Vous êtes sur la page 1sur 10

Reversed Isolation – patient is protected

from pathogens and


TYPES OF ISOLATION nosocomial infections by
Strict Isolation – highly transmissible instituting reversed
diseases by direct contact and airborne transmission precautions
routes of transmission Burns and open wounds,
Private rooms, gowns, mask, patients with artificial airway,
gloves handwashing, double immunocompromised patients
bagged techniques for soiled – leukemia, AIDS, steroid
articles therapy, radiation or cancer
Ex. Diphtheria(pharyngeal), chemotherapy, medication
Herpes Zoster, Varicella, effect of leucopenia or
Pneumonia (S. Aureus, Strep agranuloctosis
group A)
Respiratory Isolation – droplet POSITIONING FOR SPECIAL CONDITIONS
transmission (3 feet) Abdominal aneurysm surgery – Fowler’s
Private room, patient w/ same Asthma – Orthopneic position
organism, handwashing, Autonomic dysreflexia – High fowler’s
labeled plastic bags for soiled Post-bronchoscopy – Semi-fowler’s
articles Cardiac catheterization – Keep insertion
Ex. H. influenza, measles, site extended for 4-6 hours to
mumps, N. meningitidis prevent arterial occlusion
Tuberculosis/ AFB isolation – Cast – Elevate extremity
suspected/active TB Cataract – Semi-fowler’s
Private room with negative Cerebral Aneurysm – Semi-Fowler’s
pressure ventilation, mask, Cleft Lip – Supine
handwashing, bronchoscopy Cleft Palate – Prone
and dental examination Congestive Heart Failure – High-Fowler’s
postponed until 2 weeks of Craniotomy – Supratentorial:Semi-Fowler’s;
antibiotic therapy Infratentorial: Flat
Contact isolation – infectious diseases or Increased ICP – Elevate Head
multiple resistant Dumping Syndrome – Supine after meals
microorganisms that are Epistaxis – Lean forward
spread by direct contact or Flail Chest – Affected Side
close contact. Femoro-Popliteal Bypass Graft – Affected
Private room, mask, gown, extremity extended
gloves Glaucoma(post-op) – Affected side
Ex. Diphtheria (cutaneous), Hemorrhoidectomy – Side-lying
Herpes simplex, MRSA, Hiatal Hernia – Upright
Pediculosis, Scabies, Syphilis Hip Surgery – Legs in Abduction
Enteric precautions – infectious diseases Laminectomy – Back as straight as possible
transmitted through direct or Liver Biopsy – Right side-lying
indirect contact with infected Lobectomy – Semi-Fowler’s
feces Mastectomy – Elevate extremity on pillow
Handwashing, gloves, gowns Myelogram – Water-based dye:Elevate the
worn only when handling head; Oil-based dye: Flat
contaminated objects with Prolapsed cord – Knee-chest position
feces Pulmonay edema – Fowler’s
Ex. Aseptic meningitis, AGE, Pyloric stenosis – Right side-lying
Hepa A, Typhoid fever, Radium implant – Flat on bed
diarrhea Retinal detachment – Affected side towards
Drainage/Secretions precautions – patient the bed
with wound drainage or Seizure – Side-lying
infected wounds Shock except Cardiogenic shock –
Gloves, gowns indicated if Modified Trendelenburg
clothing is likely to be Cardiogenic Shock – Semi-Fowler’s
contaminated Spinal Cord Injury – Immobilize
Ex. Burns Tonsillectomy – Side-lying/Prone
Throidectomy – Semi-Fowler’s
Thrombophlebitis – Elevate Leg
Universal Blood and Bloody Fluids Total Parenteral Nutrition – Trendelenburg
Precautions – blood- borne, – During insertion
body fluids (blood, semen, Thoracentesis – Fowler’s (During procedure)
vaginal secretions, CSF, Position of comfort (After
synovial fluid, pleural fluid, procedure)
peritoneal fluid, pericardial THERAPEUTIC DIET FOR SPECIFIC
fluid, amniotic fluid) CONDITIONS
Gloves, mask, protective AGE- Clear liquids
eyegears, gown, contaminated AGN – Low Na, Low CHON
needles not recapped and Addisons’s Disease – High Na, Low K
sharps in puncture resistant Anemia, Pernicious – High CHON, Vit B
containers Anemia, Sickle Cell – High Fluid
Ex. AIDS, Hepatitis B and C, Gout – Purine Restricted
STD’s ADHD and Bipolar Disorder – Finger foods

________________________________________________________
Burn – High calorie, High CHON
Celiac Disease – Glutein-free II. SECONDARY PREVENTION
Cholecystitis – High CHON, High CHO, Low ➢ Emphasizes on early detection of
Fat disease/diagnosis (case finding)
Congestive Heart Failure – Low Na, Low ➢ Prompt intervention / treatment
Cholesterol (passive--immunoglobulin)
Crohn’s Disease – High CHON and CHO, Low ➢ health maintenance for individuals
Fat experiencing health problems
Cystic Fibrosis – High Calorie, High Na ➢ includes prevention of complication &
Urolithiasis – Acid ash for alkaline stones; disabilities (turn side-to-side, increase
Alkaline ash for acid stones fluid intake)
Decubitus ulcers – High CHON, High E.g.
Vitamin C 1. SCREENING
Diarrhea – High K, High Na 2. Encouraging regular checkups
Dumping syndrome – High Fat, High 3. Teaching BSE & TSE
Protein, Low CHO 4. Nursing assessment & CARE
Hepatic Encephalopathy – Low CHON provided (home, hospital, agency)
Hepatitis – High CHON, High calorie
Hirschprung’s Disease – Low Residue, High
CHON and CHO III. TERTIARY PREVENTION
Cirrhosis – Low CHON ➢ Begins after illness
Meniere’s Disease – Low Na ➢ When a defect/disability is fixed,
Myocardial Infarction&Hypertension – stabilized or irreversible
Low Cholesterol, Fats & Na ➢ Support for the client to achieve
Hyperthyroidism – High calorie and CHON a. successful
Hypothyroidism – Low Calorie, Low adaptation to
Cholesterol, Low Saturated Fat known risk
Nephrotic syndrome – Low Na, High CHON, b. optimal
High Calorie reconstitution
Hyperparathyroidism – Low Calcium c. re-establishment
Hypoparathyroidism – High Calcium, Low of high level
Phosphorus wellness
Osteoporosis – High Calcium, High Vitamin ➢ Focus: to rehabilitate & restore client
D to optimum level of
Pancreatitis – Low Fat functioning w/in the
PUD – High fat, High CHO, Low CHON constraints of disability
PKU – Low CHON/Phenylalanine E.g.
PIH – Hign CHON a. Referring a client w/ colostomy to a
Renal Failure (Acute) – Low CHON, High support group
CHO b. Teaching clients w/ DM to
(Oliguric Phase) – Low Na administer insulin
(Diuretic Phase) – High CHON, c. Physical therapy to post amputation
High Calorie, and restricted client
fluid
Renal Failure (Chronic) – Low CHON, Low OVERVIEW OF NURSING THEORIES
Na, Low K 1. FLORENCE NIGHTINGALE, 1850’s –
THREE LEVELS OF PREVENTION Mother of Modern Nursing
THEORY:Environmental Theory
I. PRIMARY PREVENTION NURSING: Provision of optimal conditions to
➢ Applied to generally healthy enhance the person’s reparative process and
individuals/groups prevent the reparative process of being
➢ Generalized health promotion interrupted.
(mother’s class) Nursing is religious calling for women.
➢ Specific protection against disease
2. VIRGINIA HENDERSON, 1966
(immunization)
THEORY: Definition of Nursing
➢ Precedes (before) disease or PERSON: A whole, complete and independent
dysfunction being who has 14 fundamental needs.
E.g. 1. to breathe
1. HEALTH EDUCATION about 2. eat and drink
a. prevention of accidents 3. eliminate
b. standards of nutrition 4. move and maintain posture
c. growth & development 5. sleep and rest
d. exercise 6. dress and undress
e. stress management 7. maintain body temperature
f. protection against 8. keep clean
occupational hazards 9. avoid danger
2. Immunization (active) 10. communicate
3. Risk assessment of specific 11. worship
disease 12. work
4. Family planning services & 13. play
marriage counseling 14. learn
5. Environmental sanitation & NURSING: The unique function of the nurse is
to assist clients, sick or well, in performing those
provision of adequate housing, recreation
activities contributing to health, its recovery, or
peaceful death – activities clients would perform

________________________________________________________
unaided if they have the necessary strength, will 9. HILDEGARD PEPLAU, 1952
or knowledge. THEORY: Psychodynamic Nursing Theory and
GOAL – to gain independence as soon as Interpersonal Relations Theory
possible NURSING: A maturing force that is realized as
➢ This definition was a major stepping- the personality develops through educational,
stone in the emergence of nursing as a therapeutic and interpersonal processes. It
discipline separate from medicine. involves four phases (Orientation, Identification,
➢ Nurse has complimentary and Exploitation, Resolution) The nurse acts as a
supplementary roles resource person, a counselor, and a surrogate.
➢ He/she can be a partner, a helper, or a Psychodynamic nursing is defined as
substitute for the client. understanding one’s own behavior to help
others identify felt difficulties and applying
principles of human relations to problems
3. MARTHA ROGERS,1970 arising during the experience.
THEORY: Unitary Human Beings as an Energy
Field 10. MADELEINE LEININGER, 1978
NURSING: A humanistic science dedicated to THEORY: Transcultural Care Theory or Culture
compassionate concern with maintaining and Care Diversity and Universality Theory
promoting health, preventing illness, and caring NURSING: She found it senseless to define
for and rehabilitating the sick and disabled. “nursing” as a distinct concept.
Seeks to promote symphonic interaction ➢ However, these are some of her
between the environment and the person. concepts with regards to culture care.
➢ “There can be no cure without caring,
but there may be caring without
4. DOROTHEA OREM, 1980 curing.”
THEORY: SELF-CARE DEFICIT THEORY ➢ Caring is the essence of nursing.
1. Self-care Theory ➢ Nursing care that is not congruent with
2. Self-care Deficit Theory beliefs, values of a patient’s culture will
3. Nursing System Theory lead to noncompliance and stress.
NURSING: A helping or assisting service to ➢ Through the three types of nursing care
persons who are wholly or partly dependent decisions and actions (Cultural Care
when they (to include others) are no longer able Preservation, Cultural Care
to give or supervise their care. Nursing is a Accommodation and Cultural Care
deliberate action. Restructuring), it is possible to provide
culture congruent care that is beneficial,
5. SISTER CALLISTA ROY, 1976 satisfying and meaningful to people.
THEORY: Adaptation Model
NURSING: A theoretical system of knowledge
that prescribes a process of analysis and action 11. JEAN WATSON, 1979
related to the care of the ill or potentially ill THEORY: Philosophy and Science of Nursing
person. Nursing is a science and a practice NURSING: The purpose of caring is to assist the
discipline. person in gaining control and becoming
knowledgeable, and in the process promote
6. IMOGENE KING, 1971 health changes.
THEORY: Goal Attainment Theory
NURSING: A helping profession that assists The science of caring is complementary
individuals and groups in society to attain, to science of curing.
maintain and restore health. If this is not
possible, nurses help individuals die with There are Ten (10) Carative Factors
dignity. Nurses interact with clients to 1. Formation of a Humanistic-
communicate information needed to establish Altruistic Value System
mutual goals and to explore and agree on 2. Faith-Hope
means to achieve goals (Transaction). 3. Cultivation of Sensitivity to Self
and Others
7. BETTY NEUMAN, 1972 4. Establishing a Helping-Trust
THEORY: Health Care Systems Model Relationship
NURSING: A unique profession in that it is 5. Expression of Feelings, Both
concerned with all the variables affecting an Positive and Negative
individual’s response to stressors, which are 6. Research and Systematic
intra-, inter-, and extrapersonal in nature. The Problem-Solving
concern of nursing is to prevent stress invasion, 7. Promotion of Interpersonal
or, following stress invasion, to protect the Teaching-Learning
client’s basic structure and obtain or maintain a 8. Provision for a Supportive,
maximum level of wellness. The nurse helps the Protective, and/or Corrective
client through primary, secondary, and tertiary Mental, Physical, Sociocultural
prevention modes, to adjust to environmental and Spiritual Environment
stressors and maintain client system stability. 9. Gratification of Human Needs
(low and high order needs) –
8. DOROTHY JOHNSON, 1968 survival, functional, integrative
THEORY: Behavioral System Model and growth-seeking needs.
NURSING: An external regulatory force that 10. Allowance for Existential
acts to preserve the organization and Phenomenological Force
integration of the client’s behavior at an optimal
level under those conditions in which the 12. FAYE ABDELLAH, 1960
behavior constitutes a threat to physical or THEORY: Typology of Nursing Problems
social health or in which illness is found. NURSING: Promotion of wholeness for all
whether well or ill. Must use a problem-solving
approach.

________________________________________________________
Lists 21 Nursing Problems that fall into one of science rather than one founded on the natural
the three categories. sciences.
1. Physical, emotional, social needs
2. Interpersonal needs 19. MARGARET NEWMAN, 1979
3. Common elements of client care. THEORY: Energy Field Theory – “Health as
Expanding Consciousness”
NURSING: A partner in the process of
13. ERNESTINE WIEDENBACH, 1964 expanding consciousness. The nursing process
THEORY: Helping Art of Clinical Nursing is one of pattern recognition.
NURSING: An art based on goal-directed care.
Nursing consists of identifying a “need for help” 20. PATERSON AND ZDERAD, 1976
which is desired by the individual, ministering to THEORY: Humanistic Nursing
the need, and validating that the need was met. NURSING: The nurturing response of one
person (the nurse) to another in need (the
14. Joyce Travelbee, 1966 client), by performing actions to increase the
possibility that the client will make responsible
THEORY: Human to Human Relationship Model choices.
NURSING: Nursing is accomplished through
human-to-human relationships. She defined MAINTAINING ASEPSIS
Empathy as the ability to share in the patient’s  organisms mode of transmission
experience, and thus be able to predict the determines isolation precautions
behavior of the patient. She defined Sympathy
as going beyond empathy and occurring when
 barrier used to break the chain of infection
between mode of transmission and
the nurse desires to alleviate the cause of
patient’s suffering and is “involved but susceptible host
incapacitated”.  sterile items can be only stored for 1 -2
Her works are applicable to psychiatric nursing months
and greatly influenced hospice movement.  handwashing not less than 30 seconds
 autoclave – kills all micorbes including
15. LYDIA HALL, 1960’S spores –penetrate thick linen
THEORY: Theory of Care, Core and Cure
NURSING: Nursing is helping clients move in
 patient in isolation – need sensory
stimulation
the direction of self-awareness. Nursing care is
given exclusively by nurses educated in the  soaps and detergents – remove bacteria
behavioral sciences who take the responsibility – lower surface tension of water and act as
and opportunity to coordinate and deliver the emulsifying agents
total care of their patients. This includes  antiseptic – inhibit growth
nursing, teaching, and advocacy in fostering  bactericides and disinfectants –
healing. detsroy pathogens
16. IDA ORLANDO, 1961  exudate – clear protein rich fluid
THEORY: Dynamic Nurse-Patient Relationship  good nutrition - crucial in the healing of
or Deliberative Process of Nursing pressure ulcers
NURSING: Nurse’s reaction to patient behavior THERAPIES AND TREATMENTS
forms the basis for nurse actions. It can be  phlebitis – warmth and burning sensation
Automatic or Deliberative.
Orlando emphasized patient participation in
 Z – track - prevent skin staining and
planning care by allowing the patient to give
irritation
feedback.  mid – deltoid - can accommodate only 1
ml. of medication
17. MYRA LEVINE, 1969  insulin injection- validate dose accuracy
THEORY: Four Conservation Principles of  insulin injection – G25 , 5/8 “ needle
Nursing
NURSING: Nursing is a human interaction
 G20 – IM oil based
designed to promote “wholeness” through  22G 1 ½”– im meds.
adaptation. Nursing care is seen as both  G26 – intradermal
supportive and therapeutic. The supportive  length of tubing should make no influence
aspect is designed to maintain a state of in how the infusion flows
wholeness in the face of a client’s failing health. COMFORT AND SAFETY MEASURES
The therapeutic aspect is designed to promote
adaptation that contributes to health or
 lotions containing lanolin – preferred
for backrub
restoration of health of clients.
KEY CONCEPTS  sleep deprivation causes behavior and
1. Conservation of Energy personality changes. adequate sleep
2. Conservation of Structural maintains coordination and perception and
Integrity decreases restlessness
3. Conservation of Personal  REM –deep sleep, depressed muscle tone
Integrity and possibly irregular heart and
4. Conservation of Social respiratory rates
Integrity
 NON-REM SLEEP is a deep restful sleep
18. ROSEMARY RIZZO PARSE, 1981 without dreaming
THEORY: Theory of Human Becoming  DELTA STAGE OR SLOW WAVE SLEEP –
NURSING: Focuses on man as “living unity”. non-REM stage III and IV –quiet sleep
Goal is to guide individuals and families uncover  napping in the afternoon – not
the meaning and relate it to their present conducive to nightime sleeping
situation. Parse sees nursing as a human  pain is whatever the patient says it is ,
exists whenever she says it does

________________________________________________________
 preventing pain is always easier than  Lungs and kidneys - body’s homeostatic
relieving it regulators
 bedrail only a reminder not to leave bed  Hypertonic solution enema-120 ml left
SPECIAL NEEDS in place for 7 – 10 minutes
 Aging decreased elasticity of blood  Cleansing enema – 1000 ml.
vessels, increased peripheral resistance MOBILITY
and decreased blood flow  INCREASED ADRENALIN PRODUCTION
 Azheimer’s Disease – loss of short term IN IMMOBILE PATIENTS – DECREASED
memory PERISTALSIS
 sensory deprivation- involuntary loss of  Anorexia – depleted protein stores
physical awareness caused by detachment  Anatomic alignment prevents strain
from external sensory stimuli – isolation on body parts, amintains balance and
 speak directly in front and enunciate promotes physiologic functioning
well- hearing impaired  Drawsheet is the best device to use when
 “devoid of feelings” – acceptance in the moving a patient up in bed
grieving process nurse can help ensure a  Virchow’s triad- collectively predispose a
peaceful death by providing dignified ptient to thrombophlebitis , impaired
support venous return to the heart , blood
 high protein diet – acidic urine ; hypercoagubility and injury to to blood
vegetarian diet – alkaline urine vessel wall.
 TPN CONSIDERATIONS: GENERAL  Valsalva maneuver – forced expiratory
COND;- LOSS OF 7% OF USUAL effort against a closed glottis
BODY WEIGHT OVER 2 MONTHS, LACK  Oxygen improves respiratory function
OF ORAL NUTRITION FOR 5 DAYS, PRE- only if he has symptoms of hypoxia
OP. PREPARATION OF SEVERELY  Cold skin and impalpable pulse in the
MALNOURISHED PATIENTS, CA in the GIT leg – refer ASAP (embolus)
and IBD
 Pulse rate – most reliable indicator of
 Soft diet – no fried foods , organ or red activity tolerance
meats, whole grain breads and seasoning
 Complication of immobility – foot drop
 Bland – no gastric irritants and
seasonings, fruit juice OK
 Venturi mask – precise o2 concentration. HEMATOLOGY
 Humidification of O2 – distilled H2O
 Vomiting of fluids for 3 days – loss of
fluids

DETERMINATION REFERENCE RANGE CLINICAL SIGNIFICANCE

Bleeding Time 1.5-9.5 min Prolonged in thromcytopenia,


defective platelet function and
aspirin therapy.

Factor VIII Assay 60% - 140 % Deficient in Classical


Hemophilia

PTT (Activated) 25-45 sec Prolonged deficiency of


fibrinogen factors II, V, VIII, IX,
PTT (normal 2.5x control) X , XI and XII and in heparin
therapy
60-70 sec

PT 9-14 sec Prolonged by deficiency of


Factos I, II, V, VII and X, fat
malabsorption, severe liver
disease, Coumarin
anticoagulant therapy

INR 1.0 Used to standardize the


prothrombin time and
anticoagulation therapy.

Erythrocyte count M: 4.6-6.2 x 1012/L Increased in severe diarrhea


and dehydration,
F: 4.2-5.4 x 1012/L polycythemia, acute
poisoning, pulmonary fibrosis

Decreased in all anemias, in


leukemia and after
hemorrhage when blood

________________________________________________________
volume has been restored

ESR Westergren Method <15-200 mm/h Increased in tissue


destruction, whether
ESR Zeta Centrifuge Method <0.40-0.60 inflammatory or degenerative,
during menstruation and
pregnancy and in acute febrile
illness

Hematocrit M: 42-52% Increased in erythrocytosis of


any cause and in dehydration
F: 35-47% or hemoconcentration
associated with shock.

Decreased in severe anemias,


anemia of pregnancy, acute
massive blood loss.

Hemoglobin M: 13-18 g/dL Increased in polycythemia,


COPD, failure of oxygenation
F: 12-16 g/dL because of CHF and normally
in people living at high
altitudes

Decreased in various anemias,


pregnancy, severe or
prolonged hemorrhage, with
excessive fluid intake

WBC/Leukocytes 5 000-10 000/cu mm Increased in various infections

Neutrophils 45%-73% Neutrophils increased with


acute infections, trauma or
Eosinophils 0%-4% surgery, leukemia, malignant
disease, necrosis; Decreased
Basophils 0%-1%
with viral infections, bone
Lymphocytes 20%-40% maroow suppression, primary
bone marrow disease
Monocytes 2%-8%
Eosinophils increase in
allergies, parasitic disease,
collagen disease, subacute
infections, decreased with
stress, use of some
medications (ACTH,
epinephrine, thyroxine)

Basophils increased with acute


leukemia and following
surgery or trauma, decreased
with allergic reactions, stress,
parasitic disease, use of
corticosteroids.

Lymphocytes increased with


infectious mononucleosis, viral
and some bacterial infections,
hepatitis, decreased in aplastic
anemia, SLE,
immunodeficiency including
AIDS

Monocytes increased with viral


infections, parasitic disease,
collagen and haemolytic
disorders, decreased with use

________________________________________________________
of corticosteroids, RA, HIV
infection

Platelet count 150 000-450 000/cu mm Decreased in


thrombocytopenic purpura,
acute leukemia, aplastic
anemia and during cancer
chemotherapy

SERUM, PLASMA AND WHOLE BLOOD CHEMISTRIES

DETERMINATION REFERENCE RANGE INCREASED DECREASED

Conventional SI Units
Units

Acid, total M: 2-12 U/L M: 2-12 U/L Carcinoma of


phosphatase prostate
F: 0.3-9.2 U/L F: 0.3-9.2 U/L
Advanced Paget’s
Disease

Hyperparathyroidis
m

Gaucher’s Disease

Alkaline Adults: 50-120 50-10 U/L Conditions


phosphatase U/L reflecting increased
osteoblastic
activity if the bone

Rickets

Hyperparathyroidis
m

Hepatic Disease

Bone disease

Ammonia 15-45 ug/dL 11-32 umol/L Severe liver


(plasma) (varies with disease
method)
Hepatic
decompensation

Amylase 60-a60 Somogyi 111-296 U/L Acute pancreatitis Chronic


U/dL pancreatitis
Mumps
Pancreatic
Duodenal ulcer fibrosis and
atrophy
Carcinoma of head
of pancreas Cirrhosis of liver

Prolonged elevation Pregnancy (2nd


with pseudocyst of and 3rd
pancreas trimester)

Increased by
medications that
constrict pancreatic
duct sphincters
(morphine,
codeine,

________________________________________________________
cholinergics)

AST (Aspartate M: 10-40 U/L M: 0.34-0.68 Myocardial


aminotrnasferase µkat/L infarction
) formerly SGOT F: 15-30 U/L
F: 0.25-.0.51 Skeletal muscle
µkat/L disease

Liver disease

ALT(Alanine M: 10-40 U/ml M: 0.17-0.6 Same conditions as


aminotransferase µkat/L AST (SGOT) but
) formerly SGPT F: 8-35 U/ml increase is more
F: 0.14-0.60 marked in liver
µkat/L disease than AST

Bilirubin Total: 0.3-1.0 5-17 µmol/L Hemolytic


mg/dL anemia(indirect)

Direct: 0.1-0.4 Biliary obstruction


mg/dL 1.7-3.7 µmol/L and disease

Indirect: 0.1-0.4 Hepatocellular


mg/dL damage(hepatitis)
3.4-11.2 µmol/L
Pernicious anemia

Hemoltic disease of
newborn

BLOOD GASES

Oxygen, arterial 85-95 mm Hg 10.64-12.64 kPa Polycythemia Anemia


(whole blood)
Cardiac or
Partial pressure pulmonary
(PaO2) disease

Saturation (SaO2) 95%-99% Volume fraction: Cardiac


0.95-0.99 decompensation

Chronic
obstructive lung
disease

Carbon dioxide, 35-45 m Hg 4.66-5.99 kPa Respiratory acidosis Respiratory


arterial (whole alkalosis
blood) Metabolic alkalosis
Metabolic
Partial pressure acidosis
(PaCO2)

pH (whole blood, 7.35-7.45 7.35-7.45 Vomiting Uremia


arterial)
Hyperventilation Diabetic acidosis

 Care plans should never be unchangeable


and revised prn
 NANDA – responsible for formulating
NURSING PROCESS taxonomies or classifications
 Nursing processp provides continuity of  Nursing order should include the date, the
care and patient participation in health specific nursing action, time / length of
care time and signature

________________________________________________________
 Provide safety from falls – keep bed in  The nurse managers function is to guide ,
lowest level and locking wheels direct and coordinate patient care, not to
 The point at which the brachial pulse can provide it.
no longer be palpated provides an  Primary nursing – comprehensive form of
estimate of the maximum pressure nursing in which one nurse is responsible
required to measure systolic blood for comprehensive care of a given patient
pressure.  Evaluation of staff members must be
 Last Korotkoff sound heard on auscultation based on performance criteria as
with a stethoscope is the diastolic pressure established by professional standards and
 The primary reason for bedrest is to the job description.
decrease metabolic activity, which reduces  Poor performance stems from poor morale
the cells need for oxygen.secondary is to  Trust is the foundation of positive nurse
conserve energy and decrease cardiac patient relationship
output  Therapeutic communication – two way ,
 The normal APTT is 16 – 25 seconds and PT deliberative interaction between the
is 12 – 15 seconds, these levels must patient and nurse in which they establish
remain within two to two ½ the normal mutually acceptable, achievable goals
levels ---fundamental component at all phases of
 Negligence – failure to act as an ordinary the nursing process
prudent person would.  Problem orientedmedical record-
 Malpractice – professional misconduct, information is recorded as
improper discharge of professional duties prob.,observations and plan
or failure to meet standards of care  Narrative chart – decriptive storylike
 Three elements necessary to establish record
nursing malpractice – nursing error , injury  A positive change in the patient’s behavior
and proximal cause is the best way to identify learning
 A DNR order means that basic and  Teacher should always try to involve the
advanced life support measures won’t be learner
initiated if respiratory or cardiac arrest  Asking questions shows that the patient is
occurs. It does not mean that ordinary interested in learning
treatment measures or nursing care is  Maintaining independence, a need
stopped common to patients of all age-groups,
COMMUNICATION SKILLS fosters the elderly person’s feelings of self
Nursing theory – one that generates worth
knowledge in nursing NURSING ASSESSMENT
 Conceptual model – group of general ideas  Too much Yin causes digestive disorders
that serves as framework upon which and nervousness and too much yang
nursing theories can be developed and causes dehydration , fever and irritability.
tested.  Correct sequence in abdl. Assessment is
 In 1960, Nursing schools adopted theories RLQ, RUQ, LUQ and LLQ
from the biological and psychosocial  Guaiac – hemoccult test
sciences to serve as conceptual  Rectal examination – sims , genupectoral
frameworks and dorsal recumbent
 Four concepts – person, environment –  Romberg test – test for sensory or
health and nursing(actions) cerebellar ataxia
 Martha Rogers – life process model –  Narrowed pulse pressure less than 30 –
evolving creature interacting with the hypovolemia
environment in an  Oral temp.-36.1- 37.8’C (axillary
open, adaptive manner-achieve maximum 1‘deg.lower) (rectal -1’higher)
health in his environment  BP cuff small – false high readings
 Dorothea Orem – persons need to achieve  Rectal temp – 3 to 5 mins. And axillary 10
self care. Goal of nursing is to help patient mins.
develop self- care activities to maintain  Rinne hearing tests compare sound
maximum wellness conduction through air and bone.air
 High level wellness - OLOF conduction greater than bone conduction
 Maslow – a need as a satisfaction whose normal hearing or sensorineural hearing
absence can cause illness loss. Vice versa conductive hearing loss
 Safest way to identify patient is checking  Weber’s – determine if patient hears better
identification band on his wrist in one ear or to differentiate sensorineural
 Diagnosis and Tx of human responses to hearing loss from conductive hearing loss
actual or potential health problems  Level of consciousness is the most
 Profession – requires specialized important element in assessing the
knowledge with long and intensive patient’s mental status
academic preparation  Lethargic patient sleep’s on and off but will
 Student nurses do not provide services, respond to verbal or tactile stimuli. Stupor
they are solely on the unit to learn – needs constant stimulation
 Patient safety is a major concern in all  Brain highly sensitive to inadequate
situations oxygenation ( mental changes – hypoxia –
 The goal of listening- identify problems first sign)
and needs and a supportive act.  Body’s response to elevated temperature –
 Delegating responsibility shows respect for tachycardia and peripheral
the staff members abilities to solve vasodilation(inc. metabolism) -
problems on their own hypotension

________________________________________________________
 Crisis – turning point in the course of a  Ask and relay expected solutions and
disease usually indicated by a rapid terms
decrease in temperature  Non-defensive
 Lysis – gradual improvement in condition HEALTH TEACHING
INFORMED CONSENT  C-consider support systems / compliance
 Capacity and competence  H- olds motivation and insight
 Includes explanation of
 Benefits, expected results,alternatives
 A- allow feedback
and risk  N-needs met and assured
 Voluntary  G- goals and priorities set w/ pnt.
 Information understood  E- empathetic and ensures collaboration
 Cannot sign if under alcohol or BREATHING PATTERNS
premedicated  Cheyne stokes – periodic breathing
MANAGED CARE characterized by rhytmic waxing and
 Work allocation waning
 Patient needs and conditions  Dyspnea - labored painful breathing
 Abilities of staff  Hyperventilation – abnormally rapid deep
 Continuity of care prolonged breathing
 Knowledge of staff and qualifications\  Kussmauls – air hunger , marked increase
 Right task- function , activity , in depth and rate
decision…….information , supervision ,  Tachypnea – fast shallow breathing
follow-up  Paradoxical – flail chest , deflates during
 Don’t delegate assessment,teaching inhalation
evaluation,planning  Biot’s – shallow breaths interrupted by
apnea
SCOPE THERAPEUTIC EXERCISES
 RN  Passive ROM-retention of rom and
 Planning and health teaching maintenance of circulation
 Licensure requirements  Assistive- increases motion ,
 Assessment and evaluation maintains muscle tone
 Need for knowledge and skill
 LPN/LVN-
 Active – maintains mobility of the joint
and maintains muscle strength
 Stable patients
 Standard unchanging procedures  Resistive – increases muscle power
 Simple monitoring and implementation  Isometrics- maintenance of strength
 Sequenced/predictable outcomes and prevents muscular atrophy
 State practice act inclusion DANGERS OF IMMOBILITY
 UAP-direct patient care activity and  Decubitus ulcer-osteomyelitis
standard operating unchanging  Osteoporosis-pathological fractures and
procedures renal calculi
RESTRAINTS  Increased cardiac workload-
 Liable for false imprisonment tachycardia
 Last resort  Contractures- deformities
 Informed consent(proxy)
 Alternative measures first
 Thrombus formation-pulmonary
embolism
 Benefits> risks
 Length of time and circumstances  Orthostatic hypotension-
specified weakness,faintness and dizziness
 Ensure safety – circulation checks,skin  Respiratory stasis – hypostatic
care, rom and remove q2h pneumonia
RESTRAINTS IS USED FOR:  Constipation – fecal impaction
 The purpose of discipline  Urinary stasis-urinary retention
 Comfort and convenience of provider  Negative nitrogen balance-weight
 Required to treat medical symptoms
loss/debilitation
 Ensure used to control behavior
 Prevent breach in safe and effective NUTRITION
delivery of medical therapy.
 Ensure safety of other patients
 PREMATURE INFANTS-less
 Medium of limit setting and provision of than37wks/2,500g-100-200 cal/kg/day and
external controls higher na,ca and chon
 FULL TERM-120 cal/kg/day
COMPLAINTS
 Pregnancy + 300cal/day
 Compromise / collaborative agreement
 Lactation+ 500cal/day
 Listen attentively
 Explain scopes and limitations

________________________________________________________