fundamentals of nursing notes
TRANSCRIPT
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I. Nursing Theorists
Faye Abdellah Identification of 21Nursing ProblemsLydia Hall Care, Core and Cure (3 Cs)Virginia Henderson Identification of the 14Basic Needs
Imogene King GoalAttainment TheoryMadeleine Leininger Transcultural Nursing
Myra Levine FourConservationPrinciplesFlorence Nightingale Environmental Theory
Betty Neuman Stress ReductionDorothea Orem Self-Care and Self-DeficitRosemarie Parse Human BecomingHildegard Peplau Interpersonal Relations ModelMartha Rogers Science of Unitary Human BeingsCallista Roy AdaptationModelJean Watson Human Caring
Metaparadigm for Nursing Theories: CHEN (Client, Health, Environment, Nursing)
II. CHAIN OF INFECTION
Six links
Host (susceptible)
Agent
Reservoir
Entry (mode of)
Transmission (mode of) direct, vehicle, vector
Exit (mode of)
Surgical vs Medical Asepsis
Surgical sterile free from ALL microorganisms
Medical clean free from pathogenic microorganisms
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III. ISOLATION PRECAUTIONS
Standard Precautions(Universal precautions)
Applies to ALL body fluids, secretions, blood, non-intact skin and excretions except sweat
Includes hand washing, wearing clean gloves, mask and gown
Transmission Based Precautions
Airborne used for clients with illnesses transmitted by airborne droplets (less than 5 microns)
- Examples: Tuberculosis, Chickenpox, Measles
- Place client in private room but if no private room is available place client in a room with another
client infected with the same microorganism
- Wear N95 respirator
Droplet used for clients with illnesses transmitted by droplet nuclei ( greater than 5 microns)
- Examples: Diptheria, Pertussis, Meningitis, Mumps
- Wear mask when working within 3 feet from the client
IV. PERSONAL PROTECTIVE EQUIPMENT (PPE)
Sequence of removing PPEs
Gloves
Mask
Gown
Eyewear
V. INSERTION OF NASOGASTRIC TUBE
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Measure length of tube tip of the nose to the tip of the earlobe to the xiphoid process
Position High Fowlersposition with neck hyperextended
Lubricate tip of tube with water soluble lubricant
Instruct the client to swallow or drink from a straw while the tube is being inserted
STOP and remove the tube if client becomes cyanotic or coughs
Placement- check
- Aspirate gastric secretions measure pH
- Auscultate and inject air into the tube (whooshing sound)
- X-ray best measure to determine proper placement (initial placement)
Secure tube using tape to the bridge of the clients nose and to the clients gown
VI. TUBE FEEDINGS
Position: Fowlersposition
Assessment: Check patency of tube and Aspirate residual contents before feeding (if 100 ml or more than 50%of last feeding withheld and check)
For feedingbags: Hang bag from infusion pole HEIGHT: 12 inches
Complications: Dumping syndrome, aspiration pneumonia, diarrhea, hyperglycemia, nausea and vomiting
VII. INTESTINAL OSTOMIES
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Assessment: color should be bright red( not purple, bluish, pale, etc.), peristomal skin, amount and type of
feces (Ileostomy liquid feces / acidic, ascending semi-liquid, transverse semi formed, descendingand sigmoidostomy formed feces / aromatic and smelly)
Empty bag when it is 1/3 full
Apply a barrier (i.e. Karaya gum) over the skin around the stoma to prevent skin breakdown
Control Odors (deodorizers, charcoal disks, prevent odor-causing foods)
Complications: Fluid and Electrolyte imbalance, skin breakdown, constipation, infection
VIII. ENEMAS
Classified into FOUR: Cleansing, Carminative, Retention and Return Flow
Position: Left Lateralposition
Protection: Wear clean gloves
Lubrication: lubricate with water soluble lubricant
Insertion: Insert 3-4inches (adult), 2-3inches (children)
Administration: administer gradually
IX. URINARY CATHETERIZATION
Steriletechnique
Insertion
Male FemalePosition Supine (legs slightly abducted)
Penis at 90 degree angle
Supine (with knees flexed andexternally rotated)
Length to be inserted 6-9inches 2-3inches
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Length of catheter
(Adult)
40 cm 22 cm
X. TRACHEOSTOMY
Position: (during insertion) Fowlers position
Use: Sterilegloves
Time: 2-3 minutesbetween suctions when possible, suction applied for 5-10 secondsto minimize oxygen loss
Clean with: After removing the inner cannula it is soaked in full strength hydrogen peroxideto moisten andloosen dried secretions. After cleaning the cannula, it should be rinsed with sterile normal salineto removetraces of hydrogen peroxide from the cannula before replacing it and securing it in place again.
When changing the ties: tie one end of the new tie to the eye of the flange while leaving old ties in place
Before tying the tapes: be able to put two fingersunder the tapes before tying it
Parts: Inner cannula, outer cannula and obturator
Object at bedside: Obturator(for reinsertion), suction machine/apparatus (for removing secretions)
XI. CHEST PHYSIOTHERAPY (PVP)
-done beforemeals (but not immediately before meals) or 2 hours after meals
-increase fluid intake to liquefy secretions
P ercussion
V ibration
P ostural drainage
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XII. ANTIEMBOLISM STOCKINGS
Indication: to prevent thrombophlebitis by promoting venous return from the legs
The client must be measured to ensure proper fit of the stockings
When to apply: during the morning before the client gets out of bed (elevate for at least 15 minutes)
When to remove: remove 20-30 minutes every 8 hours
Assess skin for breakdown
XIII. BLOOD TRANSFUSION
FIRST: Check if properly typed and cross matched
Gauge of needle: g #18
Drop factor: 10 gtts/min(1st30 mins.)
Duration: RBCs and whole blood 4 hours, FFP Fresh frozen plasma, platelets not more than 20
minutes
Rate: KVO
IVF: Plain NSS
Monitor: vital signs (every 15 minutes for 1sthour), any adverse reactions
When reaction happens: STOPthe transfusion and notify the physician
Common blood transfusion reactions:
Anaphylactic reaction s/sx: rashes and hives
Hemolytic reaction s/sx: flank/back pain
Pyrogenic reaction s/sx: fever, headache
Cardiogenic reaction - s/sx: dyspnea
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XIV. CHEST TUBES
What to do if:
Tube becomes disconnected from the bottle place end of tube in a bottle with NSS
Tube becomes disconnected from the client cover wound with sterile dressing
Water seal has vigorous bubbling there is a leak clamp tube nea rest the client (intermittent bubbling normal, vigorous/continuous bubbling-abnormal)
Transporting the client bottle below chest level and upright
XV. PAIN
Study: Gate control theory(Substantia gelatinosa)
Analgesics, patient controlled analgesia (PCA), transcutaneous electrical nerve stimulation (TENS), imagery,massage
Pain assessment (some common indicators)
MI Crushing pain, (someone sitting in my chest), radiates fromchest to back
Angina Stab-like pain, , radiates from chest to jaw to left shoulder andarm
Hypertension / hypertensive crisis Pounding painEctopic pregnancy Knife-like pain
Gastric ulcer Gnawing painUTI Flank pain
Pancreatitis Radiates from Left upper quadrant to left shoulder
XVI. ASSISTIVE DEVICES
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CANES
- opposite the affected leg (C-O-A-L)
- angle is 20 to 30 degrees
- the length should permit the elbow to slightly flex
WALKERS
- Hand bar below the clients waist and the elbow is slightly flexed
CRUTCHES
- Angle of elbow flexion 30 degrees
-weight of the body should be borne by the arms not the axilla to prevent CRUTCH PALSY
- Crutches are placed 6inches in front and 6inches laterally
- the feet should be slightly apart, hips and knees extended and back is straight
- Four point gait right crutch, left foot, left crutch, right foot
- Three point gait right and left crutch with weak leg, stronger leg
- Two point gait- right crutch and left foot together, left crutch and right foot
- Swing to gait- move both crutches forward, lift body weight and swing to crutches
-Swing through gait - move both crutches forward, lift body weight and swing through beyond the
crutches
- Going up the stairs (remember: all good people go to heaven) when going up, lift (good)unaffected leg first followed by the crutch, affected leg.
XVII. SPECIAL DIETS
DIET DISORDERLow carbohydrate Dumping syndrome
Low protein Renal failure, Acute glomerulonephritis, uremia, anuriaHigh protein Nephrotic syndromeLow sodium Heart failure, CVDs, Nephrotic syndromeHigh fiber Constipation, hyperlipidemia
Low residue Bowel inflammation ( diverticulitis and ulcerative colitis)Acid/Alkaline ash (depending on the lab analysis of the stones)
Retard renal calculi formationClear liquid Following acute vomiting or diarrheaFull liquid Gastrointestinal upsets, progression from clear liquids
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Gluten-free For clients with Celiac diseaseTyramine-free To prevent fermented and processed foods for clients taking
MAOIsPurine restricted Gouty arthritis, uric acid stones
XVIII. DEGREES OF BURNS
Superficial Partial Thickness
- area involved: epidermis
- tingling, erythema, minimal or no edema
Deep Partial Thickness
- area involved: epidermis, dermis
- w/ PAIN,hyperesthesia, BLISTERS, edema, weeping surface, mottled and red base
Full Thickness
- area involved: epidermis, dermis, may involve subcutaneous and connective tissue, muscle andbone
- PAIN FREE, shock, dry, PALE, WHITE leathery or charred skin, broken skin with fat exposed,edema
XIX. PRESSURE ULCERS (STAGES)
Stage 1 ERYTHEMA(redness), elevated temperature, patient complains of discomfort
Stage 2 Skin breaks, abrasions, BLISTERS, shallow crater, edema, infection may develop
Stage 3 ulcer extends into the subcutaneous tissue, necrosis and drainage, infection develops
Stage 4- ulcer extends into the muscle and bone, deep pockets of infection develop
XX. VITAL SIGNS
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TEMP
NV (Adult) 36.0-37.5 0
C
PR
60-100 bpm
RR
12-20 bpm
BP
120/80 mmHg
Oral-2-3 mins
Rectal 2-3 mins(most accurate)
Axillary 6-9 mins(least accurate)
Tympanic
AngPET Mo
A-pical
P-ulmonic
E-rbs pt.
T-ricuspid
M- itral
Others:
Brachial BP
Apical usedfor children below3 y/o
Breath Sounds:
Stridor- shrill and harsh (laryngeal obstruction)
Wheeze highpitched/musical (Asthma)
Volume:
Hypoventilation-slow andshallow (Respiratory acidosis
pursed lip)
Hyperventilation-deep andrapid (Respiratory alkalosis
brown paper bag)
-cover about 2/3 of the limb
Position:sitting
Release valve on cuff carefully -2-3mmHg/sec
Wait 1-2min before taking another BP
BP erroneously high-Cuff too narrow,arm unsupported, no rest beforeassessment, cuff wrapped loosely,
deflating too slowly (high diastolic),assessing immediately after a meal
BP erroneously low- cuff too
wide, arm above heart level
Monitor in clients
who are/has:
immunosuppressed,
receiving chemo, etc
Bleeding, takingdigitalis, has DVT
or
thrombophlebitis
Anxious, receiving morphineand Magnesium sulfate
Cardiac problems, DM, RF
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10 HERBAL PLANTS (Advocated by DOH)
Lagundi Asthma, cough, fever Bayabas For washing wounds,mouthwash/gargle, toothache
Yerba Buena Pain, headache, stomachache,toothache, menstrual and gas
pain
Akapulko Anti-fungal
Sambong Anti-edema, anti-urolithiasis Ulasimang Bato Lowers uric acid
Tsaang Gubat Diarrhea,
stomachache
Bawang For hypertension/
toothache
Niyug-niyugan Anti-helminthic Ampalaya To lower blood sugar levels