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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:
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 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.
Romberg’s test a test used by doctors: a .neurological examination, and also as; b. test for drunken driving.
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.
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
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.
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.