENSITIVITY TEST
Assess the specific etiologic agent causinggastroenteritis and bacterial sensitivity tovarious antibiotics
Use sterile test tube and sterile cotton-tipped applicator Label the specimen properly Send specimen immediately to the
laboratory
C. GUAIAC STOOLEXAMINATION (OCCULT
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EXAMINATION (OCCULTBLOOD DETERMINATION)
Microscopic study of stool for presence ofbleeding in the gastrointestinal tract
Provide hemoglobin-free diet for 3 days
(no meat for 3 days) Avoid red or dark-colored foods Temporary discontinue iron therapy Positive guaiac stool exam, indicates peptic
ulcer disease and gastric cancer
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PAIN
an unpleasant sensoryand emotional experience
i t d ith t l
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associated with actual orpotential tissue damage
or described in terms ofdamage
purpose: serves as a
warning signal ofimpending tissuemotivating the patient toseek professional help
ALGOLOGY study ofpain
PHYSIOLOGIC DIMENSIONSOF PAIN
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OF PAIN1. TRANSDUCTION conversion of mechanical, thermal, or chemical
stimulus into a neural action potential2. TRANSMISSION movement of pain impulses from the site oftransduction to the brain
Nociceptors pain receptors the fibers (alpha, beta delta) C fibers smallest & unmyelinated; slowest rate; dull sensation
Dermatomes areas on the skin that are innervated primarily by singlespinal cord segment Dorsal horn processing in the spinal cord, release of
neurotransmitters to produce activation or inhibition. Endogenousopioids (enkephalins & B-endorphins) are synthesized by the body toproduce effects same with Morphine.
Spinothalamic tract perception of pain is believed to occur at the
cerebral cortex and the efferent neurons will act on it3. PERCEPTION occurs when pain is recognized, defined andresponded to by the individual
4. MODULATION involves the activation of descendingpathways that exert inhibitory of facilitatory effects on the
transmission of pain
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PAIN THEORIES1. SPECIFICITY THEORY there are certain
specific nerve receptors that respond to noxiousstimuli
2. PATTERN THEORY any stimulus could beperceived as painful if the stimulation wereintense enough
3. GATE CONTROL THEORY if the gate is closed,the signal is stopped before it reaches the brain
Substantia gelatinosa found at the dorsal horn;responsible for exciting and inhibiting signals atthe brain
CYCLE OF PAIN
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Stimulus (nociceptors)
transmission (nervefibers) pain pathway(spinal Cord) painperception (thalamus) pain interpretation
(cerebral cortex) painresponse PAIN THRESHOLD
awareness and integrationof a stimulus
PAIN TOLERANCEpoint at which the personno longer voluntarilyaccepts the pain
CLASSIFICATION OF PAIN1 DURATION A t h t t
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1. DURATION Acute short termChronic long term
2. QUALITY Sharp sticking in natureDull annoying but not as intense as sharp
Diffuse covers a wide area
Shifting moves from one area to another
3. INTENSITY / SEVERITY Mild 1-3Moderate 4-7
Severe 8-10
4. PERIODICITY Continuous constantIntermittent repeating
Transient / brief passes quickly
5. CAUSATION Organic physiologic originPsychogenic emotional in nature
Psychophysiologic migraine
Pretended pain assumed pain
ASSESSMENT OF
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PAIN P provoking factors or precipitating
factors
Q quality R region
S Severity
T timing
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PAIN MANAGEMENT
NON-INVASIVE
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NON INVASIVE1. relaxation technique
2. refraining converting the negative to positiveones3. distraction focusing ones attention on
something other than pain4. guided imagery using imagination to provide a
substitute for pain5. humor laughter is the bestmedicine
6. biofeedback catharsis7. cutaneous stimulation stimulating the
skin to control pain8. hot and cold application
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INVASIVEWHO 3-step analgesic pain
step 1 NSAID (ibuprofen,mefenamic, paracetamol)
step 2 OPIOIDAGONIST (codeine,meperidine, pentazocine)
step 3 AGONISTS-ANTAGOSNISTS(morphine, stadol, narcan)
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NUTRITION
FOOD PYRAMID
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FOOD PYRAMID
NUTRIENTS
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CARBOHYDRATES Primary function: provide the body with energyComposed of carbon, hydrogen, oxygen (CHO)Glucose provides the most efficient form of
energy
Provides 4 kcal/gram of energyConsists of:
Simple sugars sucrose, glucose, dextrose,fructose
Complex sugars starches and fibers
PROTEINS
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Provide 4.5 kcal/gram of energy
Functions include: structure of bones,muscles, enzymes, hormones, blood, andthe immune system
Formed by linking amino acids in variousforms
Composed of carbon, hydrogen, oxygen,
nitrogen (CHON)
FATS
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Lipids are the densest form of energy available
Produce 9 kcal/gram of energyComposed of carbon, hydrogen, oxygen and
oxygen (CHOO) Lipids are insoluble in water
Triglycerides are the primary form of fat infood
Fats are divided in three categories:triglycerides, phospholipids, and sterols
Function: hormone production and providepadding to protect vital organs
MINERALS
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MINERALS
Minerals serve structural purposeand are found in all body fluids andtissues
16 essential minerals are divided into2 categories: major and minor
Minerals are plentiful in all foods,although some may be lost in foodprocessing
WATER
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Water provides a means of transportation
for nutrientsWater acts as a solvent and a lubricant
It is a by-product of metabolism
The human body is approximately 60% waterNeed to consume the equivalent of 2 liters
of fluid/day
Foods with high content of water includemelons, cantaloupe, and berries
FAT-SOLUBLE VITAMINSVITAMINS SOURCE DEFICIENCY MANIFESTATIONS
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A
(retinol)
Yellow fruits andvegetables, liver,
beef, chicken
Night blindness,
xeropththalmia
Dryness of the
cornea, blurredvision
D
(calciferol)
Milk products,tuna, sardines,margarine, egg,liver, cheese,
salmon, mackerel
Ricketts children
Osteomalacia -
adults
Soft bones andskeletal deformities
Brittle bones, bent-
bones, muscularweakness
E
(tocopherol)
Wheat, almonds,sunflower seeds,
peanut butter,cornoil, hazelnuts
Rare in humans;least toxic form
of vitamin
K(phytomenadione)
Acts as a cofactorfor prothrombin
and clotting factors
hemorrhage Bleeding episodes
WATER-SOLUBLE VITAMINSVITAMINS SOURCES DEFICIENCIES MANIFESTATIONS
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VITAMINS SOURCES DEFICIENCIES MANIFESTATIONS
B1
(thiamine)
Green leafyvegetables
Plant oils
Beri-beri
Wernicke-korsakoffsyndrome
Dry skin, irritability, with eventual death
Amnesia secondary to chronic alcoholism
B2
(riboflavin)
Green leafyvegetables
cheilosis Cracking at he sides of the lips
B3
(niacin)
Potato, banana,chicken, egg
Pellagra
(3 Ds)
Dermatatis, diarrhea, dementia
B6
(pyridoxine)
Cereal, potato,banana, chicken,
oatmeal
Microcytic anemia Weakness, fatigue, dyspnea, low immunesystem
B9
(folic acid)
Milk and milkproducts; rice
Megaloblasticanemia; neural tube
defects
Mentally retarded; neural tube defects,premature babies
B12
(cyanocobalamin)
Mollusks, clams,
liver, beef,cereals
Pernicious anemia Neurologic deficits; constipation, fatigue,
weakness
C
(ascorbic acid)
Citrus fruits andvegetables
Scurvy; difficultwound healing
Loose teeth, sore gums, connective tissueproblems
H
(biotin)
Cereal, potato,banana, chicken,
oatmeal
Acidosis anddehydration
Low bp, lethargy
Due to a diet of raw egg whites ( that have
avidin)
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NURSING PROCEDURES
NGT FEEDINGb l
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Nursing responsibilities:
1. Assess for patency a) inject small amount of air;b)aspirating 20-30ml of gastric secretions; c)measure the pH of the aspirated fluid
2. High-Fowlers position before and after feeding
3. Hang no more htan 4 hours of formula formulacontainer should be replaced every 24 hours
4. Check for fod allergies
5. Rinse the tube with water after feeding about 30ml
6. Measure intake and output7. After feeding, clamp the tube to prevent gas pain
BOWEL ELIMINATION
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NURSING RESPONSIBILITIES
1. Promote regular defecation by providing as much privacyas possible
2. Encourage the client to defecate when the urge isrecognized, and to establish a routine and time ofdefecating
3. Assure an adequate intake of fluids and fiber4. Constipated: increase OFI and include hot liquids and
fruit juices
5. Diarrhea: increase OFI and small amount of bland foods.Assess for potassium loss, avoid hot or cold beverages
6. Flatulence: limit carbonated drinks and chewing gum.Avoid use of drinking straws, avoid gas-forming foods
ENEMAS
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TYPES:
1. Cleansing given to remove feces; treat constipation;prevent contamination of sterile field during surgery;promote visualization of intestine
2. Hypertonic solutions fleet enema (medicated enema)
3. Hypotonic solution tap water4. Isotonic solution PNSS
5. Carminative enema release gas, to expel flatus; about60-80ml of fluid us used
6. Oil retention to soften feces and lubricate therectum and anal canal (mineral oil, olive oil, conttonseedoil)
7. Return-flow enema sometimes used to expel flatus
Nursing responsibilities for enemas1 Provide privacy
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1. Provide privacy2. Lubricate insertion tube
3. Place in left lateral Sims position4. Raise the solution container as advocated5. As a general rule, the solution should be about 12
inches above the rectum
6. Measure the volume instilled and document results7. Never release the enema tube when it is in the
rectum8. Client is instructed to hold the fluid for at least
10-15 minutes9. Document and do after care
CATHETHERIZATIONT
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Types:
1. Indwelling / Retention / Foley for continuousdrainage of urine, for gradual decompression of anover-distended bladder, and for intermittentbladder drainage and irrigation
2. Straight used to drain the bladder for short
periods. They are inserted and removedimmediately after the urine is drained
3. Suprapubic catheter catheter inserted through asmall incision just above the pubic area.
4. Condom catheter used for incontinent malesbecause of the risk for infection is minimal
Nursing responsibilities
1 E l i th d
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1. Explain the procedure
2. Provide privacy
3. Use sterile gloves
4. Place in dorsal recumbent or supine position
5. Cleanse the pubic area
6. Lubricate the tip7. Instruct to breathe through the mouth
8. Document accordingly
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THANK YOU
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