fundamentals of nursing notes

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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