RATIONALE<br />by: Randel C. Dalauta, RN<br />www.nursendoutfield.blogspot.com<br />
Diagnosis<br />(breakdown and putting together)<br />Analysis (breakdown)<br />Synthesis (putting together)<br />Problem i...
IPPA<br />Inspection<br />- cephalocaudal: adults<br />		- proximo-distal: child<br />Palpation<br />- light: 1-2 cm<br />...
Progesterone- hormone of pregnancy<br />Estrogen- hormone of menstruation<br />FSH- ripening and maturation of  Ovary<br /...
Secondary Sex Characteristics in Order of Onset<br />Male<br /><ul><li>increase  weight
growth of testes
growth of hair face, axilliary & pubic hair
voice changes
penile growth
increase in height
spermatogenesis</li></ul>Female<br /><ul><li>growth spurt
Increase transvers diameter of pelvis
Breast development
Growth of pubic hair
Onset of mens
Growth axilliary hair
Vaginal secretions</li></li></ul><li>Progesterone- hormone of pregnancy<br />Estrogen- hormone of menstruation<br />FSH- r...
   Personality Disorders<br />Borderline-chronic fear of emptiness,self mutilation       <br />Anti Social  -  habitual br...
PHOSPHORUS<br /><ul><li>MILK
CHEESE
MEAT
NUTS
LEGUMES
GREEN LEAFY VEGETABLES
WHOLE GRAIN CEREALS</li></li></ul><li>Recommended Weight Gain during Pregnancy<br />Ist trimester – 2 to 4 lbs.<br />   2n...
Danger Signs of Pregnancy<br /> S welling of face,finger,legs<br /> Headache, continous & severe<br />Abdominal/chest pain...
VITAMINS<br />
           TETANUS TOXOID VACCINE<br />
   Post-Partum Phase<br />Taking-In      =  focus on “SELF”   <br />		     =  PASSIVE & Talkative<br />		     =  Dependenc...
           TETANUS TOXOID VACCINE<br />
Acute Pancreatitis<br />
Hip Replacement <br />
Compartment Syndrome<br />
Pinpoint Hemorrhage<br />
 Laryngeal Diphtheria<br />
           Pregnancy Induced Hypertension<br />
  Lithotripsy<br />
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rationale - june 2004

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rationale - june 2004

  1. 1. RATIONALE<br />by: Randel C. Dalauta, RN<br />www.nursendoutfield.blogspot.com<br />
  2. 2. Diagnosis<br />(breakdown and putting together)<br />Analysis (breakdown)<br />Synthesis (putting together)<br />Problem identification<br />formulation of nursing diagnosis<br />Assessment <br />(gathering)<br />Observation <br />Interview & Interaction<br />Examination & measurement<br />Planning<br />(laying out)<br />Setting priorities<br />Establishing goals and objective<br />Planning intervention<br />Implementation<br />(execution)<br />Executing the planned intervention<br />Validating care plan<br />giving/ documenting care<br />Continuing data collection<br />Evaluation<br />(measuring and re-assessment)<br />Comparison of clients status with expected outcomes<br />
  3. 3. IPPA<br />Inspection<br />- cephalocaudal: adults<br /> - proximo-distal: child<br />Palpation<br />- light: 1-2 cm<br /> - deep: 4-6 cm, not beyond 10 cm<br />Percussion<br />- direct: plexor<br /> - indirect: pleximeter and plexor<br /> - blunt: wider (kidney punch)<br />Auscultation<br />
  4. 4. Progesterone- hormone of pregnancy<br />Estrogen- hormone of menstruation<br />FSH- ripening and maturation of Ovary<br />LH- hormone of ovulation<br />HCG- sustain pregnancy <br />
  5. 5.
  6. 6. Secondary Sex Characteristics in Order of Onset<br />Male<br /><ul><li>increase weight
  7. 7. growth of testes
  8. 8. growth of hair face, axilliary & pubic hair
  9. 9. voice changes
  10. 10. penile growth
  11. 11. increase in height
  12. 12. spermatogenesis</li></ul>Female<br /><ul><li>growth spurt
  13. 13. Increase transvers diameter of pelvis
  14. 14. Breast development
  15. 15. Growth of pubic hair
  16. 16. Onset of mens
  17. 17. Growth axilliary hair
  18. 18. Vaginal secretions</li></li></ul><li>Progesterone- hormone of pregnancy<br />Estrogen- hormone of menstruation<br />FSH- ripening and maturation of Ovary<br />LH- hormone of ovulation<br />HCG- sustain pregnancy <br />
  19. 19. Personality Disorders<br />Borderline-chronic fear of emptiness,self mutilation <br />Anti Social - habitual break of law, no guilt <br />Dependent- demand for attention,low confidence <br />Schizoid – withdrawn, “baduy”, introvert, aloof <br />Schizotypal- low social skills, odd, eccentric <br />Histrionic – “KSP”, attention seeker, extrovert<br />Avoidant – fear of criticism, fear of rejection<br />Paranoid– mistrust is high, suspicious<br />Passive-Aggressive <br />Emphatic Narcissistic – self-love, believe he’s special<br />Obsessive compulsive- high devotion to work<br />
  20. 20. PHOSPHORUS<br /><ul><li>MILK
  21. 21. CHEESE
  22. 22. MEAT
  23. 23. NUTS
  24. 24. LEGUMES
  25. 25. GREEN LEAFY VEGETABLES
  26. 26. WHOLE GRAIN CEREALS</li></li></ul><li>Recommended Weight Gain during Pregnancy<br />Ist trimester – 2 to 4 lbs.<br /> 2nd trimester – 11 – 14 lbs.<br /> 3rd trimester – 8 – 11 lbs. /<br /> 0.5 lb weekly<br />
  27. 27. Danger Signs of Pregnancy<br /> S welling of face,finger,legs<br /> Headache, continous & severe<br />Abdominal/chest pain<br />Vaginal bleeding<br />Vomiting, persistent<br />Visual changes<br />E scape of vaginal fluids<br />
  28. 28.
  29. 29. VITAMINS<br />
  30. 30.
  31. 31.
  32. 32. TETANUS TOXOID VACCINE<br />
  33. 33. Post-Partum Phase<br />Taking-In = focus on “SELF” <br /> = PASSIVE & Talkative<br /> = Dependency<br /> ( 1 – 2 days after delivery )<br />Taking-Hold = focus on the “NEONATE”<br /> = ACTIVE -show interest in caring for the baby<br /> ( 3 days)<br />Letting-Go = redefines her new role<br /> = assuming new role<br /> (5 – 6 weeks)<br />
  34. 34. TETANUS TOXOID VACCINE<br />
  35. 35.
  36. 36.
  37. 37. Acute Pancreatitis<br />
  38. 38. Hip Replacement <br />
  39. 39. Compartment Syndrome<br />
  40. 40. Pinpoint Hemorrhage<br />
  41. 41. Laryngeal Diphtheria<br />
  42. 42.
  43. 43. Pregnancy Induced Hypertension<br />
  44. 44. Lithotripsy<br />
  45. 45.
  46. 46. Personality Disorders<br />Borderline-chronic fear of emptiness,self mutilation <br />Anti Social - habitual break of law, no guilt <br />Dependent- demand for attention,low confidence <br />Schizoid – withdrawn, “baduy”, introvert, aloof <br />Schizotypal- low social skills, odd, eccentric <br />Histrionic – “KSP”, attention seeker, extrovert<br />Avoidant – fear of criticism, fear of rejection<br />Paranoid– mistrust is high, suspicious<br />Passive-Aggressive <br />Emphatic Narcissistic – self-love, believe he’s special<br />Obsessive compulsive- high devotion to work<br />
  47. 47. Prioritization<br />SAFETY NUTRITIONCIRCULATIONSocial initiation<br />ADHDCatatonicRestraintRape Victim<br />Suicidal Depressed Catatonic Battered Wife<br />ManicAlcoholic Abused Child<br />AlzheimersAnorexia <br />Crisis Manic<br />Dementia<br />Delirium<br />
  48. 48. Lithium (anti-manic)<br /><ul><li>Level: .5-1.5
  49. 49. Antedote: Mannitol(diamox)
  50. 50. Toxicity: NAVDA – early s/sx + Tremors – late sign
  51. 51. 2-3 - intake of Na/day</li></ul> - OFI/day (liters)<br /> - Onset of effect(weeks)<br /> - Checking – admission-2-3x/week<br /> - discharge – 1x/mos. <br />
  52. 52.
  53. 53. Disulfiram (Antabuse)<br /><ul><li> given 8 -12 hrs after last alcohol intake
  54. 54. AVERSION therapy
  55. 55. Avoid:</li></ul>Mouth Wash<br />OTC<br />Food suaces made of wine<br />Fuit flavored extracts<br />Aftershave lotions<br />Vinegar<br />Skin products<br />
  56. 56.
  57. 57. CHF<br />
  58. 58.
  59. 59. The Incident Report<br />Identify the client by name, hospital or id number<br />Give the date, time, and place of the incident.<br />Describe the incident as one saw it, avoid blame or conclusion.<br />Incorporate the client’s account of the accident, use direct qoutes.<br />Identify all witnesses to the incident.<br />Identify any equipment by number and any meds by name and dosage. <br />
  60. 60. Rule of 9<br />
  61. 61. HEMOVAC<br />
  62. 62.
  63. 63. Blood Transfusion<br />Use gauge 18<br />Normal saline to be used (the only compatible)<br />Vital signs prior a must (temperature)<br />Two nurses to verify client identification<br />KVO rate for first fifteen minutes <br /> (prevent abrupt hypersentivity reaction)<br />Stay with the client for the first 15 minutes (usual onset of reaction)<br />STOP if with reaction<br />Four hours to infuse (risk for hyperkalemia)<br />
  64. 64. www.nursendoutfield.blogspot.com<br />
  65. 65. The END<br />
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