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FUNDAMENTALS OF
NURSING
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Florence NIGHTINGALE(1820-1910) Lady with the Lamp Considered the founder of modernnursing
NURSING
THEORISTS
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INTERPERSONAL PROCESS4 Phases (NURSE-CLIENT RELATIONSHIP) ORIENTATION
IDENTIFICATION--Identify difficultiesand amount of needed help EXPLOITATION/EXPLANATION-nurse
utilizes available resources towardgoal of maximum health RESOLUTION/TERMINATION-goals
met
HILDEGARD PEPLAU(1952)
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14 BASIC HUMAN NEEDS BREATH EAT & DRINK ELIMINATE POSTURE SLEEP DRESS TEMPERATURE HYGIENE COMMUNICATE WORSHIP WORK PLAY LEARN AVOID DANGER
HENDERSON
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21 CLIENT NEEDS
ABDELLAH
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10.To facilitate the maintenance of regulatorymechanisms and functions
11.To facilitate the maintenance of sensory function
12.To identify and accept positive and negativeexpressions, feelings and reactions
13.Top identify and accept the interrelatedness ofemotions and organic illness
14.To facilitate the maintenance of effective verbaland nonverbal communication
15.To promote the development of productiveinterpersonal relationship
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16.To facilitate progress towardachievement of personal spiritual goals
17.To create and maintain a therapeutic
environment18.To facilitate awareness of self as anindividual with varying physical,emotionaland developmental needs
19.To accept the optimum possible goals inlight of physical and emotional limitations
20.To use community resources as an aid inresolving problems arising from illness
21.To understand the role of social problemsas influencing factors in the cause of illness.
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CONCEPTUALIZED THEDYNAMIC NURSE PATIENT
RELATIONSHIPFocuses on how the clientadapts to illness and howactual or potential stresscan affect the ability to
adapt.
IDA JEAN ORLANDO(1961)
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COINED NURSING
PROCESSCORE, CURE, CARE
CORE: THERAPEUTIC USE OF SELF CURE: DISEASE & TREATMENT AS BASED ON
DOCTORs Order CARE: Nurturance of the BODY
HALL
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Nursing care isnecessary only if the
client is unstable tofulfill biologic,
psychologic,developmental or social needs.
JOHNSON
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SCIENCE OF UNITARYHUMAN BEING
THE INDIVIDUAL IS MORETHAN and DIFFERENT
FROM THE SUM OF ITSPARTS,DITINCTIVE
PROPERTIES OF THE
ROGERS
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DESCRIBED NURSING AS AHELPING PROFESSION THATASSISTS INDIVIDUALS AND
GROUPS TO ATTAIN ,MAINTAINAND RESTORE HEALTH.
3 DYNAMIC INTERACTINGSYSTEMS: PERSONAL,INTERPERSONAL, SOCIAL FORM
THE BASIS FOR NURSE CLIENT
KING
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HEALTH CARE SYSTEMMODEL-Nursing is a
unique professionconcerned with all the
variables affecting anindividuals response
to stress.
NEUMAN
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TRANSCULTURALNURSING MODEL
AVOCATED NURSINGCARE THROUGH
SCIENTIFIC ANDHUMANISTIC ANDSPECIFIC CULTURALCARING PROCESSES
LEININGER
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ADAPTATION MODEL
HELP CLIENT TO ADAPTTO CHANGES IN
PHYSIOLOGIC NEEDS,SELF-CONCEPT, ROLEFXN, INTERDEPENDENT
RELATIONS
ROY
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HUMAN CARING MODEL Believed that a person
is a valued being to becared for, respected,nurtured, understood
and assisted, a fullyfunctional integratedself.
JEAN WATSON
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THEORY ON THEDEVELOPMENT OF
VIRTUES-the unifyingstrength of a good man.MORAL DEVELOPMENT
CONTINUES THROUGHOUTLIFEEGO STRENGTH VIRTUE/GOODMAN
NURSES ACT AS ROLE
ERICKSON
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CENTRAL CARINGCARING IS CENTRAL IN
NURSING, CREATINGPOSSIBILITIES FORCOPING & CONNECTINGWITH OTHERS
BENNER
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PHYSIOLOGICSAFETY AND SECURITYLOVE AND BELONGINGNESS
The need to love and need tobe lovedSELF-ESTEEM
Self-worth, Self-identity, BodyImage
SELF-ACTUALIZATION Need to learn
Need to be self-fulfilled
MASLOWS HIERARCHY OFNEEDS
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Organized andsystematic-composed of
6 sequential andinterrelated stepsHumanistic-individualized,involving the aspects of
human dignity
NURSING PROCESS
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Collecting, validating,organizing and recording
data about clients healthstatus to establish database.
Collection of Data Subjective Ob ective
ASSESSMENT
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Methods
Interview Observation-use of senses
PE
Sources Primary Secondary
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The clinical act of identifyingthe problem.Analysis of assessment infoand derive meaning from this
analysisFormat: P-problem R-related factors/Etiology
S-signs and symptomsOR.
P-problem E-etiology S-si ns and s m toms
DIAGNOSING
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Refers to formulating anddocumenting measurable, realisticgoals
PURPOSESTo provide individualized care Promote client participation
To plan care that is realistic andmeasurableTo allow involvement of supportpeople
OUTCOME IDENTIFICATION
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4. Planning Determiningbeforehand the strategies and
course of action beforeimplementation
PURPOSES: to identify the clients goals andappropriate nursing intervention
to direct client care activities to promote continuity of care to direct activities to be carried out
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5. Implementation putting thenursing care plan into action
a. Reassessing to ensureprompt attention to
emerging problemb. Set priorities
c. Perform nursing interventiond. Record action
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6. Evaluation assessing the
clients response to nursingintervention
PURPOSE:
-to appraise the extent towhich goals and outcome
criteria of nursing care hasbeen achieved
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Law-rules that regulate socialconduct in a formallyprescribed and legally binding
manner.Rights- PrivilegesResponsibilities- ObligationsGrievance-DisputeStare Decicis-to stand by
things decided.
JURISPRUDENCE
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Public/Criminal laws-Actionsagainst safety and welfare of thepublic
Felony-Serious Misdemeanor-Less serious
Civil/Private laws Contracts Torts-Wrong doing againstperson/property
Unintentional
Intentional
CLASSIFICATION
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INTENTIONAL TORT
Assault or battery Invasion of privacy
Defamation(Libel/Slander) Malpractice andnegligence
False Imprisonment
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NOT instituted forconvenience
False ImprisonmentAlternative measure first
Remove Q2hFor safetyNeeds Doctors order.
RESTRAINTS
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PHYSICALEXAMINATION
INDIVIDUAL ASSESSMENT OF EACH BODYSYSTEM, USUALLY CONDUCTED IN ACEPHALO-CAUDAL MANNER
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OBSERVE AREA FOR SIZE, SHAPE,SYMMETRY, POSITION & ABNORMALITIES.
INSPECTION
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PALMS & FINGER PADS:TEXTURE, CONSISTENCY &
FORMDORSUM OR BACK OFHAND: TEMPERATURE
BONY PROMINENCES OFTHE PALM: VIBRATION
PALPATION
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HEAD TO TOE ASSESSMENT
REVIEW OF SYSTEMS
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SEMI-FOWLERS FOR GASTRIC FEEDING TOREDUCE REFLUX
HIGH FOWLERS FOR EATING, NGT INSERTION ANDSUCTIONING, PROMOTES GOODCHEST EXPANSION
SUPINE FOR VERTEBRAL INJURIESDORSAL RECUMBENT
FOR ABDOMINAL EXAM
CLIENT POSITIONS
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PRONE SMALL PILLOW JUST BELOW DIAPHRAGM,SUPPORTS LUMBAR CURVE, FACILITATESBREATHING
SIMS FOR RECTAL EXAM
KNEE-CHEST/ GENUPECTORAL CLIENT PRONE, ARMS FLEXED ON SIDES,KNEE-CHEST FLEXION. FOR VAGINAL/RECTAL EXAM
LITHOTOMY HAVE CLIENT VOID PRIOR TO. FOR PELVICEXAM
VITAL SIGNS
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TEMPERATURE
VITAL SIGNS
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HEAT LOSS
1. RADIATION: no direct contact
e.g. therapy2. CONDUCTION: direct contact
e.g. TSB3. CONVECTION: air Currents
e.g. electric fan fan
4. EVAPORATION: liquid to gase.g. skin sweat
f
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Patterns of Fever:
1. Remittent: Remains high
(fever fluctuates but neverreturn to normal)
2. Intermittent: International!
(fever fluctuates b/w normal &above normal)
3. Relapsing: fever fluctuates,normalizes for days, feveragain!
4. Constant: >38C
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PULSE
RESPIRATION
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RESPIRATIONIncreased RR: stress,smoking, anemia,>altitude; Amphetamine,
CoccaineDecreased RR: acute
pain in chest/abdomen,brain damage; narcotics,
anesthesia, P tt f B thi
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Patterns of Breathing1. CHEYNE-STOKES: HV-
Apnea normal in kids & elderly whenasleep; heart failure, uremia,brain damage
2. BIOTs: Shallow breath-
Apnea3. KUSSMAULs: deep,regular, rapid
4. ORTHOPNEA: DOB supine
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BP t ki !!!
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BP taking!!! 1. 5 min rest, within 30 min no
coffee 2. Supine/sitting: arm at heartlevel, PALM UP!
3. Cuff width 40% of limbs circum;bladder encircle 2/3 of arm
4. BP cuff 1 inch above antecubital 5. Determine palpatory BP before
auscultatory BP 6. Bell: 1st Korotkoff (Systole) 7. Deflate slowly: 2-3 mmHg/sec.
Disappearance of sound (Diastole)
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Permission obtained from apatient to perform a specific testor procedure.Agreed uponFacts knownExplainedRisk and chances understood
INFORMED CONSENT
LEAVELL AND CLARKS
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PRIMARY-To encourage optimal healthand to increase the personsresistance to illness. To stopsomething from ever happening. Quit Smoking Avoid /limit alcohol Eat well-balanced diet Complete immunization programs
GOOD NUTRITION, SAFE SEX, EXERCISE PROTECTION FROM ACCIDENTS (HELMET), HYGIENE
LEAVELL AND CLARKSLEVELS OF PREVENTION
SECONDARY Health maintenance
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SECONDARY-Health maintenance.Seeks to identify specific illnessesor conditions a earlier stage. Sputum exam for TB MONTHLY SELF-EXAM (BREAST,TESTICLE, SKIN, MOUTH)
ANNUAL PAP SMEAR (STARTING 18 yo),
MAMMOGRAM (STARTING 40 yo IF hr &50 yo IF LOW RISK)
ANNUAL DIGITAL RECTAL EXAM (MALES>50 yo)
ANNUAL PHYSICAL EXAM (STARTING 35yo)
GLAUCOMA & HYPERTENSIVESCREENING
DISABILITY LIMITATIONS: Adequate tx
T ti
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Tertiary Restoration and Rehabilitation
Occurs after a disease ordisability has occurred andthe recovery process has
begun, assisting the client inobtaining an optimal healthstatus.
CVA therapyCardiac Rehabilitation foraddiction or MI
Blood Glucose Monitoring for
STAGES OF INFECTIOUS
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Incubation Period= exposure to 1stS/S
Prodromal Period= Symptoms thatmay be the 1st indication of theonset of the disease
Stage of Illness= Manifesting S/S
Convalescence=the stage to
recovery after the disease
STAGES OF INFECTIOUSPROCESS
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CONTACT TRANSMISSION DIRECT CONTACT-person to person INDIRECT CONTACT-Fomites,
dressing, needle, instrumentsDROPLET TRANSMISSIONVEHICLE TRANSMISSION- water,
bloodAIRBORNE TRANSMISSIONVECTORBORNE TRASMISSION
MODE OF TRANSMISSION
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The quality of beinginsusceptible or unaffectedby a particular disease orcondition.
IMMUNITY
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Natural Immunity Immunity that is notacquired through previous
contact with a infectious agent but is largelygeneticallydetermined.
Inherent
TYPES
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AcquiredA.Passive immunity-a state of temporary
partial insusceptibility to an infectious agentthat has been induced by IV or IM
administration of preformed antibodies.
B Active Immunity
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B.Active Immunity A state of resistance built up in an individual
following effective contact with foreign antigens
(toxoid).1)Humoral Immunity-Results from active production ofantibodies against antigens of microorganisms or theirproducts.
2)Cellular Immunity-The central position in defense (Band T cells).
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Antibodies are produced by anothersource. NATURAL-MOTHER to FETUS via placenta ARTIFICIAL-immune serum(Ab) injected to person
PASSIVE IMMUNIZATION
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HandwashingCleaningDisinfectionSterilizationUse of barriersIsolation systemsSurgical Asepsis
ASEPTIC PRACTICES
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The single most important infection controlpractice.
Effectiveness is greatly influenced byadequate friction and thoroughness of
surface cleaned.Wash hands under running water,soap and
friction for 15 to 30 sec. on each hand.
HANDWASHING
METHODS OF
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STEAM AUTOCLAVE,NONTOXIC,SPOROCIDALGAS STERILIZATION-Ethylene Oxide
Can penetrate plastic ,rubber.cotton,BP
apparatus,catheters Sterilization is expensive and takes 2 to 5 hours to
accomplish Ethylene oxide is toxic to humans
METHODS OFSTERILIZATION
RADIATION-Penetrates deeply into the objects
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CHEMICALS-Effective Disinfectants Attacks all types of Microorganisms,work with water Do NOT destroy articles Example is Chlorine
BOILING WATER
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Caps and shoe coveringsMasksGlovesPrivate roomsWaterproof disposable bags for linen ands
trashControl of airflow
Goggles and face shield
USE OF BARRIERS
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NEVER TOUCH WITHBARE HANDS ANYTHING
THAT IS WET COMINGFROM A BODY SURFACE
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DEFINITION OF TERMS:1. Medication substance
administered for diagnosis,
cure, treatment, relief orprevention of disease
2. Chemical name describes
the constituents of the drug3. Brand name the name
given by the manufacturer.
Medication Administration
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TYPES OF DOCTORS ORDER
1. Standing order carried outuntil specified period of timeor until it is discontinued by
another order2. Single order
3. Stat order
4. PRN
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Effects of drug
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1. Therapeutic
2. Side effect or secondary effect3. Drug allergy4. Anaphylactic reaction5. Drug tolerance
6. Drug abuse7. Drug dependence8. Addiction9. habituation
Effects of drug
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ASSOCIATED WITH AGING THAT
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1. Altered memory
2. Less acute vision
3. Decrease renal function4. Slower GI absorption
5. Increase proportion of fat to lean body
mass leading to toxicity6. Decreased liver function
ASSOCIATED WITH AGING THATINFLUENCE MEDICATIONADMINISTRATION ANDEFFECTIVENESS
ADMINISTERING
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1. Right drug
2. Right dose
3. Right route4. Right patient
5. Right recording
6. Right approach7. Right patient
ADMINISTERINGMEDICATION
Routes of Drug
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1. Oral2. Sublingual
3. Topical
a. dermatologicb. ophthalmic
c. otic
d. nasal
e. inhalation
f. vaginal
gAdministration
4 Rectal
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4. Rectal
5. Parenteral
a. Intradermal Dermal layer underneath theepidermis.
The sites are the inner, lower arm,
upper chest and back, and beneaththe scapula
Indicated for allergy, and tuberculintesting
Needle gauge 25,26,27. size 3/8,5/8 inches
10-15 degree angle , bevel up
Do not massage the site of injection
B. Subcutaneous
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For vaccines , preoperativemedications, narcotics, insulin,
heparin. Sites: outer aspect of upperarm, anterior aspect of the
thigh, abdomen Small doses are injected Rotate sites
Needle gauge and size same asID 45 degree angle
For obese, 90degree angle C. Intramuscular
N dl l th 1 i h 1 t 2 i h t h
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Needle length 1 inch,1 to 2 inches to reachmuscle layer
Needle gauge: 20,21,22,23
a. Dorsogluteal - uses gluteus medius muscle POSITION : Prone or side-lying AREA: Upper,outer quadrant of buttocks
b. Vastus lateralis for infants POSITION: back lying or sitting position
c. Deltoid Site - not always used. IM Z-track technique parenteral iron
preparation. retract the skin laterally, inject the medication
slowly. hold the retraction of skin until the needle is
withdrawn
do not massage
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2. Circulatory overload
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yresults from administration
of excessive volume of IVfluidsAssessment:
-headache-Flushed skin-increased BP
-weight gain-syncope-pulmonary edema
- INTERVENTION:
Sl i f i KVO
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1. Slow infusion to KVO2. High-Fowlers position
3. Bronchodilator
3. Drug Overload the patient receives anexcessive amount of fluid containing
drugs.Assessment:-dizziness-Shock
-FaintingNSG INTERVENTION:-Slow infusion to KVO. Notify the
physician
4. Superficial Thrombophlebitis it isd f i i i i
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due to overuse of a vein irritatingsolutions or drugs, clot formation,
large bore catheters.Assessment:- Pain along the course of vein- Vein may feel hard and cordlike- Edema and redness at needinsertion site
- Arm feels warmer than the other
armINTERVENTION:-Change IV site every 72 hours.
-Use large vein
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Vitamins
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Water soluble1.Ascorbic acid
for better absorption of iron
for smooth epithelium/Defenses
Sources broccoli, guava, cabbage
Deficiency scurvy (weakness , anemia,edema, spongy gums, loosening of teeth)
2. Thiamine (Vitamin B1)
Deficiency beriberi fatigue, diarrhea, appetiteand weight loss, disturbed nerve function, wasting
of limbs, edema and heart failure.
Vitamins
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5 Vit B6 (Pyridoxine)
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5.Vit.B6 (Pyridoxine) Sources:Chicken,Peanuts
Deficiency:
6. Vit.B9 (Folic acid) Sources: green leafyvegetable, liver, eggs
Deficiency:
Fat Soluble VitaminsVitamin A (Retinol) good eyesight
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1. Vitamin A (Retinol)-good eyesight;Maintenance of good epithelium
Sources-liver, fish liver oil Deficiency-night blindess, Xeropthalmia-dry lusterless cornea
2. Vitamin D (Ergocalciferol)- calciumabsorption.
Sources-dairy products,salmon, sardines Deficiency-
Rickets-Soft, pliable bone, muscle pain,Spinal curvature
Osteomalacia-Loss of calcification of boneresulting to softening of the bone.
3 Vitamin E ( Tocopherol) for
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3. Vitamin E ( Tocopherol) formaintenance of healthy skin and
good eyesight. Sources vegetable oils, leafyvegetables, peanuts
Deficiency-anemia, skin lesion
4.Vit K(Menadione) for bloodclotting.
Sources-green leafy vegetable,egg yolk.
Deficiency-bleeding
Minerals
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Minerals
1.Calcium-
bone and teeth formation- Muscular contraction- Blood coagulation- Neurotransmission- Catalyst for biologic reactionSources-milk and dairy products, nuts,tofu.
Deficiency- retarded growth, rickets,osteomalacia and tetany.
2. Potassium F and E balance,
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,Hypokalemia
-Manifested as apathy, muscular
weakness, confusionHyperkalemia- weakening in cardiac
contraction, poor respiration, numbness ofextremities
Sources-fruits
3. Sodium responsible for fluid balance.
i lli
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Hyponatremia causes swelling
Hypernatremia- crenation
4. Iron The most abundant trace element inthe body necessary for hemoglobin formation.
Sources-pork liver, lean meat
Deficiency- anemia
Excess hemosiderosis-Abnormal deposition ofIron to different tissues.
5. Iodine for normal synthesis of thyroxine.
S f d ilk
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Sources- seafoods, milk, eggs
Deficiency-goiter, cretenism, myxedema
Bowel and Bladder Elimination
1 Defecation expulsion of feces from the
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1. Defecation expulsion of feces from therectum
STOOL ASSESSMENTA. Color
B. Odor
C. Amount
D. ConsistencyE. Shape
F. Frequency
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Common elimination problems1.Constipation-passage of small, dry, hard
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p p g , y,stool or the passage of no stool for aperiod of time.
2.Fecal impaction- mass collection ofhardened feces in the folds of therectum. The stool is lodged or stucked inthe rectum
3. Diarrhea frequent evacuation of waterystool
4. Flatulence excessive gas in the
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intestine. Due to swallowed air, bacterialaction in the large intestine.
5. Fecal incontinence involuntaryelimination of bowel contents associatedwith neurologic, mental and emotional
impairment.
Urinary Elimination
*Anatomy
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*Anatomy
1. Kidney
2. Ureter3. Urinary bladder
4. Urethra
Micturition the act of expelling urine from
the bladder.Initiated by parasympatheticnervous system.
Characteristics
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1. Color amber or straw
2. Odor aromatic
3. Transparency clear
4. pH 4.6 8
5. Specific Gravity 1.010 1.025
Altered Urinary Frequency
Frequency
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1. Frequency
2. Nocturia
3. Urgency4. Dysuria
5. Hesitancy
6. Enuresis
7. Urinary Incontinence
8. Retention
Activity, mobility and exercise*Immobility
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1.Musculoskeletal System-atrophy
-disuse osteoporosis-dimineralization-contracture2.Cardiovascular System
-orthostatic hypotension-thrombus formation-embolus-thrombophlebitis
3.Respiratory
-atelectasis
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-atelectasis
-pneumonia
-respiratory acidosis
4. Urinary
-UTI- Urinary stasis- Calculi- Incontinence
5. Integumentary
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-loss of skin turgor
-decubitus ulcer reddened areas or ulcer in
the skin occuring over bony prominences
Causes:
a. Pressure
b. Friction
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BED SORE
Stages of Decubitus Ulcer
Stage I : Erythema
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Stage I : Erythema
Stage II: Involves epidermis and or dermis.
Presence of abrasion or blister or shallowcrater.
Stage III: Full thickness skin loss involvingdamage or necrosis of subcutaneous tissue
that may extend through the fascia.Stage IV: Full thickness skin loss all the wayto muscle and bone.
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Safe EnvironmentCharacteristics:
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Adequate lighting Neat and clean Safe equipment Noise level is comfortable Cleanliness
Medication Temperature of the environment
Factors that affect peoples protection
1 Age
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1. Age
2. Orientation and LOC
3. Emotion4. Injury or illness
5. Sensory or communication impairment
6. Safety awareness
Injuries
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1.Fall
2.Burns
3.Chemical trauma
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PAIN
PainA sensation of physical or mental hurt or
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- A sensation of physical or mental hurt orsuffering that causes distress or agony
Factors Influencing the pain experience1. Age2. Sex3. Cultural background
4. Psychological5. Previous experience6. Knowledge or understanding
Stages of Pain
A ti ti b i ith th ti f
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1. Activation begins with the perception ofpain.
2. Rebound the pain experience is intense butbrief.
3. Adaptation
Classification of Pain
1 Cutaneous
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1. Cutaneous
2. Somatic
3. Visceral4. Referred perceived at an area other than the
site of injury.
5. Intractable
6. Phantom
7. Radiating- felt at the source and extends thesurrounding tissue.
8.
Intermittent
SLEEP=state of lesser perception & reaction to the
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environment.
RETICULAR ACTIVATING SYSTEM (RAS)
=WAKEFULNESS: catecholamine release (E)
=SLEEPINESS: serotonin release
Stages of Sleep
1. NREM: body restoration2. REM: >brains processes
A. NREMStage 1: Lightest sleep, 10 min,
dil k
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readily awakensStage 2: Sound sleep, easily
arousable, VS decrease
Stage 3: Deep sleep, musclesrelaxed, diff to arouse
Stage 4: Deepest sleep, most relaxed,sleepwalking, enuresis, night
terrorsB. REM: Paradoxic, vivid, full color
dreams, 90 min
SLEEP DISORDERSNarcolepsy: > daytime sleepiness
l dd l k
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*Cataplexy: sudden muscle weakness
*Hypnagogic: dreams undistinguishable fromreality
Somnambulism: sleep walking
Soliloquy: sleep talking
Sleep Terrors: sudden waking, but with no dreamrecall
Bruxism: teeth grinding
Enuresis: bed-wetting
OXYGENATION
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VENTILATION: BREATHINGDIFFUSION: O2 MOVES FROM ALVEOLI TO
RBCPERFUSION: RBCS MOVE INTO CIRCULATION
OXYGENATION
THORACENTESIS
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NEEDLE INSERTION THRU CHEST WALL FORASPIRATION OF PLEURAL FF FLUID ORINSTILLATION OF MEDS
EXPLAIN PROCEDURE & INSTRUCT CLIENTNOT TO COUGH OR MOVE SUDDENLY
CHECK FOR PNEUMOTHORAX
O C S S
CARDIAC CATHETERIZATION
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R-SIDED: ANTECUBITAL VEINR HEART--PULMONARY ARTERYL-SIDED: BRACHIAL OR FEMORAL ARTERY
AORTALEFT VENTRICLE
PRE-TEST: CHECK FOR ALLERGIES; NPO 8-12HOURS PRIOR, NO ANTICOAGULANTS AT LEAST3 DAYS PRIOR
FEELING OF WARMTH OR FLUTTERING ISCOMMON AS CATHETER PASSES
POST-TEST: CHECK CIRCULATION IN AFFECTEDEXTREMITY (PULSES, COLOR, SENSATION),SANDBAG OR PRESSURE DRESSING OVERPUNCTURE SITE.
BRONCHIAL LAVAGE/STEAM INHALATION
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LIQUIFIES AND MOBILIZES SECRETIONS;MEDIUM FOR AEROSOLBRONCHODILATORS & MUCOLYTICEXPECTORANTS
COVER CHEST WITH TOWEL AND PLACESPOUT 12-18 IN. AWAY TO PREVENTBURNS. STEAM FOR 15-20 MINUTES.
THEN DEEP BREATHING AND COUGHINGTO MOBILIZE SECRETIONS
STEAM INHALATION
CHEST PHYSIOTHERAPY
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PERFORM AC TO AVOID ASPIRATIONSEMI-FOWLERS POSITIONGIVE BRONCHODILATORS 20 MIN PRIOR
*POSTURAL DRAINAGE: CAREFUL POSITIONINGALLOWS SECRETIONS TO FLOW BY GRAVITYFROM SMALLER AIRWAYS INTO LARGERAIRWAYS
*PERCUSSION: CLAPPING WITH CUPPED HANDSON CHEST WALL FOR 3-5 MIN TO DISLODGESECRETIONS
*VIBRATION: WITH HANDS PRESSED FLAT ONCHEST, UPPER ARM & SHOULDERS
TRACHEOSTOMY
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SURGICAL CREATION OF A STOMA, OPENINGINTO THE TRACHEA THROUGH THEOVERLYING SKIN FOR RELIEF OF UPPERAIRWAY OBSTRUCTION OR ACCESS FOR
MECHANICAL VENTILATION
NGT INSERTION
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PLACE PT IN HIGH-FOWLERS
NURSE ON SIDE OF NOSTRIL FOR INSERTION.MEASURE TUBE LENGTH BY NOSE-EARLOBE-XIPHOID (NEX). ADD 20-30 cm FOR DUODENALPLACEMENT. LUBRICATE TUBE.
HYPEREXTEND NECK, INSERT TUBE THRUNOSTRILS TOWARDS BACK OF THROAT WHILEROTATING TUBE 180. FLEX NECK ONCE TUBE INOROPHARYNX & ASK CLIENT TO SWALLOW.
CLIENT SITTING OR HIGH FOWLERS POSITION
NGT FEEDING
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CLIENT SITTING OR HIGH-FOWLERS POSITION(PREVENTS ASPIRATION)
CHECK FOR RESIDUAL FEEDING >150 ml:INFORM DR
WITH FEEDING BAG OR SYRINGE ELEVATED 12INCHES. ELEVATION ALLOWS EMPTYING BY
GRAVITY TO PREVENT ABDOMINALDISCOMFORT, REFLUX AND VOMITING
FOLLOW WITH WATER TO CLEAR TUBE. CLAMPTUBE BEFORE ALL THE WATER IS INSTILLED TO
PREVENT AIR BUBBLES (FLATULENCE)
PARENTERAL NUTRITION
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FOR CLIENTS WHO ARE UNABLE TO DIGESTOR ABSORB ENTERAL NUTRITION: GIOBSTRUCTION, ILEUS, SURGERY, TRAUMA
REQUIRES MONITORING OF GLUCOSE,
ELECTROLYTES, LIPIDS, PROTEINS
PARENTERAL NUTRITION
CLEAR LIQUID: BROTH, COFFEE, TEA,DIET PROGRESSION
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Q , , , FRUIT JUICES, GELATIN, POPSICLE
FULL LIQUID: ALL JUICES/ SHAKE, PUREED VEGGIES, CUSTARD, COOKED CEREALPUREE: PUREED MEAT/FRUITS, SCRAMBLED EGG, MASHED POTATOES
MECHANICAL SOFT: GROUND OR FINELY FLAKEDMEAT/ FISH, CHEESE, RICE, POTATOES,HOTCAKES, LIGHT BREAD, SOUP
SOFT: TENDER MEAT, SOFT FRESH FRUIT, CAKE,
COOKIES (NO NUTS)
BOWEL ELIMINATION
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FECES MOVES INTO RECTUM RELAXINGINTERNAL ANAL SPHINCTER THENEXTERNAL ANAL SPHINCTER RELAXES TOEXPEL FECES. IF NOT, LEVATOR ANIMUSCLES, HELP KEEP SPHINCTER CLOSED.
VALSALVA: FORCEFUL EXPIRATION THRU ACLOSED GLOTTIS. IT FACILITATESDEFECATION BY INCREASINGINTRAABDOMINAL PRESSURE.
FECALYSIS
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1 INCH (FORMED); 15-30 ml (LIQUID)COLOR: YELLOW-BROWN RT STERCOBILINODOR: PUNGENT RT INDOLE & SKATOLE
FREQUENCY: 1-3x/DAY (INFANT)CONSISTENCY: SOFT BUT FORMED, SHAPE
REFLECTS RECTAL DIAMETER.*RAPID TRANSIT TIME: LESS WATER
REABSORBEDLIQUID STOOL*SLOW OR DELAYED: MORE ABSORPTION
HARD & DRY STOOLS
BULK FORMER= SAFEST. PSYLLIUM (METAMUCIL).TAKE WITH WATER TO PREVENT IMPACTION
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STOOL SOFTENER= Na DOCUSSATE.
OSMOTIC AGENT= ABSORBS WATER.LACTULOSE: GIVE BEFOREBREAKFAST OR BEDTIME.
MILK OF MAGNESIA: LOWERDOSES ACT AS ANTACID
LUBRICANTS= MINERAL OIL. GIVE UPRIGHT: NOTWITH MEALS!CHEMICAL IRRITANTS= > PERISTALSIS
BISACODYL (DULCOLAX): GIVE ac, WAIT 1 HOUR
BEFORE MILK OR ANTACID.SENA (SENOKOT): GIVE hs, DISCOLORS URINECASTOL OIL= TAKE WITH SODA
SKIN CARE/HYGIENEBED BATH
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BED BATH*cover with top sheet up to shoulder level.
*To avoid chills: close windows; warm water;expose, wash & dry 1 body part at a time: eyes,face, ears, neck-forearms-distal arms-hands-chest-abdomen-legs-feet-back-buttocks-perineum
*Extremities: long firm strokes (D-P)*Back: P-D
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ORAL CAVITY CARECheilosis: lip cracking (Vit B12 def)
D t l C i t th di i t ti (b
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Dental Caries: teeth disintegration (browndiscoloration) lactic & pyruvic acid(product of bacterial action on CHO)
Gingivitis
Glossitis
Parotitis/MumpsPeriodontitis
Stomatitis
Tartar: visible hard deposit of plaque(bacteria, saliva, EC on teeth enamel)
EYES, EARS, NOSE CARE
Hyperopia: Farsightedness; ray of light focusBEHIND retina
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BEHIND retinaMyopia: Near; IN FRONT retina
Presbyopia: impaired near vision DT
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p *daily wear: removed overnight & not worn
>10-14 hr/day *extended wear: worn not >6 consecutive
nights without cleaning Artificial Eyes: Depress lower eyelid to remove
eye, hold it between thumb & index, clean withwarm NSS!
EARS CARE*moist washcloth, ear canal straightening
*Impacted cerumen: instill H2O2 1-2 drops/ear 3x/d
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Impacted cerumen: instill H2O2 1-2 drops/ear 3x/dfor 3d. Irrigate with 250 ml WARM water!
(hot/cold: NV)
NOSE CARE
*gentle blowing thru open nostrils
*soften crusted secretion with NSS
BED MAKINGBed Types:
1 Unoccupied Bed
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1. Unoccupied Bed
*Open: top cover (folded back)
*Closed: Top sheet (spread up)
2. Occupied Bed: bed made c pt
BiRD TaBa Po! Bottom, Rubber, Draw, Top, Blanket,
Pillow case
Grieving and Death
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Loss- actual or potential situation in whichvalued object, person changed so that it is nolonger perceived as valuable.Bereavement is a subjective response to aloss through death.
Grief-total response of emotional experience ofthe loss and is manifested in thoughts,feelingsand behaviorMourning- behavioral process through which
grief is eventually resolved or altered.
g
Stages of Grieving
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DenialAnger
BargainingDepressionAcceptance
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Signs of impending clinicaldeath
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Loss of muscle toneSlowing of circulationChanges in vital signsSensory impairment
death
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THANKS