funda-review-notes.doc

8/16/2019 Funda-Review-Notes.doc

1/35

FUNDAMENTALS OF NURSING

Outline of review for the boards

History of Nursing- World and Philippines

The Nursing theories

Concepts of Health and Illness

Human asic Needs!tress and "daptation

ASSESSING HEALTH STATUS

VITAL SIGNS

PHYSICAL ASSESSMENT

CLIENT CARE

ASEPSIS

SAFETY

HYGIENE

MEDICATIONS

SKIN INTEGRITY

TERMINAL CARE

HEATH PROMOTION AND DISEASE PREVENTION

ACTIVITY and EXERCISE

REST and SLEEP

PAIN management

NUTRITION

FECAL ELIMINATION

URINARY ELIMINATION

OXYGENATION

CIRCULATION

Flud! and Ele"t#$l%te!

History of Nursing

Intuitive Nursing

Arenti!e Nursing

D"r# Perio$ of Nursing

E$u!"te$ Nursing

Conte%or"ry Nursing

Intuitive Nursing Pri%itive "n$ unt"ug&t

Co$e of HAMMURA'I

Moses( Fat&e# $' Santat$n

Hio!r"tes( Deve)oe$ st"n$"r$s for !)ient !"re* %e$i!") st"n$"r$s "n$ nee$ for nurses

E$u!"te$ Nursing

F)oren!e Nig&ting")e( +orn M"y ,-* ,.-/ in F)oren!e ITALY

Tr"ine$0 Ger%"ny "t 1"isers2ert& S!&oo)


2/35

Foun$e$ t&e St3 T&o%"s S!&oo) of Nursing in Eng)"n$

– Te"!&ers "re $evote$ !)ini!") instru!tors so)e)y for te"!&ing

– T&e first nurse to e4ert o)iti!") ressure on govern%ent

Nursing in t&e PHILIPPINES

First S!&oo) of Nursing5 ILOILO MISSION &osit") s!&oo) of nursing

An"st"!i" Giron(Tu"s5 Foun$er of t&e PNA

R$!a#$ Delgad$( '#!t PNA )#e!dent

NURSING THEORIES

T&eories in Nursing

Four !on!ets Centr") to Nursing0

P(E(H(N

Pe#!$n

En*#$nment

Healt&

Nu#!ng

ENVIRONMENTAL THEOR6

– Re)"te n"ture 2it& t&e +ir$( Ng&tngale

– +T&e a"t $' utl,ng t&e en*#$nment $' t&e )atent t$ a!!!t &m n &! #e"$*e#%-

INTER(PERSONAL RELATIONS Mo$e)

– Re%e%+er 7 PEP. tal/ – Hldega#d PEPLAU

T&er"euti! re)"tions&i0

– O#entat$n( a!!!t "lent t$ 0unde#!tand. )#$1lem– Ident'"at$n( Clent de)enden"e2 nde and nte# &e #e"$gn,e! &! )#$1lem! n t&!

)&a!e

– E3)l$tat$n4E3)l$#at$n( De#*e! 0'ull *alue. n5e3)l$t66– Re!$lut$n( $ld and ne7 g$al! )ut a!de

N"ture of Nursing( Definition of Nursing

– T&e %e"ning of Nursing is 7VIRGIN8

– Re!")) t&e ,9 nee$s:::::

– Asso!i"te ,9 virgin HENS

– V#gna HENDERSON

– S&e +e)ieves t&"t !)ients nee$ to e4ress t&eir e%otions* re%"in in$een$ent*

"utono%ous

– T&ey %ust 2or# in su!& " 2"y t&"t t&ey fee) " sense of "!!o%)is&%ent

-, nursing ro+)e%s

7F"i$ -,8

F"ye A+$e))"&

GENERAL THEOR6 OF NURSING( SELF( CARE

– Asso!i"te 7Se)f !"re 7 to 7ORAL !"re8 or 7er ore%8

– Dorot&e" OREM

– 89 :HOLLY "$m)en!at$#%( una1le t$ "$nt#$l – ;9 PARTLY "$m)en!at$#%( una1le t$ )e#'$#m SOME !el' "a#e

–


3/35

A!!$"ate 1e&a*$# 7t& >$&n ?n >$&n and Ma#!&a@

0/a%a >OHN?!$n@ mag!um/a) /a 0

Dorot&y ;o&nson

Conserv"tion T&eory

7t&e Divine is Conserv"tive8

0Le*n. le*ne2 d*ne

GOAL ATTAINMENT

Re!")) t&"t t&e 1ING of t&e )"n$ &"s " GOAL to "tt"in for &is #ing$o%

– IMOGENE 1ING:

– Her t&eory is ")i!"+)e to t&e !&i)$ +e"ring 2o%en "n$ t&eir f"%i)ies

UNITAR6 'EING0 M"n "s t&e CENTRAL Fo!us

7Roger * Roger* )et us unite our M"n in t&e !enter of t&e +"tt)efie)$8

T&e 2&o)e is gre"ter t&"n its "rts

M"rt&" ROGERS

S&e +e)ieves in t&e use of t&e rin!i)es of NON CONTACT t&er"euti! tou!&

HEALTH CARE S6STEMS %o$e) 'etty NEUMAN

St#e!!e!2 #ea"t$n! t$ !t#e!! and ada)tat$n t$ !t#e!!$#!

A'te# $*e#"$mng t&e !t#e!!e! %$u 7ll 1e"$me a 0NE:5 Man.

Int#a)e#!$nal !t#e!!$#( llne!!

E3t#a)e#!$nal !t#e!!$#!( 'nan"al "$n"e#n!2 "$mmunt% #e!$u#"e!

Inte#)e#!$nal !t#e!!$#( un#eal!t" #$le e3)e"tat$n!

ADAPTATION MODEL

In$ivi$u") is " 'IOPS6CHOSOCIAL ADAPTIVE syste% 2it& inut "n$ outut

7"sso!i"te t&is 2it& " Nun8

SISTER RO65 n"g " "$ot ng %g" +"t"

Her t&eory suorts t&e unity +et2een t&e !)ient "n$ Go$

CULTURAL CARE DIVERSIT6

Tr"ns!u)tur") Nursing

M"$e)eine LEININGER

Nursing Pro!ess t&eory "n$ CARE* CORE "n$ CURE

T&e nurse 2&o !oine$ t&e 2or$ nursing ro!ess "n$ st"te$ 7 I !"re* I !ore "n$ I !ure8

H")) of F"%e "2"r$:::

L6DIA HALL

D6NAMIC NURSE(PATIENT Re)"tions&i

Asso!i"te $yn"%i! "!tion to t&e te"% of ORLANDO

I$" ;e"n ORLANDO::: Go Or)"n$o* t&e $yn"%i! te"%:::::

HUMAN 'ECOMING THEOR6

– Re%e%+er to +e!o%e " es t&"t !)ients "re t&e AUTHORIT6 figures "n$ $e!ision

%"#ers for t&eir erson") &e")t&


4/35

HUMAN CARING THEOR6


5/35

– He")t& is "+sen!e of $ise"se

ROLE PERFORMANCE

– He")t& is "+i)ity to fu)fi)) so!iet") fun!tions

ADAPTIVE

– He"t& is " !re"tive ro!ess of "$"t"tion

EUDEMONISTIC

– He")t& is " !on$ition of se)f("!tu")i>"tion

ECOLOGIC

– He")t& is inter"!tion of t&ree e)e%ents0

– Agent

– Host

– Environ%ent

He")t&(I))ness Continu"

#unn

Travis

He")t& T&eories

Dunn

– 7d$$n2 dt$2 dne and d#e.

– Four u"$r"nts

– HIGH )eve) e))ness is fun!tioning "t t&e 'EST ossi+)e )eve)

I))ness "n$ Dise"se

DISEASE

– A)ter"tion in +o$y fun!tions

ILLNESS

–A st"te of &ysi!")* so!i")* e%otion")* inte))e!tu")* $eve)o%ent") or siritu")fun!tioning is DIMINISHED

St"ges of I))ness0 S(A(M(D(R

!$%PTO% e&periences

– Client believe something is wrong "!!'%PTION of the sic( role

– )&cuse form wor( and family role %)#IC"* care contact

#)P)N#)NT C*I)NT role

+)CO,)+$ or +)H"I*IT"TION

HUMAN NEEDS

A+r"&"% M"s)o2=s Hier"r!&y of nee$s

Physiologic needs- o&ygen water food

!afety and security

*ove and belonginess

!elf esteem

!elf actuali.ation


6/35

!afety and security

– Physical safety– Psychological safety– !helter from harm

*ove and belonginess

–

Need to love– Need to belong– Need for affection

!elf esteem

– !elf-worth– !elf-identity

– !elf-respect– !elf-image

!elf actuali.ation

– !elf-fulfillment– !piritual fulfillmen

M"n "n$ His nee$s

M"n=s Nee$

Se)f(

A!tu")i>"ti

on

Se)f(Estee%

Love "n$ 'e)ongingness

S"fety "n$ Se!urity

P&ysio)ogi! Nee$s


7/35

Nee$ is so%et&ing $esir"+)e "n$ usefu)

Nee$s "re UNIVERSAL

Nee$s "re MET in d''e#ent :AYS

Nee$s "re inf)uen!e$ +y $ifferent FACTORS

Priorities %"y +e CHANGED

Nee$s %"y +e POSTPONED

Nee$s "re INTER5RELATED

Nee$ is so%et&ing $esir"+)e "n$ usefu)

Prioriti>"tion of nee$s %"t +e $i!t"te$ +y t&e !)ient=s er!etion

Nursing go") is t&is "re" is to0

– Meet t&e PH6SIOLOGICAL nee$s of t&e "tient

– Assess t&e "tients er!etion of &is ot&er nee$s

– E%)oy nursing Interventions "!!or$ing to t&e PERCEIVED NEEDS of t&e "tient

NOT of t&e nurse

Ev")u"tion P"r"%eters of nursing !"re

The nurse chec(s if the desired criteria dictated by patient/s needs are achieved

Chec( which interventions were helpful

+evise the plan as needed

M"n "!&ieves se)f("!tu")i>"tion

0'dan1

A !el'5a"tual,ed )e#!$n ! 1a!"all% a MENTALLY &ealt&% )e#!$n

And !el'5a"tual,at$n ! t&e e!!en"e $' mental Healt&

MAN AND NATURE OF NURSING

M"n

A 'io(Psy!&o(So!i")(Siritu") +eing

As " 'IOLOGIC "n$ SPIRITUAL 'EING

– Li#e ALL ot&er %"n

As " SOCIAL 'EING

– Li#e SOME ot&er %"n

As " PS6CHOLOGIC 'EING

– Li#e NO OTHER MAN

THE PRACTICE OF NURSING

Nursing Define$

"!t of uti)i>ing environ%ent of t&e "tient to "ssist &i% in &is re!overy8

CNA0 " $yn"%i!* !"ring* &e)ing re)"tions&i in 2&i!& t&e nurse "ssists t&e !)ient to "!&ieve

"n$ o+t"in oti%") &e")t&

Nursing Pr"!ti!e S!oe


8/35

Invo)ves four "re"s @1OIER

89 P#$m$tng &ealt& and 7ellne!!

-3 Preventing i))ness

B3 Restoring &e")t&

93 C"re of t&e $ying

Profession") Nursing in t&e P&i)

Person") "n$ rofession") u")ities

,3 Interest "n$ 2i))ingness to 2or# "n$ )e"rn 2it& in$ivi$u")s in " v"riety of settings

-3 "r% erson")ity "n$ !on!ern for eo)e

B3 Co%eten!e* initi"tive "n$ !""!ity to 2or#

Profession") 'e&"viors @Ven>on

C"ring +e&"viors

A1lt% t$ )#a"t"e legal2 ETHICO5m$#al2 !$"al #e!)$n!1lte!

Criti!") "n$ !re"tive t&in#ing

S#i)) in r"!ti!ing 1(S(A for ro%otion of &e")t&* revention of i))ness* restor"tion of &e")t&*

"))evi"tion of suffering "n$ "ssisting !)ients to f"!e $e"t& 2it& $ignity

T&e St"n$"r$ of Nursing Pr"!ti!e

T&e urose of st"n$"r$s of Nursing r"!ti!e is to $es!ri+e t&e resonsi+i)ities for 2&i!& nurses

"re "!!ount"+)e

Profession

An o!!u"tion* or !"))ing reuiring "$v"n!e$ tr"ining "n$ e4erien!e in so%e se!ifi! +o$y

of #no2)e$ge 2&i!& PROVIDES SERVICE t$ !$"et% or t&"t se!i") fie)$

Profession") Nurse

Is " erson 2&o &"s !o%)ete$ " +"si! nursing e$u!"tion rogr"% "n$ is )i!ense$ in &is&er

!ountry or st"te to r"!ti!e rofession") nursing

Profession") Go") of Nursing

As in$een$ent r"!titioners* nurses "re ri%"ri)y resonsi+)e for t&e ro%otion of

&e")t&2e))ness "n$ revention of i))ness

He")t& Pro%otion

He)ing eo)e $eve)o resour!es to %"int"in or en&an"e t&e# &ealt& and 7ell51eng

He")t& ro%otion rogr"%s

,3 Infor%"tion $isse%in"tion

-3 He")t& Ar"is")

B3 e))ness "ssess%ent rogr"%

TRANSCULTURAL NURSING

Cu)tur") !"re nursing

It is t&e rovision of nursing !"re "!ross !u)tur") +oun$"ries "n$ t"#es into "!!ount t&e

!onte4t in 2&i!& t&e !)ient )ives


9/35

It is rofession") nursing t&"t is !u)tur"))y sensitive* !u)tur"))y "rori"te* "n$ !u)tur"))y

!o%etent

T&e suggeste$ stes for !u)ture !"re "re0

,3 'e!o%e "2"re of one=s o2n !u)ture &erit"ge

-3 'e!o%e "2"re of t&e !)ient=s &erit"ge "n$ &e")t& tr"$ition

23 I$entify !)ient=s referen!e in &e")t& r"!ti!es* $iet* &ygiene* et!3 T&e!e 7ll a''e"t t&e# &ealt& )#a"t"e!93 For%u)"te " !u)ture !"re )"n

Prevention of i))ness

E%)oying "!tivities t&"t 2i)) &in$er t&e o!!urren!e of $ise"se

E40 Asesis te!&niues* iso)"tion

STRESS

Stress "n$ A$"t"tion

STRESS

– A !on$ition in 2&i!& t&e erson reson$s to !&"nges in t&e nor%") +")"n!e$ st"te

– Se)ye0 non se!ifi! resonse of t&e +o$y to "ny #in$ of $e%"n$ %"$e uon it

STRESSOR

– Any event or sti%u)us t&"t !"uses "n in$ivi$u") to e4erien!e stress

SOURCES OF STRESS

,3 Intern")

-3 E4tern")

B3 Deve)o%ent")

93 Situ"tion")

P&%!$l$g"al nd"at$#! $' !t#e!! S%m)at&et" #e!)$n!e Di)"te$ ui)s

Di"&oresis

T"!&y!"r$i"* t"!&yne"* H6PERTENSION* in!re"se$ +)oo$ f)o2 to t&e %us!)es

In!re"se$ +)oo$ !)otting

'ron!&o$i)"tion

S#in "))or

"ter retention* So$iu% retention

O)iguri"

Dry %out&* $e!re"se erist")sis

Hyerg)y!e%i"

%odels of !tress43 !TI%'*'! based models

43 +)!PON!) based models

43 T+"N!"CTION based models

!)*$)/! 5eneral "daptation TheoryA(R(E


10/35

ALARM sympathetic system is mobili.ed6

RESISTANCE adaptation ta(es place

EXHAUSTION 7 adaptation cannot be maintained

ANJIET6

CATEGOR6 %I*# %O#)+"T) !),)+) P"NIC

Perception andattention

Increasedarousal

Narrowed focus Inability to focus Distorted perception

Co%%uni!"tion In"#ea!ed

ue!t$nng

Voi!e tre%ors

Fo!us on

"rti!u)"r o+Ke!t

Diffi!u)t to

un$erst"n$

E"si)y $istr"!te$

Tre%+)ing

unre$i!t"+)e

resonse

VS !&"nges NONE S)ig&t In!re"se T"!&y!"r$i"*

Hyerventi)"tion

P")it"tion*

!&o#ing* !&est

"in

An4iety versus fe"r

ANJIET6 FEAR

!tate of mental uneasiness )motion of apprehension

!ource may not be identifiable !ource is identifiable

+elated to the future +elated to the present

,ague #efinite

+esult of psychologic or emotional conflict +esult of discrete physical or psychologicalentity definite and concrete events

VITAL SIGNS

,!

T

P

+


11/35

P

T)%P)+"T'+)

+eflects the balance between the heat produced and the heat lost from the body

CO+) T)%P+"T'+)7 deep tissues of body

Te%er"ture Monitoring

Oral- accessible and convenient+ectal- very accurate

"&illary- preferred for newborns

Tympanic- reflects core temperature

'o$y te%er"ture &"s " $iurn") v"ri"tion

POINT of Highest body temperature is )TW))N )m t$ 8; mdng&t

POINT of *owest body temperature is )TW))N am t$ am

Te%er"ture A)ter"tion

8),)+ P$+)9I" H$P)+TH)+%I"

43 Inte#mttent Periods of fever and normal temp

:3 Remttent 7 8ever fluctuates 'T above normal23 Rela)!ng 7 8ever for few days then normal for few days

;3 C$n!tant 7 "*W"$! above normal minimal fluctuation

He"t )oss

Me!&"nis% Des!rition

Con$u!tion Tr"nsfer of &e"t for% one o+Ke!t to "not&er +y $ire!t !ont"!t

Conve!tion Move%ent of "ir "n$ &e"t +y "ir !urrent

Ev"or"tion Loss of &e"t t&roug& ev"or"tion of 2"ters2e"t

R"$i"tion Tr"nsfer of &e"t fro% 2"r% o+Ke!ts to !oo) o+Ke!ts in t&e

for% of e)e!tro%"gneti! 2"ves

Pu)se

" wave of blood created by contraction of the left ventricle of the heart

Normal range7


12/35

– !ystolic pressure falls by more than 4> mmHg during INHALATION

Pu)sus ")tern"ns

– "lternating strong and wea( pulses

Resir"tory r"te

Normal range7 4: to :4 P%

+espiratory pattern

– Cheyne-!to(es– ?ussmaul– iot– "goral

')oo$ Pressure

%easure of the pressure e&erted by the blood as it flows though the arteries

!ystolic and #iastolic

"verage is 4:=@A= mmHg Ta(ing P

Width of the P bladder should be $' t&e "#"um'e#en"e

Identify the 8I,) phases of ?orot(off/s sounds

?4B systolic ?>Bdiastolic

Error of 'P re"$ing

,3 Too N"rro2 !uff

– F")se)y HIGH re"$ing

-3 Too 2i$e !uff

• F)"se)y LO re"$ing

NURSING FUNDAMENTALS IN RANDOM

8riends and )nemas

&"t is "n ENEMA?

– A so)ution intro$u!e$ into t&e re!tu% "n$ )"rge intestine for t&e uroses of0

– To re)ieve !onsti"tion

– To re)ieve f)"tu)en!e

– To "$%inister %e$i!"tion

– To ev"!u"te fe!es in $i"gnosti!s or surgery

Ene%" tyes

,3 C)e"nsing Ene%"5 inten$e$ to re%ove fe!es to revent es!"e $uring surgery* forvisu")i>"tion ro!e$ure "n$ !onsti"tion

Puroses To

,3 Prevent es!"e of fe!es $uring surgery

-3 Pre"re intestines for $i"gnosti!s "n$ surgery

B3 Re%ove fe!es in !onsti"tioni%"!tion

C"r%in"tive ene%"5 to e4e) f)"tus* /(./ %L of f)ui$s insti))e$

B3 Retention ene%"5 oi) or %e$i!"tion is insti))e$ to tre"t infe!tion


13/35

93 Return f)o2 ene%"5 ")so to e4e) f)"tus* ree"te$ ti%es

Ene%" So)utions

Hypertonic #raws water into the colon SE 7 +etention of sodium

Hypotonic #istends colon softens feces SE: 8 and ) imbalance water

into&ication

Isotonic #istends colon SE 7 possible sodium retention

!oap suds Irritates colon SE 7 %ay damage mucosa

Oil enema *ubricates feces

T&e Heig&t of t&e ENEMAS

#uring %O!T enemas 8or HI5H enema

No higher than 2= cm above rectum 'p to ;> cm above rectum

T&e TIME of t&e ENEMAS

Cleansing )nema 8or Oil retention enema

>-4= minutes 2= minutes

T&e Lengt& of t&e ENEMA tu+e insertion

• T&e #e"tal tu1e ! n!e#ted < t$ n"&e!

1VO

Intravenous Infusion7 4= gtts@min

lood Transfusion7 4= gtt@min @U$"n and := gtt@min @1o>ier

DIET ANOTHER DA6

Liui$ Diet Vs Soft $iet


14/35

Clear liuid 8ull liuid !oft diet

CoffeeTea

Carbonated drin(

ouillon

Clear fruit Duice Popsicle

Gelatin

Hard candy

Clear liuid P*'!7%il(@%il( prod

,egetable Duices

Cream butter

$ogurtPuddings

Custard

Ice cream and sherbet

"ll C* and 8* plus7%eat

,egetables

Fruits

reads and cereals Pureed foods

LEVELS OF PREVENTION

Pri%"ry Prevention E$u!"tion* E4er!ise* Diet "n$

Nutrition* I%%uni>"tion

Se!on$"ry Prevention P&ysi!") E4"%in"tion* P"=s s%e"r* 'SE* TSESutu% AF'* DRE

P#$*dng med"at$n and t#eatment

Terti"ry Prevention P&ysi!") t&er"y* Se)f(%onitoring of DM*

See!& t&er"y

Leve)s of Prevention

PRIMAR6 LEVEL OF PREVENTION

,3 F"%i)y P)"nning "n$ %"rri"ge !ounse)ing

SECONDAR6 LEVEL OF PREVENTION

,3 ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHEC1(UPS

-3 Assessing gro2t& "n$ $eve)o%ent of !&i)$ren for nutrition") ev")u"tion

TERTIAR6 LEVEL OF PREVENTION

Te"!&ing " !)ient 2it& $i"+etes se)f(%onitoring of g)u!ose )eve)

ASEPSIS CONCEPTS

H"n$(2"s&ing

T&e sing)e %ost i%ort"nt %e"sure to revent infe!tion

For #$utne "a#e* it is reuire$ t&"t vigorous &"n$ 2"s&ing 2it& so" un$er " stre"% of

2"ter for

– At )e"st ,/ se!on$s @CDC* 1o>ier

– At )e"st ,(B/ se!on$s @U$"n

T&e !&"in of infe!tion


15/35

Etio)ogi! "gent

Reservoir

Port") of e4it fro% reservoir

Met&o$ of tr"ns%ission

Port") of entry to t&e sus!eti+)e &ost

Sus!eti+)e &ost

Tyes of I%%unity

Tye Antigen or "nti+o$y sour!e $ur"tion

A!tive I%%uity Anti+o$ies "re ro$u!e$ +y t&e +o$y in

resonse to "n "ntigen

)ong

N"tur")

"!tive

Anti+o$ies "re for%e$ in t&e resen!e of "!tive

infe!tion

)ife)ong

Artifi!i")

"!tive

Antigens @v"!!inesto4oi$s "re inKe!te$ to

sti%u)"te "nti+o$y ro$u!tion

M"ny ye"rs

P"ssive I%%unity Anti+o$ies "re ro$u!e$ +y "not&er sour!e S&ort

N"tur")

"ssive

Anti+o$ies "re tr"nsferre$ n"tur"))y fro% "n

i%%une %ot&er to &er +"+y t&roug& t&e

PLACENTA or 'REAST FEEDING

A+out %ont&s

to , ye"r

Artifi!i")

"ssive

I%%une seru% @"nti+o$ies !o%es fro% "not&er

sour!e @&u%"ns"ni%")s inKe!te$ to "not&er

&u%"n

- to B 2ee#s

I%%unity

I%%unity e4"%)es

ACTIVE n"tur") Infe!tious $ise"se

ACTIVE "rtifi!i") I%%uni>"tion 2it& v"!!ines "n$

to4oi$s

PASSIVE n"tur") P)"!ent" "n$ 're"stfee$ing

PASIVE "rtifi!i") InKe!tion of I%%une seru%* "nti(to4ins

Surgi!") Asesis @U$"n

Reuire$ in t&ese situ"tions0

,3 Surgi!") ro!e$ures

-3 A)) ro!e$ures t&"t inv"$e +)oo$stre"%

B3 Pro!e$ures t&"t !"use +re"# in t&e s#in

93 Co%)e4 $ressing !&"nges "n$ 2oun$ !"re

J9 In!e#t$n $' tu1e!2 "at&ete#! nt$ !te#le 1$d% "a*te! l/e U#na#% 1ladde#

3 C"re for HIGH ris# grous0 AIDS* !"n!er* +urn t


16/35

Prin!i)es "n$ Pr"!ti!es of Surgi!") Asesis @1o>ier

,3 A)) o+Ke!ts use$ in t&e steri)e fie)$ %ust +e steri)e

-3 Steri)e o+Ke!ts +e!o%e unsteri)e 2&en tou!&e$ +y unsteri)e o+Ke!ts

B3 Steri)e ite%s t&"t "re out of vision or +e)o2 t&e 2"ist )eve) of t&e nurse "re !onsi$ere$

unsteri)e

93 Steri)e o+Ke!ts !"n +e!o%e unsteri)e +y ro)onge$ e4osure to "ir+orne %i!roorg"nis%s

3 F)ui$s f)o2 in t&e $ire!tion of gr"vity

3 Moisture t&"t "sses t&roug& steri)e o+Ke!ts $r"2s %i!roorg"nis%s for% unsteri)e surf"!es "+ove

or +e)o2 to t&e steri)e surf"!e +y !"i))"ry "!tion

3 T&e e$ges of " steri)e fie)$ "re !onsi$ere$ unsteri)e

.3 T&e s#in !"nnot +e steri)i>e$

3 Cons!ientiousness* ")ertness "n$ &onesty "re essenti") u")ities in %"int"ining "sesis

Steri)e o+Ke!ts "re #et in vie2

On)y t&e front "rt of t&e steri)e go2n of steri)e

- in!&es "+ove t&e e)+o2s to t&e !uff of t&e s)eeves is steri)e

Uti)i>e steri)e for!es to &"n$)e steri)e ite%s

A ,(in!& %"rgin "t e"!& e$ge of $r"es is !onsi$ere$ unsteri)e

P)"!e steri)e o+Ke!ts MORE t&"n , in!& insi$e t&e e$ges of t&e steri)e fie)$

Hosit") Te!&niues

@U$"n

T&ese re!"ution te!&niues )i#e st"n$"r$ re!"ution "n$ rote!tive iso)"tion "re use$ to

revent or )i%it t&e sre"$ of infe!tion

St"n$"r$ re!"ution

1l$$d51$#ne and m$!t 1$d% !u1!tan"e )at&$gen!

,3 e"ring Intended t$ )#e*ent t#an!m!!$n $' of !)e"n g)oves

-3 Perfor%ing &"n$ 2"s&ing i%%e$i"te)y

B3 e"r %"s#* eye s&ie)$ $uring ro!e$ures t&"t gener"te s)"s&es93 e"r go2n if s)"s&es* sr"ys* se!retions !"use soi)ing

3 Prevent inKuries fro% nee$)e s&"r o+Ke!ts

Pre!"ution

St"n$"r$ Pre!"ution Use$ in !"re of ALL &osit")i>e$ ersons( ")ies to +)oo$* "))

+o$y f)ui$s* se!retions* e4!retions

TRANSMISSION51a!ed

)#e"aut$n

Air+orne* Dro)et "n$ Cont"!t

AIR'ORNE

Air+orne $ro)et

nu!)ei )ess t&"n t%i!rons

Me"s)es* v"ri!e))" "n$ T'

Priv"te roo%* neg"tive "ir ressure "n$ N resir"tor 2&en

entering roo%

DROPLET

P"rti!)es gre"ter

t&"n %i!rons

Di&t&eri"* neu%oni"* ertussis* %u%s* Ger%"n %e"s)es


17/35

Cont"!t GIT* Resi* S#in "n$ 2oun$ infe!tion e"si)y tr"ns%itte$ +y

$ire!t !)ient !ont"!t or !ont"!t 2it& !)ient ite%s

inf)"%%"tion

A resonse of " )iving v"s!u)"ri>e$ tissue to inKury

It is ")so "n e4"%)e of LOCAL A$"t"tion to stress

C"r$in") Signs of inf)"%%"tion0

,3 Ru+or5 re$ness @initi") !&"nge

-3 C")or5 &e"t

B3 Tu%or5 s2e))ing

93 Do)or5 "in

3 Fun!tio )"es"5 )oss of fun!tion

St"ges0 V(C(R

V"s!u)"r Resonse

Ce))u)"r for%"tion

Re"ir

Nursing Interventions

Re$u!e inf)"%%"tory ro!ess

Mini%i>e s2e))ing

Re)ieve "in

Provi$e "$eu"te nutrition0 &ig& !")orie* &ig& rotein* &ig& vit"%in C

Pro%ote rest

A$%inister res!ri+e$ %e$i!"tions

'OD6 MECHANICS

T&e effi!ient* !oor$in"te$ "n$ s"fe use of t&e +o$y to ro$u!e %otion "n$ %"int"in +")"n!e $uring

t&e "!tivity

T&e %"Kor urose is 0

– To f"!i)it"te t&e s"fe "n$ effi!ient use of "rori"te %us!)e grous to %"int"in

+")"n!e* re$u!e t&e energy reuire$* re$u!e f"tigue "n$ $e!re"se t&e ris# for inKury

T2o ositions t&"t s&ou)$ +e "voi$e$ +y t&e nurse +e!"use t&ey !"use +"!# InKury

T2isting

Stooing

Ho2 to en&"n!e +o$y +")"n!e

,3 i$en t&e +"se of suort

,3 Lo2er t&e !enter of gr"vity +y +ringing it !)oser to t&e +"se of suort( FLEJ t&e &i "n$

#nees


18/35

Prin!i)es of 'o$y %e!&"ni!s

,3 P)"n t&e %ove%ent "n$ o+t"in "ssist"n!e

-3 A$Kust 2or#ing "re" to 2"ist )eve)

ier

Te%er"tures in 'o"r$s

Hot 2"ter '"g SIT 'ATH Coo)ing Songe '"t& A)!o&o) Songe '"t&

A$u)t "n$ %ore t&"n- ye"rs(o)$0

9(- C

Less t&"n -0

9/(9 C

5< C 85


19/35

E''$#t ! nea#l% e''$#tle!!9 Lttle mu!"ula# 7$#/ ! #eu#ed t$ m$*e a# t$ug& t&e lung!9 N$

!$und! a#e a!!$"ated 7t& t9

Assess%ent of resir"tory syste%

,3 Nursing History

Re)ev"nt $"t" in t&e &istory 2&i!& fo!uses on t&e resir"tory syste% in!)u$e !urrent "n$"st resir"tory $isor$ers* )ifesty)e* resen!e of !oug&* "in* %e$i!"tions for +re"t&ing "n$

"ssess%ent of ris# f"!tors3

-3 P&ysi!") E4"%in"tion

T&e te!&niues of Inse!tion* P")"tion* Per!ussion "n$ Aus!u)t"tion "re e%)oye$3

T&e r"te* r&yt&%* $et& "n$ u")ity of resir"tion "re o+serve$3

Note for t&e !o)or* !onsisten!y* "n$ "%ount of sutu%

UTILIE THE $i"&r"g% of t&e stet to &e"r +re"t& soun$s

A$ventitious soun$s

Cr"!#)esR")es0 Cr"!#)ing soun$ 'EST &e"r$ $uring in&")"tion

R&on!&i0 Co"rse* gurg)ing* vi+r"tions &e"r$ $uring +re"t&ing 2it& %o"ning or snoring

u")ity

Fri!tion ru+0 !re"#ing soun$

&ee>e0 Sue"#y %usi!") soun$

Soun$ C"use

Cr"!#)esR")es Air "ssing t&roug& f)ui$ or %u!us

R&on!&i Air "ssing t&roug& n"rro2e$ "ir "ss"ge2"y "s " resu)t of

t&i!# se!retions* s2e))ing* tu%or

&ee>e Air "ssing t&roug& " !onstri!te$ +ron!&us +ron!&io)es "s "

resu)t of se!retions* s2e))ing

Fri!tion ru+ Ru++ing toget&er of inf)"%e$ )eur") surf"!es

A+$o%in") Assess%ent

T&e seuen!e is ")2"ys "s# in t&e e4"%:5

– In!)e"t$n

– Au!"ultat$n

– Pe#"u!!$n

– Pal)at$n

Aus!u)t"te 2it& t&e use of t&e $i"&r"g% in ")) four u"$r"nts

– T&e usu") seuen!e is RIGHT LOER u"$r"nt RIGHT UPPER u"$r"nt

LEFT UPPER u"$r"nt LEFT LOER u"$r"nt

– Nor%") +o2e) soun$s0 &ig& it!&e$ GURGLING o!!urring every to -/ SECONDS

THE NURSING PROCESS


20/35

Assess%ent0 g"t&ering of $"t"* v")i$"te "n$ $o!u%ent $"t"

Nursing $i"gnosis0 "n")y>e $"t"* i$entify ro+)e%s "n$ for%u)"te $i"gnosti! st"te%ents

P)"nning0 rioriti>ing ro+)e%s* for%u)"te go")s "n$ se)e!t nursing interventions

I%)e%ent"tion0 !"rrying out t&e nursing %e"sures* suervising* $e)eg"ting* re"ssessing "n$

$o!u%enting "!tivities

Ev")u"tion0 Co%"re ev")u"te$ $"t" 2it&y out!o%e !riteri"* !ontinue* %o$ify or ter%in"te

!)ient !"re

C&"r"!teristi!s of t&e Nursing ro!ess

E Oen "n$ f)e4i+)e

E Cy!)i! "n$ $yn"%i!

E C)ient !entere$

E In$ivi$u")i>e$

E P)"nne$

E Go") $ire!te$

E Per%its !re"tivity

E E%&"si>es fee$+"!#s

E Univers"))y "!!ete$

ANA St"n$"r$ of C)ini!") Nursing

St"n$"r$ I

Assess%ent

T&e nurse !o))e!ts $"t"

St"n$"r$ II

Di"gnosis

T&e nurse "n")y>es t&e "ssess%ent $"t"

$eter%ining $i"gnosis

St"n$"r$ III

Out!o%e i$entifi!"tion

T&e nurse i$entifies e4e!te$ out!o%es

St"n$"r$ IVI%)e%ent"tion

T&e nurse $eve)os " )"n of !"re*res!ri+es interventions to "tt"in

e4e!te$ out!o%e

St"n$"r$ V

Ev")u"tion

T&e nurse ev")u"tes t&e !)ients= rogress

to2"r$ "tt"in%ent of out!o%es

T&e Nursing "ssess%ent

First ste

Co%onents0,3 Co))e!t $"t"

-3 Org"ni>e $"t"

B3 V")i$"te $"t"

93 Do!u%ent $"t"

A %et&o$ of infor%"tion !o))e!tion for t&e est"+)is&%ent of $"t" +"se

Tyes of D"t"


21/35

!'F)CTI,) data

• !ymptoms reported by the patient OF)CTI,) data

• !igns and manifestations that are gathered by the nurse through Inspection palpation

percussion and auscultation

Di"gnosing

-n$ ste

The process which results to a diagnostic statement

Clinical act of identifying problems

"nalysis of assessment information to derive meaning from the analysis

The nursing #iagnosis

" statement of client/s potential or actual alteration of health status

The nurse writes a summary statement that N"N#" has developed

"ctivities in this step are7

43 "naly.e data

:3 Identify health problems ris(s and strengths23 8ormulate diagnostic statements

Writing Nursing #iagnosis

#ifferent Nursing #iagnoses "ctual Nursing diagnosis

+is( nursing diagnosis

Wellness diagnosis

!yndrome diagnosis

Possible nursing diagnosis

Collaborative problems

"CT'"* Nursing #iagnosis43 'tili.e the P-r@t-) format

Problem related to etiology

:3 'tili.e the P-)-!

Problem-)tiology-!igns and !ymptoms

P-r@t-) format

Ineffective airway clearance related to wea( cough effort

P-)-! format

Ineffective airway clearance related to tracheobronchial infection as manifested by copious

sputum production and adventitious breath sounds

Gui$e)ines in 2riting ND

43 Prioriti.e according to clients/ needs

:3 Write in terms of person/s response rather than need

23 'se 7#elated t$. to connect the two parts of the statement "void the terms Gdue to and Gbecause of or Gsecondary to

! Write in legally advisable term


22/35

>3 Write without Dudgment value

e$

Mo$ifi!"tions of st"n$"r$ t&er"y "s ")i!"+)e

IMPLEMENTATION 9t& ste

T&e ste !on!erne$ 2it& $oing* $e)eg"ting "n$ $o!u%enting !)ient resonses

T&e nurse MUST re("ssess t&e !)ient 'EFORE e%)oying nursing %e"sures to +e "+)e to

$eter%ine if t&e interventions "re sti)) nee$e$ or "re sti)) s"fe

e !"rry out t2o interventions

,3 In$een$ent interventions

-3 Deen$ent interventions* Inter$een$ent or Co))"+or"tive

EVALUATION t& ste

THE fin") ste in t&e nursing ro!ess t&"t invo)ves !o))e!ting $"t" "n$ !o%"ring t&e $"t"

2it& t&e out!o%e !riteri" to $eter%ine go") "tt"in%ent

THE nurse 2i)) eit&er0

Revise t&e C"re )"n

Continue t&e !"re )"n M"#e " ne2 !"re )"n for " ne2 ro+)e%

DOCUMENTATION "n$ REPORTING

Do!u%ent"tion

•Per%"nent re!or$ of !)ient infor%"tion "n$ !"re


23/35

REPORTING

•T"#es )"!e 2&en t2o or %ore eo)e s&"re infor%"tion "+out !)ient !"re eit&er f"!e to f"!e or

+y te)e&one @U$"n

Puroses of C)ient re!or$

•Co%%uni!"tion

•Leg") Do!u%ent"tion

•Rese"r!&

•St"tisti!s

•E$u!"tion

•Au$it

•P)"nning !"re "n$ rei%+urse%ent

Tyes of Re!or$s

•Tr"$ition") !)ient re!or$

•Pro+)e% oriente$ %e$i!") re!or$

•1"r$e4( series of !"r$s 2it& entries 2ritten in en!i)

C&"r"!teristi!s of goo$ re!or$ing

,3 'revity

-3 Use of IN1

B3 A!!ur"!y

93 Arori"teness

3 Co%)ete "n$ ti%e)y org"ni>e$

3 Use st"n$"r$ ter%ino)ogy

3 SIGNED

Reorting

,3 En$orse%ents

Re)$#tng d$ne '$# "$ntnut% $' "a#e

=a!ed $n t&e &ealt& "a#e need! $' )atent t$ 1e &andled 1% t&e ne3t !&'t nu#!e!

End$#!ement! !&all 1e a! $1e"t*e a! )$!!1le #elated t$ "lent need! and "a#e

-3 Te)e&one reorts

3 Te)e&one or$ers

93 Tr"nsfer reorts

Nursing M"n"ge%ent

St"ffing is t&e ro!ess of $eter%ining "n$ rovi$ing t&e "!!et"+)e NUM'ER "n$ MIJ of

nursing ersonne) to ro$u!e " $esire$ )eve) of !"re "n$ to %eet t&e "tient $e%"n$ for !"re

Stes in St"ffing

89 Sele"t$n $' )e#!$nnel

;9 Sta'' de*el$)ment


24/35


25/35

Nurses "re "ssigne$ " se!ifi! t"s#

Nurses ten$ to +e!o%e &ig&)y !o%etent on)y 2it& t&e t"s# ree"te$)y $one

TAS1(fo!use$ "n$ Not C)ient(fo!use$

TEAM NURSING

TEAM rovi$es tot") nursing !"re to se!ifi! !)ient or "tient In$ivi$u")i>e$ "tient !"re

A )e"$er* t&e senior rofession") nurse in t&e unit* 2i)) $o t&e !oor$in"tion* suervision "n$

g"t&er !ooer"tion of ")) st"ff in $e)ivery of "tient !"re

Registere$ nurses "n$ "ssistive ersonne) "re given !)ient "ssign%ents r"t&er t&"n TAS1

La"/ $' "$ntnut% $' "a#e

Unde'ned #$le $' RN an a!!!t*e )e#!$nnel

La"/ $' tme t&e leade# "an !)#ead 7t& "lent!

PRIMAR6 NURSING

Re!ent %et&o$( HOLISTIC "ro"!& in !"re

A PRIMAR6 nurse is resonsi+)e to give tot") nursing !"re to 9 to "tients -9 HOURS "

$"y fro% &osit")i>"tion to $is!&"rge An "sso!i"te nurse usu"))y su+stitute t&e nurse 2&en off $uty* +ut t&e )"n of !"re %"$e +y

t&e ri%"ry nurse is IMPLEMENTED

Nurses &"ve AUTONOM6 "n$ AUTHORIT6 for "tient !"re

S!&e$u)ing

To "ssign 2or#ing $"ys "n$ $"y(offs to st"ff nurses in or$er to0

,3 Provi$e "$eu"te "tient !"re 2&i)e "voi$ing overst"ffing

-3 A!&ieve " $esir"+)e $istri+ution of $"ys off

B3 Tre"t in$ivi$u") st"ff nurse f"ir)y

93 A))o2 t&e st"ff to #no2 in "$v"n!e 2&"t t&eir s!&e$u)es "re

S!&e$u)ing Gui$e)ines

,3 '")"n!e t&e nee$ of e%)oyee "n$ e%)oyer

-3 Distri+ute f"ir)y goo$ "n$ +"$ $"ys off to "))

B3 M"#e sure t&ey "$&ere to s!&e$u)e3 Reuest "n$ e4!etion %ust +e in riting

93 A$v"n!e osting of s!&e$u)es

3 'e !onsistent in s!&e$u)ing

3 M"#e sure t&"t s!&e$u)es !onfor% 2it& )"+or )"2s "n$ &osit") o)i!y

3 Pre"re for e%ergen!y !&"nges

T&e NURSE MANAGER

T&e nurse %"n"ger PLANS* gives $ire!tion* $eve)os st"ff* %onitors oer"tions* gives f"ir re2"r$s

"n$ reresents 'OTH st"ff %e%+ers "n$ "$%inistr"tion "s nee$e$

Nursing ;urisru$en!e

T&e P&i)iine Nursing A!t of -//- @RA ,B IS THE 'EST GUIDE THE NURSE CAN UTILIE

"s it $efines t&e s!oe of nursing r"!ti!e

Intention") rongs5 TORTS

Tort is " )eg") 2rong !o%%itte$ "g"inst " erson or roerty in$een$ent of " !ontr"!t 2&i!&

ren$ers t&e erson 2&o !o%%its it )i"+)e for $"%"ges in !ivi) "!tion


26/35

E4"%)es of TORTS

,3 Ass"u)t5 "tte%t to tou!& "not&er erson* i%%inent t&re"t of &"r%fu) or offensive +o$i)y

!ont"!t

-3 '"ttery 5 intention")* un!onsente$ tou!&ing of "not&er erson

B3 F")se i%rison%ent5 unKustifi"+)e $etention of " erson 2it&out " )eg") 2"rr"nt

93 Inv"sion of Priv"!y "n$ +re"!& of !onfi$enti")ity

3 Li+e)5 2ritten

3 S)"n$er5 so#en

Profession") Neg)igen!e

NEGLIGENCE

Co%%ission or o%ission of "n "!t ursu"nt to " $uty* t&"t " re"son"+)y ru$ent

erson in t&e s"%e or si%i)"r !ir!u%st"n!e 2ou)$ $o or 2ou)$ not $o "n$ t&e "!ting

or t&e non("!ting of 2&i!& is t&e ro4i%"te !"use of inKury to "not&er erson or

roerty

E)e%ents of Neg)igen!e

,3 E3!ten"e $' a dut% on t&e "rt of t&e erson

-3 Falu#e t$ meet t&e st"n$"r$s of $ue !"re

B3 T&e forse"+i)ity of &"r% resu)ting fro% 'alu#e to %eet st"n$"r$

93 T&e +re"!& of t&e st"n$"r$ resu)te$ in an nu#% to t&e )"intiff

E4"%)es of Neg)igen!e

,3 F"i)ure to reort o+serv"tion to t&e &ysi!i"n

-3 F"i)ure to e4er!ise t&e $egree of $i)igen!e

B3 Mist"#en i$entity

93 rong %e$i!ine* 2rong !")!u)"tion* 2rong route "n$ 2rong $oses

3 Defe!ts in t&e eui%ent su!& "s stret!&ers "n$ 2&ee)!&"irs t&"t %"y )e"$ to f"))s

3 Errors $ue to f"%i)y "ssist"n!e

3 A$%inistr"tion of %e$i!ine 2it&out " $o!tor=s res!rition

Res is" )ouitur

T&ree !on$itions "re reuire$ to est"+)is& " neg)igen!e ITHOUT roving se!ifi! !on$u!t

,3 T&"t t&e inKury 2"s of su!& n"ture t&"t it 2ou)$ not nor%"))y o!!ur un)ess t&ere 2"s "

neg)igent "!t

-3 T&"t t&e inKury 2"s !"use$ +y "n "gen!y 2it&in !ontro) of t&e $efen$"nt

B3 T&"t t&e !o%)"in"nt &i%se)f $i$ not eng"ge in "ny %"nner t&"t 2ou)$ ten$ to +ring "+out

t&e inKury

MALPRACTICE

IMPROPER or uns#i))fu) !"re of " "tient +y " nurse

Steing +eyon$ one=s "ut&ority 2it& serious !onseuen!es NEGLIGENCE or !"re)essness of " rofession") ersonne)

Neg)igent "!t !o%%itte$ in t&e !ourse of rofession") erfor%"n!e

Consent

free "n$ r"tion") "!t t&"t resuoses #no2)e$ge of t&e t&ing to 2&i!& !onsent is +eing given

+y " erson 2&o is )eg"))y !""+)e of giving !onsent


27/35

Infor%e$ !onsent

E)e%ents0

,3 T&e $i"gnosis "n$ e4)"n"tion of t&e !on$ition

-3 F"ir e4)"n"tion of t&e ro!e$ures "n$ !onseuen!es

B3 Des!rition of ")tern"tive tre"t%ents

93 Des!rition of +enefits to +e e4e!te$3 M"teri") rig&ts

3 T&e rognosis* if refuse$

S)ee

REST( " st"te of !")%ness* re)"4"tion 2it&out e%otion") stress* "n$ free$o% fro% "n4iety

SLEEP( "n ")tere$ st"te of !ons!iousness in 2&i!& t&e in$ivi$u")=s er!etion of "n$

re"!tion to t&e environ%ent "re $e!re"se$3

T&is !"n +e $is!usse$ si%)y +y !onsi$ering t&e t&ree +"si! rese"r!& "ro"!&es0

ELECTROPH6SIOLOGIC

HORMONAL "n$

NEURAL

T6PES OF SLEEP

T&ere "re t2o tyes of s)ee i$entifie$0

T&e NREM !lee) @or t&e non(REM s)ee "n$

T&e REM !lee) @ r"i$ eye %ove%ent s)ee

,3 THE NREM SLEEP

A)so referre$ to "s t&e SLO 2"ve s)ee* +e!"use t&e +r"in 2"ves of t&e !)ient "re s)o2er

t&"n t&e ")&" "n$ +et" 2"ves of "n "2"#e or ")ert erson3

It is " dee)2 #e!t'ul !lee)

T&ere is " $e!re"se$ &ysio)ogi! fun!tions

A)) %et"+o)i! ro!esses "re re$u!e$

It is $ivi$e$ into FOUR st"ges0,(9

STAGE ,( t&e st"ge of very )ig&t s)ee* s)eeer !"n re"$i)y +e "2"#ene$* )"sts for " fe2 %inutes3 T&e

eyes ten$ to ro)) s)o2)y fro% si$e to si$e* "n$ %us!)e tension re%"ins "+sent3

STAGE -( t&e st"ge of )ig&t s)ee* +o$y ro!esses !ontinues to s)o2 $o2n* "n$ )"sts "+out ,/(,

%inutes3 C$n!ttute! 5J $' TOTAL !lee)6

STAGE B(refers to " %e$iu%($et& s)ee 2&ere vit") signs "n$ %et"+o)i! ro!esses s)o2 furt&er

+e!"use of t&e PARASYMPATHETIC nervous syste% inf)uen!e3 T&e s)eeer is $iffi!u)t to "rouse3

STAGE 9(t&is is t&e $eeest s)ee or $e)t" s)ee3 It is t&e st"ge 2&ere t&e &e"rt r"te "n$ resir"tory

r"te $ro -/(B/ +e)o2 t&ose e4&i+ite$ $uring 2"#ing &ours3 T&is st"ge is t&oug&t to restore t&e

+o$y &ysi!"))y3 So%e $re"%ing ma% o!!ur &ere3 T&! !tage ma% 1e a1!ent n t&e elde#l%9

REM S)ee

THE REM SLEEP

T&is s)ee tye usu"))y re!urs "+out every / %inutes "n$ )"sts to B/ %inutes3

Ot&er n"%e0 PARADOJICAL S)ee

T&e EEG "ttern rese%+)es t&"t of t&e 7a7a/e. st"te3

T&is is not "s restfu) "s NREM s)ee


28/35

M$!t $re"%s t"#e )"!e $uring t&is erio$ "n$ t&e $re"%s "re usu"))y re%e%+ere$ or

!onso)i$"te$ to %e%ory

T&e +r"in is &ig&)y "!tive 2it& %et"+o)i! r"te in!re"sing "s %u!& "s -/

T&e s)eeer %"y +e very $iffi!u)t to "rouse

T&ere "re r"i$ !onKug"te eye %ove%ents* %us!)e tone is $eresse$* +ut g"stri! se!retions

in!re"se* HR "n$ RR "re in!re"se$ "n$ IRREGULAR T&is s)ee erio$ +e!o%es )onger "s t&e nig&t rogresses3

NREM versus REM

NREM REM

S)o2 eye %ove%ent R"i$ Eye %ove%ent

Restfu) s)ee NOT restfu)

De!re"se$ %et"+o)is% In!re"se$ %et"+o)is%

Vit") signs LO

Mus!)e tone %"int"ine$

NO vivi$ $re"%s

Vit") signs Irregu)"r

Mus!)e tone $eresse$

Dre"%s o!!ur

S)ee Cy!)e

A)) of us un$ergoes "roun$ t !y!)es of s)ee of NREM to REM

e +egin 2it& STAGE , - B 9 B - REM


29/35

S)ee V"ri"tions

For NEONATES( ne2+orns s)ee for ,(,. &ours $ivi$e$ into s)ee erio$s3 T&ey &"ve

t2o s)ee st"tes( QUIET s)ee @t&eir NREM s)ee is !&"r"!teri>e$ +y !)ose$ eyes* regu)"r

resir"tions "n$ "+sen!e of eye+o$y %ove%ents ACTIVE s)ee is !&"r"!teri>e$ +y eye

%ove%ents o+serv"+)e t&roug& t&e !)ose$ eye)i$s* 2it& +o$y %ove%ents "n$ irregu)"r

resir"tions3

For INFANTS( so%e inf"nts s)ee for -- &ours* 2&i)e t&e "ver"ge is ,-(,9 &ours3 T&eir s)ee !y!)e is

s&orter @"+out /(/ %inutes3 T&e REM s)ee is -/(B/ @2&i!& $e!re"ses "s t&e inf"nt gro2s "n$

2i)) st"+i)i>e "t -/ unti) )"te in "$u)t&oo$3 A+out / of t&e s)ee is sent $uring LIGHT s)ee

@St"ge ,3

For TODDLERS( t&e s)ee reuire%ent is ,/(,- &ours " $"y3 T&e s"%e -/(B/ of s)ee is

REM3 T&e nor%") s)ee 2"#e "ttern is est"+)is&e$ "t "ge -(B3

=edtme #tual! $'ten de*el$) and a!!ume g#eat m)$#tan"e n )#$*dng ng&ttme !e"u#t%9

For PRESCHOLERS( t&ey usu"))y reuire ,,(,- &ours of s)ee er nig&t3 T&e REM s)ee is

sti)) -/(B/3 M"ny of t&e res!&oo)ers resist going to s)ee

Remem1e# t&at t&e )#e!"&$$le#! &a*e 'ea# $' t&e da#/ t&at nu#!e! mu!t ant")ate t$ gude t&e

m$t&e#!

For PRESCHOLERS(

Suggeste$ Me"sures +y Pi))iteri0

89 Read 1edtme !t$#e! untl )atent !lee)!

Sleep cycle

!tage 4

!tage :

!tage 2

!tage ;

!tage 2

!tage :

+)%

!tage :

!tage 2

!tage ;

"W"?)


30/35

;9 Rea!!u#e t&at "&ld ! Sa'e


31/35

P"in is "n un)e"s"nt sensory "n$ e%otion") e4erien!e "sso!i"te$ 2it& "!tu") or otenti")

tissue $"%"ge3

It is so%eti%es referre$ to "s t&e FIFTH vit") sign

PAIN

ACUTE "in CHRONIC "in

Mi)$ to severe

Su$$en

Sy%"t&eti! syste%

Pro)onge$

Persisting %ont&s or )onger

P"r"sy%"t&eti! resonses

P"in T&eory0 G"te !ontro)

Me)>"!# "n$ ")) $eve)oe$ g"te !ontro) t&eory in ,3 T&e t&eory rooses t&"t t&e su+st"nti"

ge)"tinos" @SG in t&e sin") !or$ "!ts "s " g"ting %e!&"nis% to er%it or in&i+it "ss"ge of "in


32/35

i%u)ses3 T&e 7g"te8 !"n +e 7!)ose$8 @so t&"t t&e !ont"!t is not %"$e* t&us interruting t&e "in

i%u)se +y nerve i%u)ses fro% t&e )"rge non(no!i!etive A(+et" "n$ A(")&" fi+ers or fro% t&e

$es!en$ing "t&2"ys

Im)ul!e! "$ndu"ted $*e# la#ge '1e#! n$t $nl% "l$!e t&e gate 1ut al!$ a#e !ent mmedatel% t$ t&e

"$#te3 '$# #a)d dent'"at$n2 e*aluat$n2 and m$d'"at$n $' t&e !en!$#% n)ut!

I%u)ses sent to t&e +r"inste%* t&e !enter for %otiv"tion")("ffe!tive "n$ sensory($is!ri%in"tive "!tions* !"n inf)uen!e !ognition or ev")u"tion in t&e !orte43 I%u)ses "re t&en

sent fro% t&e !orte4 +"!# to t&e SG vi" !orti!osin") "t&2"ys to in&i+it or er%it "ss"ge

of "in i%u)ses3

C"t&eteri>"tion @1o>ier

E4)"in ro!e$ure

"s& &"n$s

Dr"e "re"s e4!et erineu%

O)en t&e !te#le "at&ete#,at$n /t A))l% !te#le Gl$*e!

Lu+ri!"te !"t&eter

C)e"nse t&e %e"tus

Insert !"t&eter

Gr"s ;5< n"&e! fro% t&e !"t&eter ti "n$ insert

A$v"n!e t&e !"t&eter ; n"&e! 'u#t&e# "fter t&e urine +egins to f)o2

Male In!e#t a#$und 5 n"&e!


33/35

Female n!e#t a#$und ier

AGE 'e)iefsInfancy to > years old NO clear concept of #eath

It is "e#ersible temporary sleep

> to J years 'nderstands DE$T% is FIN$& but can be $'(IDED

J-4: years #eath is INE'IT$)&E* e#eryone will die someday

'nderstands own mortality

4:-4A years 8ears a lingering #eath


34/35

4A-;> "ttitude is influenced by religion

;>- years )&periences pea( of death an&iety

and above #eath as multiple meanings

Nursing resonsi+i)ities In De"t& "n$ $ying

Nurses nee$ to t"#e ti%e to "n")y>e t&eir o2n fee)ings "+out $e"t& +efore t&ey !"n effe!tive)y &e)

ot&ers 2it& ter%in") i))ness

T&e %"Kor go")s for t&e $ying !)ients "re0

,3 To %"int"in PH6SIOLOGIC "n$ PS6CHOLOGIC suort

-3 To A!&ieve " $ignifie$ "n$ e"!efu) $e"t&

B3 To %"int"in erson") !ontro)

De"t& "n$ Dying RESPONSI'ILITIES

P#$*de Rele' '#$m l$nelne!!2 'ea# and de)#e!!$n Hel) "lent! mantan !en!e $' !e"u#t%

Hel) "lent! a""e)t l$!!e!

P#$*de )&%!"al "$m'$#t

T&e fo2)ers

LO fo2)ers5 , to B/ $egrees

SEMI fo2)ers5 B/(9 $egrees

FOLER=s5 9(/ $egrees

HIGH Fo2)ers5 /(/ $egrees

C"r s"fety

Inf"nts u to #i)ogr"%s or -/ oun$s s&ou)$ FACE t&e REAR

C&i)$ren gre"ter t&"n #i)ogr"%s or -/ oun$s s&ou)$ +e in t&e FORARD f"!ing osition

in t&e 'AC1 se"t of t&e !"r

PAIN

Hig&)y un)e"s"nt erson") sens"tion

Most "!!et"+)e t&eory0 GATE CONTROL THEOR6

PQRST

Qu")ity0 0Tell me 7&at %$u# )an 'eel! l/e.

Pot"ssiu%

'"n"n" @s%"))5 3 %EL

Or"nge5 3 %EL


35/35

Pot"to @%e$iu%5 ,-3 %EL

"ter%e)on @,- s)i!e5 ,3B

C)e"r )iui$ $iet

L"!#s !")ories

Per%itte$ f)ui$s0

– C$''ee– Tea

– C"r+on"tes $rin#s

– F"t(free +rot&

– C)e"r '#ut u"e!

– GELATIN

– )$)!"le!

Fu)) )iui$

A)) foo$s in !)e"r )iui$

Mi)# "n$ Ml/ d#n/! Pu$$ing * !ust"r$s

I!e !re"%

Cre"%* +utter* %"rg"rine

6ogurt

Veget"+)e Kui!es

Foo$ Gui$e yr"%i$

're"$* !ere")s* ri!e "n$ "st"5 (,, servings

Fruit "n$ veget"+)es

Me"t* ou)try* fis&* $ry +e"ns* eggs

Mi)#* yogurt* !&eese

F"ts* oi)s "n$ s2eets

T&e $efinitions of 7A8

ANOMIA5 in"+i)ity to NAME o+Ke!t

AGNOSIA5 in"+i)ity to RECOGNIE t&ings

APRAJIA5 in"+i)ity to PERFORM revious)y )e"rne$ %ove%ents+e&"vior

ATAJIA5 )"!# of COORDINATION in %ove%ent

APHASIA5 )"!# of o2er to e4ress onese)f +y see!&* 2riting or signs* )"!# of o2er to un$erst"n$

so#en2ritten )"ngu"ge

funda-review-notes.doc

Documents