FUNDAMENTALS OF NURSING
Agent Reservoir Entry (mode of) Transmission (mode of) “direct, vehicle, vector Exit (mode of)
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I. Nursing Theorists
Faye Abdellah
Lydia Hall
Virginia Henderson
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Identification of 21 Nursing Problems
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Care, Core and Cure (3 C’ s) s)
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Imogene King
Goal Attainment Theory
Madeleine Leininger
Transcultural Nursing
Myra Levine
Four Conservation Principles
Florence Nightingale
Environmental Theory
Betty Neuman
Stress Reduction
Dorothea Orem Rosemarie Parse Hildegard Peplau Martha Rogers
Self-Care and Self-Deficit
Human Becoming
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Medical Clean Free from pathogenic microorganisms
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III. ISOLATION PRECAUTIONS o
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Surgical Sterile Free from ALL microorganisms
Identification of the 14 Basic Needs
Surgical vs. Medical Asepsis
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
Interpersonal Relations Model
Callista Roy
Jean Watson
Science of Unitary Human Beings Adaptation Model Human Caring
Metaparadigm for Nursing Theories:
Airborne “used for clients clients with illnesses transmitted by airborne droplets (less than 5 microns) Examples: Tuberculosis, Chickenpox, Measles »
CHEN (Client, Health, Environment, Nursing)
II. CHAIN OF INFECTION o Six links » Host (susceptible) IV. PERSONAL PROTECTIVE EQUIPMENT (PPE)
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
VII. INTESTINAL OSTOMIES OSTOMIES Sequence of removing (PPE) » Gloves Mask » » Gown » Eyewear
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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, descending and sigmoidostomy
“ formed feces / aromatic aromatic and smelly)
V. INSERTION OF NASOGASTRIC NASOGASTRIC TUBE TUBE
Measure length of tube tip of the nose to the tip of the earlobe to the xiphoid process Position High Fowler position with neck hyperextended Lubricate tip of tube with water soluble lubricant
while the tube is being inserted
Empty bag when it is 1/3 ½ 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
cyanotic or coughs Placement- check Aspirate gastric secretions measure pH Auscultate and inject air into the the tube (whooshing sound) X-ray best measure to determine proper placement (initial placement) Secure tube using tape to the bridge of the client nose and to the client gown
VI. TUBE FEEDINGS
Position: » Fowlers position 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 feeding bags: » Hang bag from infusion pole HEIGHT: 12 inches »
VIII. ENEMAS Classified into FOUR: » Cleansing, Carminative, » » Retention and » Return Flow Position: » Left Lateral position Protection: » Wear clean gloves Lubrication: » lubricate with water soluble lubricant Insertion: Insert 3-4 inches (adult), 2-3 inches (children) » Administration: » administer gradually
IX. URINARY CATHETERIZATION CATHETERIZATION
Complications: » Dumping syndrome, aspiration pneumonia, diarrhea, hyperglycemia, nausea and vomiting
Sterile technique Insertion
Male
Female
Supine (legs slightly abducted)
Supine (with knees flexed and externally rotated)
IVF:
Monitor:
Position
6-9 inches
2-3 inches
Length of catheter (Adult)
40 cm
22 cm
X. TRACHEOSTOMY Position: (during insertion)
Use:
Time:
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Fowler’s position
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Sterile gloves
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XIV. CHEST TUBES What to do if:
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2-3 minutes between suctions when possible, suction applied for 5-10 seconds to minimize oxygen loss
After removing the inner cannula it is soaked in full strength hydrogen peroxide to moisten and loosen dried secretions. After cleaning the cannula, it should be rinsed with sterile normal saline to remove traces 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 fingers under the tapes before tying it Parts: Inner cannula, outer cannula and obturator Object at bedside: Obturator (for reinsertion), suction machine/apparatus (for removing secretions)
XV. PAIN
XIII. BLOOD TRANSFUSION
FIRST: Check if properly typed and cross matched Gauge of needle: g #18 Drop factor: 10 gtts/min (1 st 30 mins.) Duration: RBCs and whole blood 4 hours, FFP Fresh frozen plasma, platelet not more than 20 minutes Rate: KVO
Pain assessment (some common indicators)
Crushing pain, (someone sitting in my chest), radiates from chest to back
MI
Stab-like pain, , radiates from chest to jaw to left shoulder and arm
Angina
done before meals (but not immediately before meals) or 2 hours after meals increase fluid intake to liquefy secretions Percussion » » Vibration » Postural drainage
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
Gate control theory (Substantia gelatinosa) Analgesics, patient controlled analgesia (PCA), transcutaneous electrical nerve stimulation (TENS), imagery, massage
XII. ANTIEMBOLISM STOCKINGS
Study:
XI. CHEST PHYSIOTHERAPY (PVP)
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 nearest the client (intermittent bubbling normal, vigorous/continuous bubbling-abnormal) Transporting the client bottle below chest level and upright
Clean with:
vital signs (every 15 minutes for 1 st hour), any adverse reactions When reaction happens: STOP the 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 »
Penis at 90 degree angle Length to be inserted
Plain NSS
Hypertension / hypertensive crisis
Pounding pain
Ectopic pregnancy
Knife-like pain
Gastric ulcer
Gnawing pain
UTI
Flank pain
Pancreatitis
Radiates from Left upper quadrant to left shoulder
XVI. ASSISTIVE DEVICES
CANES
WALKERS
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opposite the affected leg (C-O-A-L) angle is 20 to 30 degrees the length should permit the elbow to slightly flex
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 6 inches in front and 6 inches » 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.
XVIII. DEGREES OF BURNS
XVII. SPECIAL DIETS
DISORDER DIET Low carbohydrate
Dumping syndrome
Low protein
Renal failure, Acute glomerulonephritis, uremia, anuria
High protein
Nephrotic syndrome
Low sodium
Heart failure, CVDs, Nephrotic syndrome
High fiber
Constipation, hyperlipidemia
Low residue Acid/Alkaline ash
Bowel inflammation ( diverticulitis and ulcerative colitis) (depending on the lab analysis of the stones) Retard renal calculi formation
Clear liquid
Following acute vomiting or diarrhea
Full liquid
Gastrointestinal upsets, progression from clear liquids
Gluten-free
For clients with Celiac disease
Tyramine-free
To prevent fermented and processed foods for clients taking MAOIs
Purine restricted
Gouty arthritis, uric acid stones
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 and bone 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 necrosis and drainage, infection d evelops
tissue,
Stage 4
ulcer extends into the muscle and bone, deep pockets of infection develop
]XX. VITAL SIGNS
TEMP NV (Adult) 36.0-37.5 0 C
PR 60-100 bpm
Oral: »
Ang PET Mo: A-pical P-ulmonic E-rbs pt. T-ricuspid M- itral
» » » » »
Axillary: » 6-9 mins (least accurate)
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Tympanic
BP 120/80 mmHg
Breath Sounds: » Stridor- shrill and harsh ( laryngeal obstruction) » Wheeze high pitched/musical (Asthma)
2-3 mins
Rectal: 2-3 mins (most » accurate
RR 12-20 bpm
Others: Brachial BP Apical used for children below 3 y/o
-cover about 2/3 of the limb
Volume: Hypoventilation-slow and » shallow (Respiratory acidosis pursed lip) Hyperventilation-deep and » rapid (Respiratory alkalosis brown paper bag)
Position: » Sitting Release valve on cuff carefully -2-3 » mmHg/sec » Wait 1-2 min before taking another BP
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BP erroneously high: Cuff too narrow, arm unsupported, no rest before assessment, 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: Immune-suppressed, » receiving chemo, etc
Bleeding, taking digitalis, has DVT or thrombophlebitis
Anxious, receiving morphine and Magnesium sulfate
Cardiac problems, DM, RF
10 HERBAL PLANTS (Advocated by DOH) Lagundi
Asthma, cough, fever
Bayabas
For washing wounds mouthwash/ gargle, toothache
Yerba Buena
Pain, headache, stomachache, toothache, mens-trual 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
