ARCHIVE FOR THE FUNDAMENTALS OF NURSING CATEGORY

THERAPEUTIC DIET FOR SPECIFIC CONDITIONS

Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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AGE CLEAR LIQUID AGN LOW NA , LOW CHON ADDISONS HIGH NA , LOW K ANEMIA , PERNICIOUS HIGH CHON , VIT. B. ANEMIA SICKLE CELL HIGH FLUID GOUT PURINE RESTRICTED ADHD AND BIPOLAR FINGER FOODS BURN HIGH CAL. HIGH CHON CELIAC GLUTEIN FREE CHOLECYSTITIS HIGH CHON, HIGH CARB, LOW FAT CHF LOW NA , LOW CHOL. CROHNS HIGH CHON AND CHO, LOW FAT THERAPEUTIC DIET FOR SPECIFIC CONDITIONS CYSTIC FIBROSIS HIGH CAL., HIGH NA LITHIASIS-ACID ASH FOR ALK. STONESALK. ASH FOR ACID STONES DECUBITUS ULCERS HIGH CHON , HIGH VIT C DIARRHEA HIGH K AND NA DUMPING SYNDROME HIGH FAT, HIGH CHON,DRY HEPATIC ENCEPHALOPATHY-LOW CHON HEPATITIS HIGH CHON,HIGH CAL. HIRSPRUNGS LOW RESIDUE, HIGH CHON AND CHO CIRRHOSIS LOW CHON MENIERES LOW NA MI AND HPN LOW CHOL.,FATS,NA HYPERTHYROIDISM- HIGH CAL. AND CHON HYPOTHYROIDISM LOW CAL. , LOW CHOL, LOW SAT. FAT NEPHROTIC SYNDROME LOW NA, HIGH CHON , HIGH CAL. HYPERPARATHYROIDISM LOW CALCIUM

HYPOPARATHYROIDISM HIGH CA, LOW PHOSPHORUS OSTEOPOROSIS HIGH CALCIUM AND HIGH VIT. D PANCREATITIS LOW FAT PUD HIGH FAT, HIGH CARB. LOW CHON PKU LOW CHON / PHENYLALANINE PIH HIGH CHON RENAL FAILURE (ACUTE) LOW CHON,HIGH CARB LOW NA (OLIGURIC PHASE) HIGH CHON , HIGH CAL AND RESTRICTED FLUID (DIURETIC PHASE RENAL FAILURE (Chronic) LOW CHON , LOW NA , LOW K

POSITIONING FOR SPECIAL CONDITIONS

Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

ABDOMINAL ANEURYSM SURGERY-FOWLERS ASTHMA ORTHOPNEIC POSITION AUTNOMIC DYSREFLEXIA-HIGH FOWLERS POST BRONCHOSCOPY-SEMI FOWLERS CARDIAC CATHETERIZATION-KEEP INSETION SITE EXTENDED FOR 4-6 HOURS TO PREVENT ARTERIAL OCCLUSION CAST ELEVATE EXTREMITY CATARACT SEMI FOWLERS CEREBRAL ANEURYSM SEMI FOWLERS CLEFT LIP SUPINE CLEFT PALATE PRONE CHF HIGH FOWLERS CRANIOTOMY SUPRATENTORIAL SEMI FOWLERS ;INFRATENTORIAL FLAT ICP LEVATE HEAD DUMPING SYNDROME SUPINE AFTER MEALS EPISTAXIS LEAN FORWARD FLAIL CHEST AFFECTED SIDE FEMORO-POPLITEAL BYPASS GRAFT AFFECTED EXTREMITY EXTENDED GLAUCOMA(POST OP) AFFECTED SIDE

HEMORROIDECTOMY SIDE LYING HIATAL HERNIA- UPRIGHT HIP SURGERY LEGS IN ABDUCTION LAMINECTOMY BACK AS STRAIGHT AS POSSIBLE LIVER BIOPSY RIGHT SIDE LYING LOBECTOMY SEMI FOWLERS POST LP FLAT MASTECTOMY ELEVATE EXTREMITY ON PILLOW MYELOGRAM WATER BASED DYE ELEVATE THE HEAD OIL BASED DYE FLAT POSTURAL DRAINAGE LUNG SEGMENT UPPERMOST POSITION PROLAPSED CORD KNEE-CHEST PULMONARY EDEMA FOWLERS PYLORIC STENOSIS RIGHT SIDE LYING RADIUM IMPLANT FLAT ON BED RETINAL DETACHMENT AFFECTED SIDE TOWARDS THE BED SEIZURE SIDE-LYING SHOCK MODIFIED TRENDELENBURG SCI IMMOBILIZE TONSILLECTOMY SIDELYING / PRONE THYROIDECTOME SEMI FOWLERS THROMBOPHLEBITIS ELEVATE LEG TPN TRENDELENBURG DURING INSERTION THORACENTESIS FOWLERS(DURING) AFTER POSITION OF COMFORT

UNIVERSAL PRECAUTIONS
Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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Strict Isolation-highly transmissible diseases by direct contact and airborne routes of transmission Private room,gowns, mask , gloves, handwashing,double bagged techniques for soiled articles Diptheria(pharyngeal),Herpes Zoster, Varicella , Pneumonia( S.Aureus , Strep,group A) Respiratory Isolation-droplet transmission(3 feet) Private rom,patient w/ same organism,mask,handwashing,labelled plastic bags for soiled articles

H. influenza, measles, mumps, N. Meningitidis Tuberculosis/ AFB isolation-suspected / active TB Private room with negative pressureventilation so that air room is vented outside, mask, handwashing, bronchoscopy and dental examination postponed until 2 weeks of antibiotic therapy Tuberculosis Contact Isolation infectious disseases or multiple resistant microorganisms that are spread by direct contact or close contact Private room , mask gown , gloves diptheria( cutaneous), Herpes simplex, MRSA , Pediculosis , Scabies , Syphilis Enteric Precautions infectious diseases transmitted through direct or indirect contact with infected feces. Handwashing , gloves , gowns worn only when handling contaminated objects with feces Aseptic meningitis, AGE , Hepa A , Typhoid fever, diarrhea (CDT ) Drainage / Secretions precautions patients with wound drainage or infected wounds Gloves, gowns indicated if clothing is likely to be contaminated Burns Universal Blood and Body fluids precautions blood borne , body fluids pathogens ( blood , semen , vaginal secretions , CSF , synovial fluid , pleural fluid , peritoneal fluid , pericardial fluid , amniotic fluid and tissues. Gloves , mask, protective eyegears, gown , contaminated needles not recapped and sharps in puncture resistant containers Aids , Hepatitis B and C , STDs Patient is protected from pathogens and nosocomial infections by instituting reversed transmission precautions

Burns and open wounds, patients with artificial airway , immunocompromised patients leukemia , AIDS , steroid therapy , radiation or cancer chemotherapy , medication effect of leukopenia or agranulocytosis

VALUE STANDARDS
Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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MORALS STANDARDS OF RIGHT AND WRONG INTUITIONISM NOTION AUTONOMY INDEPENDENCE NON-MALEFICENCE DO NO HARM BENEFICENCE DOING GOOD JUSTICE FAIRNESS FIDELITY FAITHFULLNESS AND COMMITMENT VERACITY TRUTHFULNESS ADVOCACY- INFORMED SUPPORT / ENHANCE AUTOMOMY

COMPR. SITUATIONS NO-REFERENCE , INAPPROPRIATE TERMS OR WORDS, JUDEGMENTAL STATEMENTS, -MONITORING AND DOCUMENTATION

TELEPHONE ORDERS- REPEAT ORDER TO THE AP AND LET HIM SIGN WITHIN 24 HOURS

STRATEGIES FOR SEXUAL HARASSMENT CONFRONT REPORT INCLUDE WITNESS DOCUMENT SEEK SUPPORT INFORMED CONSENT AGGREED UPON FACTS KNOWN TREATMENT EXPLANATION RISK UNDERSTOOD CONSENT CONSIDERATIONS OB , STD,REHAB ,BLOOD DON. (MINOR CAN GIVE) ER, LIFE THREATENING(IMPLIED)

MENTALLY ILL (INCAPABLE)

MODELS FOR DELIVERY OF NURSING CASE METHOD-TOTAL CARE-CONSISTENCY FUNCTIONAL METHOD-TASK ORIENTED- CENTRALIZED DIRECTION AND CONTROL TEAM NURSING-TEAM COORDINATED CARE-INDIV. ROLES EFFICIENCY PRIMARY NURSING-COMPREHENSIVE,INDVIDUALISTIC, CONSISTENT TECHNICAL KNOWLEDGE AND MNGT.SKILLS CASE MNGT. COMPREHENSIVE CONTINOUS CARE MANAGED CARE- COST CONTAINMENT DIFFERENTIATED-COMPETENCY-DELINEATION

THE NURSING PROCESS

Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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ASSESSMENT- SYSTEMATIC COLLECTION OF DATA TO DETERMINE PATIENTS STATUS AND TO IDENTIFY ANY ACTUAL OR POTENTIAL HEALTH PROBLEMS ANALYSIS/NURSING DIAGNOSIS- IDENTIFICATION OF ACTUAL OR POTENTIAL HEALTH PROBLEMS AMENABLE TO RESOLUTIONS BY NURSING ACTIONS PLANNING- DEVELOPMENT OF GOALS AND A PLAN OF CARE DESIGNED TO ASSIST THE PATIENT IN RESOLVING THE NURSING DIAGNOSIS ( ORGANIZE,ANALYSE,SYNTHESIZE AND PRIORITIZE) (IDENTIFY PROBLEM,PNT.CHARAC. AND ETIOLOGIES) IMPLEMENTATION- ACTUALIZATION OF THE PLAN OF CARE THROUGH NURSING INTERVENTIONS ( COORDINATION,DELEGATION-CAPABILITIES ,LIMITATIONS AND SUPERVISION EVALUATION-DETERMINATION OF PATIENTS RESPONSES TO THE INTERVENTIONS AND EXTENT TO WHICH GOALS HAVE BEEN ACHIEVED(FEEDBACK)

Subjective data (symptoms)- described by person experiencing it (e.g. pain, dizziness, vertigo etc.) Objective data (signs)- can be observed (by the use of senses) and measured (e.g. BP 130/90, abdominal rigidity upon palpation, exopthalmus, pallor, redness etc.)

ASSESSMENT OBSERVATION- VISION,SMELL,HEARING,TOUCH INTERVIEWING OPENING , BODY AND CLOSING PERSONAL SPACE VARIABLES-TIME SPACE SEATING ARRANGEMENT,DISTANCE AND CULTURE EXAMINING PHYSICAL EXAMINATION(CEPHALOCAUDAL (HEAD TO TOE)

INITIAL ASSESSMENT-SPECIFIED TIME AFTER ADMISSION FOCUS OR ONGOING ASSESSMENT-ONGOING PROCESS INTEGRATED WITH NURSING CARE EMERGENCY ASSESSMENT-DURING ANY PHYSIOLOGIC OR PSYCHOLOGIC CRISIS OF THE CLIENT TIME-LAPSED- SEVERAL MONTHS AFTER INITIAL ASSESSMENT *GOALS SHOULD BE SYSTEMATIC MEASURABLE ATTAINABLE REASONABLE TIME-FRAMED

LEVELS OF PREVENTION

Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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PRIMARY- HEALTH PROMOTION AND MAINTENANCE(TOTAL PREVENTION OF CONDITION) SECONDARY CURATIVE AND EARLY DETECTION(ERALY RECOGNITION OF CONDITION AND MEASURES TAKEN TO SPEED RECOVERY TERTIARY-REHABILITATION(MINIMIZE EFFECTS OF THE CONDITION AND PREVENT LONG TERM COMPLICATIONS)

-it is a systematic method that directs the nurse and client as they together determine the need for nursing care, plan and implement the care, and evaluate the result it is a G O S H approach (goal-oriented, organize, systematic, and humanistic care) for efficient and effective provision of nursing care.

NURSING THEORIES
Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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NIGHTINGALE ENVIRONMENTAL ROGERS- UNITARY INTERACTION HENDERSON- ASSIST TO INDEPENDENCE( 14 FUNDAMENTAL NEEDS) OREM- SELF CARE DEFICIT KING GOAL ATTAINMENT ROY- ADAPTATION PATERSON / ZDERAD- HUMANISTIC NEEDS LEININGER- TRANSCULTURAL JOHNSON- BEHAVIORAL LEVINE- CONSERVATION PEPLAU- PSYCHODYNAMIC ORLANDO-NURSING PROCESS NEWMAN- HEALTHCARE SYSTEMS MODEL

FUNDA
Posted: October 4, 2011 in FUNDAMENTALS OF NURSING

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NURSING THEORISTS

NIGHTINGALE Environment Noise, nutrition, hygiene, light, comfort, socialization & hope

PEPLAU INTERPERSONAL PROCESS ORIENTATION, IDENTIFICATION, EXPLOITATION/EXPLANATION, RESOLUTION

HENDERSON

14 BASIC NEEDS

BREATH, EAT & DRINK, ELIMINATE, POSTURE, SLEEP, DRESS, TEMPERATURE, HYGIENE, COMMUNICATE, WORSHIP, WORK, PLAY, LEARN, AVOID DANGER

ABDELLAH

21 CLIENT NEEDS Nursing is a well-prepared service

ORLANDO

INTERACTION NURSING IS INTERACTING WITH CLIENTS TO MEET IMMEDIATE NEEDS BY IDENTIFYING CLIENT BEHAVIOR, NURSES REACTION & NURSING ACTION TO BE TAKEN HALL

NURSING PROCESS CORE, CURE, CARE CORE: THERAPEUTIC USE OF SELF CURE: DISEASE & TREATMENT CARE: BODY

LEVINE 4 CONSERVATION PRINCIPLE

CONSERVE CLIENTS ENERGY, STRUCTURAL, PERSONAL, SOCIAL INTEGRITY

JOHNSON BEHAVIORAL SYSTEM MODEL CONSISTS OF 7 BASIC NEEDS: SECURITY, NURTURANCE, NOURISHMENT, ELIMINATION, ACHIEVEMENT, SELF-PROTECTION, SEX

ROGERS SCIENCE OF UNITARY HUMAN BEING THE INDIVIDUAL IS MORE THAN THE SUM OF ITS PARTS

OREM SELF CARE & SELF CARE DEFICIT THEORY HELP CLIENT ATTAIN SELF CARE AND WELL-BEING KING

GOAL ATTAINMENT THEORY 3 DYNAMIC INTERACTING SYSTEMS: PERSONAL, INTERPERSONAL, SOCIAL FORM THE BASIS FOR NURSE CLIENT RELATIONSHIP

NEUMAN

HEALTH CARE SYSTEM MODEL ASSIST CLIENT IN STRESS REDUCTION VIA PRIMARY, SECONDARY, TERTIARY LEVELS OF PREVENTION

PATTERSON HUMANISTIC NURSING PRACTICE REQUIRES CLIENTS TO BE AWARE OF THEIR UNIQUENESS & COMMONALITY NURTURANCE

LEININGER TRANSCULTURAL CARING THROUGH SPECIFIC CULTURAL CARING PROCESSES

ROY ADAPTATION MODEL HELP CLIENT TO ADAPT TO CHANGES IN PHYSIOLOGIC NEEDS, SELF-CONCEPT, ROLE FXN, INTERDEPENDENT RELATIONS

WATSON HUMAN CARING MODEL PROMOTE HEALTH & PREVENT ILLNESS THROUGH CARING THAT IS TRANSPERSONAL AND HUMANISTIC PARSE

THEORY OF HUMAN BECOMING HEALTH IS A CONTINUOUS AND OPEN PROCESS

ERICKSON ROLE-MODELING THEORY NURSES ACT AS ROLE MODELS FACILITATION NURTURANCE

BENNER CARING CENTRAL CARING IS CENTRAL IN NURSING, CREATING POSSIBILITIES FOR COPING & CONNECTING WITH OTHERS

PERIOPERATIVE NSG

Effects of surgery PHYSICAL: stress response, lowered immunity, altered vascular system & organ fxn PSYCHOLOGICAL: ABI, Fear of pain, disfigurement, death, change in lifestyle

Classifications of Surgical Procedures

Accg to PURPOSE 1. AESTHETIC: improves a normal feature (Rhinoplasty) 2. CURATIVE a. ABLATIVE: removes a diseased organ (Appendectomy) b. CONSTRUCTIVE: repairs a congenital defect (Cheiloplasty) c. RECONSTRUCTIVE: repairs a damaged organ (Skin Grafting)

Classifications of Surgical Procedures

Accg to PURPOSE 3. DIAGNOSTIC: IDs & confirms dse (Breast biospy) 4. EXPLORATORY: estimates extent of dse (Explore Lap) 5. PALLIATIVE: relief of symptoms WITHOUT cure (colostomy)

Classifications of Surgical Procedures

Accg to RISK

1. MAJOR SURGERY: High Risk (Prolonged, extensive, involves major organs e.g. Explore Lap) 2. MINOR SURGERY: Low Risk (may be OPD case e.g. breast biopsy)

Classifications of Surgical Procedures

Accg to URGENCY

1. EMERGENT: life/Limb saving! (Explore Lap due to stab wound) 2. URGENT: done when client is stable (Appendectomy) 3. ELECTIVE: may be delayed or omitted (Cholecystectomy) 4. AMBULATORY: done on OPD basis (Cyst excision)

PRE-OPERATIVE PHASE

Factors that Increase Risk: 1. Age: very young & elderly 2. Nutrition: malnutrition & obesity 3. F&E imbalance 4. Health status: infxn, heart, lung, liver, kidney dses 5. Meds Complications:

Anticoag, ASA, NSAIDS: bleeding Tranquilizers & Anti-HPN: HypoT, Shock

Aminoglycosides: increase neuromuscular blockade by anesthesia Diuretics: electrolyte imbalance Steroids: Adrenocortical suppression

PRE-OPERATIVE PHASE

Factors that Increase Risk:

6. Nature of dse: Acute vs chronic, single vs multiple 7. Type, magnitude & Urgency of surgery: Major vs Minor 8. Psychological Status

PRE-OPERATIVE PHASE

PSYCHOLOGICAL PREP (pt & family)

1. Dr. explain procedure, their purpose, what to expect during & after surgery. 2. Assess pts fear/anxiety 3. Allay anxiety

PRE-OPERATIVE PHASE

LEGAL PREPARATION: INFORMED CONSENT! *Client consents to procedure s pressure, c complete understanding of the procedure, risks, benefits, complications, & alternatives (Dr.) *Necessary for all procedures (except EMERGENCIES) *Adult (>18 yo) signs own consent, unless unconscious or mentally incompetent, then next of kin signs *Minors must have parentals consent

PRE-OPERATIVE PHASE

PHYSICAL PREPARATION

1. Check past Medical hx, allergies, meds. 2. Check chart & pre-op dx tests: CXR, ECG, CBC etc. 3. Teach POST-OP Exercises: deep breathing, coughing, splinting incision, frequent turning & leg exercises. 4. Prepare skin: full bath, CLIP hairs over site, remove nail polish (pulse ox), make-up, jewelry, dentures. Leave HEARING AID. 5. Dress client in gown & cap. Check ID band. 6. NPO for at least 8 hours 7. Check special orders: enema, IV line, NGT insertion. Have client void. Check & record baseline VS on checklist.

PRE-OPERATIVE MEDS

1. To decrease anxiety & relax pt *NARCOTIC ANALGESIC: Meperidine, Fentanyl, Morphine *TRANQ: Diazepam, Droperidol *SEDATIVES: Midazolam, Secobarbital **DO NOT MIX 1st 2 with Sedatives: Respiratory Depression

2. To decrease Tracheobronchial Secretions: ANTICHOLINERGICS: Atropine, Scopolamine, Glycopyrrolate

3. To decrease Gastric Acidity *H2 Blockers: Cimetidine, Ranitidine

INTRAOPERATIVE PHASE

GENERAL ANESTHESIA =produces sensory, motor, reflex, mental block =reversible state of unconscious/CNS depression INHALATION AGENTS: initial restlessness then Respiratory Distress A. Non-Halogenated/Gas 1. Nitrous Oxide: BLUE, laughing gas, for short procedures 2. Cyclopropane: ORANGE, rarely used due to arrhythmia SE

B. Halogenated/ Liquid

1. Halothane: RED, may cause <BP & HR 2. Enflurane: YELLOW, stronger muscle relaxation 3. Sevoflurane: SWEET taste, used in Pediatric surgery

C. IV Barbiturates (quickly pass BBB: rapid induction) 1. Thiopental: Poor relaxation, bronchospasm

D. Neuroleptic Agents (Decreases motor & anx; analgesia without Loss of Consciousness) 1. Fentanyl&Droperidol: RD, <BP&HR

E. Dissociative Agents (Amnesia & Analgesia w/o LOC) 1. Ketamine: Hallucination, >BP&HR F. Adjuncts 1. Succinylcholine, Pancuronium: Neuromuscular blockers, monitor pts breathing in case of persistent paralysis.

STAGES OF GENERAL ANESTHESIA

1. INDUCTION: From admin of anesthesia to LOC. 2. DELIRIUM/EXCITEMENT: from LOC to relaxation or loss of lid reflex. Client may struggle or breath irregularly. 3. SURGICAL: from relaxation to depression of VS & reflexes. 4. MEDULLARY/DANGER: from <VS to respiratory or cardiac arrest

LOCAL ANESTHESIA =produces analgesia without LOC (LIDOCAINE & PROCAINE) 1. TOPICAL: applied over surgical site EMLA

2. FIELD/NERVE BLOCK: injected into SQ or perineural space near or around desired anesthesia site. 3. SPINAL: into subarachnoid space (inside arachnoid) 4. EPIDURAL: into epidural space (outside arachnoid), used in OB

INTRAOPERATIVE NURSING CARE

PROPER POSITIONING *Explain procedure & position to client, apply corresponding straps/restraints & arm/foot boards to prevent fall. *Avoid undue exposure, pressure on chest or excessive strain. Maintain good body alignment, respiration & circulation.

COMMON POSITIONS:

1. DORSAL TRENDELENBURG: CABG, hernia, breast & bowel surgery 2. TRENDELENBURG: Lower abdomen, pelvic surgeries 3. LITHOTOMY: Perineum/ Rectal surg 4. LATERAL: kidney, chest, hip surg 5. PRONE: Spinal, Kidney surg

B. Surgical Asepsis C. Monitoring VS, instruments, emergencies, complications *Intraoperative Fever: RT BT or drug rxn, prior infxn & malignant hyperthermia (due to Halogenated Anesthetics mixed with Succinylcholine. TX is DANTROLENE) D. Assist with wound closure: SUTURES

SUTURES! *Sutures sized by dm: the higher the number of Os, the smaller the dm (2-O > 5-O) *NON-ABSORBABLE: PROLINE, NYLON, SILK (used for skin) *ABSORBABLE: PDS, VICRYL, CATGUT (regular & chromic)

SUTURE REMOVAL GUIDELINES *Face & Neck: 3-5 days *Abdomen: 1 wk

*Back: 2 wks *Arms: 10-12 d *Legs: 12-14 d E. Documentation: blood loss, dressing, drains F. Transporting client: clean excess blood/debris, put clean gown & blanket, move ptgradually to prevent nausea, hypotension & injury

POSTOPERATIVE PHASE

IMMEDIATE POST-OP CARE/ RR Assure ABC *O2 therapy with client on side/lateral position if applicable *Maintain artificial airway until gag reflex returns *Suction secretions & encourage deep breathing *Check VS q 15 min until stable, then 30 min *Check skin color, temp, drains, dressings

2. Note level of consciousness: reorient client 3. Discharge from RR when awake & responsive with easy breathing & acceptable BP & circulation.

CONTINUING POST-OP CARE Promote optimal respiration: coughing, deep breathing, splinting incision, early ambulation, turning in bed. Promote optimal circulation: early ambulation, leg exercises Promote optimum nutrition, F&E balance, monitor IV, I&O, UO, drains, dressings, return of peristalsis (flatus, bowel movement) Pain control: analgesics & comfort measure Wound care

COMMON POST-OP COMPLICATIONS: FEVER (hydration, TSB, Antipyretic, tx CA) *Day 1-3: due to Atelectasis (collapsed lung from poor ventilation intra-op) is the most common & NOT lung infxn!) STAT: Strep wound infxn, Thyroid, Addisonian crisis, Transfusion Rxn *Day 3-5: 5Ws: Wind (lungs), Water (urinary tract), Wound infxn, Walking (DVT), Wonder drugs (Drug fever) *Day 6-10: wound/hematoma infxn, pneumonia, abscess, colitis, anastomotic leak, DVT, embolism

2. ATELECTASIS: alveolar collapse RT poor vent during surgery or inability to fully inspire RT pain or secretions. tx: deep breathing, coughing, suctioning, CPT, spirometry 3. PNEUMONIA: poor clearance of secretions from pain & immobility Etiology: G(-) org or fungal if IC *Aspiration Pneumonia: > with <LOC, intubation/extubation, non-fxning NGT, Trend position, RUL (supine), RLL (sitting) tx: 3rd gen CEPHALOSPORIN, incentive spirometry

3. DVT & PE Risk Factors: immobility, obesity, CA, >Age, >RBC *DVT: HOMANs Sign(calf pain) *PE: dyspnea, >RR, <BP, loud pulmonic in S2, fever DX: VQ scan, CXR, ECG(cor pulmonale TX: Early ambulation, anticoagulant (heparin, warfarin), Greenfield filter (metallic filter placed in IVC)

4. PARALYTIC ILEUSconsti, flatulenceObstruction *RT anesthesia, bowel manipulation, adhesions (chronic) TX: NPO, AVOID TALKING!, decompress with NGT, walk early 5. SHORT BOWEL SYNDROME *Malabsorption & diarrhea RT extensive bowel resection (<100cm of small bowel remaining) TX: TPN 12-24 hours post-op, SFF

6. URINARY RETENTIONUTI *RT anesthesia, manipulation or cathetherization TX: asepsis, catheter care, antibiotics, hydration 7. HEMORRHAGEhypovolemic shock *restlessness!, shock!, pallor TX: IFI, BT, pressure dressings, Vit K, Hemostan 8. WOUND INFXNWOUND DEHISENCE

MODELS OF HEALTH

HEALTH-ILLNESS CONTINUUM (DUNN)

HEALTH IS A DYNAMIC STATE THAT FLUCTUATES AS A PERSON ADAPTS TO CHANGES IN THE INTERNAL AND EXTERNAL ENVIRONMENT HEALTH BELIEF MODEL (Rosenstoch & Becker)

3 COMPONENTS:

A. INDIVIDUALS PERCEPTION OF SUSCEPTIBILITY TO AN ILLNESS B. INDIVIDUALS PERCEPTION OF SERIOUSNESS OF ILLNESS BASED ON MODIFYING FACTORS (demographic, socio-psychologic, and structural) C. LIKELIHOOD THAT A PERSON WILL TAKE PREVENTIVE ACTION

HEALTH PROMOTION MODEL (PENDER) MULTIDIMENTIONAL NATURE OF PERSONS AS THEY INTERACT WITHIN THEIR ENVIRONMENT TO PURSUE HEALTH AND HEALTH PROTECTION COGNITIVE, DEMOGRAPHIC & SOCIAL, PARTICIPATIVE BEHAVIOR ECOLOGIC MODEL (CLARK & LEAVELL) AGENT (STRESSOR) HOST (PERSON AFFECTED) ENVIRONMENT (EXTERNAL TO HOST) MASLOWS HIERARCHY OF NEEDS

SELF-ACTUALIZATION SELF-ESTEEM LOVE AND BELONGINGNESS SAFETY & SECURITY (physical & psychological) PHYSIOLOGIC: oxygen, fluids, food, temp, elimination, shelter, sex

3 LEVELS OF ILLNESS PREVENTION

PRIMARY PREVENTION **HEALTH PROMOTION GOOD NUTRITION, AVOID STRESSOR (SMOKING, SUN EXPOSURE, ALCOHOL), SAFE SEX, EXERCISE **SPECIFIC PROTECTION IMMUNIZATIONS, PROTECTION FROM ACCIDENTS (HELMET), HYGIENE, SANITATION

SECONDARY PREVENTION

**EARLY DIAGNOSIS & PROMPT TX 1. GENETIC COUNSELING 2. MONTHLY SELF-EXAM (BREAST, TESTICLE, SKIN, MOUTH) 3. ANNUAL PAP SMEAR (STARTING 18 yo), MAMMOGRAM (Starting 40 yo If high risk & 50 yo IF LOW RISK) 4. ANNUAL DIGITAL RECTAL EXAM (MALES >50 yo) 5. ANNUAL PHYSICAL EXAM (STARTING 35 yo) 6. GLAUCOMA & HYPERTENSIVE SCREENING **DISABILITY LIMITATIONS: Adequate tx to arrest disease & prevent further complications

TERTIARY PREVENTION **RESTORATION AND REHABILITATION

After disease to minimize disability & maximize use of remaining capacities: speech & physical therapy after CVA, cardiac rehab after MI, CBC before chemotherapy, blood glucose monitoring

PHYSICAL EXAMINATION INDIVIDUAL ASSESSMENT OF EACH BODY SYSTEM, USUALLY CONDUCTED IN A CEPHALO-CAUDAL MANNER

INSPECTION OBSERVE AREA FOR SIZE, SHAPE, SYMMETRY, POSITION & ABNORMALITIES.

PALPATION PALMS & FINGER PADS: TEXTURE, CONSISTENCY & FORM DORSUM OR BACK OF HAND: TEMPERATURE BONY PROMINENCES OF THE PALM: VIBRATION

PERCUSSION TAPPING THE BODY USING FINGERTIPS, PRODUCING VIBRATIONS TYMPANY: DRUM-LIKE, HIGH PITCH (ENCLOSED AIR SPACE) RESONANCE: HOLLOW, LOW PITCH (NORMAL LUNG) HYPERRESONANCE: VERY LOW BOOMING (EMPHYSEMA) DULLNESS: HIGH PITCH, THUD-LIKE (LIVER)

FLATNESS: SOFT & FLAT (MUSCLE) AUSCULTATION BELL: LOW PITCH (HEART & KOROTKOFF SOUNDS) DIAPHRAGM: HIGH PITCH (BOWEL & LUNG SOUNDS)

HEART SOUNDS:

S1: MITRAL VALVE CLOSURE S2:AORTIC VALVE CLOSURE S3: RAPID VENTRICULAR FILLING S4: ATRIAL CONTRACTION MURMURS: TURBULENT BLOOD FLOW FROM STENOSIS/ REGURGITATION LUNG SOUNDS

BRONCHIAL: LOUD, HIGH PITCH, HEARD OVER MANUBRIUM (I < E) VESICULAR: SOFT, LOW-PITCH, HEARD OVER MOST OF LUNGS (I > E) BRONCHOVESICULAR: INTERMEDIATE, HEARD B/W SCAPULA (I = E)

ADVENTITIOUS LUNG SOUNDS

CRACKLES: BUBBLING SOUNDS RT DISRUPTED PASSAGE OF AIR IN ALVEOLI (FROM LUNG SECRETIONS) AS IN PNEUMONIA

RONCHI: LOUD, LOW-PITCH RUMBLING RT FLUID IN THE LARGER AIRWAY

WHEEZES: HIGH-PITCH, SQUEAKY, RT HI-SPEED AIRFLOW

STRIDOR: HARSH, HIGH-PITCHED RT UPPER AIRWAY OBSTRUCTION

FRICTION RUB: DRY, GRATING SOUND BEST HEARD ON INSPIRATION RT RUBBING OF

VISCERAL OVER PARIETAL PLEURA WHEN INFLAMED

POINTERS IN P.E. POSITION & SEQUENCE OF EXAMINATION CHEST: SITTING (IPPA) BACK: STANDING (IPPA) ABDOMEN: SUPINE (IAPP) NECK PALPATION (LYMPH NODES, THYROIDS): STAND BEHIND CLIENT PERFORM OPHTHALMOSCOPY IN A DARKENED ROOM WARM SPECULUM (POURED WITH WARM WATER) FOR VAGINAL EXAM FOR DRE: ASK PATIENT TO BEAR DOWN

CLIENT POSITIONS

SEMI-FOWLERS

=FOR GASTRIC FEEDING TO REDUCE REFLUX HIGH FOWLERS =FOR EATING, NGT INSERTION AND SUCTIONING, PROMOTES GOOD CHEST EXPANSION SUPINE = FOR VERTEBRAL INJURIES DORSAL RECUMBENT = FOR ABDOMINAL EXAM

PRONE =SMALL PILLOW JUST BELOW DIAPHRAGM, SUPPORTS LUMBAR CURVE, FACILITATES BREATHING SIMS = FOR RECTAL EXAM KNEE-CHEST/ GENUPECTORAL = CLIENT PRONE, ARMS FLEXED ON SIDES, KNEE-CHEST FLEXION. FOR VAGINAL/ RECTAL EXAM LITHOTOMY =HAVE CLIENT VOID PRIOR TO. FOR PELVIC EXAM MODIFIED TRENDELENBURG

OXYGENATION

THORACENTESIS VENTILATION: BREATHING DIFFUSION: O2 MOVES FROM ALVEOLI TO RBC PERFUSION: RBCS MOVE INTO CIRCULATION

NEEDLE INSERTION THRU CHEST WALL FOR ASPIRATION OF PLEURAL FF FLUID OR INSTILLATION OF MEDS EXPLAIN PROCEDURE & INSTRUCT CLIENT NOT TO COUGH OR MOVE SUDDENLY CHECK FOR PNEUMOTHORAX

CARDIAC CATHETERIZATION R-SIDED: ANTECUBITAL VEINR HEART PULMONARY ARTERY L-SIDED: BRACHIAL OR FEMORAL ARTERYAORTALEFT VENTRICLE PRE-TEST: CHECK FOR ALLERGIES; NPO 8-12 HOURS PRIOR, NO ANTICOAGULANTS AT LEAST 3 DAYS PRIOR FEELING OF WARMTH OR FLUTTERING IS COMMON AS CATHETER PASSES POST-TEST: CHECK CIRCULATION IN AFFECTED EXTREMITY (PULSES, COLOR, SENSATION), SANDBAG OR PRESSURE DRESSING OVER PUNCTURE SITE.

BRONCHIAL LAVAGE/ STEAM INHALATION LIQUIFIES AND MOBILIZES SECRETIONS; MEDIUM FOR AEROSOL BRONCHODILATORS & MUCOLYTIC EXPECTORANTS COVER CHEST WITH TOWEL AND PLACE SPOUT 12-18 IN. AWAY TO PREVENT BURNS. STEAM FOR 15-20 MINUTES. THEN DEEP BREATHING AND COUGHING TO MOBILIZE SECRETIONS

CHEST PHYSIOTHERAPY PERFORM AC TO AVOID ASPIRATION SEMI-FOWLERS POSITION GIVE BRONCHODILATORS 20 MIN PRIOR *POSTURAL DRAINAGE: CAREFUL POSITIONING ALLOWS SECRETIONS TO FLOW BY GRAVITY FROM SMALLER AIRWAYS INTO LARGER AIRWAYS *PERCUSSION: CLAPPING WITH CUPPED HANDS ON CHEST WALL FOR 3-5 MIN TO DISLODGE SECRETIONS *VIBRATION: WITH HANDS PRESSED FLAT ON CHEST, UPPER ARM & SHOULDERS

TRACHEOSTOMY SURGICAL CREATION OF A STOMA, OPENING INTO THE TRACHEA THROUGH THE OVERLYING SKIN FOR RELIEF OF UPPER AIRWAY OBSTRUCTION OR ACCESS FOR MECHANICAL VENTILATION

NGT INSERTION PLACE PT IN HIGH-FOWLERS

NURSE ON SIDE OF NOSTRIL FOR INSERTION. MEASURE TUBE LENGTH BY NOSE-EARLOBE-XIPHOID (NEX). ADD 20-30 cm FOR DUODENAL PLACEMENT. LUBRICATE TUBE. HYPEREXTEND NECK, INSERT TUBE THRU NOSTRILS TOWARDS BACK OF THROAT WHILE ROTATING TUBE 180. FLEX NECK ONCE TUBE IN OROPHARYNX & ASK CLIENT TO SWALLOW.

NGT FEEDING CLIENT SITTING OR HIGH-FOWLERS POSITION (PREVENTS ASPIRATION) CHECK FOR RESIDUAL FEEDING >150 ml: INFORM DR WITH FEEDING BAG OR SYRINGE ELEVATED 12 INCHES. ELEVATION ALLOWS EMPTYING BY GRAVITY TO PREVENT ABDOMINAL DISCOMFORT, REFLUX AND VOMITING FOLLOW WITH WATER TO CLEAR TUBE. CLAMP TUBE BEFORE ALL THE WATER IS INSTILLED TO PREVENT AIR BUBBLES (FLATULENCE)

PARENTERAL NUTRITION FOR CLIENTS WHO ARE UNABLE TO DIGEST OR ABSORB ENTERAL NUTRITION: GI OBSTRUCTION, ILEUS, SURGERY, TRAUMA REQUIRES MONITORING OF GLUCOSE, ELECTROLYTES, LIPIDS, PROTEINS DIET PROGRESSION CLEAR LIQUID: BROTH, COFFEE, TEA, FRUIT JUICES, GELATIN, POPSICLE FULL LIQUID: ALL JUICES/ SHAKE, PUREED VEGGIES, CUSTARD, COOKED CEREAL PUREE: PUREED MEAT/FRUITS, SCRAMBLED EGG, MASHED POTATOES MECHANICAL SOFT: GROUND OR FINELY FLAKED MEAT/ FISH, CHEESE, RICE, POTATOES, HOTCAKES, LIGHT BREAD, SOUP SOFT: TENDER MEAT, SOFT FRESH FRUIT, CAKE, COOKIES (NO NUTS)

BOWEL ELIMINATION FECES MOVES INTO RECTUM RELAXING INTERNAL ANAL SPHINCTER THEN EXTERNAL ANAL SPHINCTER RELAXES TO EXPEL FECES. IF NOT, LEVATOR ANI MUSCLES, HELP KEEP SPHINCTER CLOSED. VALSALVA: FORCEFUL EXPIRATION THRU A CLOSED GLOTTIS. IT FACILITATES DEFECATION BY INCREASING INTRAABDOMINAL PRESSURE.

FECALYSIS 1 INCH (FORMED); 15-30 ml (LIQUID) COLOR: YELLOW-BROWN due to STERCOBILIN ODOR: PUNGENT due to INDOLE & SKATOLE FREQUENCY: 1-3x/DAY (INFANT) CONSISTENCY: SOFT BUT FORMED, SHAPE REFLECTS RECTAL DIAMETER. *RAPID TRANSIT TIME: LESS WATER REABSORBEDLIQUID STOOL *SLOW OR DELAYED: MORE ABSORPTION HARD & DRY STOOLS

LAXATIVES BULK FORMER= SAFEST. PSYLLIUM (METAMUCIL). TAKE WITH WATER TO PREVENT IMPACTION STOOL SOFTENER= Na DOCUSSATE. IFI, AVOID IF LOW Na DIET OSMOTIC AGENT= ABSORBS WATER. LACTULOSE: GIVE BEFORE BREAKFAST OR BEDTIME. MILK OF MAGNESIA: LOWER DOSES ACT AS ANTACID LUBRICANTS= MINERAL OIL. GIVE UPRIGHT: NOT WITH MEALS! CHEMICAL IRRITANTS= > PERISTALSIS BISACODYL (DULCOLAX): GIVE ac, WAIT 1 HOUR BEFORE MILK OR ANTACID. SENA (SENOKOT): GIVE hs, DISCOLORS URINE CASTOR OIL= TAKE WITH SODA

VITAL SIGNS TEMPERATURE (Heat Production-Heat Loss) Anterior hypothalamus: controls Heat Loss (sweating & Vasodilation) Posterior hypothalamus: controls Heat Production (Vasoconstriction & shivering)

HEAT PRODUCTION

1. BMR: heat production at rest; increased by Thyroid hormones, E/NE 2. Exercise: 50X 3. Shivering: 5X 4. Brown fat 5. Fever

HEAT LOSS 1. RADIATION: no direct contact e.g. >VD; <VC 2. CONDUCTION: direct contact e.g. TSB 3. CONVEcTION: air Currents e.g. e fan

4. EVAPORATION: liquid to gas e.g. skin sweat

Types of Temperature

1. CORE: deep tissues T kept constant by Thermoregulation Pulmonary Artery: Most accurate! Rectum: 2nd most accurate Tympanic Membrane Esophagus, U bladder 2. SURFACE: T fluctuates depending on Blood Flow & environment Oral: most accurate! Skin Axillae

Axilla: 36.5 C Oral/Tympanic: 37 C Rectal: 37.5 C

THERMOMETERS!!!

ORAL: elongated/BLUE =measure 15 min after hot/cold

RECTAL: tear shape/RED =insert lubricated .5-1.5 inches =client deep breath: to relax sphincter

AXILLARY: stubby bulb Body Temp Alterations: 1. Hyperthermia/ Pyrexia: >Normal 2. Hypothermia: <Normal 360C 3. Hyperpyrexia: Very high fever >410C

Crisis: T returns to normal Suddenly! Lysis: graduaLLy!

Patterns of Fever: 1. REmittent: REmains high (fever fluctuates but never return to normal) 2. Intermittent: (fever fluctuates b/w normal & above normal) 3. Relapsing: fever fluctuates, normalizes for days, fever again! 4. Constant: >380C PULSE

Palpable bounding BF in artery created by ejection of the LV PR= CO (5-6L/min)/ SV (60-70 ml) CO: vol of blood PUMPED by heart in 1 min SV: vol ejected per V contraction I: 120 T: 90 P: 80 S: 70 A: 60

RESPIRATION (MO) Central Chemoreceptor: primary resp center; activated if >CO2 (Carotid/Aortic bodies) Peripheral Chemoreceptor: detects <O2 Increased RR: ex, stress, smoking, anemia, >altitude; Amphetamine, Coccaine Decreased RR: acute pain in chest/ abdomen, brain damage; narcotics, anesthesia, bronchodilator

Patterns of Breathing 1. CHEYNE-STOKES: HV-Apnea =normal in kids &elderly when asleep; heart failure, uremia, brain damage 2. BIOTs: Shallow breath-Apnea

3. KUSSMAULs: deep, regular, rapid 4. ORTHOPNEA: DOB supine

BLOOD PRESSURE =Blood Flow on arterial wall *Systolic Pressure: MAXIMUM BP measured during V contraction *Diastolic Pressure: MINIMUM BP measured during V relaxation *Pulse Pressure: SD-DP BP= Pulse x SV x TPR *Pt rested 5 min before BP & not smoked/ ingested caffeine within 30 min

BP taking!!! 1. 5 min rest, within 30 min no coffee 2. Supine/sitting: arm at heart level, PALM UP! 3. Cuff width 40% of limbs circum; bladder encircle 2/3 of arm 4. BP cuff 1 inch above antecubital 5. Determine palpatory BP before auscultatory BP 6. Bell: 1st Korotkoff (Systole) 7. Deflate slowly: 1-2 mmHg/sec. Disappearance of sound (Diastole)

BP normal: I: 50/30 T:80/60 P:90/70 S:100/70 A:120/80

SKIN CARE/HYGIENE BED BATH *cover with top sheet up to shoulder level. *To avoid chills: close windows; warm water; expose, wash & dry 1 body part at a time: eyes, face, ears, neck-forearms-distal arms-hands-chest-abdomen-legs-feet-back-buttocks-perineum *Extremities: long firm strokes (D-P) *Back: P-D

PERINEAL-GENITAL CARE

*Drape, Dorsal Recumbent *Female: anterior-posterior *Male: firm strokes circular motion Glans penis tip-Shaft! *uncircumscised: retract, smegma X

BED MAKING Bed Types: Unoccupied Bed *Open: top cover (folded back) *Closed: Top sheet (spread up) 2. Occupied Bed: bed made c pt BiRD TaBa Po! Bottom, Rubber, Draw, Top, Blanket, Pillow case

ORAL CAVITY CARE Cheilosis: lip cracking (Vit B12 def) Dental Caries: teeth disintegration (brown discoloration) DT lactic & pyruvic acid (product of bacterial action on CHO) Gingivitis: gum inflam Glossitis: tongue inflam Parotitis/Mumps: parotid salivary inflam Periodontitis: teeth ligament inflam Stomatitis: buccal mucosa inflam Tartar: visible hard deposit of plaque (bacteria, saliva)

ORAL CAVITY CARE *Brush & floss regularly: brush gum-crown! *Upper Front Teeth: Downward strokes *Lower Front Teeth: Upward strokes *Top/Molar sides: Back & forth *45 degree angle: to clean gum margins

Clearing dentures: gloves, place washcloth in basin Unconscious clients: clean chewing & inner tooth surfaces first. Swab roof of mouth, gums, inside cheeks, tongue

EYES, EARS, NOSE CARE *Hyperopia: Farsightedness; ray of light focus BEHIND retina *Myopia: Near; IN FRONT retina *Presbyopia: impaired near vision DT <lens elasticity (aging) *Astigmatism: blurred vision DT uneven curvature of lens or cornea (causing light to focus on diff points) *Retinopathy: retinal vessel changes (hemorrhage, exudates, narrowing) *Strabismus: cross-eyes *Cataract: lens opacity blocks light *Glaucoma: optic atrophy (disc cupping &visual field loss) with IOP

EYE CARE Clean with WATER!, clean cloth inner-outer canthus Contact lens: Pseudomonas/Staph *daily wear: removed overnight & not worn >10-14 hr/day *extended wear: worn not >6 consecutive nights without cleaning Artificial Eyes: Depress lower eyelid to remove eye, hold it bw thumb & index, clean w warm NSS! EAR CARE *moist washcloth, ear canal straightening *Impacted cerumen: instill H2O2 1-2 drops/ear 3x/d for 3d. Irrigate with 250 ml WARM water! (hot/cold: NV)

NOSE CARE *gentle blowing thru open nostrils *soften crusted secretion with NSS

FLUIDS AND ELECTROLYTES TBW (60%) 2/3 ICF 1/3 ECF (1/4 IV,3/4 IT) 1. HYPOVOLEMIA *Isotonic imbalance= equal loss of F&E e.g. diarrhea

<BP&UO, >HR, thirst, dry mucosa *Hyperosmolar imbalance= loss of F only e.g. DI dry, sticky mucosa, sz 2. HYPERVOLEMIA *Isotonic: excess from salt retention, heart & renal failure manifest as edema & congestion (>BP) *Hypoosmolar: >SIADH & excessive water intake manifest as <LOC

Types of Solutions Hypertonic: D5LRS,D5 .9NaCl, D5 .45 NaCl, D5NM, D5NR Isotonic: NSS, LRS Hypotonic: D5W, D10W

SLEEP =state of <perception & rxn to the env RETICULAR ACTIVATING SYSTEM (ras) =WAKEFULNESS: catecholamine release (E)

BULBAR SYNCHRONIZING REGION (bsr) =SLEEPINESS: serotonin release (pons/medulla)

Stages of Sleep NREM: body restoration REM: >brains processes NREM *Stage 1: Lightest sleep, 10 min, readily awakens : EEG (THETA) *Stage 2: Sound sleep, easily arousable, VS decrease : EEG (K complex) *Stage 3: Deep sleep, muscles relaxed, diff to arouse

: EEG (DELTA) *Stage 4: Deepest sleep, most relaxed, sleepwalking, enuresis, night terrors : EEG (DELTA) B. REM: Paradoxic, >VS, >HCl, vivid, full color dreams, 90 min (BETA) SLEEP DISORDERS Narcolepsy: > daytime sleepiness *Cataplexy: sudden muscle weakness *Hypnagogic: dreams undistinguishable from reality Somnambulism: sleep walking Soliloquy: sleep talking Sleep Terrors: sudden waking, but with no dream recall Bruxism: teeth grinding Enuresis: bed-wetting

FUNDA COMPLETE
Posted: September 18, 2011 in FUNDAMENTALS OF NURSING

0
THEORETICAL FRAMEWORK of NURSING PRACTICE

Nursing As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health. Its recovery, or to a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge.

Help the client gain independence as rapidly as possible.

CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

Theorist Description FLORENCE NIGHTINGALE Developed the first theory of nursing.

Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. HILDEGARD PEPLAU FAYE ABDELLAH IDA JEAN ORLANDO Introduced the Interpersonal Model. She defined nursing as a therapeutic, interpersonal process which strives to develop anurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate. Defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people; developed list 21 nursing problem areas Developed the three elements client behavior, nurse reaction and nurse action compose the nursing situation. She observed that the nurse provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. Described the Four Conservation Principles. conservation of energy conservation of structured integrity MYRA LEVINE conservation of personal integrity conservation of social integrity

Developed the Behavioral System Model. Patients behavior as a system that is a whole with interacting parts DOROTHY JOHNSON how the client adapts to illness goal of nursing is to reduce so that the client can move more easily through recovery.

MARTHA ROGERS DOROTHEA OREM IMOGENE KING BETTY NEUMAN SISTER CALLISTA ROY LYDIA HALL JEAN WATSON ROSEMARIE RIZZO PARSE MADELEINE LENINGER ROLES AND FUNCTION OF A NURSE

Conceptualized the Science of Unitary Human Beings. She asserted that human beings are more than different from the sum of their parts; the distinctive properties of the whole are significantly different from those of its parts. Emphasizes the clients self care needs; nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention Presented the Adaptation Model. She viewed each person as a unified bio-psychosocial system in constant interaction with a changing environment. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. Introduced the notion that nursing centers around three components: person(core), pathologic state and treatment(cure) and body(care). Conceptualized the Human Caring Model. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony, which generates self-knowledge, self-control, self-care and self-healing. Introduced the Theory of Human Becoming. She emphasized free choice of personal meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange with the environment and contranscending in many dimensions as possibilities unfold. Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition

Caregiver the caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the clients dignity. Caregiving encompasses the physical, psychosocial, developmental, cultural and spiritual levels. Communicator communication is an integral to all nursing roles. Nurses communicate with the client, support persons, other health professionals, and people in the community. In the role of communicator, nurses identify client problems and then communicate these verbally or in writing to other members of the health team. The quality of a nurses communication is an important factor in nursing care. Teacher as a teacher, the nurse helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health. The nurse assesses the clients learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies and measures learning. Client advocate a client advocate acts to protect the client. In this role the nurse may represent the clients needs and wishes to other health professionals, such as relaying the clients wishes for information to the physician. They also assist clients in exercising their rights and help them speak up for themselves. Counselor counseling is a process of helping a client to recognize and cope with stressful psychologic or social problems, to developed improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual, and psychologic support. Change agent the nurse acts as a change agent when assisting others, that is, clients, to make modifications in their own behavior. Nurses also often act to make changes in a system such as clinical care, if it is not helping a client return to health. Leader a leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels; individual client, family, groups of clients, colleagues, or the community. Effective leadership is a learned process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence others. Manager the nurse manages the nursing care of individuals, families, and communities. The nurse-manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance. Case manager nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes. Research consumer nurses often use research to improve client care. In a clinical area nurses need to: Have some awareness of the process and language of research

Be sensitive to issues related to protecting the rights of human subjects

Participate in identification of significant researchable problems

Be a discriminating consumer of research findings

Concepts of Health and Illness Health As defined by the World Health Organization (WHO): state of complete physical, mental and social well-being, not merely the absence of disease or infirmity. Characteristics A concern for the individual as a total system

A view of health that identifies internal and external environment

An acknowledgment of the importance of an individuals role in life

A dynamic state in which the individual adapts to

changes in internal and external environment to maintain a state of well being

Models of Health and Illness Health-Illness Continuum (Neuman) Degree of client wellness that exist at any point in time, ranging from an optimal wellness condition, with available energy at its maximum, to death which represents total energy depletion. High Level Wellness Model (Halbert Dunn) It is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment. Agent Host environment Model (Leavell) The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment Agent any internal or external factor that disease or illness.

Host the person or persons who may be susceptible to a

particular illness or disease

Environment consists of all factors outside of the host

Health Belief Model Addresses the relationship between a persons belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies. Four Components

The individual is perception of susceptibility to an illness

The individuals perception of the seriousness of the illness

The perceived threat of a disease

The perceived benefits of taking the necessary preventive

measures

Evolutionary Based Model Illness and death serves as a evolutionary function. Evolutionary viability reflects the extent to which individuals function to promote survival and well-being. The model interrelates the following elements: Life events

Life style determinants

Evolutionary viability within the social context

Control perceptions

Viability emotions

Health outcomes

Health Promotion Model A complimentary counterpart models of health protection. Directed at increasing a clients level of well being. Explain the reason for clients participation health-promotion behaviors. The model focuses on three functions: It identifies factors (demographic and socially) enhance or decrease the participation in health promotion

It organizes cues into pattern to explain likelihood of a clients participation health-promotion behaviors

It explains the reasons that individuals engage in health activities

Illness State in which a persons physical, emotional, intellectual, social developmental or spiritual functioning is diminished or i mpaired. It is a condition characterized by a deviation from a normal, healthy state. 3 Stages of Illness Stage of Denial Refusal to acknowledge illness; anxiety, fear, irritability and aggressiveness.

Stage of Acceptance Turns to professional help for assistance

Stage of Recovery (Rehabilitation or Convalescence) The patient goes through of resolving loss or impairment of function

Rehabilitation A dynamic, health oriented process that assists individual who is ill or disabled to achieve his greatest possible level of physical, mental, spiritual, social and economical functioning.

Abilities not disabilities, are emphasized.

Begins during initial contact with the patient

Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of function as short a time as possible

Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process.

Focuses of Rehabilitation Coping pattern

Functional ability focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene, dressing/grooming, toileting and mobility

Mobility

Integrity of skin

Control of bowel and bladder function

Concepts of Stress Stress (Theory by Hans Selye)

Non specific response of the body to nay demand made upon it

Any situation in which a non specific demand requires an individual to respond or take action

Characteristics of Stress Stress is not nervous energy. Emotional reactions are common stressors

Stress is not always the result of damage to the body

Stress does not always result in feelings of distress (harmful or unpleasant stress)

Stress is a necessary part of life and is essential for normal growth and development

Stress involves the entire body acting as a whole and is an integrated manner

Stress response is natural, productive and adaptive

Stressors Factor or agent producing stress, maybe: physiological, psychological, social, environmental, developmental, spiritual or cultural and represent an unmet needs Classification of Stressors Internal Stressors originate from within the body. E.g. fever, pregnancy, menopause, emotion such as guilt External Stressors originate outside a person. E.g. change in family or social role, peer pressure, marked change in environmental temperature Factors influencing response to stressors

Physiological functioning

Personality

Behavioral characteristics

Nature of the stressor: integrity, scope, duration, number, and nature of other stressors

Homeostasis Process of maintaining uniformity, stability and constancy with in the living organisms. (from Greek word homotos like, and stasis position Adaptation Bodys adjustment to different circumstances and conditions. Process by the physiological or psychological dimensions change in response to stress; attempt to maintain optimal functioning Adaptation to Stress-Physiological Response (Hans Selye) Local Adaptation Syndrome (LAS) Response of a body tissue, organ or part to the stress of trauma, illness or other physiological change Characteristics The response is localized, it does not involve entire body systems The response is adaptive, meaning that a stressor is necessary to stimulate it The response is short term. It does not persist indefinitely The response is restorative, meaning that the LAS assists in restoring homeostasis to the body region or part Two Localized Responses Reflex Pain Response is a localized response of the central nervous system to pain. It is an adaptive response and protects tissue from further damage. The response involves a sensory receptor, a sensory nerve from the spinal cord, and an effector muscle. An example would be the unconscious, reflex removal of the hand from a hot surface.

Inflammatory Response is stimulated by trauma or infection. This response localizes the inflammation, thus revenging its spread and promotes healing. The inflammatory response may produce localized pain, swelling, heat, redness and changes in functioning. Three Phases of Inflammatory Response First Phase Narrowing of blood vessels occurs at the injury to control bleeding. Then histamine is released at the injury, increasing the number of white blood cells to combat infection. Second Phase It is characterized by release of exudates from the wound Third Phase The last phase is repair of tissue by regeneration or scar formation. Regeneration replaces damaged cells with identical or similar cells. General Adaptation Syndrome (GAS) or Stress Syndrome characterized by a chain or pattern of physiologic events. 3 Stages Alarm Reaction initial reaction of the body which alerts the bodys defenses. SELYE divided this stage into 2 parts: The SHOCK PHASE

The COUNTERSHOCK PHASE

Stage of Resistance occurs when the bodys adaptation takes place; the body attempts to adjust with the stressor and to limit the stressor to the smallest area of the body that can deal with it. Stage of Exhaustion the adaptation that the body made during the second stage cannot be maintained; the ways used to cope with the stressors have been exhausted STRESSORS stimulate the sympathetic nervous system, which in turn stimulates the hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH). During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE & NOREPINEPHRINE in response to sympathetic stimulation. Significant body responses to epinephrine include the following: Increased myocardial contractility, which increases cardiac output & blood flow to active muscles

Bronchial dilation, which allows increased oxygen intake

Increased blood clotting

Increased cellular metabolism

Increased fat mobilization to make energy available & to synthesize other compounds needed by the body.

Physiologic Indicators of Stress Pupils dilate to increase visual perception when serious threats to the body arise. Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism. The heart rate & cardiac output increase to transport nutrients and by-products of metabolism more efficiently. Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine. Sodium & water retention increase due to release of mineralocorticoids, which results in increased blood volume.

The rate & depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation. Urinary output may increase or decreases. The mouth may be dry. Peristalsis of the intestines decreases, resulting in possible constipation and flatus. For serious threats, mental alertness improves. Muscle tension increases to prepare for rapid motor activity or defense. Blood sugar increases because of release of glucocorticoids & gluconeogenesis. Psychologic Indicators psychologic manifestations of stress include anxiety, fear, anger, depression & unconscious ego defense mechanisms. Anxiety a common reaction to stress. It is a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. It can be experienced, subcutaneous or unconscious level. Can be manifested on 4 LEVELS: Fear an emotion or feeling of apprehension aroused by impending or seeming danger, or other perceived threat. The object of fear may or may not be based in reality. Anger an emotional state consisting of a subjective feeling of animosity or strong displeasure. People may feel guilty when they feel anger because they have been taught that to feel angry is wrong. Depression common reaction to events that seem overwhelming or negative. It is an extreme feeling of sadness, despair, dejection, lack of worth or emptiness. Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or numbness

Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions, loss of sexual desire, crying, sleep disturbance and social withdrawal.

Physical signs include: Loss of appetite, weight loss, constipation, headache and dizziness

Cognitive Indicators are thinking responses that include problem-solving, structuring, self-control or self-discipline, suppression and fantasy Problem solving involves thinking through the threatening situation, using a specific steps to arrive at a solution Structuring arrangement or manipulation of a situation so that threatening events do not occur. Self-Control (discipline) assuming a manner of facial expression that convey a sense of being in control or in change. Suppression consciously and willfully putting a thought or feeling out of mind Fantasy (daydreaming) likened to make believe. Unfulfilled wishes & desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality. COPING STRATEGIES (COPING MECHANISMS)

Coping dealing with problems & situations or contending with them successfully. Coping Strategy innate or acquired way of responding to a changing environment or specific problem or situation. According to Folkman and Lazarus, coping is the cognitive & behavioral effort to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person.

Coping Strategies: 2 Types

Problem-focused coping efforts to improve a situation by making changes or taking some action Emotion-focused coping does not improve the situation, but the person often feels better. Coping strategies are also viewed as: Long-term coping strategies can be constructive & realistic

Short-term coping strategies can reduce stress to a tolerable limit temporarily but are in the end od ineffective ways to deal with reality.

Coping can be adaptive or maladaptive: Adaptive Coping helps the person to deal effectively with stressful events & minimizes distress associated with them.

Maladaptive Coping can result in unnecessary distress for the person & others associated with the person or stressful event.

*Effective coping results in adaptation; ineffective coping results in maladaptation. The effectiveness of an

individuals coping is influenced by a number of factors:

The number, duration & intensity of the stressors

Past experiences of the individual

Support systems available to the individual

Personal qualities of the person

*If the duration of the stressors is extended beyond the coping powers of the individual, that person becomes exhausted and may develop increased susceptibility to health problems.

*Reaction to long term stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden & produces responses such as chronic fatigue, sleeping difficulties & high BP.

*Prolonged stress can also result in mental illness.

Relaxation Techniques used to quiet the mind, release tension & counteract the fight or flight responses of General Adaptation Syndrome (GAS). Breathing Exercises

Massage

Progressive Relaxation

Imagery

Biofeedback

Yoga

Meditation

Therapeutic Touch

Music Therapy

Humor & Laughter

PSYCHOLOGICAL RESPONSE

Exposure to a stressor results in psychological and physiological and physiological adaptive responses. As people are exposed a stressors, their ability to meet their basic needs is threatened. This threat whether actual or perceived, produces frustration, anxiety and tension. Psychological adaptive behaviors assist the persons ability to cope with stressors. These behaviors are directed at stress management and are acquired through learning and experience as a person identifies acceptable and successful behaviors.

Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves:

Task Oriented Behaviors Involve using cognitive abilities to reduce stress, solve problems, resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of a stressor. Three General Types

Attack Behavior Is acting to remove or overcome a stressor or to satisfy a need

Withdrawal Behavior Is removing the self physically or emotionally from the stressor

Compromise Behavior Is changing the usual method of operating, substituting goals or omitting the satisfaction of needs to meet other needs or to avoid stress.

Defense Mechanisms Unconscious behaviors that offer psychological protection from a stressful event. They are used by everyone and help protect against feelings of worthlessness and anxiety. Frequently activated by short-term stressors and usually do not result in psychiatric disorders. TYPES OF NURSING DIAGNOSES

Formulating the Nursing Diagnosis Actual

Clients demonstrates defining characteristics of a problem

Nurse intervenes to resolve or help client cope with the problem

High-risk

A problem is likely to develop based on assessment of risk factors

Nurse intervenes to reduce risk factors or increase protective factors

Example: encourage smoking cessation

Wellness

Client is presently healthy but wishes to achieve a higher level of function

Nurse intervenes to promote growth or maintenance of the healthy response

Collaboative Problems Definition: a potential problem the nurse manages using both independent and interdependent interventions

Example: potential complication of head injury: loss of consciousness, epidural or subdural hematoma, seizures

Usually occurs when a disease is present or a treatment is prescribed

Clients with similar disease or treatment will have the same potential for complications, which must be managed collaboratively; however, their responses to the condition will vary, so a broad range of nursing diagnoses will apply.

Example: a client with asthma will always be at risk for lowered oxygen saturation; however, the clients response to this condition will be unique based on his/her developmental level, past experiences and family configuration

Refer to Table for examples of collaborative problems

Example: Disease/Situation Complication Related to Etiology 1.Uterine atony 2. Retained placental fragment Hemorrhage Dysrhythmia Related to Related to 3. Bladder distention Low serum potassium

Potential complication of childbirth Potential complication of diuretic therapy

METHODS USED for ASSESSMENT

Collaboration of Data: Objective & Subjective Review of clinical record Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations

Reviewing the clients record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.

Interview The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support.

The goals of an interview are to develop a rapport with the client and to collect data

An interview has 3 major stages

Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time.

Body: during this phase, the client responds to open and closed-ended questions asked by the nurse.

Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.

Types of questions

Closed questions used in directive interview

Re____ short factual answers; e.g. Do you have pain?

Answers usually reveal limited amounts of information

Useful with clients who are highly stressed and/or have difficulty communicating

Open-ended questions used in nondirective interview

Encourage clients to express and clarify their thoughts and feelings; e.g. How have you been sleeping lately?

Specify the broad area to be discussed and invite longer answers

Useful at the start of an interview or to change the subject

Leading questions

Direct the clients answer; e.g. You dont have any questions about your medications, do you?

Suggests what answer is expected

Can result in client giving inaccurate data to please the nurse

Can limit client choice of topic for discussion

Nursing History Collection of information about the effect of the clients illness on daily functioning and ability to cope with the stressor (the human response)

Subjective data

May be called covert data

Not measurable or observable

Obtained from client (primary source), significant others, or health professionals (secondary sources).

For example, the client states, I have a headache

Objective data

May be called overt data

Can be detected by someone other than the client

Includes measurable and observable client behavior

For example, a blood pressure reading of 190/110 mmHg.

Physical assessment Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion

A body system format for physical assessment is found below:

General assessement Integumentary system Head, ears, eyes, nose, throat Breast and axillae Thorax and lungs Cardiovascular system Nervous system Abdomen and gastrointestinal system Anus and rectum Genitourinary system Reproductive system Musculoskeletal system Psychosocial assessment Helpful framework for organizing data

A suggested format for psychosocial assessment is found below:

The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection

Vocation/education/financial Home and Family Social, leisure, spiritual and cultural Sexual Activities of daily living Health Habits Psychological Consultation with individuals who can contribute to the clients database is helpful in achieving the most complete and accurate information about a client Consultation The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records)

Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the clients status prior to admission

Review of literature A professional nurse engages in continued education to maintain knowledge of current information related to health care

Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database

DOCUMENTING and REPORTING

Guidelines for Good Documentation and Reporting Fact information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells Accuracy information must be accurate so that health team members have confidence in it Completeness the information within a record or a report should be complete, containing concise and thorough information about a clients care. Concise data are easy to understand Currentness ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following:

Vital signs

Administration of medications and treatments

Preparation of diagnostic tests or surgery

Change in status

Admission, transfer, discharge or death of a client

Treatment fro a sudden change in status

Organization the nurse communicate in a logical format or order

Confidentiality a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed

Documentation anything written or printed that is relied on as a record of proof fro authorized persons. Purposes of Records:

Communication

Planning Client Care

Auditing Health Agencies

Research

Education

Reimbursement

Legal Documentation

Health Care Analysis

Documentation Systems Source Oriented Record The traditional client record

Each person or department makes notations in a separate section or sections of the clients chart

It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information

Example: the admissions department has an admission sheet; the physician has a physicians order sheet, a physicians history sheet & progress notes

NARRATIVE CHARTING is a traditional part of the source-oriented record

Problem Oriented Medical Record (POMR) Established by Lawrence Weed

The data are arranged according to the problems the client has rather than the source of the information.

The four (4) basic components:

Database consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physicians history, social & family data

Problem List derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved

Plan of Care care plans are generated by the person who lists the problems. Physicians write physicians orders or medical care plans; nurses write nursing orders or nursing care plans

Progress Notes chart entry made by all health professionals involved in a clients care; they all use the same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data

Example: SOAP Format Or SOAPIE and SOAPIER S Subjective data

O Objective data

A Assessment

P Plan

I Intervention

E Evaluation

R- Revision

Advantages of POMR:

It encourages collaboration

Problem list in the front of the chart alerts caregivers to the clients needs & makes it easier to track the status of each problem

Disadvantages of POMR:

Caregivers differ in their ability to use the required charting format

Takes constant vigilance to maintain an up-to-date problem list

Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.

PIE (Problems, Interventions, and Evaluation) Groups information in to three (3) categories

This system consists of a client care assessment floe sheet & progress notes

FLOW SHEET uses specific assessment criteria in a particular format, such as human needs or functional health patterns

Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes

Focus Charting Intended to make the client & client concerns & strengths the focus of care

Three (3) columns fro recording are usually used: date & time, focus & progress notes

Charting by Exception Documentation system in which only abnormal or significant findings or exceptions to norms are recorded

Incorporates three (3) key elements:

Flow sheets

Standards of nursing care

Bedside access to chart forms

Computerized Documentation

Developed as a way to manage the huge volume of information required in contemporary health care

Nurses use computers to store the clients database, add new data, create & revise care plans & document client progress.

Case Management Emphasizes quality, cost-effective care delivered within an established length of stay

Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.

Nursing Care Plan (NCP) Two Types:

Traditional Care Plan written fro each client; it has 3 columns: nursing diagnoses, expected outcomes & nursing interventions.

Standardized Care Plan based on an institutions standards of practice; thereby helping to provide a high quality of nursing care

KARDEX widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms. Information may be organized into sections: Pertinent information about the client

List of medications

List of IVF

List of daily treatments & procedures

List of Diagnostic procedures

Allergies

Specific data on how the clients physical needs are to be met

A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge / Referral Summaries completed when the client is being discharged & transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it include some or all of the following: Description of clients physical, mental & emotional state

Resolved health problems

Unresolved continuing health problems

Treatments that can be continued (e.g. wound care, oxygen therapy)

Current medications

Restrictions that relate to activity, diet & bathing

Functional/self-care abilities

Comfort level

Support networks

Client education provided in relation to disease process

Discharge destination

Referral Services (e.g. social worker, home health nurse)

PHYSICAL EXAMINATION

Purposes The nurse uses physical assessment for the following reasons:

To gather baseline data about the clients health

To supplement, confirm or refute data obtained in the nursing history

To confirm and identify nursing diagnoses

To make clinical judgments about a clients changing health status and management

Preparation of Examination Environment A physical examination requires privacy. An examination room that is well equipped for all necessary procedures is preferable

Equipment Hand washing is done before equipment preparation and the examination. Hand washing reduces the transmission of microorganisms

Client

Psychological Preparation clients are easily embarrassed when forced to answer sensitive questions about bodily functions or when body parts are exposed and examined. The possibility that the examination will find something abnormal also creates anxiety so reduction of this anxiety may be the nurses highest priority before the examination

Physical Preparation the clients physical comfort is vital to the success of the examination. Before starting, the nurse asks if the client needs to use the toilet.

Positioning during the examination, the nurse asks the clients to assume proper positions so that body parts are accessible and clients s tay comfortable. Clients abilities to assume positions will depend on their physical strength and degree of wellness.

Order of Examination General Survey includes observation of general appearance and behavior, vital signs, height and weight measurement

Review of systems

Head to toe examination

Skills in Physical Examination Inspection to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles: Make sure good lighting is available

Position and expose body parts so that all surface can be viewed

Inspect each areas fro size, shape, color, symmetry, position and abnormalities

If possible, compare each area inspected with the same area of the opposite side of the body

Use additional light (for example, a penlight) to inspect body cavities

Palpation the hands can make delicate and sensitive measurements of specific physical signs, so palpation is used to examine all accessible parts of the body. The nurse uses different parts of the hand to detect characteristics such as texture, temperature and the perception of movement. Percussion examination by striking the bodys surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue Auscultation is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope. Bowel sounds

Breath sounds

Vesicular

Bronchovesicular

Bronchial

Examples of Adventitious Breath Sounds Crackles (previously called rales)

Rhonchi

Wheeze

Friction rub

Therapeutic Communication Techniques Using silence

Providing general leads

Being specific & tentative

Using open-ended questions

Using touch

Restating to paraphrasing

Seeking clarification

Perception checking or seeking consensual validation

Offering self

Giving information

Acknowledging

Clarifying time or sequence

Presenting reality

Focusing

Reflecting

Summarizing & planning

Barriers to Communication

Stereotyping

Agreeing & disagreeing

Being defensive

Challenging

Probing

Testing

Rejecting

Changing topics & subjects

Unwarranted reassurance

Passing judgment

Giving common advice

Phases of the Helping Relationship Pre-interaction Phase

Introductory Phase

a. Opening the relationship

b. Clarifying the problem

c. Structuring & formulating the contract

Working Phase

a. Exploring & understanding thoughts or feelings

b. Facilitating & taking action

Termination Phase

PRINCIPLES of ASEPSIS and INFECTION CONTROL

Chain of Infection The chain of infection refers to those elements that must be present to cause an infection from a microorganism Basic to the principle of infection is to interrupt this chain so that an infection from a microorganism does not occur in clients Infectious agent; microorganisms capable of causing infections are referred to as an infectious agent or pathogen. Modes of transmission: the microorganism must have a means of transmission to get from one location to another, called direct and indirect Susceptible host describes a host (human or animal) not possessing enough resistance against a particular pathogen to prevent disease or infection from occurring when exposed to the pathogen; in humans this may occur if the persons resistance is low because of poor nutrition, lack of exercise of a coexisting illness that weakens the host. Portal of entry: the means of a pathogen entering a host: the means of entry can be the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract). Reservoir: the environment in which the microorganism lives to ensure survival; it can be a person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support organism that are pathogenic to humans are inanimate objects food and water, and other humans. Portal of exit: the means in which the pathogen escapes from the reservoir and can cause disease; there is usually a common escape route for each type of microorganism; on humans, common escape routes are the gastrointestinal, respiratory and the genitourinary tract. Modes of Transmission Direct contact: describes the way in which microorganisms are transferred from person to person through biting, touching, kissing, or sexual intercourse; droplet spread is also a form of direct contact but can occur only if the source and the host are within 3 feet from each other; transmission by droplet can occur when a person coughs, sneezes, spits, or talks.

Indirect contact: can occur through fomites (inanimate objects or materials) or through vectors (animal or insect, flying or crawling); the fomites or vectors act as vehicle for transmission

Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the air for long periods and dust particles containing infectious agents can become airborne infecting a susceptible host generally through the respiratory tract

Course of Infection Incubation: the time between initial contact with an infectious agent until the first signs of symptoms - > the incubation period varies from different

pathogens; microorganisms are growing and multiplying during this stage

Prodromal Stage: the time period from the onset of nonspecific symptoms to the appearance of specific symptoms related to the causative pathogen - > symptoms range from being fatigued to having a low-grade fever with

malaise; during this phase it is still possible to transmit the pathogen to

another host

Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to as the acute stage; during this stage, it may be possible to transmit the infectious agent to another, depending on the virulence of the infectious agent Convalescence: time period that the host takes to return to the pre-illness stage; also called the recovery period; - >the host defense mechanisms have responded to the infectious agent and the signs and symptoms of the disease disappear; the host, however, is more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label related to this process would be Risk for Infection Inflammation The protective response of the tissues of the body to injury or infection; the physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic Bodys response

The inflammatory response begins with vasoconstriction that is followed by a brief increase in vascular permeability; the blood vessels dilate allo wing plasma to escape into the injured tissue

WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack and ingest the invaders (phagocytosis); this process is responsible for the signs of inflammation

Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result of the heat from the increased blood in the area, swelling occurs from fluid accumulation; the pain occurs from pressure or injury to the local nerves.

Immune Response The immune response involves specific reactions in the body to antigens or foreign material

This specific response is the bodys attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes Cell mediated immunity: T-lymphocytes are responsible for cellular immunity When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen

Once theantigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen

After the antigen is gone, the lymphokines disappear

Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again.

Humoral response: the ability of the body to develop a specific antibody to a specific antigen (antigen-antibody response) B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections Active immunity is produced when the immune system is activated either naturally or artificially. Natural immunity involves acquisition of immunity through developing the disease

Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity)

Passive immunity does not require a host to develop antibodies, rather it is transferred to the individual, passive immunity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen.

Nosocomial Infection Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system Iatrogenic infection: these nosocomial infections are directly related to the clients treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning Exogenous Infection: are a result of the healthcare facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection Endogenous Infection: can occur from clients themselves or as a reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish. Factors Increasing Susceptibility to Infection Age: young infants & older adults are at greater risk of infection because of reduced defense mechanisms Young infants have reduced defenses related to immature immune systems

In elderly people, physiological changes occur in the body that make them more susceptible to infectious disease; some of these changes are:

Altered immune function (specifically, decreased phagocytosis by the neutrophils and by the macrophages)

Decreased bladder muscle tone resulting in urinary retention

Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate normal secretions

Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric emptying.

Heredity: some people have a genetic predisposition or susceptibility to some infectious diseases

Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene practices, can influence a persons susceptibility to infectious diseases

Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases; nutritional practices that do not supply the body with the basic components necessary to synthesized proteins affect the way the bodys immune system can respond to pathogens

Stress: stressors, both physical and emotional, affect the bodys ability to protect against invading pathogens; stressors af fect the body by elevating blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes energy stores, thus increasing the risk of infection

Rest, exercise and personal health habits: altered rest and exercise patterns decrease the bodys protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the bodys response to pathogens

Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal defense mechanisms in the body, making the client more susceptible to infection; the immune system functions throughout the body and depends on the following:

Intact skin and mucous membranes

Adequate blood cell production and differentiation

A functional lymphatic system and spleen

An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune disease, the body has a problem with recognizing its own tissue and cells; people with autoimmune disease are at increased risk of infection related to their immune system deficiencies.

Environmental: an environment that exposes individuals to an increased number of toxins or pathogens also increases the risk of infection; pathogens grow well in warm moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an environment that increases exposure to toxic substances also increases risk

Immunization history: inadequately immunized people have an increased risk of infection specifically for those diseases for which vaccines have been developed.

Medications and medical therapies: examples of therapies and medications that increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery

Diagnostic Tests Used to Screen for Infection

Signs and symptoms related to infections are associated with the area infected; for instance, symptoms of a local infection on the skin or mucous membranes are localized swelling, redness, pain and warmth Symptoms related to systemic infections include fever, increased pulse & respirations, lethargy, anorexia, and enlarged lymph nodes Certain diagnostic tests are ordered to confirm the presence of an infection.

THEORIES OF PAIN

Specific Theory Proposes that bodys neurons & pathways for pain transmission are specific, similar to other senses like taste

Free nerve endings in the skin act as pain receptors, accept input & transmit impulses along highly specific nerve fibers

Does not account for differences in pain perception or psychologic variables among individuals.

Pattern Theory Identifies 2 major types of pain fibers; rapidly & slowly conducting

Stimulation of these fibers forms a pattern; impulses ascend to the brain to be interpreted as painful

Does not account for differences in pain perception or psychologic variables among individuals.

Gate Control Theory Pain impulses can be modulated by a transmission blocking action within the CNS.

Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or scratching an area) and may inhibit smaller diameter fibers to prevent transmission of the impulse (close the gate).

Current Developments in Pain Theory Indicate that pain mechanisms & responses are far more complex than believed to be in the past. Pain may modulated at different points in the nervous system.

First-order neurons at the tissue level

Second-order neurons in the spinal cord that process nociceptor information

Third-order tracts & pathways in the spinal cord & brain that relay/process this information

The role of the pain experience in the development of new nociceptors and/or reducing the threshold of current nociceptor is also being investigate

TYPES OF PAIN

Acute Pain Usually temporary, sudden in onset, localized, lasts for 6 months; results from tissue injury associated with trauma, surgery, or inflammation.

Types of Acute Pain Somatic: arises from nerve receptors in the skin or close to bodys surface; may be sharp & well-localized or dull & diffuse; often accompanied by nausea & vomiting Visceral: arises from bodys organs; dull & poorly localized because of minimal noriceptors; accompanied by nausea & vomiting, hypotension & restlessness Referred pain: pain that is perceived in an area distant from the site of stimuli (e.g. pain in a shoulder following abdominal laparoscopic procedure).

Acute pain initiates the fight-or-flight response of the Autonomic Nervous System and is characterized by the following symptoms:

Tachycardia

Rapid, shallow respirations

Increased BP

Sweating

Pallor

Dilated pupils

Fear & Anxiety

Chronic Pain Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often unresponsive to medical treatment.

Types of Chronic Pain

Neuropathic: painfuil condition that results from damage to peripheral nerves caused by infection or disease; post-therapeutic neuralgia (shingles) is an example Phantom: pain syndrome that occurs following surgical or traumatic amputation of a limb. The client is aware that the body part is missing

Pain may result of stimulation of severed nerves at the site of amputation

Sensation may be experienced as an itching, pressure, or as stabbing or burning in nature

It can be triggered by stressors (fatigue, illness, emotions, weather)

This experience is limited for most clients because the brain adapts to amputated limb; however, some clients experience abnormal sensation or pain over longer periods

This type of pain requires treatment just as any other type of pain does.

Psychogenic: pain that is experienced in the absence of a diagnosed physiologic cause or event; the clients emotional needs may prompt pain sensation. Depression is a common associated symptom for the client experiencing chronic pain; feelings of despair & hopelessness along with fatigue are expected findings.

PAIN ASSESSMENT

TOOLS/INTRUMENTS USED A VERBAL REPORT using an intensity scale is a fast, easy & reliable method allowing the client to state pain intensity & in turn, promotes consisted communication among the nurse, client & other healthcare professionals about the clients pain status; the 2 most common scales used are 0 to 5 or 0 to 10. With 0 specifying no pain & the highest number specifying the worst pain A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers at both ends of the scale, such as no pain at one end and worst pain at the other, clients are asked to point or mark along the line to convey the degree of pain being experienced A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a numerical scale with the word modifiers, usually the numbers 0 to 10 are added to the scale. FACES PAIN SCALE children, clients who do not speak English & clients with communication impairments may have difficulty using a numerical pain intensity scale; the FACES pain scale may be used for children as young as 3 years old; this scale provides facial expressions (happy face reflects no pain, crying face represents worst pain) PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to assess pain for a non-communicating client, facial & vocal expression may be the initial manifestations of pain; expressions may include rapid eye blinking, biting of the lip, moaning, crying, screaming, either closed or clenched eyes, or stiff unmoving body position A B C D E method of pain assessment This acronym was developed for cancer pain; however, it is very appropriate for clients with any type of pain, regardless of the underlying disease.

A = Ask about pain

B = Believe the client & family reports pain

C = Choose pain control options appropriate for the client

D = Deliver interventions in a timely, logical &coordinated fashion

E = Empower clients & families

P Q R S T assessment for pain reception This method is especially helpful when approaching a new pain problem

P = What precipitated the pain?

Q = What are the quality & quantity of the pain?

R = What is the region of the pain?

S = What is the severity of the pain?

T = What is the timing of the pain?

Pain History Location when clients report pain all over, this generally refers to total pain or existential distress (unless there is an underlyi ng physiologic reason for pain all over the body, such as myalgias); assess the clients emotional state for depression, fear, anxiety or hopelessness. Intensity It is important to quantify pain using a standard pain intensity scale. When clients cannot conceptualize pain using a number, simple word categorizes can be useful (e.g. no pain, mild, moderate, severe). Quality Nociceptive pain are usually related to damage to bones, soft tissues, or internal organs; nociceptive pain includes somatic & visceral pains.

Somatic pain is aching, throbbing pain; example arthritis

Visceral pain is squeezing, cramping pain; example: pain associated with ulcerative colitis

Pattern pain may be always present for a client; this is often termed baseline pain. Additional pain may occur intermittently that is of rapid onset & greater intensity than the baseline pain; known as breakthrough pain. People at end-of-life often have both types of pain. Cultural beliefs regarding the meaning of pain should be examined ADMINISTRATION OF MEDICATIONS

DRUG NOMENCLATURE and FORMS

Names Chemical Name provides an exact description of the drugs composition. An example of chemical name acetylsalicylic known common as Aspirin Generic Name is given by the manufacturer who first develops the drug before it receives official approval. Protected by law, the generic name is given before a drug receives official publications. Official Name is the name under which drug is listed in official publication

Trade, Brand or Propriety Name is the name under which a manufacturer markets. Classification Nurses categorized medications with similar characteristics by their class. Drug classification indicates the effects on a body system, the symptoms relieved or the desired effect. Each class contains drugs prescribed for similar types of health problems. The physical and chemical composition of drugs within a class is not necessarily the same. A drug may also belong to more than one class. For example, aspirin is an analgesic and antipyretic and an anti-inflammatory drug. Forms Drugs are available in a variety of forms preparations. The form of the drug determines its route o administration. For example, a capsule is taken orally and a solution may be given intravenously. The composition drug is designed to enhance its absorption and metabolism within the body. Many drugs are available in several forms such as tablets, capsules, elixirs and suppositories. When administering a medication, the nurse must be certain to give the metabolism in the proper form.

Principles in Administering Medications Observe the 7 RIGHTS of Drug Administration:

Right Drug

Right Dose

Right Time

Right Route

Right Patient

Right Recording

Right Approach

Practice asepsis

Nurses who administer medications are responsible for their own actions. Question any order that you can consider incorrect.

Be knowledgeable about medications that you administer

Keep narcotics & barbiturates in locked place

Use only medications that are in clearly labeled containers

Return liquid that are cloudy or have changed in color to the pharmacy

Before administering a medication, identify the client correctly

Do not leave the medication at the bedside

If the client vomits after taking an oral medication, report this to the nurse in charge and/or physician

Preoperative medications are usually discontinued during the post operative period unless ordered to be continued

When a medication is omitted for any reason, record the fact together with the reason

When a medication error is made, report immediately to the nurse in charge and/or physician

BASIC HUMAN NEEDS

Abraham Maslow developed the five (5) levels of human needs: Physiologic Needs needs such as air, food, water, shelter, rest, sleep, activity and temperature maintenance are crucial for survival Safety and Security Needs the need for safety has both physical and physiologic aspects

Love and Belonging Needs the third level of needs includes giving and receiving affection, attaining a place in a group and maintaining the feeling of belonging Self-Esteem Needs the individual needs both self-esteem and esteem from others Self-Actualization when the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop ones maximum potential and realize ones abilities and qualities

Maslows Characteristics of a Self-Actualized Person Is realistic, sees life clearly and is objective about his or her observations

Judges people correctly

Has superior perception, is more decisive

Has a clear notion of right or wrong

Is usually accurate in predicting future events

Understands art, music, politics and philosophy

Possesses humility, listens to others carefully

Is dedicated to some work, task, duty or vocation

Is highly creative, flexible, spontaneous, courageous,

and willing to make mistakes

Is open to new ideas

Is self-confident and has self-respect

Has low degree of self-conflict; personality is integrated

Respect self, does not need fame, possesses a feeling of self-control

Is highly independent, desires privacy

Can appear remote or detached

is friendly, loving and governed more by inner directives than by society

Can make decisions contrary to popular opinion

Is problem centered rather than self-centered

Accepts the world for what it is

MEETING OXYGENATION NEEDS

Oxygenation a basic human need & is required to sustain life. Cardiovascular Physiology the function of the cardiac system is to deliver oxygen, nutrients, & other substances to the tissues and to remove the waste products of cellular metabolism

Structure and Function the heart pumps blood through the pulmonary circulation by way of the right ventricle and to the systemic circulation by way of the left ventricle Myocardial Pump the pumping action of the heart is essential to maintain oxygen delivery Myocardial Blood Flow to maintain adequate blood flow to the pulmonary and systemic circulations, myocardial blood flow must sufficiently supply oxygen and nutrients to the myocardium itself Coronary Artery Circulation blood flow to the atria and ventricles does not supply oxygen and nutrients to the myocardium itself. It is the branch of the systemic circulation that supplies oxygen and nutrients and removal of waste from the myocardium Systemic Circulation the arteries and veins of the systemic circulation deliver nutrients and oxygen and remove wastes from the tissues. Oxygenated blood flows from the left ventricle by way of of the aorta and into the large systemic arteries Regulation of Blood Flow the amount of blood ejected from the left ventricle each minute is the cardiac output. The circulating volume of blood changes according to the oxygen and metabolic needs of the body. For example, during exercise, pregnancy and fever, the cardiac output increases but during sleep, the cardiac output decreases. Steps in the Process of Oxygenation Ventilation process by which gases are moved into and out of the lungs. Adequate ventilation requires coordination of the muscular and elastic properties of the lung and thorax and intact innervation. The major inspiratory muscle is the diaphragm which is innervated by the phrenic nerve. Perfusion the primary function of pulmonary circulation is to move blood to and from the alveolar-capillary membrane so that gas exchange can occur

Exchange of Respiratory Gases respiratory gases are exchanged in the alveoli of the lungs and the capillaries of the body tissues Diffusion movement of molecules from an area of higher concentration to an area of lower concentration

Oxygen Transport delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs & tissues (perfusion), adequacy of diffusion & capacity of the blood to carry oxygen.

Carbon Dioxide Transport carbon dioxide diffuses into RBCs and I rapidly hydrated into carbonic acid because of the presence of carbonic hydrase

MEETING NUTRITIONAL NEEDS

Principles of Nutrition Digestion process by which food substances are changed into forms that can be absorbed through cell membranes Absorption the taking in of substance by cells or membranes Metabolism sum of all physical and chemical processes by which a living organism is formed and maintained and by which energy is made available Storage some nutrients are stored when not used to provide energy; e.g. carbohydrates are stored either as glycogen or as fat Elimination process of discarding unnecessary substances through evaporation, excretion Nutrients

Carbohydrates the primary sources are plant foods Types of Carbohydrates

Simple (sugars) such as glucose, galactose, and fructose

Complex such as starches (which are polysaccharides) and fibers (supplies bulk or roughage to the diet)

Proteins organic substances made up of amino acids Lipids organic substances that are insoluble in water but soluble in alcohol and ether. Fatty acids the basic structural units of all lipids and are either saturated (all the carbon atoms are filled with hydrogen) or unsaturated (could accommodate more hydrogen than it presently contains) Food sources of lipids are animal products (milk, egg yolks and meat) and plants and plant products (seeds, nuts, oils)

Vitamins organic compounds not manufactured in the body and needed in small quantities to catalyze metabolic processes Water-soluble vitamins include C and B-complex vitamins

Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts in the body

Minerals compounds that work with other nutrients in maintaining structure and function of the body Macronutrients calcium, phosphate, sodium, potassium, chloride, magnesium and sulfur

Micronutrients (trace elements) iron, iodine, copper, zinc, manganese and fluoride

The best sources are vegetables, legumes, milk and some meats

Water the bodys most basic nutrient need; it serves as a medium for metabolic reactions within cells and a transporter fro nutrients, waste products and other substances MEETING URINARY ELIMINATION NEEDS

Normal Urinary Function Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to ensure continued normal kidney function

Urine normally consists of 96% water

Solutes found in urine include:

Organic solutes: urea, ammonia, uric acid and creatinine

Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus

Common Assessment Findings Urgency strong desire to void my be caused by inflammations or infections in the bladder or urethra Dysuria painful or difficult voiding Frequency voiding that occurs more than usual when compared with the persons regular pattern or the generally accepted norm of voiding once every 3 to 6 hours

Hesitancy undue delay and difficulty in initiating voiding Polyuria a large volume of urine or output voided at any given time Oliguria a small volume of urine or output between 100 to 500 mL/24 hr Nocturia excessive urination at night interrupting sleep Hematuria RBCs in the urine URINARY CATHETERIZATION

Is the introduction of a catheter through the urethra into the bladder for the purpose of withdrawing urine.

Purposes To relieve urinary retention

To obtain a sterile urine specimen from a woman

To measure the amount of residual urine in the bladder

To obtain a urine specimen when a specimen cannot secure satisfactory by other means

To empty bladder before and during surgery and before certain diagnostic examinations

***Several BASIC FACTS about the lower urinary tract system should be borne in mind when considering catheterization.

Necessary Equipment for Catheterization Catheters are graded on the French scale according to the size of the lumen. For the female adult, No. 14 and No. 16 French catheters are usually used. Small catheters are generally not necessary and the size of the lumen is also so small that it increases the length of time necessary for emptying the bladder. Larger catheter distends the urethra and tends to increase the discomfort of the procedure. For male adult, No.18 and No. 20 French catheters usually used, but if this appears to be too large, smaller catheter should be used. No. 8 and No. 10 French catheters are commonly used for children. Preparation of the Patient Adequate exploration Position dorsal recumbent for the female and supine for the male using a firm mattress or treatment table, Sims or lateral position c an be an alternate for the female patient Provision for privacy Retention or Indwelling Catheter (Foley) A catheter to remain in place for the following purposes: The gradual decompression of an over distended bladder

For intermittent bladder drainage

For continuous bladder drainage

An indwelling catheter has a balloon which is inflated after the catheter is inserted into the bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter is retained in the bladder.

Procedure for Insertion

Inflate the balloon with the prefilled syringe before inserting the catheter to check for balloon patency. Aspirate the fluid back into the syringe when it is determined that the balloon is patent.

Hold the catheter with one hand and inflate the balloon according to the manufacturers instructions, as soon as the catheter is in the bladder and urine has begun to drain from the bladder. Usually 5 ml to 10 ml of sterile water is used If the patient complains of pain after the balloon is inflated, allow it to empty and replace the catheter with another one. The balloon is probably located in the urethra and is causing discomfort owing to distention of the urethra

Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in the bladder

Connect the catheter to the drainage tubing and drainage bag if not already connected

Tape the catheter along the interior aspect of the thigh fro a female patient. Be sure there is no tension on the catheter when it is taped to the patient

Hang the drainage bag on the frame of the bed below the level of the bladder

Caring for the Patient with an Indwelling Catheter Be sure to wash hands before and after caring for a patient with an indwelling catheter

Clean the perineal area thoroughly, especially around the meatus, twice a day and after each bowel movement. This helps prevent organisms for entering the bladder

Use soap or detergent and water to clean the perineal area and rinse the area well

Make sure that the patient maintains a generous fluid intake. This helps prevent infection and irrigates the catheter naturally by increasing urinary output

Encourage the patient to be up and about as ordered

Record the patients intake and output

Note the volume and character of urine and record observations carefully

Teach the patient the importance of personal hygiene, especially the importance of careful cleaning after having bowel movement and thorough washing of hands frequently

Report any signs of infection promptly. These include a burning sensation and irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated temperature and chills

Plan to change indwelling catheters only as necessary. The usual length of time between catheter changes varies and can be anywhere from 5 days to 2 weeks. The less often a catheter is changed, the less the likelihood than an infection will develop

Removing the Indwelling Catheter and Aftercare of the Patient Be sure the balloon is deflated before attempting to remove the catheter. This may be done by inserting a syringe into the balloon valve or by cutting the balloon valve

Have the patient take several deep breaths to help him relax while gently removing the catheter. Wrap the catheter in a towel or disposable, waterproof drape

Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removed

See to it that the patients fluid intake is generous and record the patients intake and output. Instruct the patient to void into the bedpan or urinal

Observe the urine carefully for any signs of abnormality

Record and report any usual signs such as discomfort, a burning sensation when voiding, bleeding and changes in vital signs, especially the patients temperature. B e alert to any signs of infection and report them promptly

MEETING BOWEL ELIMINATION NEEDS

Factors that influence Bowel Elimination Age

Diet

Position

Pregnancy

Fluid Intake

Activity

Psychological

Personal Habits

Pain

Medications

Surgery/Anesthesia

Characteristics of Normal Stool Color varies from light to dark brown foods & medications may affect color Odor aromatic, affected by ingested food and persons bacterial flora Consistency formed, soft, semi-solid; moist Frequency varies with diet (about 100 to 400 g/day) Constituents small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates) Common Bowel Elimination Problems Constipation abnormal frequency of defecation and abnormal hardening of stools Impaction accumulated mass of dry feces that cannot be expelled Diarrhea increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence Incontinence involuntary elimination of feces Flatulence expulsion of gas from the rectum Hemorrhoids dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation. TYPES OF ENEMAS

Cleansing Enemas: Stimulate peristalsis through irrigation of colon and rectum and by distention Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 1000 ml of water

Tap water: Give caution o infants or to adults with altered cardiac and renal reserve

Saline: For normal saline enemas, use smaller volume of solution

Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require further preparation

Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass Carminative Enema: Provides relief from gaseous distention Astringent Enema: Contracts tissue to control bleeding

Key Points: Administering Enema Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too cold, or solutions that are instilled too quickly, can cause cramping and damage to rectal tissues Allow solution to run through the tubing so that air is removed

Place client on left side in Sims position Lubricate the tip of the tubing with water-soluble lubricant

Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for children), past the external and internal sphincters Raise the water container no more than 12 to 18 inches above the client

Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The client will also be able to tolerate and retain a greater volume of solution

After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutes Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes.

NASOGASTRIC and INTESTINAL TUBES

Nasogastric Tubes Levin Tube single lumen Suctioning gastric contents

Administering tube feedings

Salem Sump Tube double lumen (smaller blue lumen vents the tube & prevents suction on the gastric mucosa, maintains intermittent suction regardless of suction source) Suctioning gastric contents

Maintaining gastric decompression

Key Points:

Prior to insertion, position the client in High-Fowlers position if possible.

Use a water-soluble lubricant to facilitate insertion

Measure the tube from the tip of the clients nose to the earlobe and from the nose to the xiphoid process to determine the approximate amount of tube to insert to reach the stomach

Flex the clients head slightly forward; this will decrease the chance of entry into the trachea

Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow occurs, progress the tube past the area of the trachea and into the esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress

Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares

Validating placement of tube. Aspirate gastric contents via a syringe to the end of the tube

Measure ph of aspirate fluid

Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A characteristic sound of air entering the stomach from the tube should be heard

Characteristics of nasogastric drainage: Normally is greenish-yellowish, with strands of mucous

Coffee-ground drainage old blood that has been broken down in the stomach

Bright red blood bleeding from the esophagus, the stomach or swallowed from the lungs

Foul-smelling (fecal odor) occurs with reverse peristalsis in bowel obstruction; increase in amount of drainage with obstruction

Intestinal Tubes provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight and allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstruction where decompression will occur

Types of Intestinal Tubes Cantor and Harris Tubes Approximately 6-10 feet long

Single lumen

Mercury placed in rubber bag prior to tube insertion

Miller-Abbot Tubes Approximately 10 feet long

Double lumen

One lumen utilized for aspiration of intestinal contents

Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stomach

Nursing Implications Maintain client on strict NPO

Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray

After the tube has been placed in the stomach, position client on the right side to facilitae passage through the pyloric valve

Advance the tube 2 to 4 inches at regular intervals as indicated by the physician

Encourage activity, to facilitate movement of the tube through the intestine

Evaluate the type of gastric secretions being aspirated

Do not tape or secure the tube until it has reached the desired position

Tubes may attached to suction and left in place for several days

Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirst

Removal of the tube depends on the relief of the intestinal obstruction

May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth

May be allowed to progress through the intestines and expelled via the rectum.

LOSS AND GRIEF

Loss absence of an object, person, body part, emotion, idea or function that was valued Actual loss is identified and verified by others

Perceived Loss cannot be verified by others

Maturational Loss occurs in normal development

Situational Loss occurs without expectations

Ultimate Loss (Death) results in a lost for a dying person

as well as for those left behind, can be viewed as a time of growth for all who

experienced it

Grieving Process (Theories of Grief, Dying and Mourning) 3 Phases of Grief Protest: lack of acceptance, concerning the loss, characterized by anger, ambivalence and crying Despair: denial and acceptance occurs simultaneously causing disorganized behavior, characterized by crying and sadness Detachment: loss is realized; characterized by hopelessness, accurately defining the relationship with the lost individual and energy to move forward in life. Kubler-5 Stages of Grieving Denial characterized by shock and disbelief, serves as a buffer to mobilize defense mechanism

Anger: resistance of the loss occurs, anger is typically directed toward others Bargaining = deals are sought with God or other higher power in an effort to postpone the loss Depression: loss is realized; may talk openly or withdraw.

Acceptance: recognition of the loss occurs, disinterest may occur; future thinking may occur. Wordens 4 Tasks of Mourning Accept the reality of the loss, the loss is accepted Experience the pain of grief, healthy behaviors are accomplished to assist in the grieving process. Adjust to the environment without the deceased, task are accomplished to reorient the environment, i.e. removing the clothes of the deceased from the closet. Emotionally relocate the deceased and move forward with life, correctly align the past, the present & look towards the future Anticipatory Grief expression of the symptoms of grief prior to the actual loss, grief period following the lost may be shortened and the intensity lessened because of the previous of grief; for example, a child told that a family move is expected may grieve about losing friends prior to actually living Complications of Bereavement Chronic Grief symptoms of grief occur beyond the expected time frame and the severity of symptoms is greater; depression may result. Delayed Grief when symptoms of grief are not expressed and are suppressed, a delayed reaction of grief occurs, the nurse should discuss the normal process of grieving with the client and give permission to express these symptoms Symptoms of Normal Grief Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and disorganization, preoccupation with the lost object or person, anxiety, depression.

Thought patterns include fear, guilt, denial, ambivalence, anger

Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of breath, tachycardia

Behaviors include crying, difficulty carrying out activities of daily living and insomia

Nursing Health Promotion (to facilitate mourning)

Help client accept that the loss is real by providing sensitive, factual information concerning the loss

Encourage the expression of feelings to support people; this build relationships and enhances the grief process

Support efforts to live without the diseased person or in the face of disability; this promotes a clients sense of control as well as a healthy vision of the future

Encourage establishment with new relationships to facilitate healing.

Allow time to grief, the work of grief may take longer for some; observe for a healthy progression of symptoms.

Interpret normal behavior by teaching thoughts, feelings, and behaviors that can be expected in the grief process

Provide continuing support in the form of the presence for therapeutic communication and resource information.

Be alert for signs of ineffective coping such as inability to carry out activities of daily living, signs of depression, or lack of expression of grief.