rationale - june 2004
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rationale - june 2004 rationale - june 2004 Presentation Transcript

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    Schizoid – withdrawn, “baduy”, introvert, aloof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