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fundamental rationalization

fundamental rationalization

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Funda Post Test Funda Post Test Presentation Transcript

  • By: RandelDalauta, RN
    www.nursendoutfield.blogspot.com
  • Nurse Maria Olivia engages in activities of teaching a client to protect an incision and change a surgical dressing and assisting handicapped individuals to attain the highest level of physical strength to which they are capable. Olivia’s health care activities focuses on:
    Nursing action help client maintain health status
    Helping people improve following a health problem or illness
    a. Health maintenance
    b. Health restoration
    Develop resources to maintain well being
    c.Health promotion
    d. Health care of the dying
    Hospice care
    (comfort & Caring
  • 2. Nurse Supervisor jacqueline assigns Nurse Abegail to give comprehensive care to a group of maternity clients with pregnancy induced hypertension during her 8 hours shift. The model for the delivery of nursing care as exemplified in this situation is:
    Advantages:
    • Nurse assumes a responsibility
    for a certain task
    • Task focused; not client focused
    • Nurse is highly competent w/ less
    complex care requirements
    Disadvantage:
    • Fragmentation of care
    “24/7 care or 1 on 1”
    • 1 nurse responsible for total care of
    client
    • solely accountable & responsible
    • role of other nurse: continue plan
    made by the main nurse during
    break/off
    “client centered”
    Advantages:
    • Case focused
    • Care from admission to discharge
    • Classification of cases handled
    a. with specific physician
    b. geographical proximity to unit
    c. by diagnosis
    Disadvantage:
    • discrimination of care
    a. Functional Method
    b. Primary nursing
    c.Case Method
    “collaboration”
    • solution to functional nursing
    • individualized care by team,members:
    a. RN-head c. Nurse aid
    b. Practical Nurse
    Disadvantage: team lacks qualified personnel, always require supervision;
    Also non continuity of care
    d. Team Nursing
  • “Doctrinal Conversion Model”(Davis 1966)
    I. Initial Innocence
    II. Labeled recognition of incongruity
    - identify, articulate & share concerns
    III. “Psyching out” and role simulation
    - identify behavior expected to demonstrate
    IV. Increasing role simulation
    Provisional Internalization
    - choose between previous & current
    VI. Stable Internalization
    - behavior reflects educational &professional approved
    model
  •  Nursing Roles
    Can’t
    Catch
    The
    Cat
    Coz
    Catwoman
    Loves
    Me,
    Run
    Cat
    Cat!”
    Care Giver
    Communicator
    Teacher
    Councilor
    Client’s Advocate
    Change Agent
    Leader
    Manager
    Researcher
    Case Manager
    Collaborator
  • Nursing Theorist
    FLORENCE NIGHTINGALE
    “Environmental Adaptation Theory”
    “21 Nursing Problems”
    FAYEGLENN ABDELLAH
    “14 Basic Needs”
    HENDERSON, VIRGINIA
    “Behavioral Systems Model”
    DOROTHY E. JOHNSON
    “Goal Attainment Theory”
    IMOGENE KING
    “Trans-cultural Nursing”
    MADELEINE LEININGER
    MYRALEVINE
    “Four Conservation Principles”
    BETTY NEUMAN
    “Health Care Systems Model”
    “Self Care Theory, Self Care Deficit Theory”
    DOROTHEA OREM
  • Nursing Theorist
    IDA JEAN ORLANDO
    “Nursing Process Theory or Dynamic Nursing”
    “Helping Art Theory of Clinical Nursing”
    ERNESTINE WEIDENBACH
    “Human Caring Model”
    JEAN WATSON
    “Interpersonal Model”
    HIDELGARD PEPLAU
    “ Science of Unitary Human Being”
    MARTHA ROGERS
    “Adaptation Model”
    SISTER CALLISTA ROY
    LYDIA HALL
    “Care, Core, Cure Theory”
    ROSEMARIE RIZZO PARSE
    “Theory of Human Becoming”
    “Stages of Nursing Expertise/Novice to Expert”
    PATRICIA BENNER
  • Models Of Health
    1. Clinical Model (smith) – health is absence of signs &
    symptoms of disease or injury
    2. Ecological Model (leavell & clark’s) – relationship of
    humans to the environment
    3 elements
    a. the host
    b. the agent
    c. the environment
    3. Role Performance Model (smith) – ability to fulfill
    societal roles even if clinically ill
    (parsons)-state of optimum capacity for the effective
    performance of roles & task
    illness – inability to perform one’s work
  • 4. Adaptive Model (smith & roy)
    principle: humans are continuously adapting to their
    environment
    - disease is a failure in adaptation
    5. Eudaemonistic Model (maslows)
    - health is a condition of actualization/realization of person’s potential
  • Stages of Illness (suchman)
    Symptom Experiences – starts to believe something is wrong
    Assumption of the Sick role – acceptance of sick role, Seek help signs and symptoms is real
    Medical Care Contact – seek professional advice, assurance one is alright
    4. Dependent Patient Role – client becomes dependent on professional help,Regression
    5. Recovery and Rehabilitation – gives up sick role and return to former old self.
  • Blood pressure
  • Blood pressure
    Facts:
    Position arm at heart level, extend elbow with palm turned upward
    Apply cuff snugly and smoothly over upper arm, 2.5 cm (1 inch) above ante-cubital space with center of cuff over brachial artery
    Inflate cuff to 30 mm Hg above point where palpated pulse disappears
    Deflating cuff at a rate of 2–3 mm Hg per second, noting reading when pulse is felt again and when it finally disappears
    Remove cuff or wait 2 minutes before taking a second reading
    Do not take an apical blood pressure on an arm with an AV shunt, IV, or if the client has a history of surgery or injury to the breast, axilla, or arm.
    Length of bladder should long enough to cover at least 2/3 of limbs
    Width of cuff must be 40% of the limbs circumference
  • Blood pressureSelected Sources of Error in Blood Pressure Assessment
  • Otoscopic Examination
    Purpose: a procedure that
    a. examine the auditory canal and tympanic membrane for infection
    b. examine for blockage due to the presence of a foreign object or build up of wax
    c. for the tympanic membrane for signs of rupture, puncture, or hearing loss,
    d. the canal for any variations from normal. Note: some otoscopes can deliver a small puff of air to the eardrum to determine if the eardrum will vibrate (which is normal)
    Preparation?
    No Preparation Required
    Normal:
    Auditory canal: Some hair, often with yellow to brown cerumen.
    Ear drum: 
    Pinkish gray in color , translucent and in neutral position. 
    Malleus lies in oblique position behind the upper part of drum.
    Mobile with air inflation.
  • Breast
  • Romberg’s test
    a test used by doctors:
    a .neurological examination, and also as;
    b. test for drunken driving.
    • procedure:
    1. patient stands with feet together, and maintains balance with eyes
    open
    2. eyes are then closed.
    3. loss of balance with the eyes closed is a positive, abnormal response.
    • Result findings:
    1. (+) Romberg test suggests that the ataxia is sensory in nature
    2. (-) Romberg test suggests that ataxia is cerebellar in nature
  • Interviewplanned communication or a conversation
    Types:
    a. Directive
    - highly structured
    - elicits specific information
    - nurse establishes the purpose of the interview
    - nurse controls the interview
    - used during limited time (emergency)
    disadvantage: client has limited
    b. Non-directive
    - aka rapport building interview
    - nurse allows the client the purpose, subject matter, & pacing
    most appropriate: combination of both type
  • Blood
    Albumine 3.5-5 g/dl
    COP – Edema
    H2O 90%
    Globuline
    Antibody Formation
    Plasma 55%
    CHON 10%
    Waste /Electrolytes
    Fobrinogen
    Clotting Factor
    Pro-thrombine
    Blood
    5 L TBW
    Formed
    Elements 45%
    RBC 4.5 – 5.5M/mm
    formation thru Erythropoiesis
    Platelet 150-450T/mm
    role clotting - Hemorrhage
    WBC 5-10T/mm
    immune responses
    Basophils0-1% for inflamation
    1. Granulocytes
    Eosinophils1-6% for allergic rxn
    Neutrophils50-70 1st to arrive
    Monocytes2-6%
    2. Agranulocytes
    T cells
    Lymphocytes 25-25%
    B cells
  • Fluids
    16 % TBW
    Interstitial Fluid
    ECF
    Plasma
    4% TBW
    20% TBW
  • Enema
    Prepare the solution, assure temperature within range of 99° to 102°F by using a thermometer or placing a few drops on your wrist.
    Wash hands and don gloves.
    Assist patient to left side-lying position/sims, with right knee bent.
    Hang bag of enema solution 12 to 18 inches above anus.
    Lubricate 4 to 5 inches of catheter tip.
    Separate buttocks, insert catheter tip into anal opening, slowly advance catheter approximately 4 inches.
    Slowly infuse solution via gravity flow
    If client complains of increased pain or cramping, or if fluid is not being retained, stop procedure, wait a few minutes, then restart
    Clamp tubing when fluid finishes infusing; remove catheter tip.
    Assist client to bedpan, commode, or toilet;
  • Enema
    If “enema till clear” is ordered, no more than 3 L fluid should be administered in any one series of enemas. Repeated enemas produce irritation of bowel mucosa and perianealarea, as well as electrolyte loss and exhaustion. If returns are not clear, consult physician for further instructions.
  • Colostomy
    Normal stoma: red or pink
    - Pale pink
    - Purple-black
    Fecal matter should not be allowed to remain on the skin
    Empty pouch when half to one-third full
    Avoid gas-forming foods
    Avoid irrigating colostomy
  • Colostomy
    Irrigation
    to empty the colon of feces, gas, or mucus, cleanse the lower intestinal tract, and establish a regular pattern of evacuation so that normal life activities may be pursued.
    performed at the same time each day, preferably 1hr after a meal
    lie on side/sit on the toilet itself
    500 to 1500 mL of lukewarm tapwater
    hung 18 to 20 in above the stoma (shoulder height when the patient is seated)
    Insert the catheter no more than 3 inches
    Never force the catheter!
    Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest before progressing.
  • Colostomy
  • Centigrade vs Fahrenheit
    Rule:
    1. Centigrade to Fahrenheit
    multiply by 1.8 and add 32
    2. Fahrenheit to Centigrade
    subtract 32 and divide 1.8
    Solution:
    99.8F = ____C
    (maliit to malaki = multiply & add)
    (malaki to maliit = subtract & divide)
    (99.8 – 32 / 1.8)
    37.7
  • Nasogastric Tube
    Insertion:
    - NEX
    - High Fowler’s position
    - Sips of water and advance tube as client swallows
    - Do not force the tube!
    Confirm placement of NGT
    Monitor and record residual volume q4h by aspirating stomach content with a syringe. A residual volume of >100-150 ml indicates delayed gastric emptying. Notify MD.
    During and after feeding keep HOB 30 degrees to prevent aspiration; For continuous feedings, keep the patient in a semi-Fowler’s position at all times
    Flush/Irrigate tube feeding with 30-60ml of PNSS q4h during continuous feeding, before and after each intermittent feeding, before and after administering meds, after each time you check residual volume
    Feeding set changed q24h. Bag rinsed q4h.
  • QUESTION?