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FUNDAMENTALS OF NURSING
Outline of review for the boards
History of Nursing- World and Philippines
The Nursing theories
Concepts of Health and Illness
Human asic Needs!tress and "daptation
ASSESSING HEALTH STATUS
VITAL SIGNS
PHYSICAL ASSESSMENT
CLIENT CARE
ASEPSIS
SAFETY
HYGIENE
MEDICATIONS
SKIN INTEGRITY
TERMINAL CARE
HEATH PROMOTION AND DISEASE PREVENTION
ACTIVITY and EXERCISE
REST and SLEEP
PAIN management
NUTRITION
FECAL ELIMINATION
URINARY ELIMINATION
OXYGENATION
CIRCULATION
Flud! and Ele"t#$l%te!
History of Nursing
Intuitive Nursing
Arenti!e Nursing
D"r# Perio$ of Nursing
E$u!"te$ Nursing
Conte%or"ry Nursing
Intuitive Nursing Pri%itive "n$ unt"ug&t
Co$e of HAMMURA'I
Moses( Fat&e# $' Santat$n
Hio!r"tes( Deve)oe$ st"n$"r$s for !)ient !"re* %e$i!") st"n$"r$s "n$ nee$ for nurses
E$u!"te$ Nursing
F)oren!e Nig&ting")e( +orn M"y ,-* ,.-/ in F)oren!e ITALY
Tr"ine$0 Ger%"ny "t 1"isers2ert& S!&oo)
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Foun$e$ t&e St3 T&o%"s S!&oo) of Nursing in Eng)"n$
– Te"!&ers "re $evote$ !)ini!") instru!tors so)e)y for te"!&ing
– T&e first nurse to e4ert o)iti!") ressure on govern%ent
Nursing in t&e PHILIPPINES
First S!&oo) of Nursing5 ILOILO MISSION &osit") s!&oo) of nursing
An"st"!i" Giron(Tu"s5 Foun$er of t&e PNA
R$!a#$ Delgad$( '#!t PNA )#e!dent
NURSING THEORIES
T&eories in Nursing
Four !on!ets Centr") to Nursing0
P(E(H(N
Pe#!$n
En*#$nment
Healt&
Nu#!ng
ENVIRONMENTAL THEOR6
– Re)"te n"ture 2it& t&e +ir$( Ng&tngale
– +T&e a"t $' utl,ng t&e en*#$nment $' t&e )atent t$ a!!!t &m n &! #e"$*e#%-
INTER(PERSONAL RELATIONS Mo$e)
– Re%e%+er 7 PEP. tal/ – Hldega#d PEPLAU
T&er"euti! re)"tions&i0
– O#entat$n( a!!!t "lent t$ 0unde#!tand. )#$1lem– Ident'"at$n( Clent de)enden"e2 nde and nte# &e #e"$gn,e! &! )#$1lem! n t&!
)&a!e
– E3)l$tat$n4E3)l$#at$n( De#*e! 0'ull *alue. n5e3)l$t66– Re!$lut$n( $ld and ne7 g$al! )ut a!de
N"ture of Nursing( Definition of Nursing
– T&e %e"ning of Nursing is 7VIRGIN8
– Re!")) t&e ,9 nee$s:::::
– Asso!i"te ,9 virgin HENS
– V#gna HENDERSON
– S&e +e)ieves t&"t !)ients nee$ to e4ress t&eir e%otions* re%"in in$een$ent*
"utono%ous
– T&ey %ust 2or# in su!& " 2"y t&"t t&ey fee) " sense of "!!o%)is&%ent
-, nursing ro+)e%s
7F"i$ -,8
F"ye A+$e))"&
GENERAL THEOR6 OF NURSING( SELF( CARE
– Asso!i"te 7Se)f !"re 7 to 7ORAL !"re8 or 7er ore%8
– Dorot&e" OREM
– 89 :HOLLY "$m)en!at$#%( una1le t$ "$nt#$l – ;9 PARTLY "$m)en!at$#%( una1le t$ )e#'$#m SOME !el' "a#e
–
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A!!$"ate 1e&a*$# 7t& >$&n ?n >$&n and Ma#!&a@
0/a%a >OHN?!$n@ mag!um/a) /a 0
Dorot&y ;o&nson
Conserv"tion T&eory
7t&e Divine is Conserv"tive8
0Le*n. le*ne2 d*ne
GOAL ATTAINMENT
Re!")) t&"t t&e 1ING of t&e )"n$ &"s " GOAL to "tt"in for &is #ing$o%
– IMOGENE 1ING:
– Her t&eory is ")i!"+)e to t&e !&i)$ +e"ring 2o%en "n$ t&eir f"%i)ies
UNITAR6 'EING0 M"n "s t&e CENTRAL Fo!us
7Roger * Roger* )et us unite our M"n in t&e !enter of t&e +"tt)efie)$8
T&e 2&o)e is gre"ter t&"n its "rts
M"rt&" ROGERS
S&e +e)ieves in t&e use of t&e rin!i)es of NON CONTACT t&er"euti! tou!&
HEALTH CARE S6STEMS %o$e) 'etty NEUMAN
St#e!!e!2 #ea"t$n! t$ !t#e!! and ada)tat$n t$ !t#e!!$#!
A'te# $*e#"$mng t&e !t#e!!e! %$u 7ll 1e"$me a 0NE:5 Man.
Int#a)e#!$nal !t#e!!$#( llne!!
E3t#a)e#!$nal !t#e!!$#!( 'nan"al "$n"e#n!2 "$mmunt% #e!$u#"e!
Inte#)e#!$nal !t#e!!$#( un#eal!t" #$le e3)e"tat$n!
ADAPTATION MODEL
In$ivi$u") is " 'IOPS6CHOSOCIAL ADAPTIVE syste% 2it& inut "n$ outut
7"sso!i"te t&is 2it& " Nun8
SISTER RO65 n"g " "$ot ng %g" +"t"
Her t&eory suorts t&e unity +et2een t&e !)ient "n$ Go$
CULTURAL CARE DIVERSIT6
Tr"ns!u)tur") Nursing
M"$e)eine LEININGER
Nursing Pro!ess t&eory "n$ CARE* CORE "n$ CURE
T&e nurse 2&o !oine$ t&e 2or$ nursing ro!ess "n$ st"te$ 7 I !"re* I !ore "n$ I !ure8
H")) of F"%e "2"r$:::
L6DIA HALL
D6NAMIC NURSE(PATIENT Re)"tions&i
Asso!i"te $yn"%i! "!tion to t&e te"% of ORLANDO
I$" ;e"n ORLANDO::: Go Or)"n$o* t&e $yn"%i! te"%:::::
HUMAN 'ECOMING THEOR6
– Re%e%+er to +e!o%e " es t&"t !)ients "re t&e AUTHORIT6 figures "n$ $e!ision
%"#ers for t&eir erson") &e")t&
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HUMAN CARING THEOR6
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– He")t& is "+sen!e of $ise"se
ROLE PERFORMANCE
– He")t& is "+i)ity to fu)fi)) so!iet") fun!tions
ADAPTIVE
– He"t& is " !re"tive ro!ess of "$"t"tion
EUDEMONISTIC
– He")t& is " !on$ition of se)f("!tu")i>"tion
ECOLOGIC
– He")t& is inter"!tion of t&ree e)e%ents0
– Agent
– Host
– Environ%ent
He")t&(I))ness Continu"
#unn
Travis
He")t& T&eories
Dunn
– 7d$$n2 dt$2 dne and d#e.
– Four u"$r"nts
– HIGH )eve) e))ness is fun!tioning "t t&e 'EST ossi+)e )eve)
I))ness "n$ Dise"se
DISEASE
– A)ter"tion in +o$y fun!tions
ILLNESS
–A st"te of &ysi!")* so!i")* e%otion")* inte))e!tu")* $eve)o%ent") or siritu")fun!tioning is DIMINISHED
St"ges of I))ness0 S(A(M(D(R
!$%PTO% e&periences
– Client believe something is wrong "!!'%PTION of the sic( role
– )&cuse form wor( and family role %)#IC"* care contact
#)P)N#)NT C*I)NT role
+)CO,)+$ or +)H"I*IT"TION
HUMAN NEEDS
A+r"&"% M"s)o2=s Hier"r!&y of nee$s
Physiologic needs- o&ygen water food
!afety and security
*ove and belonginess
!elf esteem
!elf actuali.ation
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!afety and security
– Physical safety– Psychological safety– !helter from harm
*ove and belonginess
–
Need to love– Need to belong– Need for affection
!elf esteem
– !elf-worth– !elf-identity
– !elf-respect– !elf-image
!elf actuali.ation
– !elf-fulfillment– !piritual fulfillmen
M"n "n$ His nee$s
M"n=s Nee$
Se)f(
A!tu")i>"ti
on
Se)f(Estee%
Love "n$ 'e)ongingness
S"fety "n$ Se!urity
P&ysio)ogi! Nee$s
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Nee$ is so%et&ing $esir"+)e "n$ usefu)
Nee$s "re UNIVERSAL
Nee$s "re MET in d''e#ent :AYS
Nee$s "re inf)uen!e$ +y $ifferent FACTORS
Priorities %"y +e CHANGED
Nee$s %"y +e POSTPONED
Nee$s "re INTER5RELATED
Nee$ is so%et&ing $esir"+)e "n$ usefu)
Prioriti>"tion of nee$s %"t +e $i!t"te$ +y t&e !)ient=s er!etion
Nursing go") is t&is "re" is to0
– Meet t&e PH6SIOLOGICAL nee$s of t&e "tient
– Assess t&e "tients er!etion of &is ot&er nee$s
– E%)oy nursing Interventions "!!or$ing to t&e PERCEIVED NEEDS of t&e "tient
NOT of t&e nurse
Ev")u"tion P"r"%eters of nursing !"re
The nurse chec(s if the desired criteria dictated by patient/s needs are achieved
Chec( which interventions were helpful
+evise the plan as needed
M"n "!&ieves se)f("!tu")i>"tion
0'dan1
A !el'5a"tual,ed )e#!$n ! 1a!"all% a MENTALLY &ealt&% )e#!$n
And !el'5a"tual,at$n ! t&e e!!en"e $' mental Healt&
MAN AND NATURE OF NURSING
M"n
A 'io(Psy!&o(So!i")(Siritu") +eing
As " 'IOLOGIC "n$ SPIRITUAL 'EING
– Li#e ALL ot&er %"n
As " SOCIAL 'EING
– Li#e SOME ot&er %"n
As " PS6CHOLOGIC 'EING
– Li#e NO OTHER MAN
THE PRACTICE OF NURSING
Nursing Define$
"!t of uti)i>ing environ%ent of t&e "tient to "ssist &i% in &is re!overy8
CNA0 " $yn"%i!* !"ring* &e)ing re)"tions&i in 2&i!& t&e nurse "ssists t&e !)ient to "!&ieve
"n$ o+t"in oti%") &e")t&
Nursing Pr"!ti!e S!oe
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Invo)ves four "re"s @1OIER
89 P#$m$tng &ealt& and 7ellne!!
-3 Preventing i))ness
B3 Restoring &e")t&
93 C"re of t&e $ying
Profession") Nursing in t&e P&i)
Person") "n$ rofession") u")ities
,3 Interest "n$ 2i))ingness to 2or# "n$ )e"rn 2it& in$ivi$u")s in " v"riety of settings
-3 "r% erson")ity "n$ !on!ern for eo)e
B3 Co%eten!e* initi"tive "n$ !""!ity to 2or#
Profession") 'e&"viors @Ven>on
C"ring +e&"viors
A1lt% t$ )#a"t"e legal2 ETHICO5m$#al2 !$"al #e!)$n!1lte!
Criti!") "n$ !re"tive t&in#ing
S#i)) in r"!ti!ing 1(S(A for ro%otion of &e")t&* revention of i))ness* restor"tion of &e")t&*
"))evi"tion of suffering "n$ "ssisting !)ients to f"!e $e"t& 2it& $ignity
T&e St"n$"r$ of Nursing Pr"!ti!e
T&e urose of st"n$"r$s of Nursing r"!ti!e is to $es!ri+e t&e resonsi+i)ities for 2&i!& nurses
"re "!!ount"+)e
Profession
An o!!u"tion* or !"))ing reuiring "$v"n!e$ tr"ining "n$ e4erien!e in so%e se!ifi! +o$y
of #no2)e$ge 2&i!& PROVIDES SERVICE t$ !$"et% or t&"t se!i") fie)$
Profession") Nurse
Is " erson 2&o &"s !o%)ete$ " +"si! nursing e$u!"tion rogr"% "n$ is )i!ense$ in &is&er
!ountry or st"te to r"!ti!e rofession") nursing
Profession") Go") of Nursing
As in$een$ent r"!titioners* nurses "re ri%"ri)y resonsi+)e for t&e ro%otion of
&e")t&2e))ness "n$ revention of i))ness
He")t& Pro%otion
He)ing eo)e $eve)o resour!es to %"int"in or en&an"e t&e# &ealt& and 7ell51eng
He")t& ro%otion rogr"%s
,3 Infor%"tion $isse%in"tion
-3 He")t& Ar"is")
B3 e))ness "ssess%ent rogr"%
TRANSCULTURAL NURSING
Cu)tur") !"re nursing
It is t&e rovision of nursing !"re "!ross !u)tur") +oun$"ries "n$ t"#es into "!!ount t&e
!onte4t in 2&i!& t&e !)ient )ives
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It is rofession") nursing t&"t is !u)tur"))y sensitive* !u)tur"))y "rori"te* "n$ !u)tur"))y
!o%etent
T&e suggeste$ stes for !u)ture !"re "re0
,3 'e!o%e "2"re of one=s o2n !u)ture &erit"ge
-3 'e!o%e "2"re of t&e !)ient=s &erit"ge "n$ &e")t& tr"$ition
23 I$entify !)ient=s referen!e in &e")t& r"!ti!es* $iet* &ygiene* et!3 T&e!e 7ll a''e"t t&e# &ealt& )#a"t"e!93 For%u)"te " !u)ture !"re )"n
Prevention of i))ness
E%)oying "!tivities t&"t 2i)) &in$er t&e o!!urren!e of $ise"se
E40 Asesis te!&niues* iso)"tion
STRESS
Stress "n$ A$"t"tion
STRESS
– A !on$ition in 2&i!& t&e erson reson$s to !&"nges in t&e nor%") +")"n!e$ st"te
– Se)ye0 non se!ifi! resonse of t&e +o$y to "ny #in$ of $e%"n$ %"$e uon it
STRESSOR
– Any event or sti%u)us t&"t !"uses "n in$ivi$u") to e4erien!e stress
SOURCES OF STRESS
,3 Intern")
-3 E4tern")
B3 Deve)o%ent")
93 Situ"tion")
P&%!$l$g"al nd"at$#! $' !t#e!! S%m)at&et" #e!)$n!e Di)"te$ ui)s
Di"&oresis
T"!&y!"r$i"* t"!&yne"* H6PERTENSION* in!re"se$ +)oo$ f)o2 to t&e %us!)es
In!re"se$ +)oo$ !)otting
'ron!&o$i)"tion
S#in "))or
"ter retention* So$iu% retention
O)iguri"
Dry %out&* $e!re"se erist")sis
Hyerg)y!e%i"
%odels of !tress43 !TI%'*'! based models
43 +)!PON!) based models
43 T+"N!"CTION based models
!)*$)/! 5eneral "daptation TheoryA(R(E
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ALARM sympathetic system is mobili.ed6
RESISTANCE adaptation ta(es place
EXHAUSTION 7 adaptation cannot be maintained
ANJIET6
CATEGOR6 %I*# %O#)+"T) !),)+) P"NIC
Perception andattention
Increasedarousal
Narrowed focus Inability to focus Distorted perception
Co%%uni!"tion In"#ea!ed
ue!t$nng
Voi!e tre%ors
Fo!us on
"rti!u)"r o+Ke!t
Diffi!u)t to
un$erst"n$
E"si)y $istr"!te$
Tre%+)ing
unre$i!t"+)e
resonse
VS !&"nges NONE S)ig&t In!re"se T"!&y!"r$i"*
Hyerventi)"tion
P")it"tion*
!&o#ing* !&est
"in
An4iety versus fe"r
ANJIET6 FEAR
!tate of mental uneasiness )motion of apprehension
!ource may not be identifiable !ource is identifiable
+elated to the future +elated to the present
,ague #efinite
+esult of psychologic or emotional conflict +esult of discrete physical or psychologicalentity definite and concrete events
VITAL SIGNS
,!
T
P
+
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P
T)%P)+"T'+)
+eflects the balance between the heat produced and the heat lost from the body
CO+) T)%P+"T'+)7 deep tissues of body
Te%er"ture Monitoring
Oral- accessible and convenient+ectal- very accurate
"&illary- preferred for newborns
Tympanic- reflects core temperature
'o$y te%er"ture &"s " $iurn") v"ri"tion
POINT of Highest body temperature is )TW))N )m t$ 8; mdng&t
POINT of *owest body temperature is )TW))N am t$ am
Te%er"ture A)ter"tion
8),)+ P$+)9I" H$P)+TH)+%I"
43 Inte#mttent Periods of fever and normal temp
:3 Remttent 7 8ever fluctuates 'T above normal23 Rela)!ng 7 8ever for few days then normal for few days
;3 C$n!tant 7 "*W"$! above normal minimal fluctuation
He"t )oss
Me!&"nis% Des!rition
Con$u!tion Tr"nsfer of &e"t for% one o+Ke!t to "not&er +y $ire!t !ont"!t
Conve!tion Move%ent of "ir "n$ &e"t +y "ir !urrent
Ev"or"tion Loss of &e"t t&roug& ev"or"tion of 2"ters2e"t
R"$i"tion Tr"nsfer of &e"t fro% 2"r% o+Ke!ts to !oo) o+Ke!ts in t&e
for% of e)e!tro%"gneti! 2"ves
Pu)se
" wave of blood created by contraction of the left ventricle of the heart
Normal range7
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– !ystolic pressure falls by more than 4> mmHg during INHALATION
Pu)sus ")tern"ns
– "lternating strong and wea( pulses
Resir"tory r"te
Normal range7 4: to :4 P%
+espiratory pattern
– Cheyne-!to(es– ?ussmaul– iot– "goral
')oo$ Pressure
%easure of the pressure e&erted by the blood as it flows though the arteries
!ystolic and #iastolic
"verage is 4:=@A= mmHg Ta(ing P
Width of the P bladder should be $' t&e "#"um'e#en"e
Identify the 8I,) phases of ?orot(off/s sounds
?4B systolic ?>Bdiastolic
Error of 'P re"$ing
,3 Too N"rro2 !uff
– F")se)y HIGH re"$ing
-3 Too 2i$e !uff
• F)"se)y LO re"$ing
NURSING FUNDAMENTALS IN RANDOM
8riends and )nemas
&"t is "n ENEMA?
– A so)ution intro$u!e$ into t&e re!tu% "n$ )"rge intestine for t&e uroses of0
– To re)ieve !onsti"tion
– To re)ieve f)"tu)en!e
– To "$%inister %e$i!"tion
– To ev"!u"te fe!es in $i"gnosti!s or surgery
Ene%" tyes
,3 C)e"nsing Ene%"5 inten$e$ to re%ove fe!es to revent es!"e $uring surgery* forvisu")i>"tion ro!e$ure "n$ !onsti"tion
Puroses To
,3 Prevent es!"e of fe!es $uring surgery
-3 Pre"re intestines for $i"gnosti!s "n$ surgery
B3 Re%ove fe!es in !onsti"tioni%"!tion
C"r%in"tive ene%"5 to e4e) f)"tus* /(./ %L of f)ui$s insti))e$
B3 Retention ene%"5 oi) or %e$i!"tion is insti))e$ to tre"t infe!tion
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93 Return f)o2 ene%"5 ")so to e4e) f)"tus* ree"te$ ti%es
Ene%" So)utions
Hypertonic #raws water into the colon SE 7 +etention of sodium
Hypotonic #istends colon softens feces SE: 8 and ) imbalance water
into&ication
Isotonic #istends colon SE 7 possible sodium retention
!oap suds Irritates colon SE 7 %ay damage mucosa
Oil enema *ubricates feces
T&e Heig&t of t&e ENEMAS
#uring %O!T enemas 8or HI5H enema
No higher than 2= cm above rectum 'p to ;> cm above rectum
T&e TIME of t&e ENEMAS
Cleansing )nema 8or Oil retention enema
>-4= minutes 2= minutes
T&e Lengt& of t&e ENEMA tu+e insertion
• T&e #e"tal tu1e ! n!e#ted < t$ n"&e!
1VO
Intravenous Infusion7 4= gtts@min
lood Transfusion7 4= gtt@min @U$"n and := gtt@min @1o>ier
DIET ANOTHER DA6
Liui$ Diet Vs Soft $iet
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Clear liuid 8ull liuid !oft diet
CoffeeTea
Carbonated drin(
ouillon
Clear fruit Duice Popsicle
Gelatin
Hard candy
Clear liuid P*'!7%il(@%il( prod
,egetable Duices
Cream butter
$ogurtPuddings
Custard
Ice cream and sherbet
"ll C* and 8* plus7%eat
,egetables
Fruits
reads and cereals Pureed foods
LEVELS OF PREVENTION
Pri%"ry Prevention E$u!"tion* E4er!ise* Diet "n$
Nutrition* I%%uni>"tion
Se!on$"ry Prevention P&ysi!") E4"%in"tion* P"=s s%e"r* 'SE* TSESutu% AF'* DRE
P#$*dng med"at$n and t#eatment
Terti"ry Prevention P&ysi!") t&er"y* Se)f(%onitoring of DM*
See!& t&er"y
Leve)s of Prevention
PRIMAR6 LEVEL OF PREVENTION
,3 F"%i)y P)"nning "n$ %"rri"ge !ounse)ing
SECONDAR6 LEVEL OF PREVENTION
,3 ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHEC1(UPS
-3 Assessing gro2t& "n$ $eve)o%ent of !&i)$ren for nutrition") ev")u"tion
TERTIAR6 LEVEL OF PREVENTION
Te"!&ing " !)ient 2it& $i"+etes se)f(%onitoring of g)u!ose )eve)
ASEPSIS CONCEPTS
H"n$(2"s&ing
T&e sing)e %ost i%ort"nt %e"sure to revent infe!tion
For #$utne "a#e* it is reuire$ t&"t vigorous &"n$ 2"s&ing 2it& so" un$er " stre"% of
2"ter for
– At )e"st ,/ se!on$s @CDC* 1o>ier
– At )e"st ,(B/ se!on$s @U$"n
T&e !&"in of infe!tion
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Etio)ogi! "gent
Reservoir
Port") of e4it fro% reservoir
Met&o$ of tr"ns%ission
Port") of entry to t&e sus!eti+)e &ost
Sus!eti+)e &ost
Tyes of I%%unity
Tye Antigen or "nti+o$y sour!e $ur"tion
A!tive I%%uity Anti+o$ies "re ro$u!e$ +y t&e +o$y in
resonse to "n "ntigen
)ong
N"tur")
"!tive
Anti+o$ies "re for%e$ in t&e resen!e of "!tive
infe!tion
)ife)ong
Artifi!i")
"!tive
Antigens @v"!!inesto4oi$s "re inKe!te$ to
sti%u)"te "nti+o$y ro$u!tion
M"ny ye"rs
P"ssive I%%unity Anti+o$ies "re ro$u!e$ +y "not&er sour!e S&ort
N"tur")
"ssive
Anti+o$ies "re tr"nsferre$ n"tur"))y fro% "n
i%%une %ot&er to &er +"+y t&roug& t&e
PLACENTA or 'REAST FEEDING
A+out %ont&s
to , ye"r
Artifi!i")
"ssive
I%%une seru% @"nti+o$ies !o%es fro% "not&er
sour!e @&u%"ns"ni%")s inKe!te$ to "not&er
&u%"n
- to B 2ee#s
I%%unity
I%%unity e4"%)es
ACTIVE n"tur") Infe!tious $ise"se
ACTIVE "rtifi!i") I%%uni>"tion 2it& v"!!ines "n$
to4oi$s
PASSIVE n"tur") P)"!ent" "n$ 're"stfee$ing
PASIVE "rtifi!i") InKe!tion of I%%une seru%* "nti(to4ins
Surgi!") Asesis @U$"n
Reuire$ in t&ese situ"tions0
,3 Surgi!") ro!e$ures
-3 A)) ro!e$ures t&"t inv"$e +)oo$stre"%
B3 Pro!e$ures t&"t !"use +re"# in t&e s#in
93 Co%)e4 $ressing !&"nges "n$ 2oun$ !"re
J9 In!e#t$n $' tu1e!2 "at&ete#! nt$ !te#le 1$d% "a*te! l/e U#na#% 1ladde#
3 C"re for HIGH ris# grous0 AIDS* !"n!er* +urn t
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Prin!i)es "n$ Pr"!ti!es of Surgi!") Asesis @1o>ier
,3 A)) o+Ke!ts use$ in t&e steri)e fie)$ %ust +e steri)e
-3 Steri)e o+Ke!ts +e!o%e unsteri)e 2&en tou!&e$ +y unsteri)e o+Ke!ts
B3 Steri)e ite%s t&"t "re out of vision or +e)o2 t&e 2"ist )eve) of t&e nurse "re !onsi$ere$
unsteri)e
93 Steri)e o+Ke!ts !"n +e!o%e unsteri)e +y ro)onge$ e4osure to "ir+orne %i!roorg"nis%s
3 F)ui$s f)o2 in t&e $ire!tion of gr"vity
3 Moisture t&"t "sses t&roug& steri)e o+Ke!ts $r"2s %i!roorg"nis%s for% unsteri)e surf"!es "+ove
or +e)o2 to t&e steri)e surf"!e +y !"i))"ry "!tion
3 T&e e$ges of " steri)e fie)$ "re !onsi$ere$ unsteri)e
.3 T&e s#in !"nnot +e steri)i>e$
3 Cons!ientiousness* ")ertness "n$ &onesty "re essenti") u")ities in %"int"ining "sesis
Steri)e o+Ke!ts "re #et in vie2
On)y t&e front "rt of t&e steri)e go2n of steri)e
- in!&es "+ove t&e e)+o2s to t&e !uff of t&e s)eeves is steri)e
Uti)i>e steri)e for!es to &"n$)e steri)e ite%s
A ,(in!& %"rgin "t e"!& e$ge of $r"es is !onsi$ere$ unsteri)e
P)"!e steri)e o+Ke!ts MORE t&"n , in!& insi$e t&e e$ges of t&e steri)e fie)$
Hosit") Te!&niues
@U$"n
T&ese re!"ution te!&niues )i#e st"n$"r$ re!"ution "n$ rote!tive iso)"tion "re use$ to
revent or )i%it t&e sre"$ of infe!tion
St"n$"r$ re!"ution
1l$$d51$#ne and m$!t 1$d% !u1!tan"e )at&$gen!
,3 e"ring Intended t$ )#e*ent t#an!m!!$n $' of !)e"n g)oves
-3 Perfor%ing &"n$ 2"s&ing i%%e$i"te)y
B3 e"r %"s#* eye s&ie)$ $uring ro!e$ures t&"t gener"te s)"s&es93 e"r go2n if s)"s&es* sr"ys* se!retions !"use soi)ing
3 Prevent inKuries fro% nee$)e s&"r o+Ke!ts
Pre!"ution
St"n$"r$ Pre!"ution Use$ in !"re of ALL &osit")i>e$ ersons( ")ies to +)oo$* "))
+o$y f)ui$s* se!retions* e4!retions
TRANSMISSION51a!ed
)#e"aut$n
Air+orne* Dro)et "n$ Cont"!t
AIR'ORNE
Air+orne $ro)et
nu!)ei )ess t&"n t%i!rons
Me"s)es* v"ri!e))" "n$ T'
Priv"te roo%* neg"tive "ir ressure "n$ N resir"tor 2&en
entering roo%
DROPLET
P"rti!)es gre"ter
t&"n %i!rons
Di&t&eri"* neu%oni"* ertussis* %u%s* Ger%"n %e"s)es
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Cont"!t GIT* Resi* S#in "n$ 2oun$ infe!tion e"si)y tr"ns%itte$ +y
$ire!t !)ient !ont"!t or !ont"!t 2it& !)ient ite%s
inf)"%%"tion
A resonse of " )iving v"s!u)"ri>e$ tissue to inKury
It is ")so "n e4"%)e of LOCAL A$"t"tion to stress
C"r$in") Signs of inf)"%%"tion0
,3 Ru+or5 re$ness @initi") !&"nge
-3 C")or5 &e"t
B3 Tu%or5 s2e))ing
93 Do)or5 "in
3 Fun!tio )"es"5 )oss of fun!tion
St"ges0 V(C(R
V"s!u)"r Resonse
Ce))u)"r for%"tion
Re"ir
Nursing Interventions
Re$u!e inf)"%%"tory ro!ess
Mini%i>e s2e))ing
Re)ieve "in
Provi$e "$eu"te nutrition0 &ig& !")orie* &ig& rotein* &ig& vit"%in C
Pro%ote rest
A$%inister res!ri+e$ %e$i!"tions
'OD6 MECHANICS
T&e effi!ient* !oor$in"te$ "n$ s"fe use of t&e +o$y to ro$u!e %otion "n$ %"int"in +")"n!e $uring
t&e "!tivity
T&e %"Kor urose is 0
– To f"!i)it"te t&e s"fe "n$ effi!ient use of "rori"te %us!)e grous to %"int"in
+")"n!e* re$u!e t&e energy reuire$* re$u!e f"tigue "n$ $e!re"se t&e ris# for inKury
T2o ositions t&"t s&ou)$ +e "voi$e$ +y t&e nurse +e!"use t&ey !"use +"!# InKury
T2isting
Stooing
Ho2 to en&"n!e +o$y +")"n!e
,3 i$en t&e +"se of suort
,3 Lo2er t&e !enter of gr"vity +y +ringing it !)oser to t&e +"se of suort( FLEJ t&e &i "n$
#nees
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Prin!i)es of 'o$y %e!&"ni!s
,3 P)"n t&e %ove%ent "n$ o+t"in "ssist"n!e
-3 A$Kust 2or#ing "re" to 2"ist )eve)
ier
Te%er"tures in 'o"r$s
Hot 2"ter '"g SIT 'ATH Coo)ing Songe '"t& A)!o&o) Songe '"t&
A$u)t "n$ %ore t&"n- ye"rs(o)$0
9(- C
Less t&"n -0
9/(9 C
5< C 85
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E''$#t ! nea#l% e''$#tle!!9 Lttle mu!"ula# 7$#/ ! #eu#ed t$ m$*e a# t$ug& t&e lung!9 N$
!$und! a#e a!!$"ated 7t& t9
Assess%ent of resir"tory syste%
,3 Nursing History
Re)ev"nt $"t" in t&e &istory 2&i!& fo!uses on t&e resir"tory syste% in!)u$e !urrent "n$"st resir"tory $isor$ers* )ifesty)e* resen!e of !oug&* "in* %e$i!"tions for +re"t&ing "n$
"ssess%ent of ris# f"!tors3
-3 P&ysi!") E4"%in"tion
T&e te!&niues of Inse!tion* P")"tion* Per!ussion "n$ Aus!u)t"tion "re e%)oye$3
T&e r"te* r&yt&%* $et& "n$ u")ity of resir"tion "re o+serve$3
Note for t&e !o)or* !onsisten!y* "n$ "%ount of sutu%
UTILIE THE $i"&r"g% of t&e stet to &e"r +re"t& soun$s
A$ventitious soun$s
Cr"!#)esR")es0 Cr"!#)ing soun$ 'EST &e"r$ $uring in&")"tion
R&on!&i0 Co"rse* gurg)ing* vi+r"tions &e"r$ $uring +re"t&ing 2it& %o"ning or snoring
u")ity
Fri!tion ru+0 !re"#ing soun$
&ee>e0 Sue"#y %usi!") soun$
Soun$ C"use
Cr"!#)esR")es Air "ssing t&roug& f)ui$ or %u!us
R&on!&i Air "ssing t&roug& n"rro2e$ "ir "ss"ge2"y "s " resu)t of
t&i!# se!retions* s2e))ing* tu%or
&ee>e Air "ssing t&roug& " !onstri!te$ +ron!&us +ron!&io)es "s "
resu)t of se!retions* s2e))ing
Fri!tion ru+ Ru++ing toget&er of inf)"%e$ )eur") surf"!es
A+$o%in") Assess%ent
T&e seuen!e is ")2"ys "s# in t&e e4"%:5
– In!)e"t$n
– Au!"ultat$n
– Pe#"u!!$n
– Pal)at$n
Aus!u)t"te 2it& t&e use of t&e $i"&r"g% in ")) four u"$r"nts
– T&e usu") seuen!e is RIGHT LOER u"$r"nt RIGHT UPPER u"$r"nt
LEFT UPPER u"$r"nt LEFT LOER u"$r"nt
– Nor%") +o2e) soun$s0 &ig& it!&e$ GURGLING o!!urring every to -/ SECONDS
THE NURSING PROCESS
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Assess%ent0 g"t&ering of $"t"* v")i$"te "n$ $o!u%ent $"t"
Nursing $i"gnosis0 "n")y>e $"t"* i$entify ro+)e%s "n$ for%u)"te $i"gnosti! st"te%ents
P)"nning0 rioriti>ing ro+)e%s* for%u)"te go")s "n$ se)e!t nursing interventions
I%)e%ent"tion0 !"rrying out t&e nursing %e"sures* suervising* $e)eg"ting* re"ssessing "n$
$o!u%enting "!tivities
Ev")u"tion0 Co%"re ev")u"te$ $"t" 2it&y out!o%e !riteri"* !ontinue* %o$ify or ter%in"te
!)ient !"re
C&"r"!teristi!s of t&e Nursing ro!ess
E Oen "n$ f)e4i+)e
E Cy!)i! "n$ $yn"%i!
E C)ient !entere$
E In$ivi$u")i>e$
E P)"nne$
E Go") $ire!te$
E Per%its !re"tivity
E E%&"si>es fee$+"!#s
E Univers"))y "!!ete$
ANA St"n$"r$ of C)ini!") Nursing
St"n$"r$ I
Assess%ent
T&e nurse !o))e!ts $"t"
St"n$"r$ II
Di"gnosis
T&e nurse "n")y>es t&e "ssess%ent $"t"
$eter%ining $i"gnosis
St"n$"r$ III
Out!o%e i$entifi!"tion
T&e nurse i$entifies e4e!te$ out!o%es
St"n$"r$ IVI%)e%ent"tion
T&e nurse $eve)os " )"n of !"re*res!ri+es interventions to "tt"in
e4e!te$ out!o%e
St"n$"r$ V
Ev")u"tion
T&e nurse ev")u"tes t&e !)ients= rogress
to2"r$ "tt"in%ent of out!o%es
T&e Nursing "ssess%ent
First ste
Co%onents0,3 Co))e!t $"t"
-3 Org"ni>e $"t"
B3 V")i$"te $"t"
93 Do!u%ent $"t"
A %et&o$ of infor%"tion !o))e!tion for t&e est"+)is&%ent of $"t" +"se
Tyes of D"t"
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!'F)CTI,) data
• !ymptoms reported by the patient OF)CTI,) data
• !igns and manifestations that are gathered by the nurse through Inspection palpation
percussion and auscultation
Di"gnosing
-n$ ste
The process which results to a diagnostic statement
Clinical act of identifying problems
"nalysis of assessment information to derive meaning from the analysis
The nursing #iagnosis
" statement of client/s potential or actual alteration of health status
The nurse writes a summary statement that N"N#" has developed
"ctivities in this step are7
43 "naly.e data
:3 Identify health problems ris(s and strengths23 8ormulate diagnostic statements
Writing Nursing #iagnosis
#ifferent Nursing #iagnoses "ctual Nursing diagnosis
+is( nursing diagnosis
Wellness diagnosis
!yndrome diagnosis
Possible nursing diagnosis
Collaborative problems
"CT'"* Nursing #iagnosis43 'tili.e the P-r@t-) format
Problem related to etiology
:3 'tili.e the P-)-!
Problem-)tiology-!igns and !ymptoms
P-r@t-) format
Ineffective airway clearance related to wea( cough effort
P-)-! format
Ineffective airway clearance related to tracheobronchial infection as manifested by copious
sputum production and adventitious breath sounds
Gui$e)ines in 2riting ND
43 Prioriti.e according to clients/ needs
:3 Write in terms of person/s response rather than need
23 'se 7#elated t$. to connect the two parts of the statement "void the terms Gdue to and Gbecause of or Gsecondary to
! Write in legally advisable term
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>3 Write without Dudgment value
e$
Mo$ifi!"tions of st"n$"r$ t&er"y "s ")i!"+)e
IMPLEMENTATION 9t& ste
T&e ste !on!erne$ 2it& $oing* $e)eg"ting "n$ $o!u%enting !)ient resonses
T&e nurse MUST re("ssess t&e !)ient 'EFORE e%)oying nursing %e"sures to +e "+)e to
$eter%ine if t&e interventions "re sti)) nee$e$ or "re sti)) s"fe
e !"rry out t2o interventions
,3 In$een$ent interventions
-3 Deen$ent interventions* Inter$een$ent or Co))"+or"tive
EVALUATION t& ste
THE fin") ste in t&e nursing ro!ess t&"t invo)ves !o))e!ting $"t" "n$ !o%"ring t&e $"t"
2it& t&e out!o%e !riteri" to $eter%ine go") "tt"in%ent
THE nurse 2i)) eit&er0
Revise t&e C"re )"n
Continue t&e !"re )"n M"#e " ne2 !"re )"n for " ne2 ro+)e%
DOCUMENTATION "n$ REPORTING
Do!u%ent"tion
•Per%"nent re!or$ of !)ient infor%"tion "n$ !"re
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REPORTING
•T"#es )"!e 2&en t2o or %ore eo)e s&"re infor%"tion "+out !)ient !"re eit&er f"!e to f"!e or
+y te)e&one @U$"n
Puroses of C)ient re!or$
•Co%%uni!"tion
•Leg") Do!u%ent"tion
•Rese"r!&
•St"tisti!s
•E$u!"tion
•Au$it
•P)"nning !"re "n$ rei%+urse%ent
Tyes of Re!or$s
•Tr"$ition") !)ient re!or$
•Pro+)e% oriente$ %e$i!") re!or$
•1"r$e4( series of !"r$s 2it& entries 2ritten in en!i)
C&"r"!teristi!s of goo$ re!or$ing
,3 'revity
-3 Use of IN1
B3 A!!ur"!y
93 Arori"teness
3 Co%)ete "n$ ti%e)y org"ni>e$
3 Use st"n$"r$ ter%ino)ogy
3 SIGNED
Reorting
,3 En$orse%ents
Re)$#tng d$ne '$# "$ntnut% $' "a#e
=a!ed $n t&e &ealt& "a#e need! $' )atent t$ 1e &andled 1% t&e ne3t !&'t nu#!e!
End$#!ement! !&all 1e a! $1e"t*e a! )$!!1le #elated t$ "lent need! and "a#e
-3 Te)e&one reorts
3 Te)e&one or$ers
93 Tr"nsfer reorts
Nursing M"n"ge%ent
St"ffing is t&e ro!ess of $eter%ining "n$ rovi$ing t&e "!!et"+)e NUM'ER "n$ MIJ of
nursing ersonne) to ro$u!e " $esire$ )eve) of !"re "n$ to %eet t&e "tient $e%"n$ for !"re
Stes in St"ffing
89 Sele"t$n $' )e#!$nnel
;9 Sta'' de*el$)ment
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Nurses "re "ssigne$ " se!ifi! t"s#
Nurses ten$ to +e!o%e &ig&)y !o%etent on)y 2it& t&e t"s# ree"te$)y $one
TAS1(fo!use$ "n$ Not C)ient(fo!use$
TEAM NURSING
TEAM rovi$es tot") nursing !"re to se!ifi! !)ient or "tient In$ivi$u")i>e$ "tient !"re
A )e"$er* t&e senior rofession") nurse in t&e unit* 2i)) $o t&e !oor$in"tion* suervision "n$
g"t&er !ooer"tion of ")) st"ff in $e)ivery of "tient !"re
Registere$ nurses "n$ "ssistive ersonne) "re given !)ient "ssign%ents r"t&er t&"n TAS1
La"/ $' "$ntnut% $' "a#e
Unde'ned #$le $' RN an a!!!t*e )e#!$nnel
La"/ $' tme t&e leade# "an !)#ead 7t& "lent!
PRIMAR6 NURSING
Re!ent %et&o$( HOLISTIC "ro"!& in !"re
A PRIMAR6 nurse is resonsi+)e to give tot") nursing !"re to 9 to "tients -9 HOURS "
$"y fro% &osit")i>"tion to $is!&"rge An "sso!i"te nurse usu"))y su+stitute t&e nurse 2&en off $uty* +ut t&e )"n of !"re %"$e +y
t&e ri%"ry nurse is IMPLEMENTED
Nurses &"ve AUTONOM6 "n$ AUTHORIT6 for "tient !"re
S!&e$u)ing
To "ssign 2or#ing $"ys "n$ $"y(offs to st"ff nurses in or$er to0
,3 Provi$e "$eu"te "tient !"re 2&i)e "voi$ing overst"ffing
-3 A!&ieve " $esir"+)e $istri+ution of $"ys off
B3 Tre"t in$ivi$u") st"ff nurse f"ir)y
93 A))o2 t&e st"ff to #no2 in "$v"n!e 2&"t t&eir s!&e$u)es "re
S!&e$u)ing Gui$e)ines
,3 '")"n!e t&e nee$ of e%)oyee "n$ e%)oyer
-3 Distri+ute f"ir)y goo$ "n$ +"$ $"ys off to "))
B3 M"#e sure t&ey "$&ere to s!&e$u)e3 Reuest "n$ e4!etion %ust +e in riting
93 A$v"n!e osting of s!&e$u)es
3 'e !onsistent in s!&e$u)ing
3 M"#e sure t&"t s!&e$u)es !onfor% 2it& )"+or )"2s "n$ &osit") o)i!y
3 Pre"re for e%ergen!y !&"nges
T&e NURSE MANAGER
T&e nurse %"n"ger PLANS* gives $ire!tion* $eve)os st"ff* %onitors oer"tions* gives f"ir re2"r$s
"n$ reresents 'OTH st"ff %e%+ers "n$ "$%inistr"tion "s nee$e$
Nursing ;urisru$en!e
T&e P&i)iine Nursing A!t of -//- @RA ,B IS THE 'EST GUIDE THE NURSE CAN UTILIE
"s it $efines t&e s!oe of nursing r"!ti!e
Intention") rongs5 TORTS
Tort is " )eg") 2rong !o%%itte$ "g"inst " erson or roerty in$een$ent of " !ontr"!t 2&i!&
ren$ers t&e erson 2&o !o%%its it )i"+)e for $"%"ges in !ivi) "!tion
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E4"%)es of TORTS
,3 Ass"u)t5 "tte%t to tou!& "not&er erson* i%%inent t&re"t of &"r%fu) or offensive +o$i)y
!ont"!t
-3 '"ttery 5 intention")* un!onsente$ tou!&ing of "not&er erson
B3 F")se i%rison%ent5 unKustifi"+)e $etention of " erson 2it&out " )eg") 2"rr"nt
93 Inv"sion of Priv"!y "n$ +re"!& of !onfi$enti")ity
3 Li+e)5 2ritten
3 S)"n$er5 so#en
Profession") Neg)igen!e
NEGLIGENCE
Co%%ission or o%ission of "n "!t ursu"nt to " $uty* t&"t " re"son"+)y ru$ent
erson in t&e s"%e or si%i)"r !ir!u%st"n!e 2ou)$ $o or 2ou)$ not $o "n$ t&e "!ting
or t&e non("!ting of 2&i!& is t&e ro4i%"te !"use of inKury to "not&er erson or
roerty
E)e%ents of Neg)igen!e
,3 E3!ten"e $' a dut% on t&e "rt of t&e erson
-3 Falu#e t$ meet t&e st"n$"r$s of $ue !"re
B3 T&e forse"+i)ity of &"r% resu)ting fro% 'alu#e to %eet st"n$"r$
93 T&e +re"!& of t&e st"n$"r$ resu)te$ in an nu#% to t&e )"intiff
E4"%)es of Neg)igen!e
,3 F"i)ure to reort o+serv"tion to t&e &ysi!i"n
-3 F"i)ure to e4er!ise t&e $egree of $i)igen!e
B3 Mist"#en i$entity
93 rong %e$i!ine* 2rong !")!u)"tion* 2rong route "n$ 2rong $oses
3 Defe!ts in t&e eui%ent su!& "s stret!&ers "n$ 2&ee)!&"irs t&"t %"y )e"$ to f"))s
3 Errors $ue to f"%i)y "ssist"n!e
3 A$%inistr"tion of %e$i!ine 2it&out " $o!tor=s res!rition
Res is" )ouitur
T&ree !on$itions "re reuire$ to est"+)is& " neg)igen!e ITHOUT roving se!ifi! !on$u!t
,3 T&"t t&e inKury 2"s of su!& n"ture t&"t it 2ou)$ not nor%"))y o!!ur un)ess t&ere 2"s "
neg)igent "!t
-3 T&"t t&e inKury 2"s !"use$ +y "n "gen!y 2it&in !ontro) of t&e $efen$"nt
B3 T&"t t&e !o%)"in"nt &i%se)f $i$ not eng"ge in "ny %"nner t&"t 2ou)$ ten$ to +ring "+out
t&e inKury
MALPRACTICE
IMPROPER or uns#i))fu) !"re of " "tient +y " nurse
Steing +eyon$ one=s "ut&ority 2it& serious !onseuen!es NEGLIGENCE or !"re)essness of " rofession") ersonne)
Neg)igent "!t !o%%itte$ in t&e !ourse of rofession") erfor%"n!e
Consent
free "n$ r"tion") "!t t&"t resuoses #no2)e$ge of t&e t&ing to 2&i!& !onsent is +eing given
+y " erson 2&o is )eg"))y !""+)e of giving !onsent
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Infor%e$ !onsent
E)e%ents0
,3 T&e $i"gnosis "n$ e4)"n"tion of t&e !on$ition
-3 F"ir e4)"n"tion of t&e ro!e$ures "n$ !onseuen!es
B3 Des!rition of ")tern"tive tre"t%ents
93 Des!rition of +enefits to +e e4e!te$3 M"teri") rig&ts
3 T&e rognosis* if refuse$
S)ee
REST( " st"te of !")%ness* re)"4"tion 2it&out e%otion") stress* "n$ free$o% fro% "n4iety
SLEEP( "n ")tere$ st"te of !ons!iousness in 2&i!& t&e in$ivi$u")=s er!etion of "n$
re"!tion to t&e environ%ent "re $e!re"se$3
T&is !"n +e $is!usse$ si%)y +y !onsi$ering t&e t&ree +"si! rese"r!& "ro"!&es0
ELECTROPH6SIOLOGIC
HORMONAL "n$
NEURAL
T6PES OF SLEEP
T&ere "re t2o tyes of s)ee i$entifie$0
T&e NREM !lee) @or t&e non(REM s)ee "n$
T&e REM !lee) @ r"i$ eye %ove%ent s)ee
,3 THE NREM SLEEP
A)so referre$ to "s t&e SLO 2"ve s)ee* +e!"use t&e +r"in 2"ves of t&e !)ient "re s)o2er
t&"n t&e ")&" "n$ +et" 2"ves of "n "2"#e or ")ert erson3
It is " dee)2 #e!t'ul !lee)
T&ere is " $e!re"se$ &ysio)ogi! fun!tions
A)) %et"+o)i! ro!esses "re re$u!e$
It is $ivi$e$ into FOUR st"ges0,(9
STAGE ,( t&e st"ge of very )ig&t s)ee* s)eeer !"n re"$i)y +e "2"#ene$* )"sts for " fe2 %inutes3 T&e
eyes ten$ to ro)) s)o2)y fro% si$e to si$e* "n$ %us!)e tension re%"ins "+sent3
STAGE -( t&e st"ge of )ig&t s)ee* +o$y ro!esses !ontinues to s)o2 $o2n* "n$ )"sts "+out ,/(,
%inutes3 C$n!ttute! 5J $' TOTAL !lee)6
STAGE B(refers to " %e$iu%($et& s)ee 2&ere vit") signs "n$ %et"+o)i! ro!esses s)o2 furt&er
+e!"use of t&e PARASYMPATHETIC nervous syste% inf)uen!e3 T&e s)eeer is $iffi!u)t to "rouse3
STAGE 9(t&is is t&e $eeest s)ee or $e)t" s)ee3 It is t&e st"ge 2&ere t&e &e"rt r"te "n$ resir"tory
r"te $ro -/(B/ +e)o2 t&ose e4&i+ite$ $uring 2"#ing &ours3 T&is st"ge is t&oug&t to restore t&e
+o$y &ysi!"))y3 So%e $re"%ing ma% o!!ur &ere3 T&! !tage ma% 1e a1!ent n t&e elde#l%9
REM S)ee
THE REM SLEEP
T&is s)ee tye usu"))y re!urs "+out every / %inutes "n$ )"sts to B/ %inutes3
Ot&er n"%e0 PARADOJICAL S)ee
T&e EEG "ttern rese%+)es t&"t of t&e 7a7a/e. st"te3
T&is is not "s restfu) "s NREM s)ee
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M$!t $re"%s t"#e )"!e $uring t&is erio$ "n$ t&e $re"%s "re usu"))y re%e%+ere$ or
!onso)i$"te$ to %e%ory
T&e +r"in is &ig&)y "!tive 2it& %et"+o)i! r"te in!re"sing "s %u!& "s -/
T&e s)eeer %"y +e very $iffi!u)t to "rouse
T&ere "re r"i$ !onKug"te eye %ove%ents* %us!)e tone is $eresse$* +ut g"stri! se!retions
in!re"se* HR "n$ RR "re in!re"se$ "n$ IRREGULAR T&is s)ee erio$ +e!o%es )onger "s t&e nig&t rogresses3
NREM versus REM
NREM REM
S)o2 eye %ove%ent R"i$ Eye %ove%ent
Restfu) s)ee NOT restfu)
De!re"se$ %et"+o)is% In!re"se$ %et"+o)is%
Vit") signs LO
Mus!)e tone %"int"ine$
NO vivi$ $re"%s
Vit") signs Irregu)"r
Mus!)e tone $eresse$
Dre"%s o!!ur
S)ee Cy!)e
A)) of us un$ergoes "roun$ t !y!)es of s)ee of NREM to REM
e +egin 2it& STAGE , - B 9 B - REM
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S)ee V"ri"tions
For NEONATES( ne2+orns s)ee for ,(,. &ours $ivi$e$ into s)ee erio$s3 T&ey &"ve
t2o s)ee st"tes( QUIET s)ee @t&eir NREM s)ee is !&"r"!teri>e$ +y !)ose$ eyes* regu)"r
resir"tions "n$ "+sen!e of eye+o$y %ove%ents ACTIVE s)ee is !&"r"!teri>e$ +y eye
%ove%ents o+serv"+)e t&roug& t&e !)ose$ eye)i$s* 2it& +o$y %ove%ents "n$ irregu)"r
resir"tions3
For INFANTS( so%e inf"nts s)ee for -- &ours* 2&i)e t&e "ver"ge is ,-(,9 &ours3 T&eir s)ee !y!)e is
s&orter @"+out /(/ %inutes3 T&e REM s)ee is -/(B/ @2&i!& $e!re"ses "s t&e inf"nt gro2s "n$
2i)) st"+i)i>e "t -/ unti) )"te in "$u)t&oo$3 A+out / of t&e s)ee is sent $uring LIGHT s)ee
@St"ge ,3
For TODDLERS( t&e s)ee reuire%ent is ,/(,- &ours " $"y3 T&e s"%e -/(B/ of s)ee is
REM3 T&e nor%") s)ee 2"#e "ttern is est"+)is&e$ "t "ge -(B3
=edtme #tual! $'ten de*el$) and a!!ume g#eat m)$#tan"e n )#$*dng ng&ttme !e"u#t%9
For PRESCHOLERS( t&ey usu"))y reuire ,,(,- &ours of s)ee er nig&t3 T&e REM s)ee is
sti)) -/(B/3 M"ny of t&e res!&oo)ers resist going to s)ee
Remem1e# t&at t&e )#e!"&$$le#! &a*e 'ea# $' t&e da#/ t&at nu#!e! mu!t ant")ate t$ gude t&e
m$t&e#!
For PRESCHOLERS(
Suggeste$ Me"sures +y Pi))iteri0
89 Read 1edtme !t$#e! untl )atent !lee)!
Sleep cycle
!tage 4
!tage :
!tage 2
!tage ;
!tage 2
!tage :
+)%
!tage :
!tage 2
!tage ;
"W"?)
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;9 Rea!!u#e t&at "&ld ! Sa'e
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P"in is "n un)e"s"nt sensory "n$ e%otion") e4erien!e "sso!i"te$ 2it& "!tu") or otenti")
tissue $"%"ge3
It is so%eti%es referre$ to "s t&e FIFTH vit") sign
PAIN
ACUTE "in CHRONIC "in
Mi)$ to severe
Su$$en
Sy%"t&eti! syste%
Pro)onge$
Persisting %ont&s or )onger
P"r"sy%"t&eti! resonses
P"in T&eory0 G"te !ontro)
Me)>"!# "n$ ")) $eve)oe$ g"te !ontro) t&eory in ,3 T&e t&eory rooses t&"t t&e su+st"nti"
ge)"tinos" @SG in t&e sin") !or$ "!ts "s " g"ting %e!&"nis% to er%it or in&i+it "ss"ge of "in
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i%u)ses3 T&e 7g"te8 !"n +e 7!)ose$8 @so t&"t t&e !ont"!t is not %"$e* t&us interruting t&e "in
i%u)se +y nerve i%u)ses fro% t&e )"rge non(no!i!etive A(+et" "n$ A(")&" fi+ers or fro% t&e
$es!en$ing "t&2"ys
Im)ul!e! "$ndu"ted $*e# la#ge '1e#! n$t $nl% "l$!e t&e gate 1ut al!$ a#e !ent mmedatel% t$ t&e
"$#te3 '$# #a)d dent'"at$n2 e*aluat$n2 and m$d'"at$n $' t&e !en!$#% n)ut!
I%u)ses sent to t&e +r"inste%* t&e !enter for %otiv"tion")("ffe!tive "n$ sensory($is!ri%in"tive "!tions* !"n inf)uen!e !ognition or ev")u"tion in t&e !orte43 I%u)ses "re t&en
sent fro% t&e !orte4 +"!# to t&e SG vi" !orti!osin") "t&2"ys to in&i+it or er%it "ss"ge
of "in i%u)ses3
C"t&eteri>"tion @1o>ier
E4)"in ro!e$ure
"s& &"n$s
Dr"e "re"s e4!et erineu%
O)en t&e !te#le "at&ete#,at$n /t A))l% !te#le Gl$*e!
Lu+ri!"te !"t&eter
C)e"nse t&e %e"tus
Insert !"t&eter
Gr"s ;5< n"&e! fro% t&e !"t&eter ti "n$ insert
A$v"n!e t&e !"t&eter ; n"&e! 'u#t&e# "fter t&e urine +egins to f)o2
Male In!e#t a#$und 5 n"&e!
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Female n!e#t a#$und ier
AGE 'e)iefsInfancy to > years old NO clear concept of #eath
It is "e#ersible temporary sleep
> to J years 'nderstands DE$T% is FIN$& but can be $'(IDED
J-4: years #eath is INE'IT$)&E* e#eryone will die someday
'nderstands own mortality
4:-4A years 8ears a lingering #eath
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4A-;> "ttitude is influenced by religion
;>- years )&periences pea( of death an&iety
and above #eath as multiple meanings
Nursing resonsi+i)ities In De"t& "n$ $ying
Nurses nee$ to t"#e ti%e to "n")y>e t&eir o2n fee)ings "+out $e"t& +efore t&ey !"n effe!tive)y &e)
ot&ers 2it& ter%in") i))ness
T&e %"Kor go")s for t&e $ying !)ients "re0
,3 To %"int"in PH6SIOLOGIC "n$ PS6CHOLOGIC suort
-3 To A!&ieve " $ignifie$ "n$ e"!efu) $e"t&
B3 To %"int"in erson") !ontro)
De"t& "n$ Dying RESPONSI'ILITIES
P#$*de Rele' '#$m l$nelne!!2 'ea# and de)#e!!$n Hel) "lent! mantan !en!e $' !e"u#t%
Hel) "lent! a""e)t l$!!e!
P#$*de )&%!"al "$m'$#t
T&e fo2)ers
LO fo2)ers5 , to B/ $egrees
SEMI fo2)ers5 B/(9 $egrees
FOLER=s5 9(/ $egrees
HIGH Fo2)ers5 /(/ $egrees
C"r s"fety
Inf"nts u to #i)ogr"%s or -/ oun$s s&ou)$ FACE t&e REAR
C&i)$ren gre"ter t&"n #i)ogr"%s or -/ oun$s s&ou)$ +e in t&e FORARD f"!ing osition
in t&e 'AC1 se"t of t&e !"r
PAIN
Hig&)y un)e"s"nt erson") sens"tion
Most "!!et"+)e t&eory0 GATE CONTROL THEOR6
PQRST
Qu")ity0 0Tell me 7&at %$u# )an 'eel! l/e.
Pot"ssiu%
'"n"n" @s%"))5 3 %EL
Or"nge5 3 %EL
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Pot"to @%e$iu%5 ,-3 %EL
"ter%e)on @,- s)i!e5 ,3B
C)e"r )iui$ $iet
L"!#s !")ories
Per%itte$ f)ui$s0
– C$''ee– Tea
– C"r+on"tes $rin#s
– F"t(free +rot&
– C)e"r '#ut u"e!
– GELATIN
– )$)!"le!
Fu)) )iui$
A)) foo$s in !)e"r )iui$
Mi)# "n$ Ml/ d#n/! Pu$$ing * !ust"r$s
I!e !re"%
Cre"%* +utter* %"rg"rine
6ogurt
Veget"+)e Kui!es
Foo$ Gui$e yr"%i$
're"$* !ere")s* ri!e "n$ "st"5 (,, servings
Fruit "n$ veget"+)es
Me"t* ou)try* fis&* $ry +e"ns* eggs
Mi)#* yogurt* !&eese
F"ts* oi)s "n$ s2eets
T&e $efinitions of 7A8
ANOMIA5 in"+i)ity to NAME o+Ke!t
AGNOSIA5 in"+i)ity to RECOGNIE t&ings
APRAJIA5 in"+i)ity to PERFORM revious)y )e"rne$ %ove%ents+e&"vior
ATAJIA5 )"!# of COORDINATION in %ove%ent
APHASIA5 )"!# of o2er to e4ress onese)f +y see!&* 2riting or signs* )"!# of o2er to un$erst"n$
so#en2ritten )"ngu"ge
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