1

Pressure Ulcers
„ Risk Factors „ Diminished sensation
„ Immobility
Integrated Test 3 „ Excessive body heat
„ Inadequate nutrition
„ Advanced age
„ Fecal & urinary
incontinence „ Chronic medical
conditions
„ Decreased mental
status

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Standard Precautions
6. „ Designed for all clients in hospital

Isolation Precautions „ Apply to…

„ Blood
„ All body fluids, secretions, excretions except sweat

Tier 1: Standard Precautions „ Non-intact (broken) skin

„ Mucous membranes
Tier 2: Transmission-based
Precautions „ Designed to reduce risk of transmission of
microorganisms from recognized & unrecognized
sources

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Standard Precautions „ Care of client with a sealed radiation source

„ Private room with a private bath

„ Handwash
„ Place caution sign on client’s door
„ Gloves, Goggles, Gown
„ Organize nursing tasks to minimize exposure
„ Handle soiled equipment & linen carefully „ Rotate nursing assignments to client

„ Sharps precautions „ A nurse should never care for more than one client
with a radiation implant at one time

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„ Care of client with a sealed radiation source (cont.) „ Skin Traction a. Buck’s traction
„ Limit time to ½ hour per care provider per shift „ Weights are attached
to a moleskin or
„ Wear a lead shield adhesive strip secured b. Russell traction
by elastic bandage (or
„ Do not allow a pregnant nurse to care for client
foam rubber boot) c. Cervical traction
„ Do not allow visitors who are pregnant or <16yo used to cover the
affected limb
Limit visitors to ½ hour per day; visitors should be a least 6
„
feet from source d. Pelvic traction

„ Save bed linens & dressings until the source is removed

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„ Pelvic halter/ traction b. Chronic alcoholism leads to enzyme
„ Pelvic girdle with extension straps attached to ropes and weights
induction, thus the need for increased
„ Used for low back pain to reduce muscle spasm and maintain
alignment
dosage of analgesics
c. Individualized pain thresholds
„ Usually intermittent traction
d. Dependency behavior is reinforced more
„ Client on semi-Fowler’s position with knee bent
if there’s immediate, unpredictable
„ Secure pelvic girdle around iliac crests gratification

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„ Play allows for therapeutic release of S/Sx of intestinal obstruction in an infant
tension & stress; manipulation of syringe 1. Absence of stools (esp. newborn)
& other equipment allows control over 2. Weak, thready pulse
threatening events 3. Cyanosis
4. Weak, grunting respirations from abdominal
distention, causing diaphragm to compress
lungs

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Concept of Death
„ Stages of Dying „ Stages of Grieving
Infant/toddler no concept of death „ “No, not me…” „ Shock, numbness,
„ “Why me?” disbelief
Preschool death as temporary sleep „ “If only….” „ Yearning & protest

„ (Silence) „ Identification stage

School age death as irreversible „ “Yes, it’s me.” „ Reorganization/

restitution
Late school age death as final

Adolescence understands the concept of death

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(Source: Belizario & de Leon. Philippine Textbook of Medical Parasitology 2nd ed.)

Plasmodium Incubation period „ HTLV I causes adult T cell leukemia and

tropical spastic disease
falciparum 8-15 days

vivax 12-20 days „ HTLV II causes T-hairy cell leukemia

ovale 11-16 days

malariae 18-40 days

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„ Hypersensitivity to iodine dye following
SHOCK
IVP
„ Hives, skin rashes, nausea, swelling of parotid
hypovolemic cardiogenic obstructive distributive
glands
septic neurogenic anaphylactic „ Anaphylactic (shock, dyspnea, decreased BP,
convulsions)

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„ Echolalia – stereotyped repetition of another
person’s words or phrases

„ Clang association – flow of thoughts are based

on similar sounding words

„ Neologism – making up new words

„ Word salad – stringing together of words that

seem to have no logical association