rationale for june 2004 PNLE

1. RATIONALE by: Randel C. Dalauta, RN www.nursendoutfield.blogspot.com

2. 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

3. 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

4. Progesterone- hormone of pregnancy Estrogen- hormone of menstruation FSH- ripening and maturation of Ovary LH- hormone of ovulation HCG- sustain pregnancy

7. growth of testes

8. growth of hair face, axilliary & pubic hair

9. voice changes

10. penile growth

11. increase in height

13. Increase transvers diameter of pelvis

14. Breast development

15. Growth of pubic hair

16. Onset of mens

17. Growth axilliary hair

19. 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mutilation Anti Social - habitual break of law, no guilt Dependent- demand for attention,low confidence Schizoid – withdrawn, “baduy”, introvert, aloof Schizotypal- low social skills, odd, eccentric Histrionic – “KSP”, attention seeker, extrovert Avoidant – fear of criticism, fear of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

21. CHEESE

22. MEAT

23. NUTS

24. LEGUMES

25. GREEN LEAFY VEGETABLES

27. 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

29. VITAMINS

32. TETANUS TOXOID VACCINE

33. 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)

34. TETANUS TOXOID VACCINE

37. Acute Pancreatitis

38. Hip Replacement

39. Compartment Syndrome

40. Pinpoint Hemorrhage

41. Laryngeal Diphtheria

43. Pregnancy Induced Hypertension

44. Lithotripsy

46. 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

47. Prioritization SAFETY NUTRITIONCIRCULATIONSocial initiation ADHDCatatonicRestraintRape Victim Suicidal Depressed Catatonic Battered Wife ManicAlcoholic Abused Child AlzheimersAnorexia Crisis Manic Dementia Delirium

49. Antedote: Mannitol(diamox)

50. Toxicity: NAVDA – early s/sx + Tremors – late sign

51. 2-3 - intake of Na/day - OFI/day (liters) - Onset of effect(weeks) - Checking – admission-2-3x/week - discharge – 1x/mos.

54. AVERSION therapy

55. Avoid:Mouth Wash OTC Food suaces made of wine Fuit flavored extracts Aftershave lotions Vinegar Skin products

57. CHF

59. 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.

60. Rule of 9

61. HEMOVAC

63. 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)

64. www.nursendoutfield.blogspot.com

65. The END