Fundamentals of Nursing - Basic Concepts by HamayunKhan2

VIEWS: 98 PAGES: 84

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GENERAL OBJECTIVES
*At the end of the discussion, the learners shall
be able to:
◦ Refresh their prior knowledge about concepts in
  Fundamentals of Nursing

◦ Discover certain topics which seem new to them

◦ Develop techniques that would help them in
  inculcating the concepts by heart and mind

◦ Evaluate the learning process they undergo by having
  simple quizzes and exercises

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CONTENT PREVIEW
First day
  I. Historical and Contemporary Nursing Practice
        1. Nursing Leaders
        2. Definitions of Nursing
        3. Roles and Functions of a Nurse
  II. Nursing Theories
  III. Paradigm: Definition of Terms
        1. MAN: Levels of Clientele
        2. NURSING PROCESS
        3. HEALTH
  IV. Health Promotion
        1. Levels of Prevention
        2. Health Promotion and Health Protection

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V.   Man and His Basic Human Needs
VI. Health and Illness
VII. Asepsis and Infection Control
VIII. Stress, Adaptation, Homeostasis
IX. Physiologic Responses to Stress and Illness
X.   Communication in Nursing
XI. The Nursing Process
XII. Assessing Health



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Information Overload
              Episodes of
              information
                overload



                                          Student’s
                                         information
                                         processing
                                           capacity

  Information Load




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Grassroots of Nursing:
N-U-R-S-I-N-G- L-E-A-D-E-R-S
 Florence Nightingale
  -first nursing scientist/ theorist for her work
  “Notes on Nursing: What It Is, and What It Is Not (1860/1969)”

 Clara Barton
  -organized the American Red Cross

 Lilian Wald
  -founder of Public Health Nursing.
  Henry Street Settlement and Visiting Nurse Service

 Lavinia Dock
  -Nursing leader, protested for women’s rights

 Margaret Sanger
  -Nurse activist, founder of Planned Parenthood
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Common Themes in Definition of Nursing

Nursing is caring.
Nursing is an art. (“SKILLS”)
Nursing is a science. (“THEORIES”)
Nursing is client-centered.
Nursing is holistic.
Nursing is adaptive.
Nursing is a helping profession.
Nursing is concerned with health promotion, disease
 prevention, and health restoration.


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NURSING as a science and an art.
 1. Lewis introducing the topic “research” in class.
 2. Jumbo inserting IV catheter.
 3. Gerald washed his hands first before he
  introduced the NGT because he wanted to maintain
  aseptic technique.
 4. Noel could easily recall all the definitions of
  nursing.
 5. Regina promptly performed CPR after assessing
  that the patient doesn’t have a pulse and is not
  breathing.

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Nursing as a caring profession
Five Processes of Caring:
1. Knowing
2. Being with
3. Doing for
4. Enabling
5. Maintaining Belief

Caring includes the ffg. factors:
 Providing presence- “eye contact”’
 Comforting-             “touch”
 Listening-              “attention”
 Knowing the client-     “uniqueness’
 Spiritual caring-       “transpersonally”
 Family Care-            “participants”
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Is Nursing a vocation or a profession?

Characteristics of a Profession

1.   Education
2.   Theory
3.   Service
4.   Autonomy
5.   Code of Ethics
6.   Caring
     -the most unique characteristic of nursing

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“The Nurse is basically a good person”.

Four Virtues from the Practice of Charity
1. Justice -    being righteous
2. Prudence- cautious
3. Fortitude-   support
4. Temperance- sacrifice

Exercise:
____1. The nurse encourages the patient to verbalize.
____2. The nurse respects the autonomy of the patient.
____3. The nurse should stand even in unfavorable
          conditions.
____4. Before giving the medication, the nurse verified
          the dosage to the fellow nurse.
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               Attributes of Character
Honesty    Tolerance Reliability          Resourcefulness
Loyalty    Judgment Motivation            Moderation

     1. Thinking of other alternatives.
     2. Your boss has put a lot of trust in you because of this
             attribute.
     3. You’re protecting the name of the hospital you’re
             working with.
     4. You have to control your temper when undesirable
             events happen.
     5. Informing the client about the medication you’re
             about to give.
     6. Questioning an unclear doctor’s order.
     7. Recognizing others because of a job well done.
     8. Delaying your schedule of watching a movie because of
             an exam.
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Roles and Functions of a Professional Nurse
Care Provider               Leader               Counselor
Communicator                Manager              Collaborator
Teacher                     Researcher           Change Agent
Client Advocate             Case Manager

Reporting abnormal VS to the doctor
Continuing education to improve current practice
Informing the patient about his rights
Providing the client’s needs
Gives health teachings
Plans, gives directions, develops staff, monitors operations
Interpersonal influence to promote the health of the client
Helps the patient to cope with stressful emotional problems
Initiates changes and assists the client to have modifications in lifestyle to
 promote health
You meticulously wrote your SOAPIE method in the chart to inform others
 about the care you delivered to the patient.
Coordinates the activities you planned for CVA patients to a nutritionist,
 physical therapist and speech therapist to properly manage the patient’s
 condition
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 Types of Nursing Interventions:

Independent      Dependent         Interdependent

  1. The nurse providing 2-3LPM of O2.
  2. Steam Inhalation
  3. Oral Inhaler
  4. Chest Physiotherapy
  5. Purse-lip breathing
  6. Deep Breathing Exercises
  7. Cough Excercises
  8. Health education
  9. Calories needed by the client
  10. For Chest X-ray

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        Nursing Care Delivery Models
                     * to develop BEDSIDE NURSING
Total Patient Care
                     and improve professional
                     relationships b/n staff.
Functional Nursing   *RN is responsible for all aspects
                     of care to one or more clients.
  Team Nursing       *RN is the leader together with
                     nursing assistants and health
                     aides.
 Primary Nursing
                     *Coordinates and links health
                     care services to clients and their
Case Management      families
                     *Division of tasks, one nurse
                     assumes a responsibility apart
                     from others’ task
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             Nursing Theorists
Florence Nightingale   -Environmental Theory
Virginia Henderson     -Assist the client to gain
                       independence; 14 Basic Needs
Faye Abdellah          -21 Nursing Problems
Dorothy Johnson        -Behavioral System Model
Imogene King           -Goal Attainment Theory
Madeleine Leininger    -Transcultural Nursing
Myra Levin             -Four Conservational Theory
Betty Neuman           -Health Care System Model
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Cont…

Dorothea Orem      -Self-Care Deficit Theory
Hildegard Peplau   -Interpersonal Model
Martha Rogers      -Science of Unitary Human Beings
Sister Callista Roy -Adaptation Model
Lydia Hall         -Core, Care and Cure
Ida Jean Orlando   -Dynamic Nurse-Patient Relationship
Jean Watson        -Human Caring Model
Joyce Travelbee    -Interpersonal Aspects of Nursing Model
Ernestine Weidenbach-Clinical Nursing- A Helping Art Model



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Definition of Terms

MAN -is a biopsychosocial and spiritual being who is in
 constant contact with the environment. (Roy)

LEVELS OF CLIENTELE
   I. Individuals
   II. Families
   III. Social Group
   IV. Communities

HEALTH- a complete state of physical, mental,
 emotional and social being of a person and not just
 merely the absence of disease or infirmity. (World
 Health Organization, 1947)
       -From an Old English “heal” which means “whole”

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A Simple Paradigm

MAN       NURSING PROCESS          HEALTH




Individuals     ADPIE        END GOAL
Families
Social Groups
Communities


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MAN’s Basic Needs:


                       Self-
                   Actualization

                   Self-Esteem


             Love and Belongingness


                Safety and Security


                    Physiologic


        Abraham Maslow’s Hierarchy of Needs
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Identify the following according to
Maslow’s Hierarchy of Needs:

1. Self-respect
2. The need to be fulfilled
3. Rest and sleep
4. Elimination
5. The need for shelter
6. The need to care and be cared for
7. Self-worth
8. Psychological safety
9. Oxygen
10. Spiritual fulfillment
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              Models of Health
CLINICAL/MEDICAL MODEL

ROLE PERFORMANCE MODEL

ADAPTIVE MODEL (Sister Callista Roy)

EUDOMONISTIC MODEL

AGENT-HOST-ENVIRONMENT MODEL
(Leavell & Clark)

HEALTH-ILLNESS CONTINUUM
(McCann/Flynn & Heffron, 1984)

DUNN’S HIGH- LEVEL WELLNESS GRID (1959)
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    A. Clinical Model
 hlt practitioners used this model if their focus is
  on own relief of s/sx of dse & eliminate pain &
  malfunction.
 If there is less or absence of s/sx & pain 
  health is restored.

  B. Role Performance Model
 People who can fulfil their roles are healthy
  even if they appear clinically ill.
 Assumes in this model that “sickness” is the
  inability to perform one’s work.
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    C. ADAPTIVE MODEL
    (Sister Callista Roy)
   Adaptation – it is the focus of this model
   Belief: health is a creative process. Therefore,
    disease is a failure in adaptation. (maladaptation)
   Treatment of a person: aim is to restore person by
    ability of a person to adapt, i.e. “to cope”

    D. EUDOMONISTIC MODEL
   it views that in this model, the highest aspiration of
    people is fulfilment & complete development which
    is “actualization”
   Illness is viewed as a condition that prevents self-
    actualization
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E. AGENT-HOST-ENVIRONMENT MODEL
  (Leavell & Clark)
 also known as Ecologic Model; model was
  derived due to the community health work of
  authors
 model is used in predicting illness rather than in
  promoting wellness

                  Env’t

                          Host

            Agent

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 F. HEALTH-ILLNESS CONTINUUM
 (McCann/Flynn & Heffron, 1984)


                               Wellness Model
                                                                
Premature                                                                      High-Level
Death       Disability   Symptoms   Signs   Awareness   Education Growth
                                                                               Wellness


              Treatment Model




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G. DUNN’S HIGH- LEVEL WELLNESS GRID
 (1959)     Very favorable
                           environment

          C. Protected Poor             A. High- Level
          Hlt (in favourable             Wellness (in
         env’t) thru social &            favourable
         cultural institutions          environment)
Death
 Death
 Death                                                            Peak Wellness
                                                                  Peak Wellness
                                                                  Peak
                Poor Health
            D. D. Poor Health              B. Emergent
         (unfavourable environment)                              Wellness
            (unfavourable             High-Level Wellness
            environment)                (in unfavourable
                                          environment)

                                 Very
                             unfavorable                                 Health
                             environment
                                                                         Axis



                                                            Environmental
                                                            Axis
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Classification of Diseases
         According to Etiology

1. Hereditary             •DM
2. Congenital       •Alopecia after
3. Idiopathic       chemotherapy
4. Metabolic        •Osteoarthritis
5. Deficiency      •Uterine cancer
                       •Fracture
6. Neoplastic
                     •Skin Allergy
7. Degenerative
                    •Osteomalacia
8. Iatrogenic     •Hyperthyroidism
9. Traumatic         •Cleft Palate
10. Allergic             •HPN
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According to Duration or Onset

1. Acute Illness-       short duration
2. Chronic Illness-     longer than 6 mos.
          *remission    -asymptomatic but with dse.
          *exacerbation -becomes active again with
                        pronounced s/sx


 Three Levels of Prevention
 1. Primary-   health promotion and protection
 2. Secondary- early detection, diagnosis, screening
 3. Tertiary-  rehabilitation and adaptation


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Identify the type of prevention:

1. Quit Smoking
2. Wear hazard devices
3. Physical Therapy after CVA
4. Attending Self-Management education for DM pts.
5. Have annual physical examination
6. Sputum Exam for TB
7. Weighing the children
8. Taking adequate fluids
9. Complete immunization
10. Speech therapy after laryngectomy


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       Activities to Promote Health
           and Prevent Illness
1. Have regular (yearly) PE
            -Papsmear and BSE
2. Men: regular testicular examination
3. Annual dental examination
4. Exercise regularly at least 3x per week for 30 mins.
5. Do not smoke.
6. Avoid alcohol
7. Reduce fat and increase fiber in the diet.
8. Sleep regularly 7 to 8 hours/ night
9. Eat breakfast
10. Maintain an ideal body weight
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  Health and Illness

ASEPSIS and INFECTION
      CONTROL


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Infection-          invasion by MOs
Asepsis-            free from infection
Medical Asepsis-    clean technique
Surgical Asepsis-   sterile technique
Sepsis-             presence of infection
Carrier-            asymptomatic but with infection
Reservoir-          habitat
Resident flora-     normally live on skin
Sterilization-      all MOs are destroyed
Disinfectant-       remove pathogens on
                     inanimate objects
Antiseptic-         remove pathogens on persons
                     but doesn’t necessarily destroy
Bactericidal-       destroys bacteria
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Cont…
Communicable Dse.- infectious agent that can be
                     transmitted (direct, indirect,
                     vehicle, airborne)
Pathogen-           a disease-producing
                     microorganisms
Pathogenicity-      ability to cause a disease
Virulence-          the vigor of MOs in which they
                     can grow and multiply
Nosocomial infection-        hospital-acquired
 infection
Isolation-          separation of persons with
                     communicable disease
Etiology-           the study of the causes
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Stages of Infectious Process

1.   Incubation period          time
2.   Prodromal period           non-specific to specific
3.   Illness period             s/sx
4.   Convalescent period        recovery

Chain of infection

Agent            Reservoir             Portal of exit


HOST          Portal of entry                 Mode of
                                        transmission
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             Mode of Transmission
1. Contact
   a. direct     body to body (bathing, feeding etc.)
   b. indirect   exposure (contaminated objects)
2. Droplet (<3ft.)      secretions
3. Airborne (>3ft)      fine particles suspended in air
4. Vectorborne biologic and mechanical
5. Vehicle       mediator (food, water, milk, blood etc)



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            Types of Immunization

          ACTIVE                PASSIVE




Natural               Natural

               Artificial           Artificial


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What type of immunity?
1.   Recovery from mumps
2.   Colostrum
3.   Tetanus Immuniglobulin
4.   Tetanus Toxoid
5.   OPV
6.   Recovery from Chickenpox

            2 Types of Disinfection:
            a. Concurrent
            b. Terminal
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Handwashing- is the single most important
 infection control practice.

Soap, water and alcohol are being used.
Wash hands before and after every client care
 contact.
It would be effective with adequate friction.
Medical asepsis is done b holding hands lower than
 the elbows.
Apply friction for 15 to 30 seconds on each hand.
Clean under fingernails.
Ideally, turn off the faucet with clean paper towel.


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       Health and Illness

      Stress, Adaptation,
          Homeostasis

“Stress is always a part of the fabric of daily life”.
                                     -hans selye
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Adaptation
- the adjustments that a person make in different
  situations.

Types:
1. General Adaptation Syndrome (GAS)
     a. Stage of Alarm
     b. Stage of Resistance
     c. Stage of Exhaustion
2. Local Adaptation Syndrome (LAS)
   -man may respond to stress through a particular
   body part or organ.
   -examples: inflammation, backache, headache,
   diarrhea
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Homeostasis -“homeodynamic”, because of
                  constant change
                 -a state of stability or equilibrium

Sympatho-Adreno-Medullary Responses (SAMR)

                    Stressors:
                   Physical injury,
                  dehydration etc.


                  Hypothalamus



                  Adrenal Medullla
          (Norepinephrine and epinephrine)

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Inflammatory Response
• Rubor
• Calor
• Tumor
• Dolor
• Loss of Function

Exudates
◦ Serous
◦ Serosanguinous
◦ Sanguinous
◦ Purulent
◦ Mucoid

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Healing may be classified as:
a. Primary/ First Intention
   - clean cut wound
b. Second Intention
   - wound is extensive and there is a great amount of
   tissue loss.
c. Tertiary/Third Intention
   - delayed surgical closure of infected wound

Other responses to tissue injury:
1. Necrosis    death of tissues
2. Hypertrophy increase in cell size
3. Hyperplasia increase in cell number
4. Metaplasia replacement of one mature cell type
               with another mature cell type
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      Nursing Interventions for
      Clients with Inflammation
1. Promote rest
2. Reduce swelling
        Position: Elevate part
        Cold and warm compress
3. Relieve pain
4. Increase hydration
5. Adequate nutrition: high calorie, CHON, Vit. C
6. Pharmacotherapy
       Analgesic/ antipyretic: Acetaminophen,
       Paracetamol, Aspirin, Mefenamic acid
       NSAIDS, Steroids
       Antimicrobials
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    Therapeutic Relationship
     -directed towards helping a patient heal, physically
      and emotionally.
     -a professional relationship between a nurse,
      physician or therapist and a client.
     -Focused on helping the client solve problems and
      achieve health-related goals.
     -a means for smoothly implementing the five
      processes of the nursing process.
     -TRUST is the foundation of a positive nurse-client
      relationship.
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Phases of Therapeutic Nurse-Patient Relationship
I. Pre-interaction
     -review medical records
     -client’s history
     -speak with other HCP
II. Orientation
     -perform assessment
     -formulate patient outcomes
     -plan interventions
     -ESTABLISH RAPPORT AND TRUST
III. Working Phase
     -establish a contract
     -set limits
     -discuss the time frame of your relationship
IV. Termination
     -evaluate the pt.’s progress
     -review areas that need improvement
     -discuss any feelings (positive or negative) during
     termination                            http://youngnurses2012.blogspot.com/
Stress- is an essential aspect of existence and has
 always been of human experience; it is something that
 every one has to cope.


Stress Management
    1. Supporting protective mechanism
          -rest, massage, relief of pain
    2. Exploration of feelings
    3. Facilitating problem solving
    4. Regular pattern of exercise
    5. Relaxation techniques
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      Advanced Stress Management
        and Relaxation Techniques
Autogenic training
Visualization and Imagery
Affirmation
Meditation
Therapeutic touch
Massage
Yoga
Music therapy
Anti-anxiety medications

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          Communication Techniques
1. Use silence.
2. Accepting.
3. Giving recognition.
4. Offering self.
5. Giving broad opening.
6. Offering general leads.
7. Making observations
8. Encouraging comparison
9. Restating
10. Focusing
11. Reflecting
12. Exploring
13. Giving information
14. Seeking clarification
15. Presenting reality
16. Asking direct questions
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What type of coping mechanism was used?
1. The adolescent decides to take up nursing because she
   greatly admires her mother who is a nurse.
2. The girl who is not as beautiful as her sisters, studies very hard
   and she achieves high grades.
3. The teacher who really wants to be the principal of the school
   states that she wouldn’t take the position if it were offered
   because it is a lot of work and no commensurate
   compensation.
4. The father shouts at his children as he arrives home because
   he was reprimanded by his boss at work.
5. The six year old child thumbsucks as he is confined in the
   hospital.
6. The nursing student vomits after a very difficult situation.
7. The client with cancer consults other physicians because he
   refuses to accept his diagnosis.
8. The student who hates her teacher, frequently tells the teacher
   that she admires her teaching.
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    Documenting and Reporting
Documenting- serves a permanent record.
Reporting- when two or more people share information
            about the client care, either face to face or
            by telephone.
Purposes:
1. Communication
2. Legal Documentation
3. Research
4. Statistics
5. Education
6. Audit and Quality Assurance
7. Planning Client Care
8. Reimbursement
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Types of Records
A. Source-Oriented Medical Record
   (Traditional)
- Each department makes notes on the chart.

Five Basic Components
1. Admission Sheet
2. Physician’s Order Sheet
3. Medical History
4. Nurses’ Notes
5. Special Records and Reports
   (referrals, x-ray, VS, I&O)
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B. Problem-Oriented Medical Record
 (POMR)
-integrates all data about the problem gathered by the
  HCP.
-records are recorded and arranged according to the
  source of information.

Four Basic Components
1.   Database-    all initial information
2.   Problem List
3.   Plan of care
4.   Progress notes
     (SOAPIE, Flow Sheets, Discharge notes)
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Kardex
       -makes information readily accessible to all
       members of the HCP.
       -series of flip cards
       -tool for change-of-shift-report (use a pencil only)

Data included in KARDEX:
•   Personal data
•   Basic needs
•   Allergies
•   Diagnostic tests
•   Nursing procedures
•   Medications and IV therapy, BT
•   Treatments like oxygen supply, steam inhalation,
    suctioning, change of dressing, mechanical ventilation
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Characteristics of a Good Recording
1. Brevity (concise and complete)
2. Use of ink/ permanence
3. Accuracy (chart objective facts)
           Incorrect: Ate with poor appetite.
           Correct: Ate 50% of the food served.
           Incorrect: Depressed
           Correct: Seen crying
    *Place quotation marks if it’s a client complain
    *Objective data (VS, I&O etc.)
    *Describe behaviors rather than feelings
    *Refusal of medications and treatments-
    documented
4. Appropriateness                       http://youngnurses2012.blogspot.com/
Cont…

5. Completeness and chronology
    *Notes should appear on succeeding line.
    *Date and time are included.
    *Avoid time changes in the text of other nurses.
    *Avoid double charting.
    *Avoid squeezing an information into a space.

    The following information should be charted:
    1. Physician’s visits
    2. Medication- immediately
    3. Treatment- immediately

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Cont…

6. Use of Standard Terminology (include grammar)
7. Signed (Bernard M. Lapuz, SN/ Bernard M. Lapuz, RN)
8. In case of ERROR
  -draw a horizontal line, write “ERROR”, initials/ signature
9. Confidentiality
10. Legal Awareness
11. Legible
12. Do not use the word “patient” or “pt.”; the chart belongs to
  the patient.
13. A horizontal line drawn to fill up a partial line
  -to prevent others from adding information
e.g.                                   Bernard M. Lapuz, RN


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Types of Reporting
1. Change-of-Shift Report
    -endorsement (KARDEX)
2. Telephone Reports
    a. when the call was made
    b. who made the report
    c. who was called
    d. to whom information was given
    e. what information was given
    f. what information was received
3. Telephone orders
    *ONLY RNs may receive telephone orders
    *The order must be verified; have a witness if possible
    *Should be countersigned by the physician within 24
    hours
4. Transfer reports- when transferring a pt. to another unit.
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Give the meaning of commonly used abbreviations…
a.c         OD        DOMAINS of LEARNING
ADL         OU
Ax.         OS        a. Cognitive
BID         QID       (Knowledge)
BMR         AD
BP          AU
c.c.        AS        b. Affective
                      (Emotions, Feelings and Interests)
Cap         prn
Gtt         s.s.
h.S         s.c       c. Psychomotor
IM          stat      (Skills)
IV          TID
Mcgtt       Od
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THE NURSING PROCESS




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Assessing Health

 a. Head-to-Toe Framework
  General: General Health State, VS, weight,
    nutritional status
  Head, hair, scalp, eyes, ears, oral cavity, cranial
    nerves
  Neck
  Chest
  Abdomen
  Extremities
  Genitals
  Rectum
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Body Systems Framework
Respiratory
Cardiovascular
Musculoskeletal
Gastrointestinal
Integumentary
Endocrine
Genitourinary
Reproductive
Neurologicc
Sensory
Psychosocial
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1. Body Temperature
   -balance between heat produced and heat loss in
   the body.

Types:
a. Core- deep tissues (oral and rectal)
b. Surface- skin and subQ (axilla)

Heat regulating center- HYPOTHALAMUS

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Factors affecting body’s heat:
a. Basal Metabolic rate
    *younger-higher the BMR
    *older- lower the BMR
b. Muscle Activity- exercises increases BMR
c. Thyroxine output- increases BMR
d. Catecholamines- increases BMR
e. Fever

Factors affecting temperature:
1. Age
2. Diurnal variation-     highest from 8-12MN
                          lowest from 4-6AM
3. Exercise
4. Hormones
5. Stress- Sympathetic stimulation     http://youngnurses2012.blogspot.com/
     PROCESSES in HEAT LOSS
        Radiation           Convection
        Conduction          Evaporation


1. Application of moist wash-cloth over the skin
2. Exposure of skin towards electric fan
3. Continuous vaporization of moisture from the skin,
   oral mucous, respiratory tract
4. It feels warm in a crowded area.

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Alterations in Body Temperature
1. Pyrexia/ Hyperthermia- above normal
2. Hyperpyrexia- very high, >41C
3. Hypothermia- low temp.


Types of Fever
1. Intermittent Fever- fluctuates to normal and
                       abnormal within 24 hours
2. Remittent Fever- fluctuates within 24 hours
                       of abnormal temperature
3. Relapsing Fever- fluctuates to normal and
                       abnormal few days in between
4. Constant Fever-     remains very high
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           Most accessible and       c/I: Oral Lesions,
           convenient to use         dyspnea, cough,
 ORAL                                seizure, chills,
           2-3 minutes               unconscious


           Safest and most non-      C/I: none
           invasive method
 AXILLA
           10 minutes


           Fastest                   C/I: Mastoiditis and ear
                                     infection
TYMPANIC   2-3 seconds


           Most accurate             C/I: Hemmohoidectomy,
           Assume lateral position   diarrhea, anal fissures,
                                     quadriplegic clients
RECTAL
           2 minutes                 http://youngnurses2012.blogspot.com/
Pulse
1. Rate: Newborn 120-180bpm
           Adult       60-100bpm
    *Tachycardia- above 100bpm
    *Bradycardia- below 60bpm
2. Rhythm- the pattern and intervals of beats.
    *Dysrhythmia- irregular rhythm
3. Volume- the strength of the pulse.
    *Normal pulse can be felt with moderate pressure
    *Full/ bounding- great pressure
    *Thready pulse- weak
4. Presence/ ansence of bilateral equality
    * radial, ulnar, femoral etc.
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Pulse Sites
1.   Temporal
2.   Carotid
3.   Apical
4.   Brachial
5.   Radial
6.   Femoral
7.   Posterior tibial
8.   Popliteal
9.   Pedal (Dorsalis Pedis)



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Respiration
-the act of breathing.

Three processes:
1. Ventilation – movement of gases in and out of lungs
2. Diffusion – exchange of gases
3. Pefusion – movement of blood for transport

Two types:
a. Costal (thoracic)- movement of chest
b. Diaphragmatic (abdominal)- movement of abdomen

Respiratory centers
a. Medulla Oblongata- primary respiratory center
b. Pons
   *Pneumotaxic- rhythmic quality of breathing
   *Apneustic- deep prolonged breathing http://youngnurses2012.blogspot.com/
Assessing Respiration
Rate: 12-20 RR/min
Depth- observe for movement of chest
Rhythm- observe for regularity of exhalation and inhalation
Quality- respiratory effort and sound of breathing

Terminologies:
Eupnea- normal respiration
Tachypnea- >20RR/ min
Bradypnea- <12RR/ min
Hyperventilation- Deep, rapid respiration (alkalosis)
Hypoventilation- slow, shallow respiration (acidosis)
Dyspnea- DOB
Orthopnea- ability to breath only in upright position
Apnea- absence of respirations
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Blood Pressure
- The pressure exerted by blood against the walls of the
  arteries

*Systolic Pressure- pressure of blood as a result of
 contraction of the ventricles
*Diastolic Pressure- pressure when ventricles are
 at rest.
*Pulse Pressure- difference between the systolic
 and diastolic pressures (30-40mmHg)
*Hypertension->140/90mmHg
*Hypotension- <90/60mmHg

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Determinants of BP
1.   Blood Volume
2.   Peripheral Resistance (dialte and constrict)
3.   Elasticity or compliance of blood vessels
4.   Blood Viscosity

Assessing BP
1.   Allow to rest.
2.   Sitting or supine
3.   Left arm is preferred over the right.
4.   Snugly fit
5.   Inflate
6.   Deflate- “Korotkoff sound’
7.   If Mercurial, read lower meniscus
8.   Prevent “Error of Parallax”
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Nursing Health History
-gathered through interview

Components of Nursing Health History

1. Biographic Data
2. Chief Complaint
3. History of Present Illness
4. Past Health History
5. Family History of Illness
6. Review of Systems
7. Lifestyle
8. Social data
9. Psychologic data
10. Patterns of health care
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Physical Health Examination
 -head to toes
 -determine the mental status and LOC
 -protect the client’s privacy during the examination
 -prepares the needed articles and equipment


Modes of Examination
1.   Inspection     -sight
2.   Palpation      -touch
3.   Percussion     -tapping
4.   Auscultation   -stethoscope (hear)



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Positions

1.   Dorsal recumbent
2.   Dorsal/ supine
3.   Sitting
4.   Fowler’s- semi (45 degrees) and high (90 degrees)
5.   Lithotomy
6.   Lateral
7.   Sim’s/ Semi-prone position
8.   Prone


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Pointers:
1. Sequence of assessment in abdomen?
    IAPERPAL
2. Sequence of quadrants?
    RLQ, RUQ, LUQ, LLQ
3. Best position when examining the chest?
    Sitting
4. Position when examining the back?
    Standing
5. How do we check for neck lymphadenopathy?
    Stand behind the client and palpate the neck
6. If you’ll use vaginal instrument, pour warm water
    first to ensure comfort.

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Supplemental Data
a. Urine
b. Stool
c. Sputum
d. Blood
e. Body secretions

Urine specimen
1. Clean-catch, mid-stream specimen for routine
   urinalysis, C&S
- Best time to collect is AM (concentrated)
- Discard the first flow urine.
- Sterile container. Wash first before getting the
   specimen.
- 30-50ml
- Send to the laboratory immediately http://youngnurses2012.blogspot.com/
2. 24-hour urine specimen
-Discard first voided urine
- Collect all specimen thereafter, until the same day the
  ffg. day.
- Soak the specimen in a container with ice.

3. Catheterized urine specimen
-clamp the catheter for 30 mins. to 1hour.
-cleanse the drainage port of the two-way FC
-Use sterile needle and syringe to aspirate from the
  drainage port.
-don’t collect urine from the urinary drainage bag.


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Stool
a. Routine fecalysis –determine ova/ parasites
b. Stool Culture- etiologic agents
c. Guaiac Stool Exam/ Occult Blood- bleeding

Test of Glucose in the urine
*Benedict’s Test
-collect specimen before meals
-Heat 5ml of Benedict’s solution in a test tube
-Add 8-10 drops of urine
Interpretation:
    Blue -         (-)
    Green -        +
    Yellow -       ++
    Orange -       +++
    Red -          ++++
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Test for Albumin in the urine
*Heat and Acetic Acid Test
-collect urine specimen before meals
-imaginary divide the test tube into three parts
-fill the 2/3 part with urine, heat the test tube
-add 1/3 acetic acid or just few drops, don’t boil
-CLOUDINESS indicates albuminuria


Sputum Specimen:
1. Sputum Culture and Sensitivity Test
2. Acid-fast bacilli (AFB) staining (3 consecutive
    mornings)

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