FUNDAMENTALS IN NURSING

BY: NURSE_JHEN

1. What vitamin is necessary for a patient suffering from pellagra? a. vitamin B1 c. vitamin B3 b. vitamin B2 d. vitamin B6 2. According to the intentional torts, which of the following describes the intentional touching of a person or something that person is holding or wearing, which is wrong in some way. a. assault c. domestic violence b. battery d. false imprisonment 3. What stage of illness will the person belong if the client is expectedly to gradually become independent and resume former roles and duties? a. symptom experience c. assumption of sick role b. dependent role d. recovery period 4. This is considered to be the 4th stage of grief and loss according to Kubler-Ross. a. denial c. bargaining b. anger d. depression 5. According to Jean Piaget, in his theory of cognitive development, OBJECT PERMANENCE belongs to what level? a. Preoperational c. concrete b. Sensorimotor d. formal

METAPARADIGMS IN NURSING

THEORIES OF NURSING

FLORENCE NIGHTINGALE 12 May 1820 13 August 1910

"The Lady with the Lamp Bplace: Florence, Italy Raised: England Educated: Kaiserswerth, Germany founded by Theodore Fleidner At 17 entered the covenant Crimean war

 St. Thomas Hospital School of Nursing, London June 15, 1860 Works: notes on nursing (1860) and

notes on hospital

1st theory of nursing Environmental Model

Changing or manipulating the environment The body can repair itself in a nurturing environment

FAYE GLENN ABDELLAH

born March 13, 1919 nursing research

nursing as an art and a science Identified 21 nursing problems nursing is a society Works: Better Nursing Care
Through Nursing Research and Patient-Centered Approaches to Nursing

Abdellah's Typology of 21 Nursing Problems: To promote good hygiene and physical comfort To promote optimal activity, exercise, rest, and sleep To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection To maintain good body mechanics and prevent and correct deformities To facilitate the maintenance of a supply of oxygen to all body cells To facilitate the maintenance of nutrition of all body cells To facilitate the maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiologic responses of the body to disease conditions To facilitate the maintenance of regulatory mechanisms and functions To facilitate the maintenance of sensory function To identify and accept positive and negative expressions, feelings, and reactions To identify and accept the interrelatedness of emotions and organic illness To facilitate the maintenance of effective verbal and nonverbal communication To promote the development of productive interpersonal relationships To facilitate progress toward achievement of personal spiritual goals To create and maintain a therapeutic environment To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs To accept the optimum possible goals in light of physical and emotional limitations To use community resources as an aid in resolving problems arising from illness To understand the role of social problems as influencing factors in the cause of illness

VIRGINIA AVENEL HENDERSON (Nov. 30, 1897 Mar. 19, 1996)

first lady of

nursing

born in Kansas City, Missouri graduated from the Army School of Nursing, Washington

 14 basic needs assist clients to a peaceful death nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery" Works: The Principles and Practice of Nursing described the nurse's role as substitutive (doing for the person), supplementary (helping the person), or complementary (working with the person), with the goal of helping the person become as independent as possible.

DOROTHY E. JOHNSON BSN, MPH 1919 - 1999

"first four year generic basic nursing program in the United States

 Behavioral system model 7 subsystems: ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual patients health is dependent on nurses behavior Works: One Conceptual Model of Nursing

IMOGENE KING Ed.D. RN (1971, 1981)

Goal attainment theory "General Systems Framework" theory nursing as a profession nurses help individuals die with dignity interaction between nurses and patients.

King's Conceptual System: Three Interacting Systems

Personal Systems perception
self growth & development body image space time

Interpersonal Systems interaction

communication transaction role stress

Social Systems

organization
authority status decision making

MADELINE LEININGER PhD, LHD, DS, RN, CTN, FRCNA, FAAN, LL

Transcultural nursing model Nursing is a humanistic and scientific mode of helping a client through specific cultural caring

process

 Works: Journal of Transcultural Nursing

The main goal of transcultural nursing is to provide culturally specific care focused upon differences and similarities among cultures respect to human care, health, and illness based upon the people's cultural values, beliefs, and practices, and to use this knowledge to provide cultural specific or culturally congruent nursing care to people

Transcultural Nursing

 Supportive & Therapeutic Conservation model 4 Principles

MYRA ESTRIN LEVINE (1973)

E P S S Works: Humanities in Nursing

Betty M. Neuman, R.N., B.S.N., M.S., Ph.D., PLC., FAAN

Born 1924 near Lowell, Ohio. pioneer in the field of nursing involvement in community mental health

 Health care systems model

nurses help patients adjust to environmental stressors

Works: 'Model for teaching total person approach to patient problems' in Nursing Research Neuman Systems Model
wholistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings

DOROTHEA ELIZABETH OREM (1914 June 22, 2007 )

SELF CARE and SELF CARE DEFICIT THEORY

 Self care and Self care deficit theory

'the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being.'" individuals can take responsibility for their health and the health of others

3 nursing systems W P S

HILDEGARD PEPLAU. EDd (Sept 1, 1909 - Mar 17, 1999) _

Interpersonal Relations in Nursing

emphasized the nurseclient relationship as the foundation of nursing practice Theory is the creation of a shared experience

4 Phases of Nurse-Client Relationship

1. Orientation 2. Identification 3. Exploitation 4. Resolution

DR. MARTHA ELIZABETH ROGERS 1914 - 1994

Edited a journal called: Nursing Science

 Science of Unitary Human Beings man is an energy field in the environment Man has the capacity for abstraction and imagery, language and though, sensation and emotion Works: An Introduction to the Theoretical Basis of Nursing (Rogers, 1970).

SISTER CALLISTA ROY RN, PhD, FAAN

Bachelor of Arts with a major in nursing at Mount St. Mary's College, in Los Angeles. Nursings goal is to promote adaptation in four modes: physiologic, selfconcept, role function, and

independence.

 Adaptation model man as a biopsychosocial system - The person is an open, adaptive system who uses coping skills to deal with stressors sees the environment as "all conditions, circumstances and influences that surround and affect the development and behaviour of the person" six-step nursing process which includes: assessment of behaviour, assessment of stimuli, nursing diagnosis, goal setting, intervention and evaluation.

LYDIA ELOISE HALL 1906 - 1969

Nursing process Concept of CARE, CORE, CURE Hall believed patients should receive care ONLY from professional nurses Hall was not pleased with the concept of team nursing--she said that "any career that is defined around the work that has to be done, and how it is divided to get it done, is a "trade" (rather than a profession).

 According to the Care, Core, and Cure" model, nurses work in three arenas: care (hands on bodily care), core (using the self in relationship to the patient), and cure (applying medical knowledge). three separate domains: the body (care), the illness, (cure), and the person (core).

JEAN WATSON, Phd, RN, AHN_BC, FAAN

Born:West Virginia Educated:BSN, University of Colorado, 1964 MS, University of Colorado, 1966PhD, University of Colorado, 1973 She is founder of the original Center for Human Caring in Colorado

 Human caring model Transpersonal caring Included health promotion and treatment of illness in nursing Her latest book is Caring Science as Sacred Science (2005)

TEN CARATIVE FACTORS 1. "The formation of a humanistic-altruistic system of values"(Watson, 1979). This factor develops at an early age and involves a broad awareness of self. 2. "The instillation of faith-hope"(Watson, 1979). An understanding of and sensitiviy to an individual's beliefs provides a sense of well-being for the client. 3. "The cultivation of sensitivity to one's self and to others"(Watson, 1979). This allows the nurse and the client to become increasingly sensitive, and therefore more genuine. 4. "The development of a helping-trust relationship"(Watson, 1979). Effective communication techniques such as congruence aids in the creation of this relationship. 5. "The promotion and acceptance of the expression of positive and negative feelings"(Watson, 1979). This factor recognizes that the 6. "The systematic use of the scientific problem-solving method for decision making"(Watson, 1979). The problem-solving method is foundational to the practice of nursing. 7. "The promotion of interpersonal teaching-learning"(Watson, 1979). The provision of information empowers a client to make informed decisions about health and healing. 8. "The provision for supportive, protective, and (or) corrective mental, physical, sociocultural, and spiritual environment"(Watson, 1979). This factor encompasses internal and external variables that the nurse is responsible for guiding. 9. "Assistance with the gratification of human needs"(Watson, 1979). Human needs include all acts of life, ranging from food to the need for achievement. 10. "The allowance for existential-phenomenological forces" (Watson, 1979). The nurse needs to view each person's reality through the individual's eyes. It was on Christine Donald's site

ROSEMARIE RIZZO PARSE, RN; PhD; FAAN

Theory of human being Free choice of personal meaning in relating value priorities Used terms such as revealing-concealing, enabling-limiting, connecting-separating

BASIC HUMAN NEEDS ( Abraham Maslow)

Maslows Characteristics of a Self-Actualized Person

1. 2. 3. 4. 5. 6. realistic judges people correctly superior perception, is more decisive clear notion of what is right or wrong usually accurate in preceding future events understands art, music, politics, philosophy possesses humility, listens attentively dedicated to work, task, duty, perception

7.
8.

 Health is a state of complete physical, mental and social well-being, and not just merely the absence of disease of infirmity (WHO)
Wellness is well-being. It involves in engaging in attitudes and behaviors that enhance quality of life and maximize personal potential Illness is a state in which the person perceives physical, emotional, intellectual, social, developmental or spiritual functioning to be decreased.

CONCEPTS OF HEALTH,WELLNESS AND ILLNESS

MODELS OF HEALTH AND ILLNESS

HEALTH-ILLNESS CONTINUUM (DUNN)

describes the interaction of environment with well-being and illness high-level wellness: towards optimum level of functioning if not going for OLOF, then the person is towards the illness continuum

HEALTH BELIEF MODEL (Rosenstock and Becker)

individual perceptions and modifying factors may influence health beliefs and preventive health behavior individual perceptions may include: perceived threat, perceived susceptibility, perceived seriousness modifying factors include: demographic variables (age, sex, race), sociophysilogic variables (peer group, clubs), structural variables ( knowledge, contact)

Concept

Definition

Application Define population(s) at risk, risk levels; personalize risk based on a person's features or behavior; heighten perceived susceptibility if too low. Specify consequences of the risk and the condition Define action to take; how, where, when; clarify the positive effects to be expected. Identify and reduce barriers through reassurance, incentives, assistance. Provide how-to information, promote awareness, reminders. Provide training, guidance in performing action.

Perceived Susceptibility

One's opinion of chances of getting a condition One's opinion of how serious a condition and its consequences are One's belief in the efficacy of the advised action to reduce risk or seriousness of impact One's opinion of the tangible and psychological costs of the advised action

Perceived Severity

Perceived Benefits

Perceived Barriers

Cues to Action

Strategies to activate "readiness" Confidence in one's ability to take action

Self-Efficacy

FIVE STAGES OF ILLNESS

Symptom experiences Assumption of the sick role Medical care contact Dependent client role When the person believes something is wrong; manifestations of signs and symptoms (they feel unwell or get a rash) When self-management fails, seeks confirmation from family and friends often excused from normal role expectations When symptoms persist, seeks the advice of a health professional (check- up) Becomes dependent on the professional for help with illness (admission to the hospital)

Recovery or rehabilitation

Client is expected to gradually become independent and resume former roles and duties

STRESS

MODERN STRESS THEORY (HANS SELYE)

stress is a non-specific response of the body to any demand made upon it A stressor is any stimulus that produces stress and the disturbs the bodys equilibrium

FACTS OF STRESS:
1. 2. 3. 4. 5. 6. 7. 8. stress is not a nervous energy man tends to adapt to stress stress is not always something to be avoided stress does not always lead to distress a single stress does not cause a disease stress may lead to another stress prolonged stress may lead to exhaustion stress is always a part of everyday life

GENERAL ADAPTATION SYNDROME (GAS)

whenever a man responds to stress, the whole body is involved Regardless of the cause of stress, the same chain of physiologic events occurs The GAS is a result of the release of adrenal hormones, with subsequent changes in organ systems

STAGES OF GAS: (ARE)

Stage of Alarm Stage of Resistance Stage of Exhaustion

person becomes characterized by result from aware of the adaptation prolonged exposure presence of threat levels of resistance to stress and or danger adaptive are increased levels of resistance person moves back mechanisms can no longer persist are decreased to homeostasis unless other adaptive adaptive mechanism are mechanisms will be mobilized (fight or mobilized, death flight reaction) may ensue

LOCAL ADAPTATION SYNDROME (LAS)

man may respond to stress through a particular body part or body organ response is localized It is the reaction of one organ or one part of the body Example: inflammation

HEALTH PROMOTION

HEALTH PROMOTION
these are activities directed towards increasing the level of well-being and self-actualization

THREE LEVELS OF PREVENTION

Primary Prevention
to encourage optimal health and to increase the persons resistance to illness activities includes health promotion, health teachings examples: quit smoking, exercise, immunizations, balanced diet, healthy lifestyle, avoid alcohol intake, increase water intake, maintain ideal body

Secondary Prevention

also known as health maintenance activities include early diagnosis, detection and screening; prompt treatment examples: PE, pap smear, clinical Breast Exam, sputum exam, stool exam and rectal exam

Tertiary Prevention

to support the clients achievement of successful adaptation to known risks, optimal reconstitution and/or establishment of high-level wellness examples: self-monitoring of blood glucose, physical therapy of a CVA patient, cardiac rehab after MI, self-management class for DM, speech therapy after laryngiectomy

NURSING PROCESS

NURSING PROCESS
Lydia Hall G O S H

CHARACTERISTICS OF THE NURSING PROCESS

1.
2. 3. 4. 5. 6.

7. 8.

problem oriented, it is comparable with scientific problem-solving approach goal oriented orderly, planned, step by step open to accepting new information during its application, it is flexible to meet the unique needs of the client, group or community interpersonal it requires that the nurse communicates directly and consistently with the client permits creativity among nurses and clients in devising ways to solve the health problems cyclical steps may overlap because they are interrelated universal

ASSESSMENT
collecting, validating, organizing and recording data about the clients health status purpose: ______________ TYPES OF DATA: s o METHODS: 1. interview 2. observation SOURCES: Primary Secondary

NURSING DIAGNOSIS
4 parts _______: to identify the clients health care needs and to prepare diagnostic statements
PROBLEM: ETIOLOGY: SIGNS AND SYMPTOMS: SECONDARY FACTORS:

Altered Comfort: Pain related to presence of incision site at the right lower quadrant secondary to post appendectomy

EXAMPLE:

TYPES OF NURSING DIAGNOSIS

Actual Example: fluid volume deficit Risk Example: risk for injury Potential Example: potential for growth Wellness Example: family pattern increased Syndrome Example: altered community pattern

PLANNING
Determining the strategies or course of actions to be taken before implementation of nursing care Purpose: to identify the clients goals and appropriate nursing interventions Should only have ONE GOAL but may have MANY OBJECTIVES

Should be SMART
SPECIFIC: the goal should be directed to the patient alone MEASURABLE: use of action words like demonstrate, verbalize, manifest, etc. ATTAINABLE: should be well stated in a way that the goal is achievable REALISTIC: suited for the condition of the specific patient and is applicable TIME FRAMED: the time is set for the goal to be achieved EXAMPLE: (altered comfort: pain)

At the end of my 8-hour shift, my patient will verbalize increased level of comfort as evidenced by: Reduced pain scale of 3/10 from 6/10 with 0 as no pain and 10 as most painful Participate in activities of daily living Absence of guarding behavior, facial grimacing, and moaning

IMPLEMENTATION
Putting the nursing care plan into action Purpose: to carry out planned nursing interventions to help the client attain goals

Should be organized in its presentation

INDEPENDENT: all nursing actions that needs NO doctors orders (vital signs, turning and positioning, chest physiotherapy) DEPENDENT: all nursing procedures that NEEDS doctors orders (medications, special procedures) INTERDEPENDENT: otherwise known as COLLABORATIVE, in which other health team members are being tapped for the care (speech therapy, respiratory therapy, physical therapy) REFERRAL: endorsed to the superior (NOD, head nurse, physician)

EVALUATION
Assessing the clients response to nursing interventions and then comparing the response to predetermined standards or outcome criteria Purpose: to determine the extent of which goals of nursing care have been achieved

COMPONENTS OF A NURSING GOAL:

A. CONCLUSION STATEMENTS 1. GOAL MET 2. GOAL PARTIALLY MET 3. GOAL UNMET B. JUSTIFICATIONS - written as as evidenced by EXAMPLE: Goal Met. Patient able to verbalize increased

level of comfort as evidenced by:

reduced pain scale cooperate in the ADL no more facial grimacing

COMMUNICATION

TYPES OF COMMUNICATION:
1.

2. 3.

4.
5.

NONVERBAL actions or behaviors that communicate a message without speaking facial expressions, body language, posture, hand gestures, use of space and territory VERBAL transmission of a message using the spoken language THERAPEUTIC communication that pertains to treatment and healing important elements contributing to the establishment of the therapeutic relationship are EMPATHY, ATTENDING, OBSERVING, and LISTENING NON-THERAPEUTIC communication that is a barrier to free ACTIVE LISTENING attentiveness to the client in a physical and psychological manner

 RAPPORT IPR characterized by a spirit of cooperation, confidence and harmony TRUST a risk-taking process whereby a persons situation and feeling of well-being depends on the actions of another RESPECT a relationship in which one considers the other in high esteem or regard EMPATHY ability to try and understand what other person is feeling; Not actually feeling what the other person is feeling GENUINENESS being as one appears, sincere and honest

ESSENTIAL COMPONENTS OF A THERAPEUTIC COMMUNICATION (ReGRET)

THERAPEUTIC COMMUNICATION TECHNIQUES

Listening Facing and leaning towards the client, using eye contact, relaxed body posture

Broad opening
Clarification

Open-ended comments
Nurse communicates an understanding of the thought or feeling tone of the clients message back to him/her to offer another perspective in the situation Reflects back the feeling or thought

Reflection

Confrontation
Giving information Seeking validation Self-disclosure Silence Summarizing

Describes contraindications in the clients behavior or feeling

Provides facts and information Asks to give feedback about the accuracy of the nurses perceptions Occasionally and cautiously reveals something from her own experience To communicate presence and acceptance of the client Progress, evaluates, goals

NONTHERAPEUTIC COMMUNICATION
Changing the subject Interrupting Approving Moralizing Social response Belittling Giving advice Nurse communicates an unwillingness to continue with the clients topic Nurse shows disrespect by breaking into an interfering with his/her communication Nurse uses approval and disapproval to control the client and his/her behavior Nurse passes judgment on the client Nurse uses superficial, social conversation that is not client-centered Nurse discounts the clients feelings and experiences as not being valuable or worthwhile Nurse gives advice to the client

LEGAL ISSUES

PRIVACY being apart from others for observation INFORMED CONSENT the health care provider has the responsibility to communicate pertinent information in a manner that the client is able to understand role of the nurse: advocate COMMITMENT the legal process by which the clients who have psychiatric problems are brought to and confined in a secure area because their behaviors are so extreme and severe that they pose a harm to themselves or to others CLIENT RIGHTS clients retain all of the basic rights that every citizen has clients also expect that the treatment will be individualized and collaborative with no verbal or physical abuse client rights include privacy, confidentiality, and expectation that treatment will be appropriate to needs with client participation HUMANE RESEARCH entails voluntary participation, informed consent, and freedom to withdraw from the study at any time for any reason, without penalty

LIABILITIES
MALPRACTICE incorrect treatment by a professional that causes injury or harm NEGLIGENCE the commitment of an act that a reasonable and prudent person would not have done INVASION OF PRIVACY violation of another persons rights to be left alone and free from unwarranted contact, intrusion and publicity DEFAMATION OF CHARACTER any untrue communication, written (libel) or spoken (slander) that injures the good name or reputation of another, or in any way brings that person into disrepute FALSE IMPRISONMENT the intentional, unjustified, nonconsensual detention or confinement of a client for any length of time. RESPONDEAT SUPERIOR the employer is ultimately responsible for the acts of its employees, and is thus liable for damage to the third parties

VITAL SIGNS

TEMPERATURE
balance between the heat produced by the body and the heat lost from the body body heat is primarily produced by metabolism the heat-regulating center is the hypothalamus

2 TYPES:
1. CORE deep tissues of the 2. SURFACE skin, SQ, fats body

normal core body temperature is between 36.5 C 37.5 C BASAL METABOLIC RATE the younger the person, the higher the BMR; the older the person, the lower the BMR

PROCESS INVOLVED IN THE HEAT LOSS

1. RADIATION the transfer of heat from the surface of one object to another without contact between the two objects 2. CONDUCTION transfer of heat from one surface to another but with contact between the two objects 3. CONVECTION the dissipation of heat by air currents 4. EVAPORATION the continuous vaporization of moisture from the skin, oral mucous, heat respiratory tract (insensible heat loss)

ALTERATIONS IN BODY TEMPERATURE

FEBRILE from 37.5 C to 38 C HYPERTHERMIA from 38 C to 39.5 C Febrile and hyperthermia can be relieved by TSB + antipyretics PYREXIA from 39.5 C and above HYPERPYREXIA pyrexia + convulsion Pyrexia and hyperpyrexia needs IV antipyretics + anticonvulsants Very high body temperature (41-42 C) cause irreversible brain cell damage

TYPES OF FEVER
a. INTERMITTENT temperature fluctuates between periods of fever and periods of normal/subnormal temperature b. REMITTENT temperature fluctuates within a wide range over the 24-hour period but remains above normal range c. RELAPSING the temperature is elevated for few days, alternated with 1 or 2 days of normal temperature d. CONSTANT body temperature is consistently high

NURSING INTERVENTION OF CLIENTS WITH FEVER

1. monitor VS 2. assess skin color and temp skin flushing 3. monitor WBC NEUTROPHILS will increase f due to bacterial infection 4. remove excess blankets 5. Provide adequate food and fluid replacement 6. measure I&O 7. promote rest 8. provide TSB prn 9. administer antipyretics

PULSE
A wave of blood created by contraction of the left ventricle of the heart The PR is regulated by the autonomic nervous system

FACTS:
1. females have higher PR after puberty 2. increase in metabolic rate increases PR 3. increase in blood loss increases PR 4. thready pulse weak and feeble pulse 5. bounding very strong pulse

PULSE SITES:
temporal carotid apical brachial radial femoral posterior tibial pedal (dorsalis pedis) popliteal

A. RATE the normal pulse rates per minute are as follows: Newborn: 80-180 bpm 1 year: 80-140 bpm 2 years: 80-130 bpm 6 years: 70-120 bpm 10 years: 50-90 bpm Adult: 60-100 bpm B. RHYTHM the pattern and intervals of beats. Dysrhytmia is an irregular pattern C. VOLUME (AMPLITUDE) the strength of the pulse Words to use: strong or full, weak, feeble, thready

ASSESSMENT OF THE PULSE:

RESPIRATION
PHYSIOLOGICAL PROCESSES
1. VENTILATION the movement of air in and out of the lungs 2. EXTERNAL RESPIRATION the exchange of gases from the alveoli to the capillaries and vice versa 3. PERFUSION the transport of oxygen through oxyhemoglobin throughout the body 4. INTERNAL RESPIRATION exhange of gases from the capillaries to the tissue and vice versa

TYPES OF BREATHING:
COSTAL (THORACIC) involves movement of the chest DIAPHRAGMATIC (ABDOMINAL) involves movement of the abdomen

RESPIRATORY CENTERS
A. MEDULLA OBLONGATA the primary center; in C3 or C4, where the diaphragm is innervated by the PHRENIC NERVE B. PONS
1. PNEUMOTAXIC CENTER: responsible for rhythmic quality of breathing (involuntary breathing) 2. APNEUSTIC CENTER: responsible for deep, prolonged inspiration

ASSESSING RESPIRATION
1. RATE: 16-20 cpm (adult) 2. DEPTH: observe the movement of the chest. Maybe normal, deep or shallow 3. RHYTHM: observe for regularity of inhalations and exhalations 4. QUALITY OR CHARACTER: respiratory effort and sound of breathing

RHYTHM OF RESPIRATION (ALTERED BREATHING)

1. CHEYNE-STOKES waxing and waning Char: deep, shallow with temporary apnea Conditions: increase ICP, drug toxicity 2. BIOTS also known as CLUSTER RESPIRATION Character: shallow breaths interrupted by apnea Condition: CNS disorders

 3. KUSSMAULS hyperventilation Character: tacypnea + metabolic acidosis; deep and rapid breathing Condition: DM 4. APNEUSTIC prolonged gasping inspiration followed by a very short expiration

BLOOD PRESSURE
Measure of the pressure exerted by the blood as it pulsates through the arteries BP = cardiac output x stroke volume

1.

2.
3. 4.

5.

SYSTOLIC PRESSURE pressure of the blood as a result of contraction of the ventricles (110140 mmHg) DIASTOLIC PRESSURE pressure when the ventricles are at rest (60-90 mmHg) PULSE PRESSURE difference between the systolic and diastolic pressures (normal is 3040 mmHg) HYPERTENSION abnormally high blood pressure over 140 mmHg systolic and/or 90 mmHg diastolic for at least two consecutive readings HYPOTENSION abnormally low blood pressure, systolic pressure below 100 mmHg

TERMS:

increase peripheral resistance increase BP decrease cardiac output decreases BP decrease compliance/elasticity increases BP increase hematocrit increases BP BP is at lowest in the morning and highest in the late afternoon KOROTKOFF SOUND normal heart sounds

FACTS:

LABORATORY EXAMS and DIAGNOSTIC EXAMS

COMPUTED TOMOGRAPHY (CT SCAN)

3-dimensional image INFORMED CONSENT No fasting required (except for abdomen) Assess for allergic to seafoods contrast medium of iodine-based will be used Should remain still Avoid driving immediately after the exam

ULTRASOUND ( UTZ ) / ULTRASONOGRAPHY

Use of ultrasonic waves (sound waves too high in frequency for a human ear to detect) No special preparation needed or fasting If UTZ of ABD: let the client void before the procedure If UTZ of KUB: let the client drink water and not void till the procedure is done

MAGNETIC RESONANCE IMAGING (MRI)

Non-invasive test which uses powerful magnetic fields and radio frequency pulses No radiation involved Not for pregnant women, those with metals in the body (artificial pacemakers, hip replacements, inserted metals after fracture) Bone appears black in the MRI paper Remind that it is a noisy procedure Assess for claustrophobia Keep still the whole procedure INFORMED CONSENT

CHEST X-RAY
Show the bony thorax and structures Normal: right is slightly higher than the left Costophrenic angle junction between the rib cage and diaphragm No special preparation No inform consent needed Non-invasive procedure Keep still the whole procedure

POSITRON EMISSION TOMOGRAPHY (PET)

Produces images of metabolic and physiologic function Given strong doses of radioactive tracers (radionuclides) INFORMED CONSENT Keep still the whole procedure

GASTROINTESTINAL SERIES (GI SERIES)

A. BARIUM ENEMA Examination of the patency of the lower GI NPO post NOC Give laxatives before the procedure Cleansing enema before Increase fluid intake after the procedure

BARIUM SWALLOW
Examination of the patency of the upper GI Also known as ESOPHAGOGRAM Use of radiopaque when viewed in the fluoroscope then filmed Increase fluid intake after the procedure

INTRAVENOUS PYELOGRAPHY
Radiopaque contrast medium IV Laxative given night before NPO till procedure is over INFORMED CONSENT

URINE ANALYSIS
A. CLEAN CATCH, MIDSTREAM URINE for U/A and culture and sensitivity The best time to collect urine specimen is EARLY MORNING, first void specimen Provide sterile container Do perineal care before collection of urine Discard the first flow of urine Collect the midstream: 30-50 ml Send the specimen immediately to the laboratory

24-HOUR URINE SPECIMEN

Discard first voided specimen Collect all specimen thereafter until same time the following day Soak specimen in a container with ice Add preservative as ordered

C. SECOND-VOIDED URINE SPECIMEN

Discard the first voided specimen Give water to drink After few minutes, ask to void again, and collect the urine specimen This is need for test for glucose in urine

D. CATHETERIZED URINE SPECIMEN

Clamp the catheter for 30minutes to 1 hour Cleanse the drainage port of the 2-way foley catheter with alcohol swab Use sterile needle and syringe to aspirate urine specimen from the drainage port DONTS: collect the urine specimen from the bag; detach the catheter from the connecting tube

A. ROUTINE FECALYSIS Assess the gross appearance of stool and presence of ova or parasites Secure sterile specimen container Instruct patient to defecate in the bedpan. If desired, allow the patient to void first. Discard the urine and wash the bedpan Use tongue depressor to collect the stool specimen Collect one teaspoonful or 1 inch of well-formed stool Label the specimen immediately to the laboratory. Fresh, warm specimen helps detect ova and parasites

STOOL SPECIIMEN

B. STOOL CULTURE AND SENSITIVITY TEST

Assess the specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics Use sterile test tube and sterile cottontipped applicator Label the specimen properly Send specimen immediately to the laboratory

C. GUAIAC STOOL EXAMINATION (OCCULT BLOOD DETERMINATION)

Microscopic study of stool for presence of bleeding in the gastrointestinal tract Provide hemoglobin-free diet for 3 days (no meat for 3 days) Avoid red or dark-colored foods Temporary discontinue iron therapy Positive guaiac stool exam, indicates peptic ulcer disease and gastric cancer

PAIN

 an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage purpose: serves as a warning signal of impending tissue motivating the patient to seek professional help ALGOLOGY study of pain

PHYSIOLOGIC DIMENSIONS OF PAIN

1. TRANSDUCTION conversion of mechanical, thermal, or chemical stimulus into a neural action potential 2. TRANSMISSION movement of pain impulses from the site of transduction to the brain Nociceptors pain receptors the fibers (alpha, beta delta) C fibers smallest & unmyelinated; slowest rate; dull sensation Dermatomes areas on the skin that are innervated primarily by single spinal cord segment Dorsal horn processing in the spinal cord, release of neurotransmitters to produce activation or inhibition. Endogenous opioids (enkephalins & B-endorphins) are synthesized by the body to produce effects same with Morphine. Spinothalamic tract perception of pain is believed to occur at the cerebral cortex and the efferent neurons will act on it 3. PERCEPTION occurs when pain is recognized, defined and responded to by the individual 4. MODULATION involves the activation of descending pathways that exert inhibitory of facilitatory effects on the transmission of pain

PAIN THEORIES
1. SPECIFICITY THEORY there are certain specific nerve receptors that respond to noxious stimuli 2. PATTERN THEORY any stimulus could be perceived as painful if the stimulation were intense enough 3. GATE CONTROL THEORY if the gate is closed, the signal is stopped before it reaches the brain Substantia gelatinosa found at the dorsal horn; responsible for exciting and inhibiting signals at the brain

CYCLE OF PAIN
Stimulus (nociceptors) transmission (nerve fibers) pain pathway (spinal Cord) pain perception (thalamus) pain interpretation (cerebral cortex) pain response PAIN THRESHOLD awareness and integration of a stimulus PAIN TOLERANCE point at which the person no longer voluntarily accepts the pain

CLASSIFICATION OF PAIN
1. DURATION 2. QUALITY
Acute short term Chronic long term Sharp sticking in nature Dull annoying but not as intense as sharp Diffuse covers a wide area Shifting moves from one area to another

3. INTENSITY / SEVERITY

Mild 1-3 Moderate 4-7 Severe 8-10 Continuous constant Intermittent repeating Transient / brief passes quickly
Organic physiologic origin Psychogenic emotional in nature Psychophysiologic migraine Pretended pain assumed pain

4. PERIODICITY
5. CAUSATION

ASSESSMENT OF PAIN
P provoking factors or precipitating factors Q quality R region S Severity T timing

PAIN MANAGEMENT

1. 2. 3. 4.

5.
6. 7. 8.

relaxation technique refraining converting the negative to positive ones distraction focusing ones attention on something other than pain guided imagery using imagination to provide a substitute for pain humor laughter is the best medicine biofeedback catharsis cutaneous stimulation stimulating the skin to control pain hot and cold application

NON-INVASIVE

INVASIVE
WHO 3-step analgesic pain step 1 NSAID (ibuprofen, mefenamic, paracetamol) step 2 OPIOID AGONIST (codeine, meperidine, pentazocine) step 3 AGONISTSANTAGOSNISTS (morphine, stadol, narcan)

NUTRITION

FOOD PYRAMID

CARBOHYDRATES

NUTRIENTS

Primary function: provide the body with energy Composed of carbon, hydrogen, oxygen (CHO) Glucose provides the most efficient form of energy Provides 4 kcal/gram of energy Consists of: Simple sugars sucrose, glucose, dextrose, fructose Complex sugars starches and fibers

Provide 4.5 kcal/gram of energy Functions include: structure of bones, muscles, enzymes, hormones, blood, and the immune system Formed by linking amino acids in various forms Composed of carbon, hydrogen, oxygen, nitrogen (CHON)

PROTEINS

 Lipids are the densest form of energy available Produce 9 kcal/gram of energy Composed of carbon, hydrogen, oxygen and oxygen (CHOO) Lipids are insoluble in water Triglycerides are the primary form of fat in food Fats are divided in three categories: triglycerides, phospholipids, and sterols Function: hormone production and provide padding to protect vital organs

FATS

MINERALS
Minerals serve structural purpose and are found in all body fluids and tissues 16 essential minerals are divided into 2 categories: major and minor Minerals are plentiful in all foods, although some may be lost in food processing

WATER
Water provides a means of transportation for nutrients Water acts as a solvent and a lubricant It is a by-product of metabolism The human body is approximately 60% water Need to consume the equivalent of 2 liters of fluid/day Foods with high content of water include melons, cantaloupe, and berries

VITAMINS

FAT-SOLUBLE VITAMINS
SOURCE DEFICIENCY A (retinol)
Yellow fruits and vegetables, liver, beef, chicken

MANIFESTATIONS

Night blindness, xeropththalmia

Dryness of the cornea, blurred vision

D (calciferol)

Milk products, tuna, sardines, margarine, egg, liver, cheese, salmon, mackerel
Wheat, almonds, sunflower seeds, peanut butter,corn oil, hazelnuts

Ricketts children Osteomalacia adults

Rare in humans; least toxic form of vitamin

Soft bones and skeletal deformities Brittle bones, bentbones, muscular weakness

E (tocopherol)

K
(phytomenadione)

Acts as a cofactor for prothrombin and clotting factors

hemorrhage

Bleeding episodes

WATER-SOLUBLE VITAMINS
VITAMINS B1 (thiamine) B2 (riboflavin) B3 (niacin) B6 (pyridoxine) B9 (folic acid) B12 (cyanocobalamin) C (ascorbic acid) H (biotin) SOURCES Green leafy vegetables Plant oils Green leafy vegetables Potato, banana, chicken, egg Cereal, potato, banana, chicken, oatmeal Milk and milk products; rice Mollusks, clams, liver, beef, cereals Citrus fruits and vegetables Cereal, potato, banana, chicken, oatmeal DEFICIENCIES Beri-beri Wernicke-korsakoff syndrome cheilosis Pellagra (3 Ds) Microcytic anemia MANIFESTATIONS Dry skin, irritability, with eventual death Amnesia secondary to chronic alcoholism Cracking at he sides of the lips Dermatatis, diarrhea, dementia Weakness, fatigue, dyspnea, low immune system Mentally retarded; neural tube defects, premature babies Neurologic deficits; constipation, fatigue, weakness Loose teeth, sore gums, connective tissue problems Low bp, lethargy Due to a diet of raw egg whites ( that have avidin)

Megaloblastic anemia; neural tube defects Pernicious anemia

Scurvy; difficult wound healing Acidosis and dehydration

NURSING PROCEDURES

NGT FEEDING
Nursing responsibilities: 1. Assess for patency a) inject small amount of air; b)aspirating 20-30ml of gastric secretions; c) measure the pH of the aspirated fluid 2. High-Fowlers position before and after feeding 3. Hang no more htan 4 hours of formula formula container should be replaced every 24 hours 4. Check for fod allergies 5. Rinse the tube with water after feeding about 30ml 6. Measure intake and output 7. After feeding, clamp the tube to prevent gas pain

BOWEL ELIMINATION
NURSING RESPONSIBILITIES 1. Promote regular defecation by providing as much privacy as possible 2. Encourage the client to defecate when the urge is recognized, and to establish a routine and time of defecating 3. Assure an adequate intake of fluids and fiber 4. Constipated: increase OFI and include hot liquids and fruit juices 5. Diarrhea: increase OFI and small amount of bland foods. Assess for potassium loss, avoid hot or cold beverages 6. Flatulence: limit carbonated drinks and chewing gum. Avoid use of drinking straws, avoid gas-forming foods

ENEMAS
TYPES: 1. Cleansing given to remove feces; treat constipation; prevent contamination of sterile field during surgery; promote visualization of intestine 2. Hypertonic solutions fleet enema (medicated enema) 3. Hypotonic solution tap water 4. Isotonic solution PNSS 5. Carminative enema release gas, to expel flatus; about 60-80ml of fluid us used 6. Oil retention to soften feces and lubricate the rectum and anal canal (mineral oil, olive oil, conttonseed oil) 7. Return-flow enema sometimes used to expel flatus

Nursing responsibilities for enemas 1. Provide privacy 2. Lubricate insertion tube 3. Place in left lateral Sims position 4. Raise the solution container as advocated 5. As a general rule, the solution should be about 12 inches above the rectum 6. Measure the volume instilled and document results 7. Never release the enema tube when it is in the rectum 8. Client is instructed to hold the fluid for at least 10-15 minutes 9. Document and do after care

CATHETHERIZATION
Types: 1. Indwelling / Retention / Foley for continuous drainage of urine, for gradual decompression of an over-distended bladder, and for intermittent bladder drainage and irrigation 2. Straight used to drain the bladder for short periods. They are inserted and removed immediately after the urine is drained 3. Suprapubic catheter catheter inserted through a small incision just above the pubic area. 4. Condom catheter used for incontinent males because of the risk for infection is minimal

Nursing responsibilities 1. Explain the procedure 2. Provide privacy 3. Use sterile gloves 4. Place in dorsal recumbent or supine position 5. Cleanse the pubic area 6. Lubricate the tip 7. Instruct to breathe through the mouth 8. Document accordingly

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