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NP1 (B)

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  • Intensive final coaching NURSING PRACTICE 1
  • Fundamentals of nursing
    • Theories:
    • Martha Rogers- is Human Being Unitary theory
    • Myra Levine- Human Becoming
    • ; Madeleine Leinenger = transcultural nursing
    • Hildegard Peplau- interpersonal relationship
    • Imogene King- goal attainment theory
    • nightingale=- environmental
    • Dorothea Orem- general care nursing(self care, self care deficit and nursing care)
    • Margaret newman-health care delivery system
    • Betty neuman-health unconscious
    • Ida Jean Orlando-dynamic nurse patient relationship
    • Dorothy Johnson- behavioral model
    • Sis Callista roy- adaptation theory
    • Jean watson-human caring
    • VirginianHenderson-14 basic/fundamental needs,define nursing
    • Faye Abdellah-21 basic needs
    • Lydia hall-care,cure,core
  • Unfamiliar nursing theorist
    • Anne Boykin-grand theory of nursing as CARING
    • Schulman and mekler-moral theory and the moral child is kind and just
    • Westerhoff-= faith is a way of behaving
    • Lilian Wald- founder or coined the term as PUBLIC HEALTH NURSING
    • MARGARET SANGLER- founder of planned parenthood
    • Recipient nursing care: PATIENT, CLIENT, CONSUMER
    • PERSON, HEALTH, NURSING and ENVIRONMENT are metaparadigm in nursing
    • PAINTERS-more susceptible carpal tunnel syndrome
    • LYMES dse.- from a deer tick
    • COLLABORATIVE- is best demonstrated when the nurse initiates nursing action with co-workers
    • Needs are luniversal, deferred ,interrelated and met in different ways
    • PRIORITIES- may be altered not in uniform to individuals
    • Health is the ability to maintain the internal milieu(bernard)
    • Health is to maintain homeostasis and equilibrium(cannon)
    • Health is a dynamic state in the life cycle(King)
    • Wellness- is the condition in which all parts and subparts are in harmony(neuman)
    • WELLNESS- maximize potentials, a CHOICE and a WAY of LIFE, an INTERGRATION of body, mind and spirit
    • HEALTH BELIEF MODEL(BECKER)- individual perceptions; susceptibility,seriousness and threat are influenced by the modifying factors.
    • Leavel’s and Clark ECOLOGIC MODEL(age,host & environment)
    • Stress-is the nonspecific response of the body, not a nervous energy. “Stress is always a part of the fabric of daily life” (hans Selye)
    • General adaptation syndrome- all body parts responds to stress. STAGES: stage Of Alarm, Stage of Resistance and stage of exhaustion
    • LOCAL ADAPTATION SYNDROME- responds to stress at a particular body organ
    • Sympatho-adreno-medullary response- SNS stimulated( norepinephrine release) and Adrenal Medulla (epinephrine And NE)
    • adreno-cortical response
    • stressors (HYPOGLYCEMIA)-hypothalamus-anterior pituitary(adrenal cortex)-GMA
    • Neurohypophyseal response
    • Blood loss-hypothalamus-PPG-ADH-decrease U/O-oliguria and conservation of circulating volume-prevention of hypovolemic shock
    • Inflammants- cause of inflammation
    • Neutrophils- first launch in the site of injury
    • Monocytes- perform phagocytosis in chronic tse.
    • Lymphocytes-responsible for immune response
    • Margination/pavementation- phagocytes line up at the injury sites
    • Chemotaxis- injured site release substances and bring them to the site of injury
    • emigration/diapedesisphagocytosis shift out of the blood vessels
    • REDNESS- first manifestation after injury
    • The primary cause of pain at the injury site- compression of nerve endings by edema fluids
    • First intention: primary union/ healing
    • second intention with tse. Loss; the scarring is greater
    • third intention: surgical closure(tertiary intention)
    • Fever- hypothalamus release interferon to protect from viral invasion- inc. phagocytic activity
    • REDUCE SWELLING- by hot and cold application and levating the extremity to promote venous return
    • Cold application- during 72 hrs.
    • Hot application- after 72 hrs.
    • HEAT APPLICATION-promotes vasodilation-reduces stiffness in joints, relieves edema,promotes muscle relaxation and relieves pain by inc. bld. Flow to an area.
    • COLD APPLICATION-vasoconstriction- controls bleeding,numbs the nerve endings and has a local anesthetic effect,
      • Dec. cellular metabolism,relieves edema and slows bacterial growth
      • Heat application-usually requires DOCTORS order
      • Heat and cold application- is done in 30 mins. At max. 7 average of 15-20 mins. > 30 mins. Is rebound effects
      • Check application q 15-20 mins
    • Heat cradle & HEAT LAMP- <25 watts & positioned @least 18” away from the sit to be treated if 40 watts bulb is used, inc. the distance to 24”
    • apply topical med. After the tx
    • Hot water bag- temp. of water is <125F, fill only the bag to ½ to 2/3 full and expel the air, hold it upside/down
    • Warm soak- the temp. of water should be 105-115F
    • SITZ BATH or HIP BATH– SOAK up the pelvic area, the temp. of water should be 105-115F check the BP and PR before and after 5 mins. w/c result to dizziness and or fainting, it promotes vasodilation and thus causing dizziness and fainting
    • ICE COLLAR- neck application of crushed ice, fill ½ or 2/3 full
    • Ice cap-fill the bag 1/3 full application over the chest & ½ full over the abd.
    • 3 levels of prevention:
      • Primary: health promotion & health protection (immunization)
      • Secondary: early detection &prompt tx (reg. pap smear test & monthly BSE)
      • Tertiary: rehab.(attend self-mgt educ for diabetes)
    • ENHANCE PEOPLE QLTY. OF LIFE- nsg. Activities in health promotion
    • Accident prevention prog.- for coy. Nses.
    • Coordinating health educ.-primary purpose of health promotion
    • Knowledge on ill effects of smoking-strong way to quit smoking
    • Smoking cessation prog. Is more likely be successful-if intervention focuses on the behavior most concern
    • Behavior change- is the key to effective health educ.
    • The PHN should be a model of health-as an effective health promoter
    • REHAB-begins when a pt is admitted to hosp.
    • Self-responsibility-is imp. When implementing health promotion plan
    • Pt shoud be MOTIVATED- as best result in rehab
    • Adaptability-involves ADJUSTMENT on what the nse says
    • COMMUNICATION-is the basic component of human relationship & nse-client relationship
    • NONVERBAL COMM. Is more accurate expression than verbal comm.
    • In nonverbal-consider CULTURAL influences
    • Effective comm.- is a reciprocal interaction
    • TRUST- is the foundation of NSE-PT RELATIONSHIP
    • COVERT COMM. –inner feelings and VALIDATION is most effective skill
    • Nursing audit-monitor the qlty. of care received by the client and competence of health care givers
      • 1. SOURCE ORIENTED MEDICAL RECORD-traditional client record 5 components: admission sheet; physician’s order sheet; medical hx sheet,nse’s notes,labs,dx findings, V/S,I/O
      • 2.PROBLEM ORIENTED MED. RECORD-DATA PROB. 4 components: data base,prob. List,soapie,flowsheets and discharge notes or referral summaries.
    • LEARNING-a change in human disposition or capabilty that persist over a period of time
    • Theories of learning-humanism=natural of people to learn,cogniitism=is a complex cognive act.(LEWIN)
    • Behaviorism-transfer of knowledge if the new situation closely resembled the old situation
    • DOMAINSof LEARNING- cognitive(technical skills),affective(feelings);psychomotor(motor skills) e.g self monitoring bld. Glucose
    • Trust & respect basically the key in teaching and success in learning
    • The pt. may test the nse. B4 establishing full trust.
    • Brevity and accuracy , appropraiteness & chronology- are qlties. Of a good recording
    • Demonstration-best way in teaching a client for self-injection
    • Growth-facilitating- most imp. Char. In nse-pt relationship
    • Read the reading material for it’s clarity and accuracy
    • Many elderly pt. need support in maintaining independence
    • Notify the Dr.-if the pt. request for discharge
    • Active listening is better than observation
    • LYDIA HALL-(1955) originated the term nsg. Process (Organized,systemic,goal oriented and humainstic care)
    • If the pt. feels dyspneic and SOB-position orthopneic
    • BODY TEMP. – the bal. b/w the heat produce and lost
    • CORE temp.-deep tse.
    • SURFACE temp. –skin,SQ and fat
    • Normal body temp.-36.7c-37C(98.6F
    • The younger the person the higher the BMR
    • SNS- epi., NE=inc. cellular metabolism
    • ELDER people are at risk for HYPOTHERMIA-because of dec. thermoregulatory controls,dec. SQ fats and sedentary act.
    • Diurnal variations-highest temperature is between 8:oo P.M to 12:00 MN and the lowest tempeature is between 4:00 to 6:00 AM
    • ESTROGEN decrease body temperature
    • PROGESTERONE,EPINEPHRINE,NOREPI,THYROXINE-increase the body temperature
    • SNS stimulation-stimulated the release of NOREPI and EPI
    • PYREXIA-body temperature above the normal range
    • HYPERPYREXIA-very high (41 C)
    • INTERMITTENT fever-on and off fever;
    • REMITTENT fever-fluctuation above the normal range in 24 hours
    • RELAPSING fever-the temperature is elevated for few days.altered with 1 to 2 days of normal temperature
    • CONSTANT fever- BT is very high >41-42C
    • CRISIS-sudden decline of fever while LYSIS-gradual decline
    • Clinical signs off fever-ONSET (chills and shiver),COURSE (no chills)
    • and DEFERVESCENCE 9 skin that appears warm and flushed
    • TSB-temperature of water is between 80-90 or 26.7C –36.7 allow 15 minutes to elapse before getting temperature after hot or cold food or smoking
    • ORAL temp-most accessible and convenient
    • RECTAL temp- most accurate
    • AXILLARY temp-safest and non –invasive (9 mins in adult and 5 minutes in infants)
    • DEHYDRATION-lead to increase in body temperature
    • PULSE-is a wave of blood created by the LEFT VENTRICLE of the heart.it is regulated by the ANSs
    • Younger person has a higher pulse rate than elder ones after a puberty,females have a higher pulse rate than males
    • DIGITALIS,BETA BLOCKERS-decrease pulse rate and EPINEPHRINE and ATROPINE SO4 increase pulse rate
    • HEMORRHAGE-increase pulse rate ascompensatory mechanism
    • Decrease BP-increase HR,in sitting / standing position venous return decresed and decrease BP and increase HR
    • HTN-respi acidos because the respi rate becomes slow and HPN
    • Volume (amplitude)-the strength of the pulse
    • Costal (chest movement) and diagphragmatic (abdominal)-breathing
    • Medulla oblangata-is the PRIMARY CENTER of respiration
    • PONS-responsible in the rhythmic quality of the breathing
    • DEPTH-deep and shallow
    • Inc. temp. dec. RR
    • Hyperventilation- deep and prolonged resp. (resp. alk)
    • Hypoventilation- slow and shallw resp.(resp acidosis)
    • Orthopnea-ability to breath only in upright position
    • BP=C.O x total peripheral resistance
    • Systolic pressure-contraction of the ven tricles
    • Diastoilc pressure- ventricle are at risk
    • Dec. C..O-dec. BP
    • Older client-dec elasticity of the vessels thereby inc BP
    • Bld. Viscosity- inc when the hct is more than 6o-65% and it raises the BP
    • After age puberty and b4 65 y/o-makes have higher BP
    • After age 65y/o-due to hormonal change/variations Female has a higher BP
    • Diurnal Variation-BP is lowest in the morning and highest in the p.m early
    • Position pt in SUPINE or sitting position while taking BP
    • The systolic pressure is usually higher in popliteal artery at 10-40 mmHg than brachial artery.the diastolic is the same
    • Horizontal recumbent-back lying and legs extended w/ small pillow on the head
    • Dorsal rec. is also called a supine –back lying
    • Prone- face lying w/ the haed turn to side
    • genupectoral-/knee chest-90 deg. Angle to hips in kneeling poition
    • I-Am-Pe-Pa in abdomanal assessment.other ass. follows;:I –Pal-Per-Aus
    • Sequence in abdominal ass: RLQ-RUQ-LUQ-LLQ
    • Best position in examining the chest-sitting or upright –to assess anterior and posterior chest
    • Best position in examining the back-standing position- to assess the posture and gait of the client
    • Palpate the neck for lYMPHADENOPATHY-nse stands at the back of the client
    • If OPTHOLMOSCOPY is done-darken the rm for better illumination
    • If a male Dr. examine a female client-a female nse/attendant must be present
    • Is the instrument for vaginal exam is done-pour warm water over the speculum before use
  • Pulmonary fxn studies
    • Ventilatory studies-use of incentive spirometer to determine how well the lung is ventilating
    • Vital capacity(VC)- largest amt of air that can be expelled after maximal inspiration
    • Normal=4000-5000 mL
    • dec.-indicate lung dse.
    • inc. or dec. =indicate chronic obstructive lung des.
    • 2. forced expiratory vol.(FEV)- percentage of vital capacoty that can be forcibly expired in 1,2,or 3 sec.
      • Normal+80-83% in 1 sec
      • 90-94% in 2 sec
      • 95-97% in 3 sec.
      • Dec.= indicate expiratory airway obstruction
  • Sputum collection
    • 1. gross sputum evaluations- collection of sputum samples tp ascertain quantity,consistency, color and odor
    • 2.sputum smear-sputum is smeared thinly on a slide so that it can be studied microscopically.
    • used to determine cytological changes or presence of pathogenic microorganism
    • Sputum culture-sputum samples are implanted or inoculated into special media
    • used to diagnosed pullmonary infection
    • Gastric analysis- aspiration of the contents of the fastinfg stomach analysis of free and total acid
    • Gastric acidity inc.: duodenal ulcer
    • Gastric acidity dec.; pernicious anemia CA of the stomach
  • Glucose testing
    • -to detect disorder of glucose metabolism, such as diabetes
    • FBS-bld. Sample is drawn after a 12 fast(usually midnight).water is allowed.
    • normal bld. Glucose : 60-120mg/dl
    • diabetic client: 126mg/dl
    • 2. 2hr. Postprandial (PPBS)- bld is taken after meal
      • Pt.’s prep:
        • Offer a high CHO diet for 2-4 days testing
        • Pt. fast overnight
        • Eats a hgh CHO breakfast
        • Bld. Sample is drawn 2 hr interval
        • No cigarette smoking and caffeine for thsese may inc. glucose level
    • Uterotubal insufflation(Rubin’s test)- injection of carbon dioxide into the cervical canal.
    • used to determine fallopian tube patency
    • Parecentesis- after the procedure: observe for signs of hypovolemic shock- may occur due to fluid shift from vascular compartment following removal of protein- rich ascitic fluid
    • Renal angiogram-small catheterbis inserted into the femoral Artery and passed into the aorta or renal artery radiopaque fluid is instlled, and serial films are taken
    • used to diagnosed renal HPN and pheochromocytoma and differentiate renal cyst from tumors.
    • Post angiogram nsg actions.
    • 1.check pedal pulse for signs of dec. circulation
    • BRONCHOSCOPY-introduction of a fiberoptic scope into the trachea and bronchi
    • -used to inspect tracheobronchial tree for pathological changes,
      • Remove foreign bodies or mucous plugs cAusing airway obstruction,and apply chemotherapeutic agents.
      • A. prebronchoscopy interventions:
      • oral hygiene
      • postural drainage as indicated
      • b. postbronchoscopy interventions:
      • -instruct pt. not to swallow oral secretions
        • Save expectorated sputum for lab analysis
        • NPO tll gag reflex returns
        • Observe for SQ emphysema and dyspnea
        • Apply ice collar to reduce throat discomfort
  • Specimen collection
    • 1. clean catch/midstream urine specimen-for culture and sensitivity test and routine u/a
    • -do perineal care b4 collection to reduce microorganism at external genitalia
    • -discard the first flow to ensure it is uncontaminated
    • COLLECT tHE MIDSTREAM: 30-50mL for routine U/A & 5-10mL for C/S
    • -discard the last flow of urine in MALES- maybe contaminated by semen
    • 2.24hrs specimen- for kidney fxn
    • -discard the first voided,start collecting to the next void of the day and cont. to collect until the next day at the same time
    • -soak specimen in a container w/ ice
    • 3.Second-voided urine
    • -discard the first voided- give the pt. one glass of water-after few mins. Ask the pt to void again and collect the specimen
    • -this type of specimen-to test for glucose in urine
    • 4. catheterized urine specimen-clamp the catheter for 30 mins- 1 hr.
    Test Indiaction Antigen skin Test to rule out cancer of the lungs Benedict’s test For glucose monitoring
  • Bentonite flacculation test Test for filiariasis Beutler’s test Test for galactosemia Blanching test Determines the impairment in circulation Bronsulpthlein test Liver angiography Caloric test Test done by placing water in the ear canal causes nystagmus. A test for inner ear
  • Cd4 determination Checking the immune status to AIDS pt Cerebral perfusion test Test used to check the cerebral fxn Coomb’s test Determines the prod. Of the antibodies. RhoGAM is given (1 st &@ hrs CPK BB Test for brain muscles CPK MB Test for cardiac muscles for MI CPK MM Test for muscle injury
  • Dark field illuination test and kalm test Determination for the presence of syphilis Dick test Detect scarlet fever Doll’s eye test Determines the presence .of blindness. Done in 1 st ten days (+) normal (-) abnormal ELISA Test Determines presence of HIV Gram staining& culture of cervical &urethral smear Determination for the presence of gonorrhea Gross hearing test Test used by whispering words or spoken voice test
  • Guthrie test Test for PKU Heat and acetic acid test For protein or album detection Immunochromatographic test A rapid assessment method done for filariasis. The antigen test that can be done at daytime Jones criteria One way of diagnosing Rheumatic heart fever Lepronin test A screening test for leprosy Liver enzyme test For SGOT & SGPT Liver profile test Determines hepa B surface antigen
  • Lumbar puncture Determines for the presence of meningitis &encephalitia.position in side lying Malaria smear Test to confirm malaria;specimen is taken 2 the lht. Or peak of fever Mantoux test Determinetion for TB exposure Menire’s test Test vestibular fxn Methylene blue test For ketone detection Moloney test Hypersensitivity test for diphtheria
  • Oxytocin challenge test Determine if the fetus can tolearte uterine contraction Pandy’s test Determine the presence of protein in the csf Phenosulpthalein test Kidney angiogram Queckkenstedt’s Test the compression of jugular vein Rectal swab Done in pt. w/ cholera.pinworm detection Rinne test Shifted b/w mastoid bone & 2” from the ear canal opening
  • Romberg’s test Assess gait & station such as ataxia Schick test Susceptibility test for diphtheria(+) no immunity(-) w/ immunity Schiller’s test Staining the cervix w/ an iodine sol.. Healthy tses. Will turn brown while cancerous tse resist tha stain Schilling test Used to pt w/ severe chilling sensation; for confirmation of pernicious anemia Schwabach test Differentiate b/w conductive & sensorineuraldeafness, mastoid of pt and examiner Shake test Determines jthe amt of surfactant in tha lungs
  • Skin test Purpose it to produce antigen reaction Slit skin smear A confirmatory test for leprosy Specific gravity test FOR DM & DI as well as for dehydration Sperm count test For male infertility(Low spermlow sperm count –OVERSEX!) Sputum exam For detection and sensitivity of causative microorganism, for pneumonia and TB Sulkowitch test Urine test detection for Ca deficiency an Ca in the urine
  • Sweat chloride test Used to diagnose cystic fibrosis Tensilon (endophonium) test For rapid detection of MG Tonometer Test used to measure ocular tension & helping in detecting early glaucoma N=12-20mmHg Tournuquet test Done to determine presence of petechiae in DHF
  • TZANK test Determination for the presenceof herpes simplex Weber test Evaluation of bone conduction. Tuning fork is placed on pt.’s forehaed or teeth Widal’s test For typhoid fever determunation Western blot test A confirmatory for aids
    • Cardiac catheterization – insertion of a radiopaque catheter into a vein to study the heart great vessels.
    • - Used to confirm diagnosis of heart disease and determine extent of disease, measure pressures in the heart chamber and great vessels, obtain estimate of cardiac output, and obtain blood samples to measure oxygen content.
    • a. Right heart catheterization – catheter is inserted through a cut-down in the antecubital vein into the superior vena cava, through the right atrium and ventricle and into the pulmonary activity.
    • b. Left-heart catheterization- catheter maybe passed retrograde to the left ventricle through the brachial and femoral artery, it can be passed through the left
    • atrium after right-heart catherization by means of a special needle that punctures the septa; or it may be passed directly into the left ventricle by means of a posterior puncture.
    • Specific nursing considerations:
    • 1. Preprocedure patient teaching:
    • a. Fatigue is a common complaint due to lying still for 3 hr
    • b. Feeling of fluttery sensation while the catheter is passed back into the left ventricle
    • c. Flushed, warm feeling may occur when contrast medium is injected.
    • 2. Postprocedure observations:
    • a. monitor ECG pattern for arrhythmias
    • b. check extremities for color and temperature, peripheral pulses for quality.
    • 3. Angiography (Arteriography) – injection of a contrast medium in to the arteries to study the vascular tree.
    • -Used to determine obstructions or narrowing of peripheral arteries
    • Catheterized urine specimen  clamp the catheter for 30 minutes to 1 hour
          • Clean the drainage port with alcohol/cotton swab
          • DONT’S: collect the urine from the urinary drainage bag and detach it from the bag
          • NOTE: introduce the needle diagonally to allow self sealing of the rubber material of the catheter.
    • Benedict’s test: test for glucose
    • Collect urine before meals
    • Put 5 ml of solution in the test tube
    • Heat ht Benedict’s solution ( if color change it is contaminated)
    • Add 8-10 drops of urine
    • Heat the benedict’s solution with urine ( do not boil)
    • Blue (-) , green ( +) ; yellow ( ++) ; orange ( +++) and red ( ++++)
    • Clinitest  test for glucose
    • collect urine specimen before meals
    • put 1 clinitest tablet in a test tube
    • add 5 drops of urine and 10 drops of water
    • compare with the standard of color inn the chart
    • HEAT and ACETIC ACID  test for the albumin in the urine; collect urine before meals
    • Divide the test tube in 3 parts (imaginary)
    • PUR 2/3 PARTS of urine in the test tube and 1/3 acetic acid ( DONOT HEAT because it may explodes)
    • ROUTINE ANALYSIS  to asses gross appearance and presence of ova / parasites ; use tounge depressor in collecting ; collect one teaspoon or 1 inch well formed stool. Allow the patient to void first , discard and wash the bedpan. Label it and send immediately to lab  warm specimen helps detect ova and parasite
    • STOOL C & S  for Gastroenteritis and bacterial sensitivity to various abx; use test tube and cotton-tipped applicator
    • GUAIAC STOOL  occult blood determination  provide hgb-free diet for 3 days ( no meat for 3 days) ; discontinue IRON therapy ; (+) means PUD and gastric CA
    • SPUTUM SPECIMEN  collect in the morning ; rinse mouth with water only, no stringent or mouthwash . ensure pt deep breath and hack up sputum
    • C&S sputum  for respi disease ; collect it before the first dose of antimicrobials
    • AFB staining  to asses presence of ACTIVE PTB ( collect sputum for 3 consecutive morning)
    • CYTOLOGIC/PAPANICOLAU  to assess the CA cells
    • BLOOD SPECIMEN for FASTING  collect before meals in finger pin pricks ; insulin injecton should be administered before meals
    • Palms down in taking the radial pulse
    • STRESS is the primary factor that affects BP
    • BROMHIDROSIS  foul smelling perspiration
    • In doing tracheostomy  keep AMBUBAG at the bedside:
    • Shallow suctioning  3 inches
    • Deep suctioning  5-6 inches