Promoting Wellness Through Life Span

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PROMOTING WELLNESS THROUGH LIFE SPAN

GROWTH AND DEVELOPMENT CONCEPTS


Theories of personality development Psychosexual Psychosocial Cognitive Developmental tasks Moral Interpersonal

Libido – inner drive Parts of body –focus of gratification Unsuccesful resolution - fixation Structures of personality



Freuds psychosexual theory

Id – pleasure principle-instinct Ego – controls action and perception –reality principle Superego – moral behavior - conscience





0-18 m0s ;oral – mouth – trust and discriminating 18 mos. – 3 years ; anal – bowels – holding on or letting go




Negativism and toilet training age

3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension)


Gender identification and genital awareness Oedipus and Electra complex // Castration anxiety and penis envy


6-12 years –latency (quiet stage) sexual energy diverted to play. Institution of superego…control of instinctual impulses 12 – young adult – genital ; reawakening of sexual drives – relationships


Sexual maturation Sexual identity ,ability to love and work


0-12mos; 1-3y 3-6 6-12 12-18 18-25 25-60 60 and above
 

Psychosocial – Erickson developmental milestones //delay
TRUST AUTONOMY INITIATIVE INDUSTRY IDENTITY INTIMACY GENERATIVITY EGO INTEGRITY

CONSISTENT MATERNAL –CHILD INTERACTION – TRUST INNER FEELING OF SELF WORTH HOPE

INFANCY



ALLOW EXPLORATION PROVIDE FOR SAFETY


TODDLER

NO NO – NEGATIVISM OFFER CHOICES / REVERSE PSYCHOLOGY TOILET TRAINING – 18 MOS.-BOWEL

 

DAYTIME BLADDER -2 Y NIGHTIME BLADDER 3 Y



REWARD W/ PRAISE AND AFFECTION

INDEPENDENCE

PROVIDE PLAY MATERIALS SATISFY CURIOSITY TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR) SIBLING RIVALRY
 

PRE-SCHOOL

WILLPOWER

HOW TO DO THINGS WELL-SUPPORT EFFORTS CHUMS AND HOBBIES


SCHOOL AGE

NEEDS TO EXCEL/ACCOMPLISH NEED FOR PRIVACY AND PEER INTERACTION  COMPETENCE


MAKE DECISION,EMANCIPATION FROM PARENTS BODY IMAGE CHANGES
 

ADOLESCENCE

NEED TO CONFORM BUT KEEP INDIVIDUALITY SELF - AWARENESS



YOUNG ADULT


COMMITMENT AND FIDELITY



RESPONSIBILITY ACHIEVEMENT OF INDEPENDENCE



SUPPORT-PERIOD OF ROLE TRANSITIONS MIDLIFE CRISIS
 

MIDDLE ADULTHOOD

ADJUSTMENT AND COMPROMISE MOST PRODUCTIVE AND CREATIVE ALTRUISM





SELF ACCEPTANCE SELF WORTH

LATE ADULTHOOD



WISDOM

PIAGET’S COGNITIVE THEORY
0-2 SENSORIMOTOR

REFLEXES IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING


SELF-CENTERED,EGOCENTRIC CANNOT CONCEPTUALIZE OTHER’S VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES)


2-7Y PRE-OPERATIONAL

LOGICAL CONCRETE THOUGHT INDUCTIVE RESAONING (SPECIFIC TO GENERAL) CAN RELATE ,PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION


7-12Y CONCRETE OPERATIONAL

Abstract thinking Separation of fantasy and fact Reality oriented Deductive reasoning Apply scientific method


12-ABOVE FORMAL OPERATIONAL THOUGHT

Havighurst Developmental Tasks


Baby to early childhood


Right from wrong and Conscience



Late childhood


Physical skills,wholesome attitude,social roles Conscience morality and values

Fundamental skills in academics Personal independence




Adolescence


Sexual social roles Relationships Independence and ideology



Early adulthood


Career Selecting a mate Finding Civic or social responsibility Achieving Civic or social responsibility Adjusting to changes Satisfactory career performance Adjusting to aging parents Adjusting to parental roles
   



Middle age



Old age

Adjusting to changes Establishing satisfactory living arrangements and affiliations

Kohlberg – MORAL DEVELOPMENT/ THINKING/ JUDGEMENT


PRE-CONVENTIONAL (0-6)


PUNISHMENT AND OBEDIENCE OBEDIENCE TO RULES TO AVOID PUNISHMENT MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY




CONVENTIONAL ( 6-12 )

SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE


POST –CONVENTIONAL (12 – 18 Y) PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS


INTERPERSONAL THEORY
NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS


SULLIVANS

INFANCY

CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT


TODDLERHOOD / EARLY CHILDHOOD

DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN


PRE-SCHOOL

THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX


SCHOOL AGE

LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX


ADOLESCENCE

BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT


YOUNG ADULTHOOD LATER ADULTHOOD SENESCENCE

LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS


DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY


FORMATION OF PERSONALITY CERTAIN GOALS MUST BE ACCOMPLISHED, IF THIS GOALS ARE NOT ACCOMPLISHED AT A CERTAIN STAGE,….PERSONALITY WILL BE WEAKENED….

FACTORS IN EACH STAGE PERSISTS AS A PERMANENT PART OF PERSONALITY…. EACH STAGE HAS MAJOR TRAUMAS AND FRUSTRATIONS THAT MUST BE OVERCOME …….SUCCESSFUL RESOLUTION OF CONFLICTS ASSOCIATED WITH EACH STAGE IS ESSENTIAL TO DEVELOPMENT…..UNRESOLVED CONFLICTS REMAIN IN THE UNCONSCIOUS AND MAY, AT TIMES, RESULT IN MALADAPTIVE BEHAVIOR

PREVENTION AND EARLY DETECTION OF DISEASE
DEVELOPMENTAL TASKS---MILESTONES ---DELAYS(FIXATIONS/LAG)
 

GROWTH AND DEVELOPMENT

IQ = MA / CA X 100


JUDGEMENT , COMPREHENSION AND LISTENING



DDST – BIRTH TO 6 YEARS


PERSONAL SOCIAL, FINE , GROSS MOTOR AND LANGUAGE SKILL AREAS

HEALTH SCREENING


OB – GYNE / REPRODUCTIVE TESTS
 

UTZ-5 WKS CONFIRM PREGNANCY AND AOG AMNIOCENTESIS – 16 WKS-DETECT GENETIC DISORDERS – 30 WEEKS – L/S RATIO ( 2-4 WKS RESULT)(EMPTY Bladder) OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN 10 MINUTES- REACTIVE NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR ACCELERATION OF 15BPM/MORE LASTING 15 SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE – REACTIVE DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION) AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE DEFECTS – 16-18 WKS CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-12 WKS

NEWBORN/INFANT HEALTH SCREENING

PKU – GUTHRINE BLOOD TEST-EAT CHON FOR 2 DAYS MIN.(PHEONISTICS – DIAPER) SICKLE CELL DISEASE –ABNORMALLY SHAPED Hg , ELISA AND WESTERN BLOT CARRIER SCREENING FOR CYSTIC FIBROSIS AND SWEAT CHLORIDE TEST




HEARING AND VISION TESTS


SCHOOL AGE

ALLEN PICTURE CARDS SNELLEN CHART-20/40 AT TODDLER AND 20/20 AT SCHOOL AGE WEBER’S-SENSORINEURAL AND CONDUCTIVE RINNE’S- CONDUCTIVE DENTAL EXAM – STARTS AT 2 YEARS

PPD – INDURATION – 72 HOURS BSE – (18-20 YRS.) POST MENSTRATION/MONTHLY TSE – MONTHLY (18-20 YRS) PELVIC EXAM WITH PAP SMEAR – IF SEXUALLY ACTIVE OR 18 Y.O. ANNUALLY


ADOLESCENT

HPN , DM, HEARING AND VISION PROSTATE –ANNUALLY@40 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS FECAL OCCULT BLOOD TEST- > 50 = ANNUALLY DIGITAL RECTAL EXAM - > 40 Y.O. = YEARLY PELVIC EXAM – 18-40 Y.O. =PERFORMED Q 1 – 3 YEARS WITH PAP TEST MAMMOGRAM – 35-39 = BASELINE


ADULT/ELDERLY

40-49 = Q2Y 50 AND OLDER = QYEAR



CONTRAINDICATIONS:
 

BP SCREENING(mmHg) IMMUNITY pg 127-130

SEVERE FEBRILE ILLNESS LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED ALLERGIES RECENTLY ACQUIRED PASSIVE IMMUNITY(BLOOD TRANSFUSION AND IMMUNOGLOBULINS) Give DPT,TOPV,TINE 4-6 WKS LATER MMR 1 MONTH AFTER DPT AND TOPV REPEATED IN ANOTHER MONTH AGAIN IN 10-16 MOS.




if child –no evidence of immunization <7 y.o.



CAN GIVE DPT,MMR,TOPV, AND TINE SIMULTANEOUSLY

TD- 2 DOSES 4-8 WKS APART;3RD DOSE 6-12 MOS;BOOSTER AT 10 YRS FO LIFE RD OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3 DOSE 2 -12 MOS ND AFTER 2 (OPV NOT USED IN US) MMR-ONE DOSE – 12 MOS VARICELLA – TWO DOSES 4-8 WEEKS APART STARTS AT 12 MOS. ND HEPA B – 3 DOSES;2 1-2 MOS AFTER;3RD 4-6 MS AFTER PPV- ONE DOSE ;IF 65 AND RECEIVED > 5YEARS – ADMINISTER INFLUENZA –ANNUALLY EACH FALL


EGGS – INFLUENZA , MMR NEOMYCIN – VARICELLA,IPV,MMR YEAST – HEPA-B GELATIN – VARICELLA
 

ALLERGY CONTRAINDICATIONS

PREGNANCY C/I: MMR AND VARICELLA IMMUNOSUPPRESSED; VARICELLA WITH Ig or BT PREVIOUS 3-11 MOS – MMR AND VARICELLA



DPT - IM – ANTERIOR OR LATERAL THIGH

CONSIDERATIONS-IMMUNIZATION

FEVER AND SWELLING 24-48 H POTENTIAL SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC AND SCREAMING


 

MMR – SC – ANTERIOR OR LATERAL THIGH


RASH, FEVER ARTHRITIS-10DAYS-2 WKS

TRIVALENT OPV – PO

PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS – EVALUATED 48-72 HOURS


TEACHING OPPURTUNITY INSPECTION –VISUALLY  PALPATION-WARM HANDS



PHYSICAL ASSESSMENT

DORSUM OF FINGERS FOR TEMP



PERCUSSION-DIRECT,INDIRECT,BLUNT
 

RESONANCE-MODERATE LOW PITCHED CLEAR HOLLOW(LUNG) HYPERRESONANCE-OVERINFLATED(EMPHYSEMA) TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL) DULL-SOFT MUFFLED,DENSE FLUID FILLED TISSUE(LIVER) FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-(MUSCLE/BONE)

AUSCULTATIONDIAPHRAGM-HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW PITCHED(HEART MURMURS)
 



TEMPERATURE:


VITAL SIGNS

ORAL – 98.6 ‘F / 37 ‘C RECTAL – 99.6 ‘F / 37.6’C AXILLARY – 97.6’F / 36.5’C





NEWBORN=30 – 50 / MIN; 120 – 140 / MIN; 60/40 – 80/50 mmHg 1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN; 90/60 – 99/65 mmHg


NORMAL VITAL SIGNS

5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60 mmHg


ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –140 / 90 mmHg


CHEYNE STOKES – PERIODIC BREATHING CHARACTERIZED BY RHYTMIC WAXING AND WANING DYSPNEA - LABORED PAINFUL BREATHING HYPERVENTILATION – ABNORMALLY RAPID DEEP PROLONGED BREATHING KUSSMAULS – AIR HUNGER , MARKED INCREASE IN DEPTH AND RATE TACHYPNEA – FAST SHALLOW BREATHING PARADOXICAL – FLAIL CHEST , DEFLATES DURING INHALATION BIOT’S – SHALLOW BREATHS INTERRUPTED BY APNEA


BREATHING PATTERNS

PULSE PRESSURE – 30-40 mmHg Intracranial pressure – 10 mmHg PULSE DEFICIT – MINIMAL(3-5 ACCEPTABLE)
 

NORMAL FINDINGS

IDEAL BODY WEIGHT –


MALES -106 LBS FOR 1ST 5FT THEN ADD 6LBS/INCH ST FEMALE – 100LBS FOR 1 5 FT THEN ADD 5LBS/INCH ADD OR SUBTRACT 10% DEPENDING ON BODY FRAME. OBESE AND UNDERWEIGHT IF DEVIATION IS > 20%

SCARS,BRUISES AND LESIONS CHECK COLOR EDEMA – GRADING


SKIN

0-NO EDEMA 1-BARELY DETECTABLE 2-INDENTATION<5MM 3-INDENTATION 5-10MM 4-INDENTATION >10MM
 



PRESSURE SORE –GRADING
1-NONBLANCHABLE ERYTHEMA 2-EPIDERMIS,PARTIAL THICKNESS 3-FULL DERMIS AND SQ 4- SUPPORTING TISSUES AND BONES
 



TURGOR-PINCH SKIN TENTED 3 SECS NORMAL(ELDERLY-OVER STERNUM)



HIRSUTISM-EXCESS

HAIR AND NAILS



ALOPECIA-THINNING

SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING ANGLE > 180 DUE TO PROLONGED DECREASED OXYGENATION BLANCHING =< 3 SECS-NORMAL


SYMMETRY, SIZE AND SHAPE CRANIAL NERVE ASSESSMENTS



HEAD

OPTIC-SNELLEN OCULOMOTOR- PERRLA TRIGEMINAL – BITE DOWN AND STROKES WITH COTTON FACIAL – FACIAL MOVEMENT AND TASTE ACCOUSTIC – HEARING AND BALANCE(WATCH TICK TEST,OTOSCOPIC EXAMS AND POSTURE TESTS) GLOSSOPHARYGEAL-GAG AND SWALLOW VAGUS- SWALLOWING AND SPEAKING

PTOSIS-DROOPING OF THE UPPER EYELID ASTIGMATISM – UNEVEN CURVATURE OF CORNEA LEADING TO REFRACTION ERRORS NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE MOVEMENTS STRABISMUS-ASSYMETRICAL LIGHT EFLECTION ON EACH CORNEA RED REFLEX FROM RETINA-NORMAL COVER UNCOVER TEST – DET.EYE ALIGNMENT SNELLEN – FAR DISTANCE VISION/VISUAL ACUITY IOP-TONOMETRY TESTS INDENTATION(6-12)


EYES

PINNA BACK-UP-ADULT;DOWN-BACK-CHILD RINNE TEST – COMPARES AIR CONDUCTION WITH BONE CONDUCTION,VIBRATING FORK PLACED ON THE MASTOID IF SOUND NO LONGER HEARD POSITIONED IN FRONT OF EAR CANNAL. SHOULD HEAR A SOUND= 2:1 ; AIR CONDUCTION > THAN BONE CONDUCTION ;= POSITIVE RINNE



EARS

ASSESS CONDUCTIVE HEARING LOSS



WEBER – SENSORINEURAL AND CONDUCTIVE HEARING LOSS

EARS

FORK PLACED MIDDLE OF FORE HEAD,SHOULD BE HEARD EQUALLY=WEBER NEGATIVE  IF NOT EQUAL=SENSORINEURAL HEARING LOSS. SOUND HEARD BETTER IN THE IMPAIRED EAR=BONE CONDUCTIVE HEARING LOSS, IF VICE VERSA = SENSORINEURAL DISTURBANCE


TEETH-32 TONSILS – NO TPC , + GAG REFLEX CERVICAL LYMPH NODES=<1CM CAROTID – PALPATE THRILL,LISTEN BRUIT JUGULAR VEINS – NOT DISTENDED TRACHEA-MIDLINE



NECK,MOUTH AND PHARYNX

APL DIAMETER-1:2 – 5:7


THORAX AND LUNGS

1:1 = BARREL CHEST

TACTILE FREMITUS NORMAL-BRONCHOPHONY,EGOPHONY AND WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGS BREATH SOUNDS

 

VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –PERIPHERAL LUNG SURFACES BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM BRONCHI BRONCHIAL- LOUD COARSE - TRACHEA RALES-FINE SHORT,CRACKLING OR HIGH PITCHED SOUNDS-INSPIRATION RHONCHI-CONTINOUS LOW PITCHED COARSEGURGLING HARSH SNORING BEST HEARD ON EXHALATION WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON INHALATION FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ LIKE VIBRATIONS – BOTH INHALATION AND EXHALATION
 



ADVENTITIOUS BREATH SOUNDS

AORTIC AND PULMONIC VALVE AREAS- 2ND ICS, R AND L RESPECTIVEY RD ERBS POINT 3 ICS TH TRICUSPID AREA-4 / 5TH ICS TH MITRAL AREA – 5 ICS , LEFT MCL TH PMI-5 ICS MCL –(INFANTS-LATERAL TO LEFT NIPPLE-4TH ICS) S1LUBB-CLOSURE OFAV VALVES S2DUBB-CLOSURE OF SEMILUNAR VALVES MURMURS , GALLOP-ABNORMAL HEART SOUNDS


HEART SOUNDS

PERIPHERAL VASCULAR SYSTEM

ASSESS PAIN,PALLOR,PARALYSIS,PARESTHESIASAND PULSES. ASSESS HOMAN’S SIGN PULSE DEFICIT


START – UPPER OUTER CLOCKWISE ASSESS FOR SIZE,SHAPE,SYMMETRY AND NODES


BREASTS

DORSAL RECUMBENT INSPECT,AUSCULTATE,PERCUSS AND PALPATE BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 5-25/MIN NORMAL) IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS. MORE. SEQUENCE IS CLOCKWISE FROM RLQ


ABDOMEN

HYPOACTIVE < 3 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT TINKLING SOUND – BOWEL OBSTRUCTION
 

REBOUND TENDERNESS- INFLAMMATION OF PERITONEUM



ABDOMEN

KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLE KIDNEY PUNCH TEST





MUSCLE TONE AND STRENGTH
 

MUSCULOSKELETAL SYSTEM

0=COMPLETE PARALYSIS 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT 3=50% - NORMAL MOVEMENT AGAINST GRAVITY 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE 5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE

JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS ARE ABNORMAL FASCICULATION ABNORMAL CONTRACTIONS AND SHORTENING OF MUSCLE FIBERS TREMOR-INVOLUNTARY TREMBLING TEST FOR ROM AND ASSESS FOR ATROPHY/HYPERTROPHY/CONTRACTURES
 



MENTAL STATUS 

NEUROLOGIC TESTS

LANGUAGE-CEREBRAL CORTEX-APHASIA ORIENTATION(TIME,PLACE,PERSON)(CONFUSION) MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY ATTENTION SPAN AND CALCULATION JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL VIEWS PERCEPTION – SENSORY ANALYSIS AND INTEGRATION

CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING MOVEMENTS,GAIT  CRANIAL NERVE FUNCTIONS SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSERHOMBERG’S TEST)




DEEP TENDON REFLEX


NEUROLOGIC TESTS

0-NO REFLEX +1 – MINIMAL ACTIVITY(HYPOACTIVE) +2 – NORMAL RESPONSE +3 – MORE ACTIVE THAN NORMAL +4 – MAXIMUM ACTIVITY ( HYPERACTIVE)

PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY



GLASGOW COMA SCALE=15 POINTS, 7 COMA


LEVEL OF CONSCIOUSNESS

EYE OPENING
 

SPONTANEOUS=4 TO VERBAL COMMAND=3 TO PAIN=2 NO RESPONSE=1


MOTOR RESPONSE
TO VERBAL COMMAND=6 TO PAINFUL STIMULI/LOCALIZES PAIN=5 FLEXES AND WITHDRAWS=4 DECORTICATE=3 DECEREBRATE=2 NO RESPONSE=1
 



VERBAL RESPONSE
ORIENTED,CONVERSES=5 DISORIENTED,CONVERSES=4 USES INAPPROPRIATE WORDS=3 USES INCOMPREHENSIBLE SOUNDS=2 NO RESPONSE=1
 



WALKING GAITS

ASSESSING MOTOR FUNCTION

ROMBERGS TEST- STAND FEET TOGETHER ARMS RESTING AT THE SIDES,EYES OPEN THEN CLOSED. NEG. ROMBERG – MAY SWAY BUT KEEPS BALANCE.


SENSORY ATAXIA-CANNOT BALANCE EYES SHUT CEREBELLAR ATAXIA-CANNOT BALANCE EYES SHUT OR EPON


HEEL-TOE WALKING AND VICE VERSA FINGER TO NOSE TEST AND OTHER SENSORY FUNCTION TEST (ONE AND TWO POINT DISCRIMINATION)  EXTINCTION PHENOMENON-SYMMETRICAL AREAS ARE TOUCHED BUT SENSATION ON ONE SIDE CANNOT BE FELT INDICATES LESIONS OF SENSORY CORTEX


ASSESS APPEARANCE AND ORIFICES AND INGUINAL LYMPH NODES INSPECT CERVICAL OS AND VAGINA-SPECULUM DEVIATIONS


GENITALIA , ANUS AND RECTUM

CYSTOCELE, RECTOCELE,ENTEROCELE HYPO AND EPISPADIAS-URETHRAL OPENING DISPLACED HERNIAS-DIRECT,INDIRECT , FEMORAL INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE
 

DIGITAL RECTAL EXAM –INSPECTION AND PALPATION –POSITION BOTH=SIM’S , FEMALES – LITHOTOMY;MALES =STAND AND BEND FORWARD PROSTATE GLAND-4 CM ;CERVIX = 2-3 CM HEMORRHOIDS =DILATED VEINS


SELF CONCEPT – COLLECTION OF FEELING BELIEFS ABOUT ONE’S SELF SELF ESTEEM – CONFIDENCE IN ONE’S ABILITIES AND JUDGEMENT
 

STRESS , ANXIETY AND CRISIS SELF- AWARENESS

ASSERTIVENESS + SELF - EVALUATION



GAS – ALARM-RESISTANCE-EXHAUSTION COPING AND STRESS MANAGEMENT


STRESS



ANXIETY

MILD – SLIGHT AROUSAL AND INCREASED PERCEPTION MODERATE-INC. TENSION AND SELECTIVE INATT. SEVERE – DEC. PERCEPTION AND FOCUSSED ENERGY PANIC – OVERPOWERING AND LOSS OF CONTROL



RELAXATION TECHNIQUES


STRESS MANAGEMENT

RELAXATION BREATHING PROGRESSIVE MUSCLE SETTING AUTOGENIC TRAINING(SELF-SUGGESTIONS) IMAGERY(MENTAL VACATION) DISTRACTION

GRIEF AND LOSS Loss is a universal experience that occurs throughout life span Grief is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement Responses to loss are strongly influenced by one’s cultural background The grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss. Responses to loss and patterns of coping with loss are developed early in life.


Stages of Grieving (Kubler-Ross) Denial- refuses to believe that the loss has occurred Anger- the individual resists the loss and may “act out” feelings. Bargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss. Depression- overwhelming feeling of loneliness and withdrawal from others Acceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, and the interaction to other people resumed.



DEATH CONCEPTS

LOSS ,GRIEVING AND DEATH

1-5Y.O – IMMOBILITY AND INACTIVITY Wishes and unrelated action responsible for action 5-10 – final but can be avoided 9-12 – understands own mortality and fears death 12 – 18 – fears and fantasizes avoidance 18-45 – increased attitude awareness 45-65 – accepts mortality Above 65 – multiple meanings, encounters and fears
 

D – SUPPORTIVE

KUBLER ROSS – STAGES OF GRIEF



A- PROVIDE STRUCTURE AND CONTINUITY B – LISTEN AND ENCOURAGE D- ALLOW EXPRESSION AND PROVIDE FOR SAFETY A- ENCOURAGE PARTICIPATION







6 MOS – 2 YEARS PROVISION OF DIGNIFIED PAIN FREE DEATH( QUEST. ANSWERED AND EMT. SUPPORT) DNR- COMFORT AND HYGIENE NEEDS ON-GOING CURE GOALS ----- COMFORT GOALS


CONCEPTS

HINDU – REINCARNATION , AUTOPSY , ORGAN DONATION, CREMATION ISLAM – NO TO ORGAN DONATION , CREMATION AND AUTOPSY …..CONFESS AND TURN TO MECCA JUDAISM – WASHED NATIVE AMERICAN – NOT TO AUTOPSY BUDDIST – OK – EUTHANASIA AND WITH LAST RITES


CONCEPTS

SAFETY AND INFECTION CONTROL

NON – SPECIFIC AND SPECIFIC CHAIN OF INFECTION
 

PROTECTING HEALTH

UNIVERSAL PRECAUTION PRINCIPLES OF SURGICAL ASEPSIS INFECTION CONTROL MEASURES ISOLATION – CATEGORY SPECIFIC AND DISEASE SPECIFIC MEDICAL AND SURGICAL ASEPSIS


Strict Isolation-highly transmissible diseases by direct contact and airborne routes of transmission


Universal Precautions

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)



Universal Precautions

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


Universal Precautions

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



Universal Precautions

Private room , mask gown , gloves


diptheria( cutaneous), Herpes simplex, MRSA , Pediculosis , Scabies , Syphilis

Universal Precautions

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



Universal Precautions

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.


Universal Precautions

Gloves , mask, protective eyegears, gown , contaminated needles not recapped and sharps in puncture resistant containers



Aids , Hepatitis B and C , STD’s

Patient is protected from pathogens and nosocomial infections by instituting reversed transmission precautions


Reverse Isolation

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


Infectious agents- pathogens (bacteria, fungi, virus, protozoa) Reservoirs- sources or places for growth of the pathogens ReservoirsPortal of Exit and Entry- provides the way for the pathogen to leave one host and enter Entryanother host Modes of transmission- vehicles of transmission of the pathogens transmissionSusceptible Host- a carrier capable of supporting and transmitting microorganism Host



Body Defenses Against Infection



Normal Flora

Intact Skin Saliva and Mucus Membrane Cilia of the Upper Respiratory Tract Infection Inflammatory process Immune Response


Medical Asepsis/ Clean Technique Principles: Pathogens move through spaces or air current Pathogens are transferred from one surface to another whenever objects touch. Hand washing removes microorganism Pathogens are released into the air on droplet nuclei when person speaks, breaths, and sneeze. Pathogens are transferred by virtue of gravity Pathogens move slowly on dry surface but very quickly through moisture.


Surgical Asepsis/ Sterile Technique Areas of the body considered sterile are:


Blood stream Spinal Fluid Peritoneal Cavity Urinary Tract Muscles Bones Chamber of the Eyes


Sterile object remains sterile when touched by another sterile object Sterile objects or fields, which falls out of the range of vision or below one’s waist, are considered contaminated. Sterile items become contaminated when they come in contact with microorganism transported through the air. When sterile object/ field come in contact with another surface, it becomes contaminated. Fluids flows in the direction of gravity. The edges of the sterile field are considered unsterile.


Isolation Practices Strict Isolation- prevents transmission of highly communicable disease by contact and airborne transmission Respiratory isolation- prevents transmission by droplet Enteric precaution- prevents transmission through ingestion Wound and skin precaution- prevents cross-infection by direct contact with wounds and contaminated articles Discharge precaution- prevent cross-infection by secretions-contaminated articles Blood precaution- prevent transmission by contact with blood or items contaminated with blood

PQRST AND QUEST PHARMACOLOGICAL Tx PAIN GATEWAY CONTROL THEORY PLAN AND PREVENT INJURY/HARM PROVIDE ALTERNATIVE MEASURES PROPHYLACTIC/PREVENTIVE PCA PREFERENCE AND PARTICIPATION
 

COMFORT AND PAIN *COMFORT AND PAIN

Pain The noxious stimilation of threatened or actual tissue damage (Geach, 1987) Whatever the experiencing person says it is, existing whenever he or she says it does (McCaferry, 1979) It is highly subjective and individual and that is one of the body’s defense mechanism indicating that there is a problem. It is protective as it gives warning or signal for tissue injury
Assessment of Pain Precipitating Factors- “ What triggers the pain or makes it worse?” Quality of Pain- “Tell me what the pain feels like” Alleviating Factors- “What measures relieve your pain” Meaning of pain- “ How do you interpret the pain?”


Pattern Location Pain- “Where is your pain” Periodicity- “How long have you felt the pain sensation?”


REM – DREAM PARADOXICAL SLEEP PRIMARY AND SECONDARY SLEEP DISORDERS


REST AND SLEEP *REST AND SLEEP

RESTFUL ENVT. RITUALS RELAXATION RELEVANT MEDS AND RELATED THERAPY & NON PHARMACOLOGIC Tx RECORD ASSESSMENTS AND HISTORY


Stages of Sleep: Non-Rapid Eye Movement (NREM)- for body restoration

 

Very Light Sleep- drowsy, and readily awakened Light Sleep- Heart and respiratory rate decreases and the body temperature gradually falls. PNS domination- Difficult to arouse Deep Sleep- Decrease metabolism and very difficult to arouse

Rapid Eye movement (REM)- increase synthetic processes of the brain Paradoxical Sleep Dream state of the sleep Close to wakefulness but difficult to arouse


Common Sleep Disorders Insomia- sleeplessness Hypersomia- Excessive sleep at day time Narcolepsy- Sleep attack Parasomias


Somnambolism- sleep walking Soliloqy- Sleep talking Bruxism- clenching and grinding of teeth Night Terrors- bad dreams Nocturnal Erections- wet dreams




Nocturnal Enuresis - BEDWETTING

SAFETY
Rest is the diminished state of activity Sleep is a state of decreased perception and reaction to the environment There are theories of sleep:



Active theory- there are parts of the brain that inhibit other brain parts Passive theory- the reticular activating system of the brain fatigues and becomes depressed, thus sleeps occurs

TRIAGE DISASTER MANAGEMENT -=A,B,C
 

*SAFETY

P REVENT ABSORPTION O FF AND OUT I DENTIFY S UPPORT AND SUPPLY ANTIDOTE O NGOING MONITORING N OTIFY

POISONING
CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL THE NURSE SHOULD INTERVENE IF A MOTHER OF A VICTIM OF POISONING VERBALIZES TO DO THE FOLLOWING:


PLANS TO INDUCE VOMITING FOR PATIENT WITH ASPIRIN POISONING


PLANS TO INDUCE VOMITING WHEN SHE IS CERTAIN THAT HER CHILD’S GAG REFLEX AND LOC ARE INTACT WILL NOT GIVE IPECAC IF CHILD IS EXHIBITING NARROWED PULSE PRESSURE WILL WAIT FOR THE SEIZURE TO END BEFORE ADMINISTERING IPECAC


SEIZURE SUBNORMAL LOC AND GAG REFLEX SUBSTANCE CORROSIVE/PETROLEUM DISTILATE SHOCK-SEVERE


CONTRAINDICATIONS OF IPECAC / INDUCTION OF VOMITING

TRIAGE-GREATEST GOOD FOR THE GREATEST NUMBER OF PEOPLE PRINCIPLES- ABCD , MASLOWS


DISASTER PLANNING

RED-UNSTABLE – IMMEDIATE CARE YELLOW- STABLE – CAN WAIT 30-60 MIN GREEN –STABLE- CAN WAIT LONGER BLACK- UNSTABLE – FATAL, LAST SEEN DOA – SUPPORTIVE COMFORT MEASURES


AMBULATORY BEDRIDDEN CRITICAL TERMINAL


DURING FIRE WHICH SET OF PATIENTS WILL THE NURSE MOBILIZE FIRST

ALARM CONTAIN MOBILIZE EXTINGUISH


WHICH STEP IN FIRE MANAGEMENT COMES LAST?

READ ENSURE SUPERVISION LOCK AVOID TRANSFERING TEACH AND EDUCATE MANAGEMENT IPECAC ACTIVATED CHARCOAL H2O OR MILK NA SO4 SPECIFIC ANTIDOTE OR ANTAGONIST


POISONING
CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL
 

FALLS(RAT) RISK ASSESSMENT TOOL
ALTERATION IN SENSATION AND PERCEPTION AWARENESS LEVEL ABILITY TO COMMUNICATE ALTERED GAIT AND POSTURE AMBULATION NEEDS ANXIETY AND EMOTIONAL STATE ASSOCIATED INJURY AND DISEASE ACCESS(LIFESTYLE)

SAFETY

AMPUTATION – TOURNIQUET AUTONOMIS HYPERREFLEXIA – CATHETER


BEDSIDE SAFETY/EMERGENCY MATERIALS / EQUIPMENTS

CHEST TUBE DRAINAGE- EXTRA BOTTLE- FORCEPS – VASELINIZED GAUZE CHOLINERGIC AND MYASTHENIC CRISIS – ENDOTRACHEAL TUBE / TRACHEOSTOMY SET EPIGLOTITIS - ENDOTRACHEAL TUBE / TRACHEOSTOMY SET PIH – PADDED MOUTH GAG PARKINSONS – SUCTION APPARATUS


RADIUM IMPLANT – LEAD CONTAINER , FORCEPS SENGSTAKEN BLAKEMORE TUBE – SCISSORS SCI AND THYROIDECTOMY – TRACHEOSTOMY TONSILLECTOMY – FLASHLIGHT TRACHEOSTOMY TUBE – OBTURATOR , HEMOSTAT


BEDSIDE SAFETY/EMERGENCY MATERIALS / EQUIPMENTS

L IGHTING L OWER BED POSITION L OCATE GRAB BARS AND CALL BELL S UFFICIENT ORIENTATION S IDERAILS S UPERVISE AND ORIENT


PREVENTION OF FALLS

ASSIST FREQUENTLY ASSIGN HEALTH CARE PROCEDURES IN PAIRS AREA SUPERVISION ADIMINISTRATION ADJUSTMENTS ALLOW ROCKER CHAIR AND FREQUENT WALKS APPLY PILLOW,WEDGE , PADS AND PROPER POSITIONING ALLEVIATE AGITATION ASSESS AND MONITOR


RESTRAINTS

RESTRAINTS-(HALF BOW KNOT/CLOVE HITCH,SQUARE OR REEF KNOT)


LIMB MUMMY ELBOW MITT OR HAND JACKET BELT OR SAFETY STRAP


CONTROL IMMEDIATE SITUATION OUT OF AREA MAINTAIN CALM BE FIRM AND SET LIMITS ALTERNATIVE TO RESTRAINTS,ASSESS AND ASSIST TRY POSITIVE CONSEQUENCES


CONFUSED AND COMBATIVE

INFANT BATHING COMPLETE ADULT BED BATH TUB BATH THERAPEUTIC


HYGIENE *HYGIENE AND COMFORT

SALINE OATMEAL CORNSTARCH NACHO3 KMnO4


PERINEAL / GENITAL CARE FOOT AND NAIL CARE HAIR CARE ORAL CARE BEDMAKING
 

HYGIENE AND COMFORT

PRESSURE ULCER

GRADING PREVENTION TREATMENT




ERGONOMICS

ACTIVITY AND EXERCISE *ACTIVITY AND EXERCISE



TYPES AND PRINCIPLES


ROM AND ISOMETRICS

PROBLEMS OF IMMOBILITY AND NURSING INTERVENTIONS
 

ACTIVITY ORDERS

POSITIONING MOVING AND LIFTING


*MOBILITY AND IMMOBILTY

AMBULATION AMBULATION AIDS


TRANSFERS TRANSFER AIDS


PASSIVE ROM-RETENTION OF ROM AND MAINTENANCE OF CIRCULATION ASSISTIVE- INCREASES MOTION , MAINTAINS MUSCLE TONE ACTIVE – MAINTAINS MOBILITY OF THE JOINT AND MAINTAINS MUSCLE STRENGTH RESISTIVE – INCREASES MUSCLE POWER ISOMETRICS- MAINTENANCE OF STRENGTH AND PREVENTS MUSCULAR ATROPHY



THERAPEUTIC EXERCISES

ABDOMINAL ANEURYSM SURGERY-FOWLERS

POSITIONING FOR SPECIAL CONDITIONS

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


POSITIONING FOR SPECIAL CONDITIONS

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


POSITIONING FOR SPECIAL CONDITIONS

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


POSITIONING FOR SPECIAL CONDITIONS



SEIZURE – SIDE-LYING

POSITIONING FOR SPECIAL CONDITIONS

SHOCK – MODIFIED TRENDELENBURG SCI – IMMOBILIZE TONSILLECTOMY – SIDELYING / PRONE THYROIDECTOME – SEMI – FOWLERS THROMBOPHLEBITIS – ELEVATE LEG TPN – TRENDELENBURG – DURING INSERTION THORACENTESIS – FOWLER’S(DURING)



AFTER – POSITION OF COMFORT

POSTURE AND BODY ALIGNMENT-ERECT JOINT MOVEMENTS=RANGE OF MOTION CONNECTIVE TISSUE


MOBILITY AND IMMOBILITY

BONE TO BONE-LIGAMENT BONE TO MUSCLE – TENDON COVERS BONES/JOINTS - CARTILAGE




TYPES OF JOINT
 

SYNARTHROSES(CARTILAGENOUS) DIARTHROSES( SYNOVIAL) AMPIARTHROSES(FIBROUS)

PRIORITY-ASSESS PERSONAL CAPACITY 1ST USE PROTECTIVE DEVICES/ TRANSFER AIDS CHANGE POSITION SLOWLY-ORTHOSTATIC HYPOTENSION(DANGLE LEGS FIRST) PIVOT ON THE STRONGER SIDE,MOVE PNT TOWARDS STRONGER SIDE USE LARGER MUSCLES OF THE BODY AND FACE THE DIRECTION OF THE MOVEMENT PULL SHEETS ARE BETTER METHOD THAN SLIDING ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE AN ASSISTANT STANDING BY. ROCK FROM FRONT TO BACK/VICE VERSA.WIDE BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF THE BODY.USE APPROPRIATE TRANSFER AND AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE BOARD, DRAW SHEET AND TRANSFER BELT


ERGONOMICS-BODY POSITIONING AND MECHANICS

DECUBITUS ULCER-OSTEOMYELITIS OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND RENAL CALCULI INCREASED CARDIAC WORKLOAD- TACHYCARDIA CONTRACTURES- DEFORMITIES THROMBUS FORMATION-PULMONARY EMBOLISM ORTHOSTATIC HYPOTENSION-WEAKNESS,FAINTNESS AND DIZZINESS RESPIRATORY STASIS – HYPOSTATIC PNEUMONIA


DANGERS OF IMMOBILITY

CONSTIPATION – FECAL IMPACTION URINARY STASIS-URINARY RETENTION NEGATIVE NITROGEN BALANCE-WEIGHT LOSS/DEBILITATION


HIGH FOWLERS-60-90’ FOWLER-45-60’ SEMI-FOWLERS-30-45’ LOW-FOWLERS-15-30’ SUPINE DORSAL RECUMBENT LITHOTOMY TRENDELENBURG SIMS LATERAL MODIFIED TRENDELENBURG PRONE KNEE-CHEST SIDE-LATERAL ORTHOPNEIC


SPECIFIC THERAPEUTIC POSITION



CRUTCHES



ASSISTIVE DEVICES

CRUTCH HEIGHT-

STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 CM

TEACH MUSCLE STRENGTHENING EXERCISES PRIOR TO AMBULATION.WEIGHT ON THE HAND GRIP (TO AVOID CRUTCH PALSY) ELBOWS SHOULD BE FLEXED 20-30’ AND CRUTCHES SHOULD BE KEPT 6 INCHES LATERALLY AND 6 INCHES TO THE FRONT=TRIPOD POSITION(810 INCHES-OK) INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTURE




CRUTCH WALKING GAITS
 

FOUR POINT-SLOW SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS TWO POINT- FASTER SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS THREE-POINT-NON WEIGHT BEARING OF ONE LEG SWINGTO/SWINGTHROUGH-PARTIAL WEIGHT BEARING ALLOWED FOR BOTH LEGS GETTING INTO A CHAIR –BOTH CRUCHES TO THE WEAK SIDE , STRONGER ARM HOLDS THE ARMREST ST GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1 AND BAD GOES ST DOWN 1 .

WALKERPROVIDES STABILITY AND BALANCE MOVE WALKER AHEAD 15 CM (6INCHES-8-10 INCHES)WHILE WEIGHT IS BORNE BY BOTH LEGS.THEN ALTERNATE WEIGHT BEARING ASSISTED BY THE ARMS ELBOWS SHOULD BE FLEXED-20-30’ IF ONE LEG IS WEAKER MOVE THAT LEG TOGETHER WITH THE WALKER

CANE HOLD CANE ON THE STRONGER SIDE FLEX ELBOW 30’ AND TIP OF CANE 15 CM LATERAL TO THE SIDE OF THE 5TH TOE. ADVANCE CANE AND AFFECTED LEG ,WEIGHT ON CANE WHEN MOVING THE GOOD LEG BUT FOR MAXIMUM SUPPORT ADVANCE CANE 1 FEET ,MOVE AFFECTED LEG THEN THE STRONGER LEG GOING UP AND DOWN THE STAIRS –SAME WITH CRUTCHES


PREMATURE INFANTS-LESS THAN37WKS/2,500G-100-200 CAL/KG/DAY AND HIGHER Na,Ca AND CHON FULL TERM-120 CAL/KG/DAY PREGNANCY + 300CAL/DAY LACTATION+ 500CAL/DAY


*NUTRITION *NUTRITION



CONDITIONS
 

ENTERAL FEEDINGS

PREOPERATIVE NEED FOR NUTRITIONAL SUPPORT GI PROBLEMS ONCOLOGY THERAPY ALCOHOLISM,CHRONIC DEPRESSION AND EATING DISORDERS HEAD,NECK DISORDERS OR SURGERY ASPIRATIONTUBE DISPLACEMENT CRAMPING,VOMITING,DIARRHEA HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE INTOLERANCE
 



COMPLICATIONS

SPECIFIC NUTRIENT MODIFICATION CALORIC MODIFICATION CONSISTENCY
 

NUTRITION

SPECIAL DIETS FOR SPECIFIC DISEASES DIETARY MODIFICATIONS FOR SPECIAL CONDITIONS


INCREASE,DECREASE,RESTRICTED

NUTRIENT MODIFICATION

CA,K,NA,Fe,FOLIC ACID,VIT C&B COM.,ADEK, CHOLESTEROL,GLUTEIN FIBER, PHENYLALAMINE,TYRAMINE CHO,FATS/LIPIDS,CHON


AGE – CLEAR LIQUID AGN – LOW NA , LOW CHON ADDISON’S – 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. STONES------ALK. 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.


THERAPEUTIC DIET FOR SPECIFIC CONDITIONS

HIRSPRUNGS – LOW RESIDUE, HIGH CHON AND CHO CIRRHOSIS – LOW CHON MENIERE’S 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


THERAPEUTIC DIET FOR SPECIFIC CONDITIONS



RENAL FAILURE (ACUTE) – LOW CHON,HIGH CARB
 

THERAPEUTIC DIET FOR SPECIFIC CONDITIONS

LOW NA (OLIGURIC PHASE) HIGH CHON , HIGH CAL AND RESTRICTED FLUID (DIURETIC PHASE

RENAL FAILURE (Chronic) – LOW CHON , LOW NA , LOW K



TYPES OF SOLUTIONS
 

TOTAL PARENTERAL NUTRITION

TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE BACTERIAL FILTER USED TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID, DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTER

PERIPHERAL=NO >10% DEXTROSE AND 2 WKS ONLY CENTRAL – INCOMPATIBLE WITH MEDS AND BLOOD IF SINGLE LUMEN USED ATRIAL-HICKMAN/BIOVAC AND GROSHONG- HUBBER NEEDLE USED TO ACCESS PORT THROUGH SKIN
 

INITIAL RATE OF INFUSION 50 ML/HR THEN 100-125/HR. COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS, PNEUMOTHORAX

 

TPN

FAST RATE=HYPEROSMOLAR STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS) SLOWED RATE=REBOUND HYPOGLYCEMIA



X-RAY CONFIRMS PLACEMENT ATTACH TO PUMP

IV TUBING AND FILTER CHANGED Q24 HOURS ALLOW SOLUTION TO WARM IMMEDIATELY BEFORE USE IF NO SOLUTION USE DEXTROSE 10% W SOLUTION


CHECK DAILY CBG,WEIGHT,TEMP. I AND O , CHECK 3X A WEEK BUN, ELECT, ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND PT,PTT
 



TOILET TRAINING

*ELIMINATION BOWEL ELIMINATION



FACTORS AFFECTING PROBLEMS MANAGEMENT-CATHARTICS , ENEMA , SURGERY DIAGNOSTIC AND THERAPEUTIC PROCEDURES
ENEMA COLOSTOMY/ILEOSTOMY,OTHER SURGERIES BARIUM STUDIES SCOPIC EXAMS ROENTOLOGIC EXAMS
 

  

ENEMA
They act by distending the intestines that increases peristalsis and expulsion of feces and flatus. Enemas serve the following purpose:


Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications


Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches Position: adult- left lateral; infants and children- dorsal recumbent


ENEMA

Administration- administer the enema in a minimum of 15 minutes duration. Conatainer’s Height- 12 inches above the rectum Temperature- 42°C or less


PERMANENT/TEMPORARY STOMA RED AND SLIGHT BLEEDING WHEN TOUCHEDBURNING SENSATION UNDER FACEPLATE INDICATES SKIN BREAKDOWN,REFER ABDL DISTENTION/DISCOMFORT, KARAYA POWDER(DEC.IRRITATION), CHARCOAL/BISMUTH CARBONATEDEODORIZER APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-72H AND 24-48H IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODED ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODOR COLOSTOMY-FORMED , CAN BE IRRIGATED 300-500ML AND REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCE
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OSTOMIES



BLADDER TRAINING

URINARY ELIMATION



LABS AND DIAGNOSTIC TESTS CONDITIONS CATHETERIZATION AND IRRIGATIONS





BUN – 10-20 MG/DL CREA – 0.7 – 1.4 MG/DL 24 HOUR URINE PRODUCTION-1000-1500CC


URINARY ELIMINATION

ANURIA<100ML/24H OLIGURIA< 400 ML/24H POLYURIA > 2000 ML/24H


KEGELS –STRENGTHEN MUSCLES OF THE PELVIC FLOOR-TIGHTEN FOR 3 SECS THEN RELAX FOR 3 SECS PERFORM LYING DOWN, SITTING AND STANDING FOR TOTAL OF 45 BLADDER RETRAINING


INTERMITTENT CATHETERIZATION AFTER ATTEMPTING TO VOID Q 2-3H, TIME INCREASES GRADUALLY BUT NO MORE THAN 8 HOURS BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H THEN ATTEMP TO VOID 30 MINS LATER-TIME GRADUALLY INCREASED TRIGGERING TECHNIQUES-CREDES MANEUVER AND VALSALVA CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE TO VOID 3-4 HOURS AFETR REMOVAL


DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS


HEMODIALYSIS

TENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES: CAPD(4-6H INDWELLING),AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING


PERITONEAL DIALYSIS

OXYGENATION
PULMONARY FUNCTION TESTS DIAGNOSTIC LABORATORIES(ABG, SPUTUM CS AND THROAT CULTURE) VISUALIZATION AUSCULTATION


OXYGENATION

OXYGEN DELIVERY EQUIPMENT CHEST PHYSIOTHERAPY ARTIFICIAL AIRWAYS THORACOCENTESIS,THORACOSTOMY.TRACHEOSTOMY AND ET INTUBATION SUCTIONING CHEST TUBES AND DRAINAGE SYSTEMS


CHEST PHYSIOTHERAPY

TURNING COUGHING DEEP BREATHING POSTURAL DRAINANGE PERCUSSION AND VIBRATION INCENTIVE SPIROMETRY SUCTIONING TRACHEOSTOMY CARE OXYGEN THERAPY VENTILATOR CARE AND MANAGEMENT


Chest Physiotherapy It is the combination of percussion, vibration, and postural drainage Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes Vibration is done during 5 exhalations Postural drainage is done for 15-20 minutes usually performed 3-4 times a day. Instruct the client to increase fluid intake to liquefy secretions This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery. This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen. Humidify the oxygen first before you administer. Check for bubbles in the humidifier to promote adequate flow of oxygen Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: “NO smoking: Oxygen is in used” Instruct the client not to use woolen blankets as this may create static electricity


tidal volume- 500 residual volume- 1200 expiratory reserve volume –1200 inspiratory reserve volume – 3100
 

pulmonary function tests

Vital Capacity- tidal volume + IRV + ERV = 4800 Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000



Forced Residual Capacity – ERV + RV

incentive spirometry – hold 2-6 sec; 4-5 times/H (TO MAXIMIZE RESP.&MOBILIZE SECRETIONS endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly visualization –


X ray Lung Scxan – 20-40mins isotopes in body for 8 H laryngoscopy Bronchoscopy Thoracentesis- consent, VS and baseline X-ray + post Procedural
 

tie new trache tie before removing the old tie to prevent accidental dislodgement.ALLOW 2 FINGERS TO BE INSERTED UNDER TIE use precut gauze and perform care OD at least. soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well suction prn, oral care prn(PROCEDURE DONE q8h AND PRN)


Tracheostomy Care

cannula – 2-6 LPM – 24-45% Mask – 5-8 LPM – 40-60% parial rebreather – 6-10 LPM – 60-90% non rebreather – 10-15 LPM – 95-100% tent – 4-8 LPM – 30-50 % Venturi mask –


Oxygen Delivery Equipment

2-3 LPM – 24-28% 4 LPM – 30% 6 LPM – 35% 8 LPM – 45% 14LPM – 55%


Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT:


ASSESS BREATH SOUNDS

Hyperoxygenate the patient before and after the procedure. Apply intermittent suction on withdrawal of the catheter. Do not suction the patient for more than 15 seconds. IDEAL 10 SECS


Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space. space. NURSING ALERT: Check the consent. Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder. Instruct the patient not to cough, breath deeply or move during the procedure. After the procedure: Position the patient on the unaffected side/puncture site up. Check for bleeding at the puncture site and monitor the respiratory function. Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.
 

INFANT-DISTRACT TODDLER-ALLOW REGRESSION AND INVOLVE PARENTS,CONSISTENT CAREGIVER PRE-SCHOOL-LET CHILD HANDLE EQUIPMENT,EXPRESSION OF FEELINGS THROUGH PLAY DEMOFAMILIAR SORROUNDINGS SCHOOL AGE- EXPLAIN SIMPLY AND ALLOW CHOICES ADOLESCENTS- INVOLVE AND POINT OUT STRENGTHS AND BENEFITS,EXPECT RESISTANCE
 

*PERI-OPERATIVE NURSING PREOP CARE

PREOP CHECKLIST


CONSENT HEALTH TEACHING (SPEC. POST OP PROCEDURES) LAB TESTS,ECG,X-RAY SKIN PREP BOWEL PREP IV’S NPO PREOP MEDS,SEDATION AND ANTIBIOTICS REMOVAL OF DENTURES,NAILPOLISH AND JEWELRY NUTRITION-TPN OR ENTERAL FEEDINGS PREOP

INTRAOP- MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT STATUS,, APPROPRIATE GROUNDING DEVICES, FLUID BALANCE AND SPONGE/INSTRUMENT COUNT POST OP- MONITOR VS Q15X4;Q30X2;Q1HX2 THEN PRN MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC RESPIRATORY PHYSIOTHERAPY,TCBD INCENTIVE SPIROMETRY-20 SECS INHALATION ENCOURAGE AMBUALTION REFER IF UNABLE TO VOID IN 8 HOURS APPLY TED HOSE AND PNEUMATIC COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGN

WOUNDS NOTE DRESSING AND INCISION FEVER 1-2 DAYS POST OP-ATELECTASIS/ DEHYDRATION 3-7 DAYS – INFECTION UPPER GI TUBES-GASTRIC DECOMPRESSION LOWER GI TUBES – BOWEL DECOMPRESSION ST WOUND HEALING BY 1 INTENTION-SUTURED AND APPROXIMATED ; 3RD INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINS ND WOUND HEALING BY 2 INTENTION-INCREASED INCIDENCE OF INFECTION , INCREASED SCARRING AND LONGER HEALING TIME
 

SHOCK PARALYTIC ILEUS ATELECTASIS AND PNEUMONIA - 2ND DAY EMBOLISM- 2ND DAY WOUND INFECTION-3-5D DEHISCENCE AND EVISCERATION-5-6D PSYCHOSIS CARDIOVASCULAR COMPROMISEURINARY RETENTION-8-12H URINARY INFECTION -5-8 D DVT-6-14 DAYS-1 YEAR
 

POST-OP COMPLICATIONS

WOUND CARE


WOUND TYPES AND



HEALING DRESSING DRAINS







SENSORY DEPRIVATION SENSORY OVERLOAD SENSORY DEFICITS

SENSORY PERCEPTION AND COGNITION







MEDICATION ADMINISTRATION

THERAPEUTICS



IVF INFUSIONS(INCLUDING MIO) BLOOD TRANSFUSION PHYSICAL AND OCCUPATIONAL THERAPY







NORMAL VALUES

SUPPLEMENTS



DIAGNOSTIC TESTS THERAPEUTIC PROCEDURES



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