Fundamental of Nursing

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Fundamental of Nursing Nursing

P- wellness; yet vulnerable 1. Health promotion- maintenance, support,client has no dse orientation 2. Specific protection- illness prevention;injury and illness oriented S- has intervention, Dse. Illness; stop dse. Prevent disability and further complication 1.Early Dx 2.Early treatment and intervention T-Dse, Illness- stabilized, cannot be fixed already. 1.Restoration 2. Rehabilitaion(upon admission already starts but stabilize the px) Roles Care provider- spirit of nursing, welfare of the patients Communicator- vital responsibility of the nurse; helps us assess, identify needs of us our clients, and establish relationship with clients 4 phases of nurse client relationship Preorientation- self awareness Orientation- contract, identification and trust Working- longest Termination – end of contract; goal may/not be met Interpersonal model- Hildegard Peplau Orientation Identification- needs Exploitation- implementation Resolution Interpersonal process theory- ida jean Orlando VS peplau

Fr. Nutritious
Services offered to clients/ patients Leninger- transcultural nursing- individual, family, community 4 1. scopes Promote health – models >Clinical –s/sx +s/sx = client is ill; stop occurrence of s/sx >Adaptive model- Sr. Roy(adaptation theory) –make use of conscious mind in order to balance in his environment :Illness-responses of the client based on the given dse. :Diseases- alteration in body function >Role performance model- client is able to perform his task for adl even if ill d. orem –self care-capable to perform adl self deficit- disability adl self care deficit- assist client in achieving health care; wholly compensatory(dependent client) , partially compensatory (collaboration between nurse and client), supportive and educative (focus on motivation by inC awareness) ;health education is the best way to promote health >eudemonistic model- Self Actualization (non nursing model)- client is able to maximize potential V. Henderson- 14 fundamental needs- lack of any need could lead to illness - assist clients toward recovery; and gain independence B. neuman 3 levels of health health care delivery system

KenSanRN

Dynamic nurse client relationship Joyce Travelbee- impt. Of communication Nursing is a human to human interaction Advocate Advocacy- Action that shows concern to other people or interaction   Patient is the main focus Intercede in behalf of the client (put yourself in the shoe of the patient t understand the patient) yr)

competent 2-3 yr of experience(planning and organizing act for the unit) proficient 3-5 yr of experience(holistic understanding and perception on their client ) expert 5yrs of experience (fluid)analytical and intuitive Expanded role of nurses Expert nurses- adv level of education/ training -nurse educator- in academe or teaching institution (MAN, 1 Nurse midwifeNurse entrepreneur- health related business Nurse practitioner- 2 yrs.- primary ambulatory care- chronic and acute illnesses Clinical nurse specialist- expert Nurse anesthetist- icu/rr Nurse traveler- floaters 2. Prevention of illness and occurrence of dse. 5 stages of illness behavior >s/sx experiences1. physical changes/ alteration in body fx., 2. cognitive- we tend to interpret the problem 3. emotional- anxiety / fear is N >assumption of sick role-teNd to confirm the problem > medical care contactValidate, understand, Reassure

Change agent- Goal oriented; looking for change – modify client behavior and environment Teacher- impart knowledge to our client Manager- delegation and budgeting Collaborator- work with other health care team/ hosp. Leader- influence our client Nurse counselor- client to modify their behavior(guide and listen but not to decide for the client)

Imogene King- goal attainment theory (transaction process) transaction is needed bet. Nurse and patient in order to achieve the goal decision making but final decision should come to the patient

>dependent client role- Px gives up independence >Recovery/rehabilitation- abatement of s/sx

nurses are allowed to decide for px in crises mgt. Researcher- update ourselves with the trends CPE- enhancement, updates trend and tech, expertise 5 stages- P. Benner (based on yrs. ) noviceinflexible nurses (knowledge, skills ) adv. Beginner 1-2 yr of experience (clinical judgment; knows to prioritize)

:Promotion/Prevention/Rehabilitation/Care of Dying

Hx: INTUITIVE shaman= white magic trephening- first operation

KenSanRN

code of Hammurabi- first document that governs the practice of medicine concept of cleanliness- handwashing / service charges china= material medica- pharma india= male nurses-knowledge, clever, devoted, purity of mind and body(no sex including masturbation) shushurutu= design that req. for aspiring nurses Israel= moses father of sanitation Egypt= art of embalming/ recognized 250 dse. basis of specialization/

PERIOD OF CONTEMPORARY NURSING      After world war II – present Scientific and technological development and social changes marks this period. Events and trends; technology WHO was established Readjustment in the curriculum

Data collection- Base line data Subjective- verbalized by patient, symptom, covert, illness Objective- observable and measurable data, sign, objective, dse. Sources of data Primary= client/px Secondary= significant others, consultation, record and report Documentation SOMR-Source Oriented Medical Record- traditional Narrative format POMR-Problem Oriented Medical Record- 4 components Baseline data; problem list; plan of care; progress notes SOAP/IE/R FOCUS –Dx Action Response PIE Kardex- concise documentation that is used for indorsement Report being verbalized Change of shift report- endorsement/ end of shift - continuity of care/ legalities & liabilities Nursing rounds- endorsement on bedside( assess before indorse) Telephone order- between 2 health care professional MD-RN, document @ once (signed by nurse and cosigned by MD W/in 24 hrs.) basic orders Telephone report- md-rn-rn-md-md Methods of data collection Interview- plan communication Open ended and close ended- open (therapeutic, explore and expound of data) Directive approach- nurse manipulated- close ended Indirect approach- client manipulatedObservation- physical senses= objective data Increase the clinical eye level of the nurse Examination- gather objective data

APPRENTICE OJT period >Crimean war>Florence nightingale- environmental theory- Lady with Lamp >training school- pastor t. fliedner- germany Dark (reformation) >martin luther >nurse- unwanted women- prosti and prisoners JOHN HOWARD- prison reformer  teacher of the prosti and prisoner

PERIOD OF EDUCATED NURSING   Began on June 15, 1860 Opened Florence Nightingale School of Nursing at St, Thomas Hospital in London.  Arousal of Social consciousness  Facts about Florence Nightingale: o “Mother of Modern Nursing” o “Lady with a Lamp”  England pioneer country in modern nursing  Resident physician- instructor;  standard curriculum- 6 months;  clinical training/ expansion of roles

1.

Health assessment- vital signs
a.

Temp= balance in heat loss and heat production i. Core – underlying organ. 37.5‟ c ii. Surface- skin and underlying tissue- 36.5-37.5 >rectal- 1-3 min; ci: hemorrhoid, diarrhea, rectal operation: last option

KenSanRN

>oral - .5‟ c of 1‟ f lower than rectal, ci: too young, unconscious, vomits, prone in having seizure attack, angry irritable or confused, contraption > axilla; 1.1 „c or 2-3‟ f lower than rectal-6-9 mins >tympanic- core- one of safest Basal Metabolic Rate- amt of heat needed by the body in order to perform vital process; the younger the higher Direct- respiratory chamber- heat evolving is measured. Indirect – get rr,- 12 – 16 hours after eating, resting or sleeping, Diurnal- most at 6 pm and 8-12 mm - Least -6 am 1-4 am Hormones Inc EE, nor epi, proges Dec estrogen Stress SAMR: inc in epi and nor epi Hypothermia- lower than N. 36 below Mild- 32-37 Moderate- 28-32 Severe -22-28 Pyrexia- fever higher than 38.1 centigrade Intermittentfever. Remittent always above 38.1 Relapsing feverConstant/ high fever- remittent with fluctuation up to 41‟c Hyperthermia- above 41‟c Respiration- controlled by medulla oblongata- fx as primary receptor(cpu), pons rhythmic act of respiration, if pons and medulla fails carotid and aortic bodies take over(limited time can cause alkalosis) • Three processes: Ventilation, Diffusion, Perfusion
• •

Apical-lying position; after radial identical with radial, 3yrs below (4 ics) , Brachial- cardiac arrest kids Radial(most accessible) Femoral-cardiac arrest Posterior Tibial, Pedal (dorsalis pedis), Popliteal- circulation of blood to lower legs Radial-apical assessment- two nurse method One nurse method A>R- refer immediately, indication for cardio prob Pulse deficit = difference of two pulse BLOOD PRESSURE


th

fluctuation

normal

to

Determinants of Blood Pressure Blood volume- increase causes increase Viscosity- hematocrit Peripheral Resistance- vasoconstriction or vasodilation Cardiac output Elasticity or Compliance



Factors Affecting Blood Pressure Age= y, dec BP Exercise Stress- could increase or decrease Race

Types of breathing: Costal (thoracic) and Diaphragmatic(abdominal) Factors affecting respiratory rate Exercise, Stress, Environment, Increased

altitude, medication Pulse- autonomic nervous system • Factors Affecting Pulse Rate Age , Sex/Gender, Exercise, Fever, Medications, Hemorrhage, Stress, Position Changes


Obesity Sex/Gender- f 65 inc Bp Medications Diurnal Variations-4-6 pm high 7-9pm; early am low or upon awakening.. Disease Process

Pulse Sites Temporal (brain circulation), Carotid- cardiac arrest adult

KenSanRN

Position- lying best position.. level with heart. Orthostatic blood pressure measurement- drop of BP to prevent positional hypotension.., lying then sitting then standing with 5 mins interval Hypertensive- 2-3 times 140/90

Fasting blood sugar- 6-8 hours NPO, side of the fingers, 70-110mg/dl Somogyi rule - 60-100mg/dl Fulin‟s- 80-120mg/dl Wu‟s- 80-120mg/dl Vanillymandelic acid test- urine; to check tumor, cancer cells in adrenal
area, avoid vanilla rich food and aspirin Urine- normal pH 4.6-8 Sp. Gravity-1.010-1.035 Color of urine- amber to straw Red- inc. CHON, hematuria, black or brownbleeding, white- infection pus. Volume-30-60ml/hr Poly- excessive urination more than 100ml/hr (hypercalcemia, hyperparathyroid, diabetes, diuretics); oli- less than 30 ml/hr but higher than 10 ml(500ml/day)(renal failure hypertension , neprhotic syndrome ); anuria-absence or always <10 ml/ hr(100ml/day), (hemorrhage, metal poisoning) Methods Clean catch- culture and sensitivity (5-10ml), routine urinalysis(10ml, (30-50ml), 24hr collection, catheterized collection (clamp for a minimum of 30mins to 2hours) Stool- fecalysis, culture and sensitivity , occult blood (GUIAC)- peptic ulcer determination, gastric ca analysis, no: red meat, iron, dark colored food, hgb. (2-3days) pea size is enough . Sputum – culture sensitivity, acid fast bacilli staining-TB (collected 3 consecutive moring) -early morning collection -avoid commercial mouth wash -before giving any type of antibiotic >deep breathing and cough exercise-able to cough/expectorate -cascade-able to cough and expectorate with minimal effort -pursed lip technique; inhale thru nose hold for 5 sec., exhale thru pursed lips 3x. then inhale thru nose and hold and cough -huff able to cough and expectorate but max effort is needed - inhale thru nose hold for 5 sec., exhale while stating huff 3x. then inhale thru nose and hold and cough quad- person wchich need effort in terms of respiration. inhale inward upward exhale release. Inhale inward upward hold and cough release >suctioning- able to cough but not expectorate

2.

Physical assessment- validate or refuse certain data
Consent must be secured Non invasive and invasive requires consent Verbal consent is impt. Empty the bladder twice, before doing the assessment and before assessing the abdomen Position must be considered- best is either standing or sitting; all area are accessible Gown Observe privacy- proper draping, area only to be assessed - age -gender 4 modes of PA ; system, cephalocaudal- age, severity, protocol Iwell lighted and ventilated area P- light(suoerficial), deep ( size, mobility consistency of organ or mass) ; finger pads, P- flat(muscles and bones), tympanic sounds (stomach), dull(hollow organ, liver pancreas heart), resonance (normal lungs),hyper resonance increase level of secretion(normal if 3 y.o.) A- direct – unaided ear indirect- gadget or instrument Battery- touched, assault- verbalized

3.

Lab procedure

Use of diff. specimen; blood semen urine stool sputum Huhner‟s Test-post coital examination.(sperm as specimen) use to determine the motility of the sperm. 2-3 hours prior to collect Arterial blood gas- most recommended radial artery, 10 ml preheparinized syringe; placed on ice filled container

pH: pO2: pCO2: HCO3: o2sat:

7.35-7.45 80-100 35-45 22-26 95

7.31-7.41 30-40 41-45 21-29 60-80

respiratory acidosis: rr decrease; temp decrease; bp decrease, pulse increasedisoriented, depress, apathetic, confused metabolic acidosis; nausea, mild to moderate dehydration, abdominal cramping, diarrhea metabolic alkalosis; vomiting, nausea respiratory alkalosis; fever, anxiety

KenSanRN

4.

Visualization

-naso/oro pharyngeal- able to cough and expectorate -naso oro thracheal- not able to cough and not able to expectorate Rule of thumb- nose to earlobe -tracheal- artificial airway >CPT- if the client cant expectorate at least 30 ml of secretion, nebulization before cpt, ci; emaciated -chest percussion- lower to upper -chest vibration -postural drainage- high fowlers‟ (upper lobe), trendelenburg (lower lobe), superior(supine), posterior(prone) 15 -20 mins/ position

   Solution  

Preschool 300-500ml, fr 16-18, 2-3in School age to adult- 500-1000ml, fr22-30, 34in

   

Water- to lower temperature Soap-sud- cleansing enema to stimulate peristalsis  Castile soap, 20cc:1000ml Nsaline/ water Sodium phosphate- constipation  Commercially prepared solution  Fleet enema Saline based solution-0.9% NaCl Oil-retention enema Cleansing enema- allowed to perform to a max of 3time , 5-10 mins o High cleansing- 1000 ml, 12-18inch above the rectum o Low cleansing- 500ml, <12 in Carminative enema-expel flatus, 80 -100 ml,water Oil retention enema- best to relieve fecal impaction, 5-6x, Fullness stop and kink lower the irrigation and unkink after 30 secs.

>direct- invasive procedure, obtain consent, NPO for atleast 6-8‟, sedation >indirect- use of x ray to visualize, remove all metal, - dye- assess for allergy -electrical impulse- remove all metal Elimination 1. Constipation a. High fiber diet b. Increase fluid intake c. Exercise d. Respond immediately for any urge to defecate e. Laxative as ordered. i. Can cause diarrhea ii. Could destroy normal defecatingreflexes Bulk forming –psyllium- increase solid liquid gas- increase fluid intake, It‟ll take 3 days. Saline based- (salt) fluin retention- form bulk e.g. milk of magnesia, Not to be used for too young and too old. Stool softener- colace- 1-3 days before effect, allows water to enter dtool, delays drying of stool Chemical irritant- castor oil- increases gastric motility to empty bowel Can lead to fluid and electrolyte imbalance. Lubricant- mineral oil  Softens the stool while lubricating the anal canal f. Enema i. Evacuation, empty bowel of content esp. prior operation ii. Lower body temperature  Age- volume, catheter size and total length  Infant 50-200ml, fr 10-12, 1-1.5 in  Toddler 200-300ml, fr 14-16, 2-3 in

 

2. 3.

4.

Fecal impaction- defecation is absent for 3-5 day i. Best removal-is manual; oil retention before digital removal Flatulence – too much air swallowed, blood diffusion, bacterial action i. Avoid gas forming food ii. Avoid the use of straw iii. Avoid chewing gum iv. Provide warm fluid v. Proper positioning- knee chest position, prone position (place a small pillow under the stomach) Diarrhea i. Place in low fiber diet ii. Replace all fluid and electrolyte loss iii. Conserve energy iv. Encourage increase potassium intake a. Gatorade-small frequent sip v. BRAT diet vi. Bland diet

Urinary elimination 1. Dysuria- painful voiding 2. Hematuria- blood in urine 3. Enuresis- frequent urination a. Nocturnal enuresis- night b. Diurnal enuresis-day c. Primary enuresis- didn‟t learn how to control

KenSanRN

4.

d. Secondary enuresis- assoc. with dse. Incontinence- not capable to control voiding a. Functional- aware of urge– unpredictable passage of urine b. Urge – aware of the urge- minimal warning- uncontrollable passage of urine i. Place a client on toilet training, discipline the client, teach how to control; days-every two hours, nightevery 4 hours c. Stress incontinence- increase abdominal pressure- leakage of urine/ uncontrollable passage of urine; dribbling urine i. Lessen the pressure= pelvic exercise=keggel d. Reflex- is not aware of any urge to void; uncontrollable feeling i. Catheter

Ointment- inner to outer (close eyes wipe the excess med) Otic- straighten the ear canal Adult –up and back Child- down and back (3yo below) Nasal installation- supine pos., slightly hyperextend neck, gently lift nose and drop medication maintain pos. 3-5 mins Rectal – sims lateral Vaginal-dorsal recumbal Injectionim -90 „ -1 – 3 ml max per injection - deltoid - vastus lateralis (7 mo below), mid leg -ventro gluteal (7 mo above) - dorso gluteal (3yrs old above)(has been walking for 1 yr) - deep Im- Z track – prevent leakage of med back to subQ - slow admin; 0.1ml:1sec. Id- just beneath the skin(5-15”), skin test and tuberculin test Skin test -to identify whether a client is having allergic reaction towards any medication -hairless(left is for tuberculin, right for skin test) - bevel up, form bleb, and outline with blue or black and place a micropore near a site for infos. - assess for temp, rashes, itchiness after 30 mins Mantoux test -for tb - tuberculin syringe - PPD 1 cc -assess for induration, measure in (mm) after 12 hours; peak of interpretation after 48 to 72 5-9 mm= ?= tx; 10 mm= + =tx Subq -administered in fat layer - 45 or 90‟ - 0.5ml-1.5 ml; if more than= pain - insulin- never massage site might cause hypogly - regular, short, clear first, air intro start with the other. - anticoagulant- avoid green leafy veg., never massage, no aspiration IV Isotonic - equilibrium - inc. extra cellular fluid .9 NaCl- isotonicity of blood

Sites

Catheterization = last option and priority Aseptic technique;  consider for the gender; Male= fr. 16- 18, supine, 6-9 in, lower abdomen, Female= fr. 12-14, dorsal recumbent, 3-4 in, upper inner thigh  type o straight catheterization-1 way foley catheter  gradual decompression, at level of symphysis pubis, not more than 1000 ml/ per irrigation= can cause hypovolemic shock  repeat after 2-3 hours retention catheter  2way foley- inflate with 5-10 ml of water  3 way foley- continous bladder irrication- Cystoclysis 

o

MEDICATION Chemical substances that are used to treat diagnose and cure Administration Right client- ask to state name Right drugRight doseAge Height and weight Right time- can be 30 mins before or after the time Right documentation Right routeInternalOral Buccal Sublingual Topical – Through our skin (hairless) Eyes-dropslower conjunctival sac 1-2cm (press nasolacrimal)

KenSanRN

-

.5% dextrose- when it enters body changes to hypertonic Ringer- Na Cl K Ca Lactated Ringer- has lactic acid and forms bicarbonate- and is for metabolic acidosis Hypotonic- lesser con. than body fluid Lowers osmotic pressure O.45 % NaCl- nutrient solution – rich in water and carbo 0.33% NaCl2.5% Dextrose Hypertonic- greater con. than body fluid Increase osmotic pressure Increase extra cellular fluid D5LR, D5W, D5NaCl, D25W Complications with IV: Infection: iv tubing, cannula should be replaced every 2-3days : iv dressing site should be replaced every shift, 8‟ , Infiltration: out of vein; dislodge, pallor, cold : remove cannula, and apply warm compress Phlebitis: inflammation of the vein : caused by over use of vein, irritation of the vein due to overdose or over concentration of med, warm, red :cold; and warm compress (if swelling goes away) 5 cardinal signs :Inflammation Rubor- red- increase blood volume Calor-heat- increase blood volume Tumor-swelling Dolor-pain Functio laesa- loss of function

>initiate after 30 min >stay with client for first 15-30 min. >4 hours Whole blood- 300-400- 4 hours Packed RBC-250-300- 4hours Albumin- 10-20- 20 mins Plasma-300ml- 3 hours FFP- 6 hours Complications Allergic reaction Mild- hyper sensitivity of the plasma of the donor >rashes, urticaria, itchiness Severe- antigen antibody formation >hypotension, DOB, chest pain Septic Reaction >contaminated blood >nausea, vomiting, hypotension, headache, drowsiness, dizziness, DOB, Chest pain Hemolytic Reaction >incompatible blood > tachycardia, hypotension, DOB, chest pain, lower back pain, hematuria Febrile reaction >non hemolytic reaction >hypersensitivity to plasma, rbc, wbc >fever, hypotension, Circulatory overload >hypertension > distended neck vein SToP infusion, and start 0.9% NaCl (fast drip), monitor V/S, administer antihistamine/ antibiotic/ bronchodilator/ antipyretic Comfort measure Rest- Free from any form of anxiety Sleep- State of consciousness the individual perception and responses to stimuli is decrease NREM- a very light sleep to deepest stage of sleep To conserve energy REM - dream state of sleep Increase synthesis processes in our brain 5 Stages of Sleep 1- very light sleep= 5-10 min muscle relaxation till s.4, easily arousable till s 2 2- sound sleep= 10-20 min, normal-slow 3- initial stage of deep sleep= 15-30min, slow-decline

Blood transfusion Restores blood volume Improve o2carrying capacity >aseptic technique >proper documentation >secure consent >V/s monitoring >type, cross matching, serial code, expiration >before and after infuse .9naCl- KVO (10ml) >18/19 gauge >label blood >warm blood @ room temp

KenSanRN

45-

deep sleep= dream state= 90 min after sleep, loosing of skeletal tone

Vitamins Water soluble Vit. C –ascorbic acid: antioxidant, boost immune system X= scurvy B1- thiamine carbohydrate metabolism X=beriberi B2-riboflavin protein synthesis X=skin lesion B3- niacin skin and cellular respiration X= dermatitis, pellagra B6 pyridoxine calcium reabsorption, growth and devt X=peripheral neuritis B9 folic carbohydrate metabolism X=megaloblastic anemia B12cobalamin X= pernicious anemia Biotin/panthotenic acid fat metabolism X=muscle weakness, fatigue Fat soluble A retinol X=night blindness D ergocalciferol x= rickets E tocoferol X= anemia K menadione X=bleeding Anorexia- fear of eating Gradual approach= small frequent feeding Trace any anxiety N/V= metabolic alkalosis Ice chips, Hot ginger ale/kalamansi/lemo/honey Crackers or Toast Prevent aspiration; position Remove sources of unpleasant odor Replace fluid and electrolyte Clear diet diet Bulimia- eat purge cycle Psychological approach Malnutrition Over or under nutrition IBW- 1-10% Over nutrition Overweight 11-20% Obese

insomniainitial- problem in initiating sleep terminal- early awakening intermittent- difficulty in staying asleep hypersomnia prolong sleep narcolepsy sleep attack, uncontrollable sleepiness sleep apnea difficulty in sleeping due cessation of breathing sleep deprivation disturbed sleep pattern Parasomnia Bruxism- grinding of teeth Somnambulism- sleep walk >companionship, check client, assign near station Soliloquy- sleep talker Nocturnal enuresis- bedwetting Nocturnal erection/ emissionDrugs Alcohol- speed onset of sleep; easily arousable Caffeine-CNS stimulant, increase alertness, prolong use increases the alertness Diuretics- take/give during morning Hypnotics- interferes reaching deep sleep Nasal decongestant- drowsiness Anti histamine- drowsiness, prolong day time sleepiness Narcotics- suppress REM Beta adrenergic blocker- causes nightmare Anti depressant- suppress REM Benzodiazepam- Prolong sleepiness Promote sleep: Increase protein intake: high in tryptopan Exercise before 2 hours sleep Conducive environment for rest and sleep Provide relaxation technique Attend to bed time rituals Nutrition Organic and inorganic chemicals found in food that are converted to energy and is expressed as calories :water 1kg= 1kcal :carbohydrates I gm=4cal ;CHON 1gm=4cal :fats 1gm=9cal

KenSanRN

Mild21-40% above Under Nutrition Kwashiorkor Marasmus

moderate 41-100%

severe

100%

and

>Consider for the preference >age of the patient >culture >practices >recommended diet >liquid diet- clear- acute and chronic/ vomited/ post or (short term therapy) -Full/ transitional diet- post or/ (long term therapy) high in CHO, fat and H2O min of CHON >soft- for those with dysphagia - Pureed (head/neck injury) -mechanical (stomatitis)

Special diets

>diabetic diet- small frequent feeding: high in fiber, CHO(50-60% of intake) >BRAT diet- diarrhea >bland diet- no spices- a gastric/bowel irritable syndrome >DAT>low cholesterol diet- heart‟s meal diet- max 300mg/day >low Na- no salt added- renal, cardiac, hpn >Stimulate appetite > Food safety >perform/encourage hand washing >wash food: food bleach: 1cc:100ml >discard / refrigerate >expiration date >assist in feeding >NGT-Lavage, (NEX) >NET- Gavage (NEX+12-20cm) >aseptic head of bed >measure of length of catheter with water based >advance(hyperextend-nose-nasopharynx-tiltoropharynx) Proper Placement >X-ray >Immersion Safety and mobility >crutches -pair >Auscultate >Aspirate >lubricate

-measure- anterior aspect of axilla to the foot +2.5 cm (lying); anterior aspect of axilla to the foot 3+4 finger (standing) - stand- promote tripod position( place crutches 6 inch forward and sideward)(max 1ft.) -Walk >gaits  4 point gait- min of 3 bearing point- right crutchleft foot-left crutch-right foot  3point/orthopedic gait -weaker extremity that can bear weight- both crutch and weak leg followed by the strong leg  2point gait – modification of 4 point gait- right crutch&left foot-left crutch&right foot  Swinging gait- crutches first then legs o Swing to: safer, maximize tripod- swing towards the level of crutch o Swing through: swing towards the level and beyond of crutch -stairs: going up good leg bad leg crutches : going down crutch bad leg good leg -sitting >cane -measure- level of the greater trochanter -support- stronger side of the body -walk –cane-weaker-stronger (great stability) -cane & weaker- stronger (lesser) >walker _ measure- level of the greater trochanter --walk –walker-weaker-stronger (great stability) -walker & weaker- stronger (lesser) >restraint - to limit the client‟s physical activity - client should be free from any form of restraint; restraint if to transport, procedure, has disruptive behavior -secure doctor‟s order within 25 hours -consent - restraint should be anchored to the bed frame - adequate ventilation - free movement as possible - assess every 2 hours, V/S -check site every 15 min to 1 hour - remove restraint every two hours - remove one at a time with 30 min interval • Mechanical- gadget/ instruments attached to client • Chemical- drug/medication >pressure sore  Pressure  Friction  Shearing force  Malnourish o Obese

>elevate

KenSanRN

    

o Emaciated o Decrease CHON Immobile Bowel and bladder incontinence Decrease mental capacity Diminished sensation Increased temperature

Stages of pressure sore  One-non blanchable erythema of the intact skin(epidermis)  Two- Partial skin thickness loss, bleeding, hollow crater formation (dermis)  Three - Full thickness skin loss crater formation, (epi,dermis, subq)  Four- Full thickness skin loss crater formation (epi,dermis, subq, bones, muscles)

KenSanRN

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