Fundamentals of nursing notes

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I. Nursing

Theorists

Faye Abdellah Lydia Hall Virginia Henderson Imogene King Madeleine Leininger Myra Levine Florence Nightingale Betty Neuman Dorothea Orem Rosemarie Parse Hildegard Peplau Martha Rogers Callista Roy Jean Watson

Identification of 21 Nursing Problems Care, Core and Cure (3 C’s) Identification of the 14 Basic Needs Goal Attainment Theory Transcultural Nursing Four Conservation Principles Environmental Theory Stress Reduction Self-Care and Self-Deficit Human Becoming Interpersonal Relations Model Science of Unitary Human Beings Adaptation Model Human Caring

Metaparadigm for Nursing Theories: CHEN (Client, Health, Environment, Nursing)

II. CHAIN

OF INFECTION

Six links Host (susceptible) Agent Reservoir Entry (mode of) Transmission (mode of) –direct, vehicle, vector Exit (mode of) Surgical vs Medical Asepsis Surgical – “sterile― free from ALL microorganisms Medical – “clean― free from pathogenic microorganisms

III. ISOLATION

PRECAUTIONS

Standard Precautions (Universal precautions) Applies to ALL body fluids, secretions, blood, non-intact skin and excretions except sweat Includes hand washing, wearing clean gloves, mask and gown Transmission –Based Precautions Airborne – used for clients with illnesses transmitted by airborne droplets (less than 5 microns) - Examples: Tuberculosis, Chickenpox, Measles - Place client in private room but if no private room is available place client in a room with another client infected with the same microorganism - Wear N95 respirator Droplet – used for clients with illnesses transmitted by droplet nuclei ( greater than 5 microns) - Examples: Diptheria, Pertussis, Meningitis, Mumps - Wear mask when working within 3 feet from the client

IV. PERSONAL

PROTECTIVE EQUIPMENT (PPE)

Sequence of removing PPE’s Gloves Mask Gown Eyewear

V. INSERTION

OF NASOGASTRIC TUBE

Measure length of tube – tip of the nose to the tip of the earlobe to the xiphoid process Position – High Fowler’s position with neck hyperextended Lubricate tip of tube with water soluble lubricant Instruct the client to swallow or drink from a straw while the tube is being inserted STOP and remove the tube if client becomes cyanotic or coughs Placement- check - Aspirate gastric secretions –measure pH - Auscultate and inject air into the tube (whooshing sound) - X-ray – best measure to determine proper placement (initial placement) Secure tube using tape to the bridge of the client’s nose and to the client’s gown

VI. TUBE

FEEDINGS

Position: Fowler’s position Assessment: Check patency of tube and Aspirate residual contents before feeding (if 100 ml or more than 50% of last feeding –withheld and check) For feeding bags: Hang bag from infusion pole – HEIGHT: 12 inches Complications: Dumping syndrome, aspiration pneumonia, diarrhea, hyperglycemia, nausea and vomiting

VII. INTESTINAL

OSTOMIES

Assessment: color should be bright red ( not purple, bluish, pale, etc.), peristomal skin, amount and type of feces (Ileostomy –liquid feces / acidic, ascending – semi-liquid, transverse – semi formed, descending and sigmoidostomy – formed feces / aromatic and smelly) Empty bag when it is 1/3 – ½ full Apply a barrier (i.e. Karaya gum) over the skin around the stoma to prevent skin breakdown Control Odors (deodorizers, charcoal disks, prevent odor-causing foods) Complications: Fluid and Electrolyte imbalance, skin breakdown, constipation, infection

VIII. ENEMAS

Classified into FOUR: Cleansing, Carminative, Retention and Return Flow Position: Left Lateral position Protection: Wear clean gloves Lubrication: lubricate with water soluble lubricant Insertion: Insert 3-4 inches (adult), 2-3 inches (children) Administration: administer gradually

IX. URINARY

CATHETERIZATION

Sterile technique Insertion Male Supine (legs slightly abducted) Penis at 90 degree angle 6-9 inches Female Supine (with knees flexed and externally rotated) 2-3 inches

Position

Length to be inserted

Length of catheter (Adult)

40 cm

22 cm

X. TRACHEOSTOMY

Position: (during insertion) Fowler’s position Use: Sterile gloves Time: 2-3 minutes between suctions when possible, suction applied for 5-10 seconds to minimize oxygen loss Clean with: After removing the inner cannula it is soaked in full strength hydrogen peroxide to moisten and loosen dried secretions. After cleaning the cannula, it should be rinsed with sterile normal saline to remove traces of hydrogen peroxide from the cannula before replacing it and securing it in place again. When changing the ties: tie one end of the new tie to the eye of the flange while leaving old ties in place Before tying the tapes: be able to put two fingers under the tapes before tying it Parts: Inner cannula, outer cannula and obturator Object at bedside: Obturator (for reinsertion), suction machine/apparatus (for removing secretions)

XI. CHEST

PHYSIOTHERAPY (PVP)

-done before meals (but not immediately before meals) or 2 hours after meals -increase fluid intake to liquefy secretions P – ercussion V – ibration P – ostural drainage

XII. ANTIEMBOLISM

STOCKINGS

Indication: to prevent thrombophlebitis by promoting venous return from the legs The client must be measured to ensure proper fit of the stockings When to apply: during the morning before the client gets out of bed (elevate for at least 15 minutes) When to remove: remove 20-30 minutes every 8 hours Assess skin for breakdown

XIII. BLOOD

TRANSFUSION

FIRST: Check if properly typed and cross matched Gauge of needle: g #18 Drop factor: 10 gtts/min (1st 30 mins.) Duration: RBC’s and whole blood – 4 hours, FFP Fresh frozen plasma, platelets – not more than 20 minutes Rate: KVO IVF: Plain NSS Monitor: vital signs (every 15 minutes for 1st hour), any adverse reactions When reaction happens: STOP the transfusion and notify the physician Common blood transfusion reactions: Anaphylactic reaction – s/sx: rashes and hives Hemolytic reaction – s/sx: flank/back pain Pyrogenic reaction – s/sx: fever, headache Cardiogenic reaction - s/sx: dyspnea

XIV. CHEST

TUBES

What to do if: Tube becomes disconnected from the bottle – place end of tube in a bottle with NSS Tube becomes disconnected from the client – cover wound with sterile dressing Water seal has vigorous bubbling – there is a leak – clamp tube nearest the client (intermittent bubbling – normal, vigorous/continuous bubbling-abnormal) Transporting the client – bottle below chest level and upright

XV. PAIN

Study: Gate control theory (Substantia gelatinosa) Analgesics, patient controlled analgesia (PCA), transcutaneous electrical nerve stimulation (TENS), imagery, massage Pain assessment (some common indicators) MI Angina Hypertension / hypertensive crisis Ectopic pregnancy Gastric ulcer UTI Pancreatitis Crushing pain, (someone sitting in my chest), radiates from chest to back Stab-like pain, , radiates from chest to jaw to left shoulder and arm Pounding pain Knife-like pain Gnawing pain Flank pain Radiates from Left upper quadrant to left shoulder

XVI. ASSISTIVE

DEVICES

CANES - opposite the affected leg (C-O-A-L) - angle is 20 to 30 degrees - the length should permit the elbow to slightly flex WALKERS - Hand bar below the client’s waist and the elbow is slightly flexed CRUTCHES - Angle of elbow flexion – 30 degrees -weight of the body should be borne by the arms not the axilla to prevent CRUTCH PALSY - Crutches are placed 6 inches in front and 6 inches laterally - the feet should be slightly apart, hips and knees extended and back is straight - Four point gait – right crutch, left foot, left crutch, right foot - Three point gait – right and left crutch with weak leg, stronger leg - Two point gait- right crutch and left foot together, left crutch and right foot - Swing to gait- move both crutches forward, lift body weight and swing to crutches -Swing through gait - move both crutches forward, lift body weight and swing through beyond the crutches - Going up the stairs (remember: all good people go to heaven) – when going up, lift (good) unaffected leg first followed by the crutch, affected leg.

XVII. SPECIAL

DIETS
DISORDER Dumping syndrome Renal failure, Acute glomerulonephritis, uremia, anuria Nephrotic syndrome Heart failure, CVD’s, Nephrotic syndrome Constipation, hyperlipidemia Bowel inflammation ( diverticulitis and ulcerative colitis) (depending on the lab analysis of the stones) Retard renal calculi formation Following acute vomiting or diarrhea Gastrointestinal upsets, progression from clear liquids

DIET Low carbohydrate Low protein High protein Low sodium High fiber Low residue Acid/Alkaline ash

Clear liquid Full liquid

Gluten-free Tyramine-free Purine restricted

For clients with Celiac disease To prevent fermented and processed foods for clients taking MAOI’s Gouty arthritis, uric acid stones

XVIII. DEGREES

OF BURNS

Superficial Partial Thickness - area involved: epidermis - tingling, erythema, minimal or no edema Deep Partial Thickness - area involved: epidermis, dermis - w/ PAIN, hyperesthesia, BLISTERS, edema, weeping surface, mottled and red base Full Thickness - area involved: epidermis, dermis, may involve subcutaneous and connective tissue, muscle and bone - PAIN FREE, shock, dry, PALE, WHITE leathery or charred skin, broken skin with fat exposed, edema

XIX. PRESSURE

ULCERS (STAGES)

Stage 1 –ERYTHEMA(redness), elevated temperature, patient complains of discomfort Stage 2 – Skin breaks, abrasions, BLISTERS, shallow crater, edema, infection may develop Stage 3 – ulcer extends into the subcutaneous tissue, necrosis and drainage, infection develops Stage 4- ulcer extends into the muscle and bone, deep pockets of infection develop

XX. VITAL

SIGNS

TEMP NV (Adult) 36.0-37.5 0 C Oral-2-3 mins Rectal – 2-3 mins (most accurate) Axillary – 6-9 mins (least accurate) Tympanic

PR 60-100 bpm Ang PET Mo A- pical P-ulmonic E-rb’s pt. T-ricuspid M- itral Others: Brachial – BP Apical – used for children below 3 y/o Bleeding, taking digitalis, has DVT or thrombophlebitis

RR 12-20 bpm Breath Sounds: Stridor- shrill and harsh ( laryngeal obstruction) Wheeze – high pitched/musical (Asthma) Volume: Hypoventilation-slow and shallow (Respiratory acidosis –pursed lip) Hyperventilation-deep and rapid (Respiratory alkalosis – brown paper bag)

BP 120/80 mmHg -cover about 2/3 of the limb Position: sitting Release valve on cuff carefully -2-3 mmHg/sec Wait 1-2 min before taking another BP BP erroneously high-Cuff too narrow, arm unsupported, no rest before assessment, cuff wrapped loosely, deflating too slowly (high diastolic), assessing immediately after a meal BP erroneously low- cuff too wide, arm above heart level

Monitor in clients who are/has: immunosuppressed, receiving chemo, etc

Anxious, receiving morphine and Magnesium sulfate

Cardiac problems, DM, RF

10 HERBAL PLANTS (Advocated by DOH) Lagundi Asthma, cough, fever Bayabas For washing wounds, mouthwash/gargle, toothache Anti-fungal

Yerba Buena

Pain, headache, stomachache, toothache, menstrual and gas pain Anti-edema, anti-urolithiasis Diarrhea, stomachache

Akapulko

Sambong Tsaang Gubat

Ulasimang Bato Bawang

Lowers uric acid For hypertension/ toothache

Niyug-niyugan

Anti-helminthic

Ampalaya

To lower blood sugar levels

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