6541999 Fundamentals of Nursing p1

8/10/2019 6541999 Fundamentals of Nursing p1

1/30

Far Eastern University-Institute of NursingIn-House Nursing Review Hand-out

FUNDAMENTALS OF NURSING

OVERVIEW

I. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. Nursing

B. Conc!"s of H#$"% #n& I$$nssC. Conc!"s of S"rss'. Ho(os"#sisE. A!"#"ionF. A!"#"ion "o S"rss ) P%*sio$ogic#$ Rs!ons +H#ns S$*,G. P%*sio$ogic In&ic#"ors of S"rss

II. COPING STRATGIES +COPING MECHANISMS,A. - T*!s of Co!ing S"r#"gisB. R$##"ion Tc%ni/us

III. PS0CHOLOGICAL RESPONSEA. T#s1 ) Orin"& B%#2iorsB. 'fns Mc%#nis(sC. Co((on 'fns Mc%#nis(s

IV. T0PES of NURSING 'IAGNOSESA. For(u$#"ing "% Nursing 'i#gnosisB. Co$$#3or#"i2 Pro3$(s

V. METHO'S USE' for ASSESSMENTA. Co$$c"ion of '#"#4 O35c"i2 #n& Su35c"i2

VI. 'OCUMENTING #n& REPORTINGA. Gui&$ins for Goo& 'ocu(n"#"ion #n& R!or"ingB. 'ocu(n"#"ionC. 'ocu(n"#"ion S*s"(s'. Nursing C#r P$#n +NCP,E. KAR'E6F. Nursing 'isc%#rg 7 Rfrr#$ Su((#ris

VII. PH0SICAL E6AMINATIONA. Pur!ossB. Pr!#r#"ion of E#(in#"ionC. Or&r of E#(in#"ion'. S1i$$s in P%*sic#$ Assss(n"E. E#(!$s of A&2n"i"ious Br#"% Soun&s

VIII. THE COMMUNICATION PROCESSA. Mo&s of Co((unic#"ionB. Vr3#$ Co((unic#"ionC. Non2r3#$ Co((unic#"ion'. F#c"ors Inf$uncing "% Co((unic#"ion ProcssE. T%r#!u"ic Co((unic#"ion Tc%ni/u

F. B#rrirs "o Co((unic#"ionG. P%#ss of "% H$!ing R$#"ions%i!

PRINCIPLES #n& PRACTICE of NURSING CARE

I6. PRINCIPLES of ASEPSIS #n& INFECTION CONTROL

A. C%#in of Infc"ionB. Mo&s of Tr#ns(issionC. Cours of Infc"ion'. Inf$#((#"ionE. I((un Rs!onsF. Nosoco(i#$ Infc"ionG. F#c"ors Incr#sing Susc!"i3i$i"* "o Infc"ionH. 'i#gnos"ic Ts"s Us& "o Scrn for Infc"ion

6. THEORIES OF PAINA. S!cific T%or*B. P#""rn T%or*C. G#" Con"ro$ T%or*'. Currn" '2$o!(n"s in P#in T%or*

1


2/30


6I. T0PES OF PAIN

A. Acu" P#inB. C%ronic P#in

6II. PAIN ASSESSMENTA. TOOLS7INSTRUMENTS USE'

B. A B C ' E ("%o& of !#in #ssss(n"C. P 8 R S T #ssss(n" for !#in !rc!"ion'. P#in His"or*

A'MINISTRATION OF ME'ICATIONS

6III. 'RUG NOMENCLATURE #n& FORMSA. N#(sB. C$#ssific#"ionC. For(s'. T*!s of 'rug Ac"ionsE. Princi!$s in A&(inis"ring M&ic#"ions

6IV. BASIC HUMAN NEE'SA. A3r#%#( M#s$o9

B. M#s$o9:s C%#r#c"ris"ics of # S$f)Ac"u#$i;& Prson

6V. MEETING O60GENATION NEE'SA. O*gn#"ionB. C#r&io2#scu$#r P%*sio$og*C. S"ruc"ur #n& Func"ion'. S"!s in "% Procss of O*gn#"ionE.

6VI. MEETING NUTRITIONAL NEE'SA. Princi!$s of Nu"ri"ionB. Nu"rin"s

6VII. MEETING URINAR0 ELIMINATION NEE'SA. Nor(#$ Urin#r* Func"ionB. Co((on Assss(n" Fin&ings

6VIII. URINAR0 CATHETERI #n& Mourning,C. An"ici!#"or* Grif

'. Co(!$ic#"ions of Br#2(n"E. S*(!"o(s of Nor(#$ GrifF. Nursing H#$"% Pro(o"ion +"o f#ci$i"#" (ourning,

================================================================================================================================================

2


3/30


1. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. Nursing

As 3* "% INTERNATIONAL COUNCIL OF NURSES +ICN> ?@, #s 9ri""n 3* Virgini#Hn&rson4 T% uni/u func"ion of "% nurs is "o #ssis" "% in&i2i&u#$> sic1 or 9$$> in "%!rfor(#nc of "%os #c"i2i"is con"ri3u"ing "o %#$"%. I":s rco2r*> or "o # !#cfu$ "% "%#""% c$in" 9ou$& !rfor( un#i&& if % %#& "% ncss#r* s"rng"%> 9i$$ or 1no9$&g.

H$! "% c$in" g#in in&!n&nc #s r#!i&$* #s !ossi3$.

1. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

Theorist Descritio!

FLORENCENIGHTINGALE

'2$o!& "% firs" "%or* of nursing.

Focus& on c%#nging #n& (#ni!u$#"ing "% e!"iro!#e!tin or&r "o

!u" "% !#"in" in "% 3s" !ossi3$ con&i"ions for n#"ur "o #c".

HIL'EGAR' PEPLAU In"ro&uc& "% In"r!rson#$ Mo&$. S% &fin& nursing #s # "%r#!u"ic> in"r!rson#$ !rocss 9%ic%

s"ri2s "o &2$o! # !$rse%&tie!t re'&tio!shiin 9%ic% "% nurssr2s #s # rsourc !rson> couns$or #n& surrog#".

FA0E AB'ELLAH 'fin& nursing #s %#2ing # ro('e#%so'"i!) &ro&ch> 9i"% 1*

nursing !ro3$(s r$#"& "o %#$"% n&s of !o!$ &2$o!& $is" -?nursing !ro3$( #r#s

I'A DEAN ORLAN'O '2$o!& "% "%r $(n"s ) c$in" 3%#2ior> nurs r#c"ion #n&

nurs #c"ion ) co(!os "% nursing si"u#"ion. S% o3sr2& "%#" "%nurs !ro2i& &irc" #ssis"#nc "o (" #n i((&i#" n& for %$! inor&r "o #2oi& or "o #$$2i#" &is"rss or %$!$ssnss.

M0RA LEVINE 'scri3& "% Fo$r Co!ser"&tio! Pri!ci'es.

?. consr2#"ion of nrg*-. consr2#"ion of s"ruc"ur& in"gri"*. consr2#"ion of !rson#$ in"gri"*. consr2#"ion of soci#$ in"gri"*

'OROTH0 DOHNSON '2$o!& "% *eh&"ior&' S+ste# Mo,e'.

?. P#"in":s 3%#2ior #s # s*s"( "%#" is # 9%o$ 9i"% in"r#c"ing!#r"s

-. %o9 "% c$in" #!"s "o i$$nss. go#$ of nursing is "o r&uc so "%#" "% c$in" c#n (o2 (or

#si$* "%roug% rco2r*.

MARTHA ROGERS Conc!"u#$i;& "% Scie!ce of U!it&r+ H$#&! *ei!)s. S% #ssr"&"%#" %u(#n 3ings #r (or "%#n &iffrn" fro( "% su( of "%ir !#r"s "%&is"inc"i2 !ro!r"is of "% 9%o$ #r signific#n"$* &iffrn" fro( "%os ofi"s !#r"s.

'OROTHEA OREM E(!%#si;s "% c$in":s se'f c&re !ee,s nursing c#r 3co(sncss#r* 9%n c$in" is un#3$ "o fu$fi$$ 3io$ogic#$> !s*c%o$ogic#$>&2$o!(n"#$ or soci#$ n&s.

IMOGENE KING Nursing !rocss is &fin& #s &*n#(ic i!tererso!&' rocess3"9nnurs> c$in" #n& %#$"% c#r s*s"(.

BETT0 NEUMAN Stress re,$ctio!is # go#$ of s*s"( (o&$ of nursing !r#c"ic. Nursing#c"ions #r in !ri(#r*> sconr* or "r"i#r* $2$ of !r2n"ion

SISTER CALLISTARO0

Prsn"& "% A,&t&tio! Mo,e'. S% 2i9& #c% !rson #s & $!ifie,(io%s+chosoci&' s+ste#in cons"#n" in"r#c"ion 9i"% # c%#ngingn2iron(n". T% go#$ of nursing is "o %$! "% !rson #!" "o c%#ngsin !%*sio$ogic#$ n&s> s$f=conc!"> ro$ func"ion #n& in"r&!n&n"r$#"ions &uring %#$"% #n& i$$nss.

3


4/30


L0'IA HALL In"ro&uc& "% no"ion "%#" nursing cn"rs #roun& "%r co(!onn"s4erso!-core/ &tho'o)ic st&te &!, tre&t#e!t-c$re &!, (o,+-c&re.

DEAN WATSON Conc!"u#$i;& "% H$#&! C&ri!) Mo,e'. S% (!%#si;& "%#" nursing

is "% #!!$ic#"ion of "% #r" #n& %u(#n scinc "%roug% "r#ns!rson#$c#ring "r#ns#c"ions "o %$! !rsons #c%i2 (in&=3o&*=sou$ %#r(on*>9%ic% gnr#"s s$f=1no9$&g> s$f=con"ro$> s$f=c#r #n& s$f=%#$ing.

ROSEMARIE RI 3$ifs #n& !r#c"ics,"o i(!ro2 or (#in"#in # %#$"% con&i"ion

0. ROLES AND FUNCTION OF A NURSE

#. C&re)i"er) "% c#rgi2r ro$ %#s "r#&i"ion#$$* inc$u&& "%os #c"i2i"is "%#" #ssis" "%c$in" !%*sic#$$* #n& !s*c%o$ogic#$$* 9%i$ !rsr2ing "% c$in":s &igni"*.C#rgi2ing nco(!#sss "% !%*sic#$> !s*c%osoci#$> &2$o!(n"#$> cu$"ur#$ #n&s!iri"u#$ $2$s.

3. Co##$!ic&tor) co((unic#"ion is #n in"gr#$ "o #$$ nursing ro$s. Nurss co((unic#"9i"% "% c$in"> su!!or" !rsons> o"%r %#$"% !rofssion#$s> #n& !o!$ in "%co((uni"*. In "% ro$ of co((unic#"or> nurss i&n"if* c$in" !ro3$(s #n& "%nco((unic#" "%s 2r3#$$* or in 9ri"ing "o o"%r ((3rs of "% %#$"% "#(. T%/u#$i"* of # nurs:s co((unic#"ion is #n i(!or"#n" f#c"or in nursing c#r.

c. Te&cher) #s # "#c%r> "% nurs %$!s c$in"s $#rn #3ou" "%ir %#$"% #n& "% %#$"% c#r!roc&urs "%* n& "o !rfor( "o rs"or or (#in"#in "%ir %#$"%. T% nurs

#sssss "% c$in":s $#rning n&s #n& r#&inss "o $#rn> s"s s!cific $#rninggo#$s in con5unc"ion 9i"% "% c$in"> n#c"s "#c%ing s"r#"gis #n& (#surs$#rning.

&. C'ie!t &,"oc&te) # c$in" #&2oc#" #c"s "o !ro"c" "% c$in". In "%is ro$ "% nurs (#*r!rsn" "% c$in":s n&s #n& 9is%s "o o"%r %#$"% !rofssion#$s> suc% #sr$#*ing "% c$in":s 9is%s for infor(#"ion "o "% !%*sici#n. T%* #$so #ssis" c$in"sin rcising "%ir rig%"s #n& %$! "%( s!#1 u! for "%(s$2s.

. Co$!se'or) couns$ing is # !rocss of %$!ing # c$in" "o rcogni; #n& co! 9i"%s"rssfu$ !s*c%o$ogic or soci#$ !ro3$(s> "o &2$o!& i(!ro2& in"r!rson#$r$#"ions%i!s> #n& "o !ro(o" !rson#$ gro9"%. I" in2o$2s !ro2i&ing (o"ion#$>in"$$c"u#$> #n& !s*c%o$ogic su!!or".

f. Ch&!)e &)e!t) "% nurs #c"s #s # c%#ng #gn" 9%n #ssis"ing o"%rs> "%#" is> c$in"s> "o(#1 (o&ific#"ions in "%ir o9n 3%#2ior. Nurss #$so of"n #c" "o (#1 c%#ngs

in # s*s"( suc% #s c$inic#$ c#r> if i" is no" %$!ing # c$in" r"urn "o %#$"%.g. Le&,er) # $#&r inf$uncs o"%rs "o 9or1 "og"%r "o #cco(!$is% # s!cific go#$. T%

$#&r ro$ c#n 3 (!$o*& #" &iffrn" $2$s in&i2i&u#$ c$in"> f#(i$*> grou!s ofc$in"s> co$$#gus> or "% co((uni"*. Effc"i2 $#&rs%i! is # $#rn& !rocssr/uiring #n un&rs"#n&ing of "% n&s #n& go#$s "%#" (o"i2#" !o!$> "%1no9$&g "o #!!$* "% $#&rs%i! s1i$$s> #n& "% in"r!rson#$ s1i$$s "o inf$unco"%rs.

%. M&!&)er) "% nurs (#n#gs "% nursing c#r of in&i2i&u#$s> f#(i$is> #n& co((uni"is.T% nurs=(#n#gr #$so &$g#"s nursing #c"i2i"is "o #nci$$#r* 9or1rs #n& o"%rnurss> #n& su!r2iss #n& 2#$u#"s "%ir !rfor(#nc.

i. C&se #&!&)er) nurs c#s (#n#grs 9or1 9i"% "% (u$"i&isci!$in#r* %#$"% c#r "#( "o(#sur "% ffc"i2nss of "% c#s (#n#g(n" !$#n #n& "o (oni"or ou"co(s.

5. Rese&rch co!s$#er) nurss of"n us rs#rc% "o i(!ro2 c$in" c#r. In # c$inic#$ #r#

nurss n& "o4 H#2 so( #9#rnss of "% !rocss #n& $#ngu#g of rs#rc%

B snsi"i2 "o issus r$#"& "o !ro"c"ing "% rig%"s of %u(#n su35c"s

P#r"ici!#" in i&n"ific#"ion of signific#n" rs#rc%#3$ !ro3$(s

B # &iscri(in#"ing consu(r of rs#rc% fin&ings

B. Concepts of Health and Illness

4


5/30


I. He&'th) As &fin& 3* "% Wor$& H#$"% Org#ni;#"ion +WHO,4 s"#" of co(!$"!%*sic#$> (n"#$ #n& soci#$ 9$$=3ing> no" (r$* "% #3snc of &is#s or infir(i"*.

a. Characteristicsi. A concrn for "% in&i2i&u#$ #s # "o"#$ s*s"(ii. A 2i9 of %#$"% "%#" i&n"ifis in"rn#$ #n& "rn#$ n2iron(n"iii. An #c1no9$&g(n" of "% i(!or"#nc of #n in&i2i&u#$:s ro$ in $if

A &*n#(ic s"#" in 9%ic% "% in&i2i&u#$ #!"s "oc%#ngs in in"rn#$ #n& "rn#$ n2iron(n" "o (#in"#in # s"#" of 9$$ 3ing

b. Models of Health and Illness

i. H#$"%=I$$nss Con"inuu( +Nu(#n) 'gr of c$in" 9$$nss "%#" is" #"#n* !oin" in "i(> r#nging fro( #n o!"i(#$ 9$$nss con&i"ion> 9i"% #2#i$#3$nrg* #" i"s (#i(u(> "o "% 9%ic% r!rsn"s "o"#$ nrg* &!$"ion.

ii. Hig% ) L2$ W$$nss Mo&$ +H#$3r" 'unn, ) I" is orin"& "o9#r& (#i(i;ing"% %#$"% !o"n"i#$ of #n in&i2i&u#$. T%is (o&$ r/uirs "% in&i2i&u#$ "o(#in"#in # con"inuu( of 3#$#nc #n& !ur!osfu$ &irc"ion 9i"%in "%n2iron(n".

iii. Agn" ) Hos" ) n2iron(n" Mo&$ +L#2$$, ) T% $2$ of %#$"% of #n

in&i2i&u#$ or grou! &!n&s on "% &*n#(ic r$#"ions%i! of "% #gn"> %os" #n&n2iron(n"

Agn" ) #n* in"rn#$ or "rn#$ f#c"or "%#" &is#s or i$$nss.

Hos" ) "% !rson or !rsons 9%o (#* 3 susc!"i3$ "o #

!#r"icu$#r i$$nss or &is#s En2iron(n" ) consis"s of #$$ f#c"ors ou"si& of "% %os"

i2. H#$"% ) B$if Mo&$ ) A&&rsss "% r$#"ions%i! 3"9n # !rson:s 3$if#n& 3%#2iors. I" !ro2i&s # 9#* of un&rs"#n&ing #n& !r&ic"ing %o9 c$in"s9i$$ 3%#2 in r$#"ion "o "%ir %#$"% #n& %o9 "%* 9i$$ co(!$* 9i"% %#$"% c#r"%r#!is.

Four Co(!onn"s T% in&i2i&u#$ is !rc!"ion of susc!"i3i$i"* "o #n i$$nss

T% in&i2i&u#$:s !rc!"ion of "% sriousnss of "% i$$nss T% !rci2& "%r#" of # &is#s

T% !rci2& 3nfi"s of "#1ing "% ncss#r* !r2n"i2

(#surs

2. E2o$u"ion#r* ) B#s& Mo&$ ) I$$nss #n& "% sr2s #s # 2o$u"ion#r*func"ion. E2o$u"ion#r* 2i#3i$i"* rf$c"s "% "n" "o 9%ic% in&i2i&u#$:s func"ion"o !ro(o" sur2i2#$ #n& 9$$=3ing. T% (o&$ in"rr$#"s "% fo$$o9ing$(n"s4

Lif 2n"s

Lif s"*$ &"r(in#n"s

E2o$u"ion#r* 2i#3i$i"* 9i"%in "% soci#$ con""

Con"ro$ !rc!"ions

Vi#3i$i"* (o"ions

H#$"% ou"co(s

2i. H#$"% Pro(o"ion Mo&$ ) A co(!$i(n"#r* coun"r!#r" (o&$s of %#$"%!ro"c"ion. 'irc"& #" incr#sing # c$in":s $2$ of 9$$ 3ing. E!$#in "%r#son for c$in":s !#r"ici!#"ion %#$"%=!ro(o"ion 3%#2iors. T% (o&$ focusson "%r func"ions4

I" i&n"ifis f#c"ors +&(ogr#!%ic #n& soci#$$*, n%#nc or

&cr#s "% !#r"ici!#"ion in %#$"% !ro(o"ion I" org#ni;s cus in"o !#""rn "o !$#in $i1$i%oo& of # c$in":s

!#r"ici!#"ion %#$"%=!ro(o"ion 3%#2iors I" !$#ins "% r#sons "%#" in&i2i&u#$s ng#g in %#$"% #c"i2i"is

II. I''!ess) S"#" in 9%ic% # !rson:s !%*sic#$> (o"ion#$> in"$$c"u#$> soci#$&2$o!(n"#$ or s!iri"u#$ func"ioning is &i(inis%& or i(!#ir&. I" is # con&i"ionc%#r#c"ri;& 3* # &2i#"ion fro( # nor(#$> %#$"%* s"#".

a. 3 Stages of Illnessi. S"#g of 'ni#$ ) Rfus#$ "o #c1no9$&g i$$nss #ni"*> f#r>

irri"#3i$i"* #n& #ggrssi2nss.ii. S"#g of Acc!"#nc ) Turns "o !rofssion#$ %$! for #ssis"#nc

5


6/30


iii. S"#g of Rco2r* +R%#3i$i"#"ion or Con2#$scnc, ) T% !#"in"gos "%roug% of rso$2ing $oss or i(!#ir(n" of func"ion

3. R%#3i$i"#"ioni. A &*n#(ic> %#$"% orin"& !rocss "%#" #ssis"s in&i2i&u#$ 9%o is i$$ or

&is#3$& "o #c%i2 %is gr#"s" !ossi3$ $2$ of !%*sic#$> (n"#$>s!iri"u#$> soci#$ #n& cono(ic#$ func"ioning.

ii. A3i$i"is no" &is#3i$i"is> #r (!%#si;&.iii. Bgins &uring ini"i#$ con"#c" 9i"% "% !#"in"i2. E(!%#sis is on rs"oring "% !#"in" "o in&!n&nc or rg#in %is !r=

i$$nss7!r&is#3i$i"* $2$ of func"ion #s s%or" # "i( #s !ossi3$2. P#"in" (us" 3 #n #c"i2 !#r"ici!#n" in "% r%#3i$i"#"ion go#$ s""ing

#n &in r%#3i$i"#"ion !rocss.

c. Focuss of R%#3i$i"#"ioni. Co!ing !#""rnii. Func"ion#$ #3i$i"* ) focuss on s$f=c#r4 #c"i2i"is of i$* $i2ing +A'L,

f&ing> 3#"%ing7%*gin> &rssing7groo(ing> "oi$"ing #n& (o3i$i"*iii. Mo3i$i"*i2. In"gri"* of s1in

2. Con"ro$ of 3o9$ #n& 3$#&&r func"ion

C. Concepts of StressI. Stress +T%or* 3* H#ns S$*,

#. Non s!cific rs!ons of "% 3o&* "o n#* &(#n& (#& u!on i"3. An* si"u#"ion in 9%ic% # non s!cific &(#n& r/uirs #n in&i2i&u#$ "o rs!on& or

"#1 #c"ion

II. Ch&r&cteristics of Stress#. S"rss is no" nr2ous nrg*. E(o"ion#$ r#c"ions #r co((on s"rssors

3. S"rss is no" #$9#*s "% rsu$" of (#g "o "% 3o&*

c. S"rss &os no" #$9#*s rsu$" in f$ings of &is"rss +%#r(fu$ or un!$#s#n" s"rss,

&. S"rss is # ncss#r* !#r" of $if #n& is ssn"i#$ for nor(#$ gro9"% #n&&2$o!(n"

. S"rss in2o$2s "% n"ir 3o&* #c"ing #s # 9%o$ #n& is #n in"gr#"& (#nnr

f. S"rss rs!ons is n#"ur#$> !ro&uc"i2 #n& #!"i2

III. Stressors) F#c"or or #gn" !ro&ucing s"rss> (#*34 !%*sio$ogic#$> !s*c%o$ogic#$>soci#$> n2iron(n"#$> &2$o!(n"#$> s!iri"u#$ or cu$"ur#$ #n& r!rsn" #n un("n&s

a. Classification of Stressorsi. In"rn#$ S"rssors ) origin#" fro( 9i"%in "% 3o&*. E.g. f2r>!rgn#nc*> (no!#us> (o"ion suc% #s gui$"

ii. E"rn#$ S"rssors ) origin#" ou"si& # !rson. E.g. c%#ng inf#(i$* or soci#$ ro$> !r !rssur> (#r1& c%#ng inn2iron(n"#$ "(!r#"ur

b. F&ctors i!f'$e!ci!) reso!se to stressors

i. P%*sio$ogic#$ func"ioningii. Prson#$i"*iii. B%#2ior#$ c%#r#c"ris"icsiv. N#"ur of "% s"rssor4 in"gri"*> sco!> &ur#"ion> nu(3r> #n&

n#"ur of o"%r s"rssors

D. Homeostasis) Procss of (#in"#ining unifor(i"*> s"#3i$i"* #n& cons"#nc* 9i"% in "% $i2ingorg#nis(s. +fro( Gr1 9or& homotos) $i1> #n& stasis) !osi"ion,

E. Adaptation) Bo&*:s #&5us"(n" "o &iffrn" circu(s"#ncs #n& con&i"ions. Procss 3* "%!%*sio$ogic#$ or !s*c%o$ogic#$ &i(nsions c%#ng in rs!ons "o s"rss #""(!" "o (#in"#ino!"i(#$ func"ioning

6


7/30

Stressor

Epinephrine

Tachycardia Myocardial contractility

Blood clotting Metabolism

Norepinephrine Blood to !idney

"enin

#otisone

$rotein catablism%l&coneogenesis

Stage o' "esistance

(daptation

Shoc! $hase

Stage o' E)ha&stion

T%"%rs"#gsof#!"#"ion

"os"rss4"%#$#r(r

#c"ion>

"%

s"#gofrsis"#nc#n&

"%s"#gof%#us"ion.


F. Adaptation to Stress!h"siological #esponse $Hans Sel"e%I. Loc#$ A!"#"ion S*n&ro( +LAS, ) Rs!ons of # 3o&* "issu> org#n or !#r" "o "%

s"rss of "r#u(#> i$$nss or o"%r !%*sio$ogic#$ c%#nga. Characteristics

i. T% rs!ons is 'oc&'ie,> i" &os no" in2o$2 n"ir 3o&* s*s"(sii. T% rs!ons is &,&ti"e> (#ning "%#" # s"rssor is ncss#r* "o s"i(u$#" i"iii. T% rs!ons is short ter#. I" &os no" !rsis" in&fini"$*iv. T% rs!ons is restor&ti"e> (#ning "%#" "% LAS #ssis"s in rs"oring

%o(os"#sis "o "% 3o&* rgion or !#r"

b. &'o (ocali)ed #esponsesi. Rf$ P#in Rs!ons ) is # localied res!onseof "% cn"r#$

nr2ous s*s"( "o !#in. I" is #n #!"i2 rs!ons #n& !ro"c"s "issu fro(fur"%r (#g. T% rs!ons in2o$2s # snsor* rc!"or> # snsor* nr2fro( "% s!in#$ cor&> #n& #n ffc"or (usc$. An e"am!le would #e theunconscious$ refle" removal of the hand from a hot surface.

ii. Inf$#((#"or* Rs!ons ) is s"i(u$#"& 3* "r#u(# or infc"ion. T%is rs!ons$oc#$i;s "% inf$#((#"ion> "%us r2nging i"s s!r#& #n& !ro(o"s %#$ing.T% inf$#((#"or* rs!ons (#* !ro&uc localied !ain$ swelling$ heat$

redness and changes in functioning.c. &hree !hases of Inflammator" #esponse

i. Firs" P%#s ) Narrowing of #lood vesselsoccurs #" "% in5ur* "o con"ro$ 3$&ing.T%n %is"#(in is r$#s& #" "% in5ur*> incr#sing "% nu(3r of 9%i" 3$oo&c$$s "o co(3#" infc"ion.

ii. Scon& P%#s ) I" is c%#r#c"ri;& 3* release of e"udatesfro( "% 9oun&

iii. T%ir& P%#s ) T% $#s" !%#s is re!air of tissue3* rgnr#"ion or sc#rfor(#"ion. Rgnr#"ion r!$#cs (#g& c$$s 9i"% i&n"ic#$ or si(i$#r c$$s.

II. *eneral Adaptation S"ndrome $*AS% or Stress S"ndrome) c%#r#c"ri;& 3* #

c%#in or !#""rn of !%*sio$ogic 2n"s.a. + Stages

i. A$#r( R#c"ion ) ini"i#$ r#c"ion of "% 3o&* 9%ic% #$r"s "% 3o&*:s&fnss. SEL0E &i2i&& "%is s"#g in"o - !#r"s4 T% SHOCK PHASE

T% COUNTERSHOCK PHASE

ii. S"#g of Rsis"#nc ) occurs 9%n "% 3o&*:s #!"#"ion "#1s!$#c "% 3o&* #""(!"s "o #&5us" 9i"% "% s"rssor #n& "o $i(i" "%s"rssor "o "% s(#$$s" #r# of "% 3o&* "%#" c#n $ 9i"% i".

iii. S"#g of E%#us"ion ) "% #!"#"ion "%#" "% 3o&* (#& &uring"% scon& s"#g c#nno" 3 (#in"#in& "% 9#*s us& "o co!9i"% "% s"rssors %#2 3n %#us"&

+


8/30


#. SESS,#Ss"i(u$#" "% s*(!#"%"ic nr2ous s*s"(> 9%ic% in "urns"i(u$#"s "% %*!o"%#$#(us. T% H0POTHALAMUS r$#ss cor"ico"ro!%inr$#sing %or(on +CRH,. 'uring "i(s of s"rss> "% A'RENAL ME'ULLAscr"s EPINEPHRINE NOREPINEPHRINE in rs!ons "o s*(!#"%"ics"i(u$#"ion. Signific#n" 3o&* rs!onss "o !in!%rin inc$u& "% fo$$o9ing4

i. Incr#s& (*oc#r&i#$ con"r#c"i$i"*> 9%ic% incr#ss c#r&i#c ou"!u" 3$oo& f$o9 "o #c"i2 (usc$s

ii. Bronc%i#$ &i$#"ion> 9%ic% #$$o9s incr#s& o*gn in"#1iii. Incr#s& 3$oo& c$o""ingiv. Incr#s& c$$u$#r ("#3o$is(v. Incr#s& f#" (o3i$i;#"ion "o (#1 nrg* #2#i$#3$ "o

s*n"%si; o"%r co(!oun&s n&& 3* "% 3o&*.

*. !h"siologic Indicators of Stressa. %u!ils dilate"o incr#s 2isu#$ !rc!"ion 9%n srious "%r#"s "o "% 3o&* #ris.

#. Sweat !roduction+&i#!%orsis, incr#ss "o con"ro$ $2#"& 3o&* %#" &u "oincr#s& ("#3o$is(.

c. T% heart rate & cardiac out!ut increase"o "r#ns!or" nu"rin"s #n& 3*=!ro&uc"s of("#3o$is( (or fficin"$*.

d. S'in is !allid 3c#us of cons"ric"ion of !ri!%r#$ 2ss$s> #n ffc" of nor!in!%rin.

e. Sodium & water retention increase&u "o r$#s of (inr#$ocor"icoi&s> 9%ic% rsu$"sin incr#s& 3$oo& 2o$u(.

f. T% rate & de!th of res!irations increase3c#us of &i$#"ion of "% 3ronc%io$s>!ro(o"ing %*!r2n"i$#"ion.

g. Urinary out!ut may increase or decreases.

h. T% mouth(#* 3 dry.

i. %eristalsis of "% in"s"ins &cr#ss> rsu$"ing in !ossi3$ cons"i!#"ion #n& f$#"us.

(. For srious "%r#"s> mental alertness im!roves.

'. )uscle tension increases"o !r!#r for r#!i& (o"or #c"i2i"* or &fns.

l. *lood sugar increases3c#us of r$#s of g$ucocor"icoi&s g$uconognsis.

H. !s"chologic Indicators) !s*c%o$ogic (#nifs"#"ions of s"rss inc$u& #ni"*> f#r> #ngr>&!rssion unconscious go &fns (c%#nis(s.

#. Ani"* ) # co((on r#c"ion "o s"rss. I" is # s"#" of (n"#$ un#sinss> #!!r%nsion>&r#&> or for3o&ing or # f$ing of %$!$ssnss r$#"& "o #n i(!n&ing or#n"ici!#"& uni&n"ifi& "%r#" "o s$f or signific#n" r$#"ions%i!s. I" c#n 3!rinc&> su3cu"#nous or unconscious $2$. C#n 3 (#nifs"& on LEVELS4

3. F#r ) #n (o"ion or f$ing of #!!r%nsion #rous& 3* i(!n&ing or s(ing ngr>or o"%r !rci2& "%r#". T% o35c" of f#r (#* or (#* no" 3 3#s& in r#$i"*.

c. Angr ) #n (o"ion#$ s"#" consis"ing of # su35c"i2 f$ing of #ni(osi"* or s"rong&is!$#sur. Po!$ (#* f$ gui$"* 9%n "%* f$ #ngr 3c#us "%* %#2 3n"#ug%" "%#" "o f$ #ngr* is 9rong.

&. '!rssion ) co((on r#c"ion "o 2n"s "%#" s( o2r9%$(ing or ng#"i2. I" is #n"r( f$ing of s#&nss> &s!#ir> &5c"ion> $#c1 of 9or"% or (!"inss.

E(o"ion#$ s*(!"o(s c#n inc$u&4 F$ings of "ir&nss> s#&nss> (!"inss> or nu(3nss

B%#2ior#$ signs inc$u&4 Irri"#3i$i"*> in#3i$i"* "o concn"r#"> &ifficu$"* (#1ing &cisions> $oss ofsu#$ &sir> cr*ing> s$! &is"ur3#nc #n& soci#$ 9i"%&r#9#$.

P%*sic#$ signs inc$u&4 Loss of #!!"i"> 9ig%" $oss> cons"i!#"ion> %#c% #n& &i;;inss

I. Cogniti-e Indicators) #r "%in1ing rs!onss "%#" inc$u& !ro3$(=so$2ing> s"ruc"uring>

,


9/30


s$f=con"ro$ or s$f=&isci!$in> su!!rssion #n& f#n"#s*

a. Pro3$( so$2ing ) in2o$2s "%in1ing "%roug% "% "%r#"ning si"u#"ion> using #s!cific s"!s "o #rri2 #" # so$u"ion

#. S"ruc"uring ) #rr#ng(n" or (#ni!u$#"ion of # si"u#"ion so "%#" "%r#"ning2n"s &o no" occur.

c. S$f=Con"ro$ +&isci!$in, ) #ssu(ing # (#nnr of f#ci#$ !rssion "%#" con2*# sns of 3ing in con"ro$ or in c%#ng.

d. Su!!rssion ) conscious$* #n& 9i$$fu$$* !u""ing # "%oug%" or f$ing ou" of (in&

e. F#n"#s* ) +*&r#(ing, ) $i1n& "o (#1 3$i2. Unfu$fi$$& 9is%s &sirs #r i(#gin& #s fu$fi$$&> or # "%r#"ning !rinc is r9or1& orr!$#*& so "%#" i" n&s &iffrn"$* fro( r#$i"*.

0. COPING STRATEGIES -COPING MECHANISMS

+o!ing) $ing 9i"% !ro3$(s si"u#"ions or con"n&ing 9i"% "%( succssfu$$*.

+o!ing Strategy) inn#" or #c/uir& 9#* of rs!on&ing "o # c%#nging n2iron(n" or s!cific!ro3$( or si"u#"ion.

Accor&ing "o Fo$1(#n #n& L#;#rus> co!ing is "% cogni"i2 3%#2ior#$ ffor" "o (#n#g s!cific"rn#$ #n&7 or in"rn#$ &(#n&s "%#" #r #!!r#is& #s "#ing or c&ing "% rsourcs of "%!rson.

A. Coping Strategies / &"pesI. Pro3$(=focus& co!ing ) ffor"s "o i(!ro2 # si"u#"ion 3* (#1ing c%#ngs or "#1ing

so( #c"ionII. E(o"ion=focus& co!ing ) &os no" i(!ro2 "% si"u#"ion> 3u" "% !rson of"n f$s

3""r.

+o!ing strategies are also viewed as,a. Long="r( co!ing s"r#"gis ) c#n 3 cons"ruc"i2 r#$is"ic#. S%or"="r( co!ing s"r#"gis ) c#n r&uc s"rss "o # "o$r#3$ $i(i" "(!or#ri$*

3u" #r in "% n& o& inffc"i2 9#*s "o $ 9i"% r#$i"*.+o!ing can #e ada!tive or malada!tive4

B. A!"i2 Co!ing ) %$!s "% !rson "o $ ffc"i2$* 9i"% s"rssfu$ 2n"s (ini(i;s &is"rss #ssoci#"& 9i"% "%(.

C. M#$#!"i2 Co!ing ) c#n rsu$" in unncss#r* &is"rss for "% !rson o"%rs #ssoci#"& 9i"% "% !rson or s"rssfu$ 2n".

Effc"i2 co!ing rsu$"s in #!"#"ion inffc"i2 co!ing rsu$"s in (#$#!"#"ion.T% ffc"i2nss of #n

in&i2i&u#$:s co!ing is inf$unc& 3* # nu(3r of f#c"ors4 T% nu(3r> &ur#"ion in"nsi"* of "% s"rssors

P#s" !rincs of "% in&i2i&u#$

Su!!or" s*s"(s #2#i$#3$ "o "% in&i2i&u#$

Prson#$ /u#$i"is of "% !rson

If "% &ur#"ion of "% s"rssors is "n&& 3*on& "% co!ing !o9rs of "%in&i2i&u#$> "%#" !rson 3co(s %#us"& #n& (#* &2$o! incr#s&susc!"i3i$i"* "o %#$"% !ro3$(s.

R#c"ion "o $ong "r( s"rss is sn in f#(i$* ((3rs 9%o un&r"#1 "% c#r of# !rson in "% %o( for # $ong !rio&. T%is s"rss is c#$$& c#rgi2r 3ur&n !ro&ucs rs!onss suc% #s c%ronic f#"igu> s$!ing &ifficu$"is %ig% BP.

Pro$ong& s"rss c#n #$so rsu$" in (n"#$ i$$nss.

D. #ela0ation &echni1ues) us& "o /ui" "% (in&> r$#s "nsion coun"r#c" "% fig%" orf$ig%" rs!onss of Gnr#$ A!"#"ion S*n&ro( +GAS,.

I. Br#"%ing ErcissII. M#ss#gIII. Progrssi2 R$##"ionI2. I(#gr*

-


10/30


2. Biof&3#c12I. 0og#2II. M&i"#"ion2III.T%r#!u"ic Touc%I3. Music T%r#!*

3. Hu(or L#ug%"r

2. PS3CHOLOGICAL RESPONSE

E!osur "o # s"rssor rsu$"s in !s*c%o$ogic#$ #n& !%*sio$ogic#$ #n& !%*sio$ogic#$ #!"i2rs!onss. As !o!$ #r !os& # s"rssors> "%ir #3i$i"* "o (" "%ir 3#sic n&s is "%r#"n&.T%is "%r#" 9%"%r #c"u#$ or !rci2&> !ro&ucs frus"r#"ion> #ni"* #n& "nsion. Ps*c%o$ogic#$#!"i2 3%#2iors #ssis" "% !rson:s #3i$i"* "o co! 9i"% s"rssors. T%s 3%#2iors #r &irc"" s"rss (#n#g(n" #n& #r #c/uir& "%roug% $#rning #n& !rinc #s # !rson i&n"ifis#cc!"#3$ #n& succssfu$ 3%#2iors.

Ps*c%o$ogic#$ #!"i2 3%#2iors #r #$so r$#"& "o #s COPING MECHANISMS. I" in2o$2s4

A. T&s4 5 Orie!te, *eh&"iors) In2o$2 using cogni"i2 #3i$i"is "o r&uc s"rss> so$2 !ro3$(s>rso$2 conf$ic"s #n& gr#"if* n&s. I" n#3$s # !rson "o co! r#$is"ic#$$* 9i"% "% &(#n&s of

# s"rssor.

T%r Gnr#$ T*!sI. A""#c1 B%#2ior ) Is #c"ing "o r(o2 or o2rco( # s"rssor or "o s#"isf* # n&II. Wi"%&r#9#$ B%#2ior ) Is r(o2ing "% s$f !%*sic#$$* or (o"ion#$$* fro( "%

s"rssorIII. Co(!ro(is B%#2ior ) Is c%#nging "% usu#$ ("%o& of o!r#"ing> su3s"i"u"ing

go#$s or o(i""ing "% s#"isf#c"ion of n&s "o (" o"%r n&s or "o #2oi& s"rss.

B. Defe!se Mech&!is#s) Unconscious 3%#2iors "%#" offr !s*c%o$ogic#$ !ro"c"ion fro( #s"rssfu$ 2n". T%* #r us& 3* 2r*on #n& %$! !ro"c" #g#ins" f$ings of 9or"%$ssnss#n& #ni"*. Fr/un"$* #c"i2#"& 3* s%or"="r( s"rssors #n& usu#$$* &o no" rsu$" in !s*c%i#"ric&isor&rs.

6. T3PES OF NURSING DIAGNOSES

A. Formulating the Nursing DiagnosisI. Ac"u#$

a. C$in"s &(ons"r#"s &fining c%#r#c"ris"ics of # !ro3$(#. Nurs in"r2ns "o rso$2 or %$! c$in" co! 9i"% "% !ro3$(

II. Hig%=ris1a. A !ro3$( is $i1$* "o &2$o! 3#s& on #ssss(n" of ris1 f#c"ors#. Nurs in"r2ns "o r&uc ris1 f#c"ors or incr#s !ro"c"i2 f#c"orsc. E#(!$4 ncour#g s(o1ing css#"ion

III. W$$nssa. C$in" is !rsn"$* %#$"%* 3u" 9is%s "o #c%i2 # %ig%r $2$ of func"ion#. Nurs in"r2ns "o !ro(o" gro9"% or (#in"n#nc of "% %#$"%* rs!ons

B. Co''&(or&ti"e Pro('e#sI. 'fini"ion4 # !o"n"i#$ !ro3$( "% nurs (#n#gs using 3o"% in&!n&n" #n&

in"r&!n&n" in"r2n"ions

II. E#(!$4 !o"n"i#$ co(!$ic#"ion of %#& in5ur*4 $oss of consciousnss> !i&ur#$ orsu3&ur#$ %(#"o(#> si;urs

III. Usu#$$* occurs 9%n # &is#s is !rsn" or # "r#"(n" is !rscri3&

I2. C$in"s 9i"% si(i$#r &is#s or "r#"(n" 9i$$ %#2 "% s#( !o"n"i#$ forco(!$ic#"ions> 9%ic% (us" 3 (#n#g& co$$#3or#"i2$* %o92r> "%ir rs!onss "o"% con&i"ion 9i$$ 2#r*> so # 3ro#& r#ng of nursing &i#gnoss 9i$$ #!!$*.

a. E#(!$4 # c$in" 9i"% #s"%(# 9i$$ #$9#*s 3 #" ris1 for $o9r& o*gns#"ur#"ion %o92r> "% c$in":s rs!ons "o "%is con&i"ion 9i$$ 3 uni/u 3#s&on %is7%r &2$o!(n"#$ $2$> !#s" !rincs #n& f#(i$* configur#"ion

#. Rfr "o T#3$ for #(!$s of co$$#3or#"i2 !ro3$(s E#(!$4

1.


11/30


'is#s7Si"u#"ion Co(!$ic#"ion R$#"& "o E"io$og*

Po"n"i#$ co(!$ic#"ionof c%i$&3ir"%

Po"n"i#$ co(!$ic#"ionof &iur"ic "%r#!*

H(orr%#g

'*sr%*"%(i#

R$#"& "o

R$#"& "o

?.U"rin #"on*-. R"#in& !$#cn"#$fr#g(n". B$#&&r &is"n"ion

Lo9 sru( !o"#ssiu(

7. METHODS USED for ASSESSMENT

A. Co''&(or&tio! of D&t&8 O(9ecti"e : S$(9ecti"e

I. #e-ie' of clinical recorda. C$in" rcor&s con"#in infor(#"ion co$$c"& 3* (#n* ((3rs of "%

%#$"%c#r "#(> suc% #s &(ogr#!%ics> !#s" (&ic#$ %is"or*> &i#gnos"ic "s"rsu$"s #n& consu$"#"ions

#. R2i9ing "% c$in":s rcor& 3for 3ginning #n #ssss(n" !r2n"s "%nurs fro( r!#"ing /us"ions "%#" "% c$in" %#s #$r#&* 3n #s1& #n&i&n"ifis infor(#"ion "%#" n&s c$#rific#"ion.

II. Inter-ie'a. T% !ur!os of #n in"r2i9 is "o g#"%r #n& !ro2i& infor(#"ion> i&n"if*

!ro3$(s of concrns> #n& !ro2i& "#c%ing #n& su!!or".#. T% go#$s of #n in"r2i9 #r "o &2$o! # r#!!or" 9i"% "% c$in" #n& "o co$$c"

"#c. An in"r2i9 %#s (#5or s"#gs

i. O!ning4 !ur!os is "o s"#3$is% r#!!or" 3* cr#"ing goo&9i$$ #n&"rus" "%is is of"n #c%i2& "%roug% # s$f ) in"ro&uc"ion> non2r3#$gs"urs +# %#n&s%#1,> #n& s(#$$ "#$1 #3ou" "% 9#"%r> $oc#$

s!or"s "#(> or rcn" currn" 2n" "% !ur!os of "% in"r2i9is #$so !$#in& "o "% c$in" #" "%is "i(.

ii. Bo&*4 &uring "%is !%#s> "% c$in" rs!on&s "o o!n #n& c$os&=n&& /us"ions #s1& 3* "% nurs.

iii. C$osing4 i"%r "% c$in" or "% nurs (#* "r(in#" "% in"r2i9>i" is i(!or"#n" fro "% nurs "o "r* "o (#in"#in "% r#!!or" #n& "rus""%#" 9#s &2$o!& "%us f#r &uring "% in"r2i9 !rocss.

d. T*!s of /us"ions

i. C$os& /us"ions us& in &irc"i2 in"r2i9 RJJJJ s%or" f#c"u#$ #ns9rs .g. 'o *ou %#2 !#in

Ans9rs usu#$$* r2#$ $i(i"& #(oun"s of infor(#"ion

Usfu$ 9i"% c$in"s 9%o #r %ig%$* s"rss& #n&7or %#2

&ifficu$"* co((unic#"ing

ii. O!n=n&& /us"ions us& in non&irc"i2 in"r2i9 Encour#g c$in"s "o !rss #n& c$#rif* "%ir "%oug%"s #n&

f$ings .g. Ho9 %#2 *ou 3n s$!ing $#"$*: S!cif* "% 3ro#& #r# "o 3 &iscuss& #n& in2i" $ongr

#ns9rs Usfu$ #" "% s"#r" of #n in"r2i9 or "o c%#ng "% su35c"

iii. L#&ing /us"ions 'irc" "% c$in":s #ns9r .g. 0ou &on:" %#2 #n* /us"ions

#3ou" *our (&ic#"ions> &o *ou Suggs"s 9%#" #ns9r is !c"&

C#n rsu$" in c$in" gi2ing in#ccur#" "# "o !$#s "% nurs C#n $i(i" c$in" c%oic of "o!ic for &iscussion

III. Nursing Histor"a. Co$$c"ion of infor(#"ion #3ou" "% ffc" of "% c$in":s i$$nss on i$*

func"ioning #n& #3i$i"* "o co! 9i"% "% s"rssor +"% %u(#n rs!ons,

11


12/30


#. Su35c"i2 "#i. M#* 3 c#$$& co2r" "#ii. No" (#sur#3$ or o3sr2#3$iii. O3"#in& fro( c$in" +!ri(#r* sourc,> signific#n" o"%rs> or %#$"%

!rofssion#$s +sconr* sourcs,.iv. For #(!$> "% c$in" s"#"s> I %#2 # %#c%

c. O35c"i2 "#i. M#* 3 c#$$& o2r" "#ii. C#n 3 &"c"& 3* so(on o"%r "%#n "% c$in"iii. Inc$u&s (#sur#3$ #n& o3sr2#3$ c$in" 3%#2ioriv. For #(!$> # 3$oo& !rssur r#&ing of ?@7?? ((Hg.

I2. !h"sical assessmenta. S*s"(#"ic co$$c"ion of infor(#"ion #3ou" "% 3o&* s*s"(s "%roug% "% us of

o3sr2#"ion> ins!c"ion> #uscu$"#"ion> !#$!#"ion #n& !rcussion#. A 3o&* s*s"( for(#" for !%*sic#$ #ssss(n" is foun& 3$o94

2. !s"chosocial assessment

a. H$!fu$ fr#(9or1 for org#ni;ing "##. A suggs"& for(#" for !s*c%osoci#$ #ssss(n" is foun& 3$o94

c. T% &2$o!(n"#$ of Eric1son> Fru&> H#2ig%urs"> Ko%$3rg #n& Pi#g" (#*#$so 3 %$!fu$ for gui&ing "# co$$c"ion

2I. Consultationa. T% nurs co$$c"s "# fro( (u$"i!$ sourcs4 !ri(#r* +c$in", #n& sconr*

+f#(i$* ((3rs> su!!or" !rsons> %#$"%c#r !rofssion#$s #n& rcor&s,#. Consu$"#"ion 9i"% in&i2i&u#$s 9%o c#n con"ri3u" "o "% c$in":s "#3#s is

%$!fu$ in #c%i2ing "% (os" co(!$" #n& #ccur#" infor(#"ion #3ou" # c$in"c. Su!!$(n"#$ infor(#"ion fro( sconr* sourcs +#n* sourc o"%r "%n "%

c$in", c#n %$! 2rif* infor(#"ion> !ro2i& infor(#"ion for # c$in" 9%o c#nno"&o so> #n& con2* infor(#"ion #3ou" "% c$in":s s"#"us !rior "o #&(ission

2II. #e-ie' of literaturea. A !rofssion#$ nurs ng#gs in con"inu& &uc#"ion "o (#in"#in 1no9$&g of

currn" infor(#"ion r$#"& "o %#$"% c#r#. R2i9ing !rofssion#$ 5ourn#$s #n& ""3oo1s c#n %$! !ro2i& #&&i"ion#$ "#

"o su!!or" or %$! #n#$*; "% c$in" "#3#s

;. DOCUMENTING &!, REPORTING

A. *uidelines for *ood Documentation and #eporting

12

Gnr#$ #ssss(n"

In"gu(n"#r* s*s"( H#&> #rs> *s> nos> "%ro#"

Br#s" #n& #i$$#

T%or# #n& $ungs

C#r&io2#scu$#r s*s"(

Nr2ous s*s"(

A3&o(n #n& g#s"roin"s"in#$ s*s"(

Anus #n& rc"u(

Gni"ourin#r* s*s"(

R!ro&uc"i2 s*s"(

Voc#"ion7&uc#"ion7fin#nci#$

Ho( #n& F#(i$*

Soci#$> $isur> s!iri"u#$ #n& cu$"ur#$

Su#$

Ac"i2i"is of i$* $i2ing

H#$"% H#3i"s

Ps*c%o$ogic#$


13/30


I. Fact) infor(#"ion #3ou" c$in"s #n& "%ir c#r (us" 3 f#c"u#$. A rcor& s%ou$& con"#in&scri!"i2> o35c"i2 infor(#"ion #3ou" 9%#" # nurs ss> %#rs> f$s #n& s($$s

II. ccuracy) infor(#"ion (us" 3 #ccur#" so "%#" %#$"% "#( ((3rs %#2 confi&ncin i"

III. +om!leteness) "% infor(#"ion 9i"%in # rcor& or # r!or" s%ou$& 3 co(!$">con"#ining concis #n& "%oroug% infor(#"ion #3ou" # c$in":s c#r. Concis "# #r#s* "o un&rs"#n&

I2. Currn"nss ) ongoing &cisions #3ou" c#r (us" 3 3#s& on currn"$* r!or"&infor(#"ion. A" "% "i( of occurrnc inc$u& "% fo$$o9ing4a. Vi"#$ signs#. A&(inis"r#"ion of (&ic#"ions #n& "r#"(n"sc. Pr!#r#"ion of &i#gnos"ic "s"s or surgr*d. C%#ng in s"#"use. A&(ission> "r#nsfr> &isc%#rg or "% of # c$in"f. Tr#"(n" fro # su&&n c%#ng in s"#"us

2. Org#ni;#"ion ) "% nurs co((unic#" in # $ogic#$ for(#" or or&r2I. Confi&n"i#$i"* ) # confi&n"i#$ co((unic#"ion is infor(#"ion gi2n 3* on !rson "o

#no"%r 9i"% "rus" #n& confi&nc "%#" suc% infor(#"ion 9i$$ no" 3 &isc$os&

B. Documentation) #n*"%ing 9ri""n or !rin"& "%#" is r$i& on #s # rcor& of !roof fro

#u"%ori;& !rsons.

Pur!oss of Rcor&s4I. Co((unic#"ionII. P$#nning C$in" C#rIII. Au&i"ing H#$"% AgncisI2. Rs#rc%2. E&uc#"ion2I. Ri(3urs(n"2II. Lg#$ 'ocu(n"#"ion2III.H#$"% C#r An#$*sis

C. Documentation S"stems

I. Sourc ) Orin"& Rcor&a. T% "r#&i"ion#$ c$in" rcor. E#c% !rson or &!#r"(n" (#1s no"#"ions in # s!#r#" sc"ion or sc"ions

of "% c$in":s c%#r"c. I" is con2nin" 3c#us c#r !ro2i&rs fro( #c% &isci!$in c#n #si$* $oc#"

"% for(s on 9%ic% "o rcor& "# #n& i" is #s* "o "r#c "% infor(#"iond. E#(!$4 "% #&(issions &!#r"(n" %#s #n #&(ission s%" "% !%*sici#n

%#s # !%*sici#n:s or&r s%"> # !%*sici#n:s %is"or* s%" !rogrss no"se. NARRATIVE CHARTING is # "r#&i"ion#$ !#r" of "% sourc=orin"& rcor&

II. Pro3$( ) Orin"& M&ic#$ Rcor& +POMR,a. Es"#3$is%& 3* L#9rnc W. T% "# #r #rr#ng& #ccor&ing "o "% !ro3$(s "% c$in" %#s r#"%r "%#n "%

sourc of "% infor(#"ion.

T% four +, 3#sic co(!onn"s4i. '#"#3#s ) consis"s of #$$ infor(#"ion 1no9n #3ou" "% c$in" 9%n

"% c$in" firs" n"rs "% %#$"% c#r #gnc*. I" inc$u&s "%nursing #ssss(n"> "% !%*sici#n:s %is"or*> soci#$ f#(i$* "#

ii. Pro3$( Lis" ) &ri2& fro( "% "#3#s. Usu#$$* 1!" #" "% fron"of "% c%#r" sr2s #s #n in& "o "% nu(3r& n"ris in "%!rogrss no"s. Pro3$(s #r $is"& in "% or&r in 9%ic% "%* #ri&n"ifi& "% $is" is con"inu#$$* u!"& #s n9 !ro3$(s #ri&n"ifi& o"%rs rso$2&

iii. P$#n of C#r ) c#r !$#ns #r gnr#"& 3* "% !rson 9%o $is"s"% !ro3$(s. P%*sici#n:s 9ri" !%*sici#n:s or&rs or (&ic#$ c#r!$#ns nurss 9ri" nursing or&rs or nursing c#r !$#ns

iv. Progrss No"s ) c%#r" n"r* (#& 3* #$$ %#$"% !rofssion#$sin2o$2& in # c$in":s c#r "%* #$$ us "% s#( "*! of s%" frono"s. Nu(3r& "o corrs!on& "o "% !ro3$(s on "% !ro3$($is" #n& (#* 3 $""r& for "% "*! of "#

E#(!$4 SOAP For(#" Or SOAPIE #n& SOAPIERS ) Su35c"i2 "#O ) O35c"i2 "#

A ) Assss(n"

13


14/30


P ) P$#nI ) In"r2n"ionE ) E2#$u#"ionR= R2ision

A&2#n"#gs of POMR4 I" ncour#gs co$$#3or#"ion

Pro3$( $is" in "% fron" of "% c%#r" #$r"s c#rgi2rs "o "%

c$in":s n&s (#1s i" #sir "o "r#c1 "% s"#"us of #c%!ro3$(.

'is#&2#n"#gs of POMR4 C#rgi2rs &iffr in "%ir #3i$i"* "o us "% r/uir& c%#r"ing

for(#" T#1s cons"#n" 2igi$#nc "o (#in"#in #n u!="o=" !ro3$( $is"

So(9%#" infficin" 3c#us #ssss(n"s in"r2n"ions

"%#" #!!$* "o (or "%#n on !ro3$( (us" 3 r!#"&.

III. PIE +Pro3$(s> In"r2n"ions> #n& E2#$u#"ion,

a. Grou!s infor(#"ion in "o "%r +, c#"goris#. T%is s*s"( consis"s of # c$in" c#r #ssss(n" f$o s%" !rogrss no"sc. FLOW SHEET ) uss s!cific #ssss(n" cri"ri# in # !#r"icu$#r for(#"> suc%

#s %u(#n n&s or func"ion#$ %#$"% !#""rnsd. E$i(in#" "% "r#&i"ion#$ c#r !$#n incor!or#" #n ongoing c#r !$#n in"o "%

!rogrss no"s

I2. Focus C%#r"inga. In"n&& "o (#1 "% c$in" c$in" concrns s"rng"%s "% focus of c#r#. T%r +, co$u(ns fro rcor&ing #r usu#$$* us&4 " "i(> focus

!rogrss no"s

2. C%#r"ing 3* Ec!"ion

a. 'ocu(n"#"ion s*s"( in 9%ic% on$* #3nor(#$ or signific#n" fin&ings orc!"ions "o nor(s #r rcor&&

#. Incor!or#"s "%r +, 1* $(n"s4i. F$o9 s%"sii. S"#nr&s of nursing c#riii. B&si& #ccss "o c%#r" for(s

2I. Co(!u"ri;& 'ocu(n"#"iona. '2$o!& #s # 9#* "o (#n#g "% %ug 2o$u( of infor(#"ion r/uir& in

con"(!or#r* %#$"% c#r#. Nurss us co(!u"rs "o s"or "% c$in":s "#3#s> #&& n9 "#> cr#"

r2is c#r !$#ns &ocu(n" c$in" !rogrss.

2II. C#s M#n#g(n"a. E(!%#si;s /u#$i"*> cos"=ffc"i2 c#r &$i2r& 9i"%in #n s"#3$is%& $ng"%of s"#*

#. Uss # (u$"i&isci!$in#r* #!!ro#c% "o !$#nning &ocu(n"ing c$in" c#r> usingcri"ic#$ !#"%9#*s.

D. Nursing Care !lan $NC!%T9o T*!s4

I. Tr#&i"ion#$ C#r P$#n ) 9ri""n fro #c% c$in" i" %#s co$u(ns4 nursing &i#gnoss>!c"& ou"co(s nursing in"r2n"ions.

II. S"#nr&i;& C#r P$#n ) 3#s& on #n ins"i"u"ion:s s"#nr&s of !r#c"ic "%r3*%$!ing "o !ro2i& # %ig% /u#$i"* of nursing c#r

E. 4A#DE39i&$* us&> concis ("%o& of org#ni;ing rcor&ing "# #3ou" # c$in"> (#1inginfor(#"ion /uic1$* #ccssi3$ "o #$$ %#$"% !rofssion#$s. Consis"s of # sris of c#r&s 1!" in #!or"#3$ in& fi$ or on co(!u"r gnr#"& for(s. Infor(#"ion (#* 3 org#ni;& in"osc"ions4

I. Pr"inn" infor(#"ion #3ou" "% c$in"II. Lis" of (&ic#"ionsIII. Lis" of IVFI2. Lis" of i$* "r#"(n"s !roc&urs2. Lis" of 'i#gnos"ic !roc&urs

14


15/30


2I. A$$rgis2II. S!cific "# on %o9 "% c$in":s !%*sic#$ n&s #r "o 3 ("2III.A !ro3$( $is"> s"#"& go#$s $is" of nursing #!!ro#c%s "o (" "% go#$s

F. Nursing Discharge 5 #eferral Summaries) co(!$"& 9%n "% c$in" is 3ing &isc%#rg& "r#nsfrr& "o #no"%r ins"i"u"ion or "o # %o( s""ing 9%r # 2isi" 3* # co((uni"* %#$"% nursis r/uir&. Rg#r&$ss of for(#"> i" inc$u& so( or #$$ of "% fo$$o9ing4

I. 'scri!"ion of c$in":s !%*sic#$> (n"#$ (o"ion#$ s"#"II. Rso$2& %#$"% !ro3$(sIII. Unrso$2& con"inuing %#$"% !ro3$(sI2. Tr#"(n"s "%#" c#n 3 con"inu& +.g. 9oun& c#r> o*gn "%r#!*,2. Currn" (&ic#"ions2I. Rs"ric"ions "%#" r$#" "o #c"i2i"*> &i" 3#"%ing2II. Func"ion#$7s$f=c#r #3i$i"is2III.Co(for" $2$I3. Su!!or" n"9or1s

3. C$in" &uc#"ion !ro2i&& in r$#"ion "o &is#s !rocss3I. 'isc%#rg &s"in#"ion3II. Rfrr#$ Sr2ics +.g. soci#$ 9or1r> %o( %#$"% nurs,

"% nurs #s1s if "% c$in" n&s "o us "% "oi$".

c. Posi"ioning ) &uring "% #(in#"ion> "% nurs #s1s "% c$in"s "o #ssu(!ro!r !osi"ions so "%#" 3o&* !#r"s #r #ccssi3$ #n& c$in"s s"#* co(for"#3$.C$in":s #3i$i"is "o #ssu( !osi"ions 9i$$ &!n& on "%ir !%*sic#$ s"rng"% #n&&gr of 9$$nss.

C. ,rder of E0aminationI. Gnr#$ Sur2* ) inc$u&s o3sr2#"ion of gnr#$ #!!#r#nc #n& 3%#2ior> 2i"#$

signs> %ig%" #n& 9ig%" (#sur(n"II. R2i9 of s*s"(sIII. H#& "o "o #(in#"ion

D. S6ills in !h"sical E0aminationI. Ins!ection) "o &"c" nor(#$ c%#r#c"ris"ics or signific#n" !%*sic#$ signs. To ins!c"

3o&* !#r"s #ccur#"$* "% nurs o3sr2s "% fo$$o9ing !rinci!$s4a. M#1 sur goo& $ig%"ing is #2#i$#3$#. Posi"ion #n& !os 3o&* !#r"s so "%#" #$$ surf#c c#n 3 2i9&c. Ins!c" #c% #r#s fro si;> s%#!> co$or> s*(("r*> !osi"ion #n& #3nor(#$i"isd. If !ossi3$> co(!#r #c% #r# ins!c"& 9i"% "% s#( #r# of "% o!!osi"

si& of "% 3o&*e. Us #&&i"ion#$ $ig%" +for #(!$> # !n$ig%", "o ins!c" 3o&* c#2i"is

II. %al!ation) "% %#n&s c#n (#1 &$ic#" #n& snsi"i2 (#sur(n"s of s!cific!%*sic#$ signs> so !#$!#"ion is us& "o #(in #$$ #ccssi3$ !#r"s of "% 3o&*. T%nurs uss &iffrn" !#r"s of "% %#n& "o &"c" c%#r#c"ris"ics suc% #s ""ur>"(!r#"ur #n& "% !rc!"ion of (o2(n".

15


16/30


III. %ercussion) #(in#"ion 3* s"ri1ing "% 3o&*:s surf#c 9i"% # fingr> 2i3r#"ion #n&soun& #r !ro&uc&. T%is 2i3r#"ion is "r#ns(i""& "%roug% "% 3o&* "issus #n& "%c%#r#c"r of "% soun& &!n&s on "% &nsi"* of "% un&r$*ing "issu

I2. uscultation) is $is"ning "o soun& cr#"& in 3o&* org#ns "o &"c" 2#ri#"ions fro(nor(#$. So( soun&s c#n 3 %#r& 9i"% "% un#ssis"& #r> #$"%oug% (os" soun&sc#n 3 %#r& on$* "%roug% # s""%osco!.

a. Bo9$ soun&s#. Br#"% soun&s

i. Vsicu$#rii. Bronc%o2sicu$#riii. Bronc%i#$

E. E0amples of Ad-entitious Breath SoundsI. Cr#c1$s +!r2ious$* c#$$& r#$s,II. R%onc%iIII. W%;I2. Fric"ion ru3

T%r#!u"ic Co((unic#"ion Tc%ni/us?. Using si$nc

-. Pro2i&ing gnr#$ $#&s. Bing s!cific "n"#"i2. Using o!n=n&& /us"ions. Using "ouc%. Rs"#"ing "o !#r#!%r#sing. S1ing c$#rific#"ion. Prc!"ion c%c1ing or s1ing consnsu#$ 2#$i"ion@. Offring s$f?. Gi2ing infor(#"ion??. Ac1no9$&ging?-. C$#rif*ing "i( or s/unc?. Prsn"ing r#$i"*?. Focusing

?. Rf$c"ing?. Su((#ri;ing !$#nning

B. B#rrirs "o Co((unic#"ion?. S"ro"*!ing-. Agring &is#gring. Bing &fnsi2. C%#$$nging. Pro3ing. Ts"ing. R5c"ing. C%#nging "o!ics su35c"s@. Un9#rr#n"& r#ssur#nc?. P#ssing 5u&g(n"

??. Gi2ing co((on #&2ic

P%#ss of "% H$!ing R$#"ions%i!

?-. Pr=in"r#c"ion P%#s?. In"ro&uc"or* P%#s

#. O!ning "% r$#"ions%i!3. C$#rif*ing "% !ro3$(c. S"ruc"uring for(u$#"ing "% con"r#c"

?. Wor1ing P%#s#. E!$oring un&rs"#n&ing "%oug%"s or f$ings3. F#ci$i"#"ing "#1ing #c"ion

?. Tr(in#"ion P%#s

>. PRINCIPLES of ASEPSIS &!, INFECTION CONTROL

A. Chain of InfectionI. T% ch&i! of i!fectio!rfrs "o "%os $(n"s "%#" (us" 3 !rsn" "o c#us #n

infc"ion fro( # (icroorg#nis(

16


17/30


II. B#sic "o "% !rinci!$ of infc"ion is "o i!terr$t this ch&i!so "%#" #n infc"ion fro( #(icroorg#nis( &os no" occur in c$in"s

III. Infc"ious #gn" (icroorg#nis(s c#!#3$ of c#using infc"ions #r rfrr& "o #s #ni!fectio$s &)e!t or &tho)e!.

I2. Mo,es of tr&!s#issio!8"% (icroorg#nis( (us" %#2 # (#ns of "r#ns(ission "og" fro( on $oc#"ion "o #no"%r> c#$$& &irc" #n& in&irc"

2. S$sceti('e host&scri3s # %os" +%u(#n or #ni(#$, no" !ossssing noug%rsis"#nc #g#ins" # !#r"icu$#r !#"%ogn "o !r2n" &is#s or infc"ion fro(occurring 9%n !os& "o "% !#"%ogn in %u(#ns "%is (#* occur if "% !rson:srsis"#nc is $o9 3c#us of !oor nu"ri"ion> $#c1 of rcis of # cois"ing i$$nss "%#"9#1ns "% %os".

2I. Port&' of e!tr+8"% (#ns of # !#"%ogn n"ring # %os"4 "% (#ns of n"r* c#n 3"% s#( #s on "%#" is "% !or"#$ of i" +g#s"roin"s"in#$> rs!ir#"or*> gni"ourin#r*"r#c",.

2II. Reser"oir8"% n2iron(n" in 9%ic% "% (icroorg#nis( $i2s "o nsur sur2i2#$ i"

c#n 3 # !rson> #ni(#$> #r"%ro!o&> !$#n"> oi$ or # co(3in#"ion of "%s "%ingsrsr2oirs "%#" su!!or" org#nis( "%#" #r !#"%ognic "o %u(#ns #r in#ni(#"o35c"s foo& #n& 9#"r> #n& o"%r %u(#ns.

2III.Port&' of e?it4 "% (#ns in 9%ic% "% !#"%ogn sc#!s fro( "% rsr2oir #n& c#nc#us &is#s "%r is usu#$$* # co((on sc#! rou" for #c% "*! of(icroorg#nis( on %u(#ns> co((on sc#! rou"s #r "% g#s"roin"s"in#$>rs!ir#"or* #n& "% gni"ourin#r* "r#c".

Modes of &ransmission?. 'irc" con"#c"4 &scri3s "% 9#* in 9%ic% (icroorg#nis(s #r "r#nsfrr&

fro( !rson "o !rson "%roug% 3i"ing> "ouc%ing> 1issing> or su#$in"rcours &ro!$" s!r#& is #$so # for( of &irc" con"#c" 3u" c#n occur

on$* if "% sourc #n& "% %os" #r 9i"%in f" fro( #c% o"%r"r#ns(ission 3* &ro!$" c#n occur 9%n # !rson coug%s> sn;s> s!i"s>or "#$1s.

-. In&irc" con"#c"4 c#n occur "%roug% fo(i"s +in#ni(#" o35c"s or (#"ri#$s,or "%roug% 2c"ors +#ni(#$ or insc"> f$*ing or cr#9$ing, "% fo(i"s or2c"ors #c" #s 2%ic$ for "r#ns(ission

. Air4 #ir3orn "r#ns(ission in2o$2s &ro!$"s or &us" &ro!$" nuc$i c#nr(#in in "% #ir for $ong !rio&s #n& &us" !#r"ic$s con"#ining infc"ious#gn"s c#n 3co( #ir3orn infc"ing # susc!"i3$ %os" gnr#$$* "%roug%"% rs!ir#"or* "r#c"

B. Course of Infection

I. I!c$(&tio!4 "% "i( 3"9n initial contact9i"% #n infc"ious #gn" until the firstsigns of s"mptoms = = "% incu3#"ion !rio& 2#ris fro( &iffrn"!#"%ogns (icroorg#nis(s #r gro9ing #n& (u$"i!$*ing &uring "%is s"#g

II. Pro,ro#&' St&)e4 "% "i( !rio& fro( "% onset of nonspecific s"mptoms to theappearance of specific s"mptomsr$#"& "o "% c#us#"i2 !#"%ogn

= = s*(!"o(s r#ng fro( 3ing f#"igu& "o %#2ing # $o9=gr#& f2r 9i"%(#$#is &uring "%is !%#s i" is s"i$$ !ossi3$ "o "r#ns(i" "% !#"%ogn "o#no"%r %os"

III. F$'' St&)e4 (#nifs"#"ions of specific signs 7 s"mptomsof infc"ious #gn"rfrr& "o #s "% #cu" s"#g &uring "%is s"#g> i" (#* be possible to transmit theinfectious agent to another8&!n&ing on "% 2iru$nc of "% infc"ious #gn"

I2. Co!"&'esce!ce4 "i( !rio& "%#" "% host "#1s "o return to the preillness stage#$so c#$$& "% reco-er" period = = "% %os" &fns (c%#nis(s %#2 rs!on&&"o "% infc"ious #gn" #n& "% signs #n& s*(!"o(s of "% &is#s &is#!!#r "%%os"> %o92r> is (or 2u$nr#3$ "o o"%r !#"%ogns #" "%is "i( #n #!!ro!ri#"nursing &i#gnos"ic $#3$ r$#"& "o "%is !rocss 9ou$& 3 #is6 for Infection

1+


18/30


C. Inflammation) T% !ro"c"i2 rs!ons of "% "issus of "% 3o&* "o in5ur* or infc"ion "%!%*sio$ogic#$ r#c"ion "o in5ur* or infc"ion is "% inf$#((#"or* rs!ons i" (#* 3 #cu" orc%ronic

Bo&*:s rs!onsI. T% inf$#((#"or* rs!ons 3gins 9i"% 2#socons"ric"ion "%#" is fo$$o9& 3* # 3rif

incr#s in 2#scu$#r !r(#3i$i"* "% 3$oo& 2ss$s &i$#" #$$o9ing !$#s(# "o sc#!in"o "% in5ur& "issu

II. WBCs +nu"ro!%i$s> (onoc*"s> #n& (#cro!%#gs, (igr#" "o "% #r# of in5ur* #n""#c1 #n& ings" "% in2#&rs +!%#goc*"osis, "%is !rocss is rs!onsi3$ for "%signs of inf$#((#"ion

III. R&nss occurs 9%n 3$oo& #ccu(u$#"s in "% &i$#"& c#!i$$#ris 9#r("% occurs #s# rsu$" of "% %#" fro( "% incr#s& 3$oo& in "% #r#> s9$$ing occurs fro( f$uiccu(u$#"ion "% !#in occurs fro( !rssur or in5ur* "o "% $oc#$ nr2s.

D. Immune #esponseI. T% i((un rs!ons in2o$2s s!cific r#c"ions in "% 3o&* "o #n"igns or forign

(#"ri#$

II. T%is s!cific rs!ons is "% 3o&*:s #""(!" "o !ro"c" i"s$f> "% 3o&* !ro"c"s i"s$f3* #c"i2#"ing - "*!s of $*(!%oc*"s> "% T=$*(!%oc*"s #n& B=$*(!%oc*"s

III. C$$ (&i#"& i((uni"*4 T=$*(!%oc*"s #r rs!onsi3$ for c$$u$#r i((uni"*a. W%n fungi > !ro"o;o#> 3#c"ri# #n& so( 2iruss #c"i2#" T=$*(!%oc*"s> "%*

n"r "% circu$#"ion fro( $*(!% "issu #n& s1 ou" "% #n"ign#. Onc "%#n"ign is foun& "%* !ro&uc !ro"ins +$*(!%o1ins, "%#" incr#s

"% (igr#"ion of !%#goc*"s "o "% #r# #n& 1! "%( "%r "o 1i$$ "% #n"ignc. Af"r "% #n"ign is gon> "% $*(!%o1ins &is#!!#rd. So( T=$*(!%oc*"s r(#in #n& 1! # ((or* of "% #n"ign #n& #r

r#c"i2#"& if "% #n"ign #!!#rs #g#in.

I2. Hu(or#$ rs!ons4 "% #3i$i"* of "% 3o&* "o &2$o! # s!cific #n"i3o&* "o # s!cific

#n"ign +#n"ign=#n"i3o&* rs!ons,a. B=$*(!%oc*"s !ro2i& humoral immunity #y !roducing anti#odies"%#" con2*

s!cific rsis"#nc "o (#n* 3#c"ri#$ #n& 2ir#$ infc"ions

#. ctive immunityis !ro&uc& 9%n "% i((un s*s"( is #c"i2#"& i"%rn#"ur#$$* or #r"ifici#$$*.

i. N#"ur#$ i((uni"* in2o$2s #c/uisi"ion of i((uni"* "%roug%&2$o!ing "% &is#s

ii. Ac"i2 i((uni"* c#n #$so 3 !ro&uc& "%roug% 2#ccin#"ion 3*in"ro&ucing in"o "% 3o&* # 9#1n& or 1i$$& #n"ign +#r"ifici#$$*#c/uir& i((uni"*,

iii. P#ssi2 i((uni"* &os no" r/uir # %os" "o &2$o! #n"i3o&is>r#"%r i" is "r#nsfrr& "o "% in&i2i&u#$> !#ssi2 i((uni"* occurs

9%n # (o"%r !#sss #n"i3o&is "o # n93orn or 9%n # !rsonis gi2n #n"i3o&is fro( #n #ni(#$ or !rson 9%o %#s %#& "%&is#s in "% for( of i((un g$o3u$ins "%is "*! of i((uni"* on$*offrs "(!or#r* !ro"c"ion fro( "% #n"ign.

E. Nosocomial InfectionI. Nosocomial Infections4 #r "%os "%#" #r #c/uir& #s # rsu$" of # %#$"%c#r

&$i2r* s*s"(

II. Iatrogenic infection,"%s nosoco(i#$ infc"ions #r &irc"$* r$#"& "o "% c$in":s"r#"(n" or &i#gnos"ic !roc&urs #n #(!$ of #n i#"rognic infc"ion 9ou$& 3 #3#c"ri#$ infc"ion "%#" rsu$"s fro( #n in"r#2#scu$#r $in or Psu&o(on#s #ruginos#!nu(oni# #s # rsu$" of rs!ir#"or* suc"ioning

III. E"ogenous Infection4 #r # rsu$" of "% %#$"%c#r f#ci$i"* n2iron(n" or !rsonn$#n #(!$ 9ou$& 3 #n u!!r rs!ir#"or* infc"ion rsu$"ing fro( con"#c" 9i"% #c#rgi2r 9%o %#s #n u!!r rs!ir#"or* infc"ion

I2. Endogenous Infection4 c#n occur fro( c$in"s "%(s$2s or #s # r#c"i2#"ion of #!r2ious &or(#n" org#nis( suc% #s "u3rcu$osis #n #(!$ of n&ognousinfc"ion 9ou$& 3 # *#s" infc"ion #rising in # 9o(#n rci2ing #n"i3io"ic "%r#!*

1,


19/30


"% *#s" org#nis(s #r #$9#*s !rsn" in "% 2#gin#> 3u" 9i"% "% $i(in#"ion of "%nor(#$ 3#c"ri#$ f$or#> "% *#s" f$ouris%.

F. Factors Increasing Susceptibilit" to Infection

I. ge4 *oung inf#n"s o$&r #&u$"s #r #" gr#"r ris1 of infc"ion 3c#us of r&uc&&fns (c%#nis(s

a. 0oung inf#n"s %#2 r&uc& &fnss r$#"& "o i((#"ur i((un s*s"(s#. In $&r$* !o!$> !%*sio$ogic#$ c%#ngs occur in "% 3o&* "%#" (#1 "%(

(or susc!"i3$ "o infc"ious &is#s so( of "%s c%#ngs #r4i. A$"r& i((un func"ion +s!cific#$$*> &cr#s& !%#goc*"osis 3*

"% nu"ro!%i$s #n& 3* "% (#cro!%#gs,ii. 'cr#s& 3$#&&r (usc$ "on rsu$"ing in urin#r* r"n"ioniii. 'i(inis%& coug% rf$> $oss of $#s"ic rcoi$ 3* "% $ungs $#&ing

"o in#3i$i"* "o 2#cu#" nor(#$ scr"ionsiv. G#s"roin"s"in#$ c%#ngs rsu$"ing in &cr#s& s9#$$o9ing #3i$i"*

#n& &$#*& g#s"ric (!"*ing.

II. Hr&i"*4 so( !o!$ %#2 # gn"ic !r&is!osi"ion or susc!"i3i$i"* "o so(infc"ious &is#ss

III. Cu$"ur#$ !r#c"ics4 %#$"%c#r 3$ifs #n& !r#c"ics> #s 9$$ #s nu"ri"ion#$ #n& %*gin!r#c"ics> c#n inf$unc # !rson:s susc!"i3i$i"* "o infc"ious &is#ss

I2. Nu"ri"ion4 in#&/u#" nu"ri"ion c#n (#1 # !rson (or susc!"i3$ "o infc"ious&is#ss nu"ri"ion#$ !r#c"ics "%#" &o no" su!!$* "% 3o&* 9i"% "% 3#sic co(!onn"sncss#r* "o s*n"%si;& !ro"ins #ffc" "% 9#* "% 3o&*:s i((un s*s"( c#nrs!on& "o !#"%ogns

2. S"rss4 s"rssors> 3o"% !%*sic#$ #n& (o"ion#$> #ffc" "% 3o&*:s #3i$i"* "o !ro"c"#g#ins" in2#&ing !#"%ogns s"rssors #ffc" "% 3o&* 3* $2#"ing 3$oo& cor"ison$2$s if $2#"ion of sru( cor"ison is !ro$ong&> i" &cr#ss "% #n"i=inf$#((#"or*rs!ons #n& &!$"s nrg* s"ors> "%us incr#sing "% ris1 of infc"ion

2I. Rs"> rcis #n& !rson#$ %#$"% %#3i"s4 #$"r& rs" #n& rcis !#""rns&cr#s "% 3o&*:s !ro"c"i2> (c%#nis(s #n& (#* c#us !%*sic#$ s"rss "o "%3o&* rsu$"ing in #n incr#s& ris1 of infc"ion !rson#$ %#$"% %#3i"s suc% #s !oornu"ri"ion #n& un%#$"%* $ifs"*$ %#3i"s incr#s "% ris1 of infc"ious o2r "i( 3*#$"ring "% 3o&*:s rs!ons "o !#"%ogns

2II. In#&/u#" &fnss4 #n* !%*sio$ogic#$ #3nor(#$i"* or $ifs"*$ %#3i" c#n inf$uncnor(#$ &fns (c%#nis(s in "% 3o&*> (#1ing "% c$in" (or susc!"i3$ "oinfc"ion "% i((un s*s"( func"ions "%roug%ou" "% 3o&* #n& &!n&s on "%fo$$o9ing4

a. In"#c" s1in #n& (ucous ((3r#ns#. A&/u#" 3$oo& c$$ !ro&uc"ion #n& &iffrn"i#"ionc. A func"ion#$ $*(!%#"ic s*s"( #n& s!$n

d. An #3i$i"* "o &iffrn"i#" forign "issu #n& !#"%ogns fro( nor(#$ 3o&* "issu#n& f$or# in #u"oi((un &is#s> "% 3o&* %#s # !ro3$( 9i"% rcogni;ing i":so9n "issu #n& c$$s !o!$ 9i"% #u"oi((un &is#s #r #" incr#s& ris1 ofinfc"ion r$#"& "o "%ir i((un s*s"( &ficincis.

2III.En2iron(n"#$4 #n n2iron(n" "%#" !oss in&i2i&u#$s "o #n incr#s& nu(3r of"oins or !#"%ogns #$so incr#ss "% ris1 of infc"ion !#"%ogns gro9 9$$ in 9#r((ois" #r#s 9i"% o*gn +#ro3ic, or 9i"%ou" o*gn +#n#ro3ic, &!n&ing on "%(icroorg#nis(> #n n2iron(n" "%#" incr#ss !osur "o "oic su3s"#ncs #$soincr#ss ris1

I3. I((uni;#"ion %is"or*4 in#&/u#"$* i((uni;& !o!$ %#2 #n incr#s& ris1 ofinfc"ion s!cific#$$* for "%os &is#ss for 9%ic% 2#ccins %#2 3n &2$o!&.

3. M&ic#"ions #n& (&ic#$ "%r#!is4 #(!$s of "%r#!is #n& (&ic#"ions "%#"incr#s c$in"s ris1 for infc"ion inc$u&s r#&i#"ion "r#"(n"> #n"i=no=!$#s"ic &rugs>#n"i inf$#((#"or* &rugs #n& surgr*

*. Diagnostic &ests 9sed to Screen for InfectionI. Signs #n& s*(!"o(s r$#"& "o infc"ions #r #ssoci#"& 9i"% "% #r# infc"& for

ins"#nc> sym!toms of a local infection on the s'in or mucous mem#ranes arelocalied swelling$ redness$ !ain and warmth

1-


20/30


II. S*(!"o(s r$#"& "o s"stemic infections include fever$ increased !ulse &res!irations$ lethargy$ anore"ia$ and enlarged lym!h nodes

III. Cr"#in &i#gnos"ic "s"s #r or&r& "o confir( "% !rsnc of #n infc"ion.

@. THEORIES OF PAINA. S!ecific heory

I. Pro!oss "%#" 3o&*:s nurons !#"%9#*s for !#in "r#ns(ission #r s!cific> si(i$#r"o o"%r snss $i1 "#s"

II. Fr nr2 n&ings in "% s1in #c" #s !#in rc!"ors> #cc!" in!u" "r#ns(i"i(!u$ss #$ong %ig%$* s!cific nr2 fi3rs

III. 'os no" #ccoun" for &iffrncs in !#in !rc!"ion or !s*c%o$ogic 2#ri#3$s #(ongin&i2i&u#$s.

B. %attern heoryI. I&n"ifis - (#5or "*!s of !#in fi3rs r#!i&$* s$o9$* con&uc"ing

II. S"i(u$#"ion of "%s fi3rs for(s # !#""rn i(!u$ss #scn& "o "% 3r#in "o 3in"r!r"& #s !#infu$

III. 'os no" #ccoun" for &iffrncs in !#in !rc!"ion or !s*c%o$ogic 2#ri#3$s #(ongin&i2i&u#$s.

C. /ate +ontrol heoryI. P#in i(!u$ss c#n 3 (o&u$#"& 3* # "r#ns(ission 3$oc1ing #c"ion 9i"%in "% CNS.II. L#rg=&i#("r cu"#nous !#in fi3rs c#n 3 s"i(u$#"& +.g. ru33ing or scr#"c%ing

#n #r#, #n& (#* in%i3i" s(#$$r &i#("r fi3rs "o !r2n" "r#ns(ission of "%i(!u$s +c$os "% g#",.

D. +urrent 0evelo!ments in %ain heory 1In&ic#" "%#" !#in (c%#nis(s rs!onss #r f#r

(or co(!$ "%#n 3$i2& "o 3 in "% !#s".I. P#in (#* (o&u$#"& #" &iffrn" !oin"s in "% nr2ous s*s"(.

a. Firs"=or&r nurons #" "% "issu $2$#. Scon&=or&r nurons in "% s!in#$ cor& "%#" !rocss nocic!"or infor(#"ionc. T%ir&=or&r "r#c"s !#"%9#*s in "% s!in#$ cor& 3r#in "%#" r$#*7!rocss "%is

infor(#"ion

II. T% ro$ of "% !#in !rinc in "% &2$o!(n" of n9 nocic!"ors #n&7orr&ucing "% "%rs%o$& of currn" nocic!"or is #$so 3ing in2s"ig#"

1. T3PES OF PAINA. cute %ain

I. Usu#$$* "(!or#r*> su&&n in ons"> $oc#$i;&> $#s"s for (on"%s rsu$"s fro( "issu

in5ur* #ssoci#"& 9i"% "r#u(#> surgr*> or inf$#((#"ion.

y!es of cute %aina. So(#"ic4 #riss fro( nr2 rc!"ors in "% s1in or c$os "o 3o&*:s surf#c

(#* 3 s%#r! 9$$=$oc#$i;& or &u$$ &iffus of"n #cco(!#ni& 3* n#us# 2o(i"ing

#. Viscr#$4 #riss fro( 3o&*:s org#ns &u$$ !oor$* $oc#$i;& 3c#us of (ini(#$noric!"ors #cco(!#ni& 3* n#us# 2o(i"ing> %*!o"nsion rs"$ssnss

c. Rfrr& !#in4 !#in "%#" is !rci2& in #n #r# &is"#n" fro( "% si" of s"i(u$i+.g. !#in in # s%ou$&r fo$$o9ing #3&o(in#$ $#!#rosco!ic !roc&ur,.

II. Acu" !#in ini"i#"s "% fig%"=or=f$ig%" rs!ons of "% Au"ono(ic Nr2ous S*s"(#n& is c%#r#c"ri;& 3* "% fo$$o9ing s*(!"o(s4

a. T#c%*c#r&i##. R#!i&> s%#$$o9 rs!ir#"ionsc. Incr#s& BPd. S9#"inge. P#$$orf. 'i$#"& !u!i$sg. F#r Ani"*

2.


21/30


B. +hronic %ainI. Pro$ong&> $#s"ing $ongr "%#n (on"%s> of"n no" #""ri3u"& "o # &fini" c#us> of"n

unrs!onsi2 "o (&ic#$ "r#"(n".

T*!s of C%ronic P#ina. Nuro!#"%ic4 !#infui$ con&i"ion "%#" rsu$"s fro( (#g "o !ri!%r#$ nr2s

c#us& 3* infc"ion or &is#s !os"="%r#!u"ic nur#$gi# +s%ing$s, is #n#(!$

#. P%#n"o(4 !#in s*n&ro( "%#" occurs fo$$o9ing surgic#$ or "r#u(#"ic #(!u"#"ionof # $i(3.

i. T% c$in" is #9#r "%#" "% 3o&* !#r" is (issingii. P#in (#* rsu$" of s"i(u$#"ion of s2r& nr2s #" "% si" of

#(!u"#"ioniii. Sns#"ion (#* 3 !rinc& #s #n i"c%ing> !rssur> or #s

s"#33ing or 3urning in n#"uriv. I" c#n 3 "riggr& 3* s"rssors +f#"igu> i$$nss> (o"ions>

9#"%r,

v. T%is !rinc is $i(i"& for (os" c$in"s 3c#us "% 3r#in#!"s "o #(!u"#"& $i(3 %o92r> so( c$in"s !rinc#3nor(#$ sns#"ion or !#in o2r $ongr !rio&s

vi. T%is "*! of !#in r/uirs "r#"(n" 5us" #s #n* o"%r "*! of !#in&os.

c. Ps*c%ognic4 !#in "%#" is !rinc& in "% #3snc of # &i#gnos&!%*sio$ogic c#us or 2n" "% c$in":s (o"ion#$ n&s (#* !ro(!" !#insns#"ion.

II. '!rssion is # co((on #ssoci#"& s*(!"o( for "% c$in" !rincing c%ronic!#in f$ings of &s!#ir %o!$ssnss #$ong 9i"% f#"igu #r !c"& fin&ings.

11. PAIN ASSESSMENT

A. &,,(S5INMEN&S 9SEDI. A VERBAL REPORT using #n in"nsi"* sc#$ is # f#s"> #s* r$i#3$ ("%o&

#$$o9ing "% c$in" "o s"#" !#in in"nsi"* in "urn> !ro(o"s consis"&co((unic#"ion #(ong "% nurs> c$in" o"%r %#$"%c#r !rofssion#$s #3ou" "%c$in":s !#in s"#"us "% - (os" co((on sc#$s us& #r "o or "o ?. Wi"% s!cif*ing no !#in "% %ig%s" nu(3r s!cif*ing "% 9ors" !#in

II. A VISUAL ANALOG SCALE is # %ori;on"#$ !#in=in"nsi"* sc#$ 9i"% 9or& (o&ifirs #"3o"% n&s of "% sc#$> suc% #s no !#in #" on n& #n& 9ors" !#in #" "% o"%r>c$in"s #r #s1& "o !oin" or (#r1 #$ong "% $in "o con2* "% &gr of !#in 3ing!rinc&

III. A GRAPHIC RATING SCALE is si(i$#r "o "% 2isu#$ #n#$og sc#$ 3u" #&&s #nu(ric#$ sc#$ 9i"% "% 9or& (o&ifirs> usu#$$* "% nu(3rs "o ? #r #&&& "o"% sc#$.

I2. FACES PAIN SCALE c%i$&rn> c$in"s 9%o &o no" s!#1 Eng$is% c$in"s 9i"%co((unic#"ion i(!#ir(n"s (#* %#2 &ifficu$"* using # nu(ric#$ !#in in"nsi"*sc#$ "% FACES !#in sc#$ (#* 3 us& for c%i$&rn #s *oung #s *#rs o$& "%issc#$ !ro2i&s f#ci#$ !rssions +%#!!* f#c rf$c"s no !#in> cr*ing f#c r!rsn"s9ors" !#in,

2. PH0SIOLOGIC IN'ICATORS OF PAIN (#* 3 "% on$* (#ns # nurs c#n us "o#ssss !#in for # non=co((unic#"ing c$in"> f#ci#$ 2oc#$ !rssion (#* 3 "%ini"i#$ (#nifs"#"ions of !#in !rssions (#* inc$u& r#!i& * 3$in1ing> 3i"ing of "%$i!> (o#ning> cr*ing> scr#(ing> i"%r c$os& or c$nc%& *s> or s"iff un(o2ing3o&* !osi"ion

B. A B C D E method of pain assessmentI. T%is #cron*( 9#s &2$o!& for c#ncr !#in %o92r> i" is 2r* #!!ro!ri#" for

c$in"s 9i"% #n* "*! of !#in> rg#r&$ss of "% un&r$*ing &is#s.II. A Q As1 #3ou" !#inIII. B Q B$i2 "% c$in" f#(i$* r!or"s !#in

21


22/30


I2. C Q C%oos !#in con"ro$ o!"ions #!!ro!ri#" for "% c$in"2. ' Q '$i2r in"r2n"ions in # "i($*> $ogic#$ coor&in#"& f#s%ion2I. E Q E(!o9r c$in"s f#(i$is

C. ! : # S & assessment for pain receptionI. T%is ("%o& is s!ci#$$* %$!fu$ 9%n #!!ro#c%ing # n9 !#in !ro3$(II. P Q W%#" !rci!i"#"& "% !#inIII. 8 Q W%#" #r "% /u#$i"* /u#n"i"* of "% !#inI2. R Q W%#" is "% rgion of "% !#in2. S Q W%#" is "% s2ri"* of "% !#in2I. T Q W%#" is "% "i(ing of "% !#in

D. !ain Histor"I. Loc#"ion ) 9%n c$in"s r!or" !#in #$$ o2r> "%is gnr#$$* rfrs "o "o"#$ !#in or

is"n"i#$ &is"rss +un$ss "%r is #n un&r$*ing !%*sio$ogic r#son for !#in #$$ o2r"% 3o&*> suc% #s (*#$gi#s, #ssss "% c$in":s (o"ion#$ s"#" for &!rssion> f#r>#ni"* or %o!$ssnss.

II. In"nsi"* ) I" is i(!or"#n" "o /u#n"if* !#in using # s"#nr& !#in in"nsi"* sc#$. W%nc$in"s c#nno" conc!"u#$i; !#in using # nu(3r> si(!$ 9or& c#"gori;s c#n 3usfu$ +.g. no !#in> (i$&> (o&r#"> s2r,.

III. 8u#$i"*a. Nocic!"i2 !#in #r usu#$$* r$#"& "o (#g "o 3ons> sof" "issus> or

in"rn#$ org#ns nocic!"i2 !#in inc$u&s so(#"ic 2iscr#$ !#ins.i. So(#"ic !#in is #c%ing> "%ro33ing !#in #(!$ #r"%ri"isii. Viscr#$ !#in is s/u;ing> cr#(!ing !#in #(!$4 !#in

#ssoci#"& 9i"% u$cr#"i2 co$i"is

I2. P#""rn ) !#in (#* 3 #$9#*s !rsn" for # c$in" "%is is of"n "r(& 3#s$in !#in.A&&i"ion#$ !#in (#* occur in"r(i""n"$* "%#" is of r#!i& ons" gr#"r in"nsi"* "%#n"% 3#s$in !#in 1no9n #s 3r#1"%roug% !#in. Po!$ #" n&=of=$if of"n %#2 3o"%"*!s of !#in. Cu$"ur#$ 3$ifs rg#r&ing "% (#ning of !#in s%ou$& 3 #(in&

ADMINISTRATION OF MEDICATIONS

10. DRUG NOMENCLATURE &!, FORMSA. Names

I. C%(ic#$ N#( ) !ro2i&s #n #c" &scri!"ion of "% &rug:s co(!osi"ion. An#(!$ of c%(ic#$ n#( #c"*$s#$ic*$ic 1no9n co((on #s As!irin

II. Gnric N#( ) is gi2n 3* "% (#nuf#c"urr 9%o firs" &2$o!s "% &rug 3for i"rci2s offici#$ #!!ro2#$. Pro"c"& 3* $#9> "% gnric n#( is gi2n 3for # &rugrci2s offici#$ !u3$ic#"ions.

III. Offici#$ N#( ) is "% n#( un&r 9%ic% &rug is $is"& in offici#$ !u3$ic#"ion

I2. Tr#&> Br#n& or Pro!ri"* N#( ) is "% n#( un&r 9%ic% # (#nuf#c"urr (#r1"s.

B. Classificatio!) Nurss c#"gori;& (&ic#"ions 9i"% si(i$#r c%#r#c"ris"ics 3* "%ir c$#ss.'rug c$#ssific#"ion in&ic#"s "% ffc"s on # 3o&* s*s"(> "% s*(!"o(s r$i2& or "%&sir& ffc". E#c% c$#ss con"#ins &rugs !rscri3& for si(i$#r "*!s of %#$"% !ro3$(s. T%!%*sic#$ #n& c%(ic#$ co(!osi"ion of &rugs 9i"%in # c$#ss is no" ncss#ri$* "% s#(. A &rug(#* #$so 3$ong "o (or "%#n on c$#ss. For #(!$> #s!irin is #n #n#$gsic #n& #n"i!*r"ic#n& #n #n"i=inf$#((#"or* &rug.

C. Forms) 'rugs #r #2#i$#3$ in # 2#ri"* of for(s !r!#r#"ions. T% for( of "% &rug

&"r(ins i"s rou" o #&(inis"r#"ion. For #(!$> # c#!su$ is "#1n or#$$* #n& # so$u"ion (#*3 gi2n in"r#2nous$*. T% co(!osi"ion &rug is &sign& "o n%#nc i"s #3sor!"ion #n&("#3o$is( 9i"%in "% 3o&*. M#n* &rugs #r #2#i$#3$ in s2r#$ for(s suc% #s "#3$"s>c#!su$s> $iirs #n& su!!osi"oris. W%n #&(inis"ring # (&ic#"ion> "% nurs (us" 3cr"#in "o gi2 "% ("#3o$is( in "% !ro!r for(.

D. !rinciples in Administering MedicationsI. O3sr2 "% RIGHTS of 'rug A&(inis"r#"ion4

a. Rig%" 'rug#. Rig%" 'osc. Rig%" Ti(d. Rig%" Rou"

22


23/30


e. Rig%" P#"in"f. Rig%" Rcor&ingg. Rig%" A!!ro#c%

II. Pr#c"ic #s!sis

III. Nurss 9%o #&(inis"r (&ic#"ions #r rs!onsi3$ for "%ir o9n #c"ions. 8us"ion#n* or&r "%#" *ou c#n consi&r incorrc".

I2. B 1no9$&g#3$ #3ou" (&ic#"ions "%#" *ou #&(inis"r

2. K! n#rco"ics 3#r3i"ur#"s in $oc1& !$#c

2I. Us on$* (&ic#"ions "%#" #r in c$#r$* $#3$& con"#inrs

2II. R"urn $i/ui& "%#" #r c$ou&* or %#2 c%#ng& in co$or "o "% !%#r(#c*

2III.Bfor #&(inis"ring # (&ic#"ion> i&n"if* "% c$in" corrc"$*

I3. 'o no" $#2 "% (&ic#"ion #" "% 3&si&

3. If "% c$in" 2o(i"s #f"r "#1ing #n or#$ (&ic#"ion> r!or" "%is "o "% nurs in c%#rg#n&7or !%*sici#n

3I. Pro!r#"i2 (&ic#"ions #r usu#$$* &iscon"inu& &uring "% !os" o!r#"i2 !rio&un$ss or&r& "o 3 con"inu&

3II. W%n # (&ic#"ion is o(i""& for #n* r#son> rcor& "% f#c" "og"%r 9i"% "%r#son

3III.W%n # (&ic#"ion rror is (#&> r!or" i((&i#"$* "o "% nurs in c%#rg #n&7or!%*sici#n

12. *ASIC HUMAN NEEDSA. Abraham Maslo') &2$o!& "% fi2 +, $2$s of %u(#n n&s4

I. P%*sio$ogic N&s ) n&s suc% #s #ir> foo&> 9#"r> s%$"r> rs"> s$!> #c"i2i"* #n&"(!r#"ur (#in"n#nc #r cruci#$ for sur2i2#$

II. S#f"* #n& Scuri"* N&s ) "% n& for s#f"* %#s 3o"% !%*sic#$ #n& !%*sio$ogic#s!c"s

III. Lo2 #n& B$onging N&s ) "% "%ir& $2$ of n&s inc$u&s gi2ing #n& rci2ing#ffc"ion> #""#ining # !$#c in # grou! #n& (#in"#ining "% f$ing of 3$onging

I2. S$f=Es"( N&s ) "% in&i2i&u#$ n&s 3o"% s$f=s"( #n& s"( fro( o"%rs2. S$f=Ac"u#$i;#"ion ) 9%n "% n& for s$f=s"( is s#"isfi&> "% in&i2i&u#$ s"ri2s

for s$f=#c"u#$i;#"ion> "% inn#" n& "o &2$o! on:s (#i(u( !o"n"i#$ #n& r#$i;on:s #3i$i"is #n& /u#$i"is

B. Maslo';s Characteristics of a SelfActuali)ed !ersonI. Is r#$is"ic> ss $if c$#r$* #n& is o35c"i2 #3ou" %is or %r o3sr2#"ionsII. Du&gs !o!$ corrc"$*III. H#s su!rior !rc!"ion> is (or &cisi2I2. H#s # c$#r no"ion of rig%" or 9rong2. Is usu#$$* #ccur#" in !r&ic"ing fu"ur 2n"s2I. Un&rs"#n&s #r"> (usic> !o$i"ics #n& !%i$oso!%*2II. Posssss %u(i$i"*> $is"ns "o o"%rs c#rfu$$*2III.Is &&ic#"& "o so( 9or1> "#s1> &u"* or 2oc#"ionI3. Is %ig%$* cr#"i2> f$i3$> s!on"#nous> cour#gous>

#n& 9i$$ing "o (#1 (is"#1s3. Is o!n "o n9 is3I. Is s$f=confi&n" #n& %#s s$f=rs!c"3II. H#s $o9 &gr of s$f=conf$ic" !rson#$i"* is in"gr#"&3III. Rs!c" s$f> &os no" n& f#(> !osssss # f$ing of s$f=con"ro$3I2.Is %ig%$* in&!n&n"> &sirs !ri2#c*32. C#n #!!#r r(o" or &"#c%&32I. is frin&$*> $o2ing #n& go2rn& (or 3* innr &irc"i2s "%#n 3* soci"*32II. C#n (#1 &cisions con"r#r* "o !o!u$#r o!inion32III. Is !ro3$( cn"r& r#"%r "%#n s$f=cn"r&3I3. Acc!"s "% 9or$& for 9%#" i" is

23


24/30


16. MEETING O=3GENATION NEEDSA. ,0"genation) # 3#sic %u(#n n& is r/uir& "o sus"#in $if.

B. Cardio-ascular !h"siolog") "% func"ion of "% c#r&i#c s*s"( is "o&$i2r o*gn> nu"rin"s> o"%r su3s"#ncs "o "% "issus #n& "o r(o2 "% 9#s" !ro&uc"sof c$$u$#r ("#3o$is(

C. Structure and Function) "% %#r" !u(!s 3$oo& "%roug% "% !u$(on#r* circu$#"ion 3* 9#* of"% rig%" 2n"ric$ #n& "o "% s*s"(ic circu$#"ion 3* 9#* of "% $f" 2n"ric$

I. M*oc#r&i#$ Pu(! ) "% !u(!ing #c"ion of "% %#r" is ssn"i#$ "o (#in"#in o*gn&$i2r*

II. M*oc#r&i#$ B$oo& F$o9 ) "o (#in"#in #&/u#" 3$oo& f$o9 "o "% !u$(on#r* #n&s*s"(ic circu$#"ions> (*oc#r&i#$ 3$oo& f$o9 (us" sufficin"$* su!!$* o*gn #n&nu"rin"s "o "% (*oc#r&iu( i"s$f

III. Coron#r* Ar"r* Circu$#"ion ) 3$oo& f$o9 "o "% #"ri# #n& 2n"ric$s &os no" su!!$*o*gn #n& nu"rin"s "o "% (*oc#r&iu( i"s$f. I" is "% 3r#nc% of "% s*s"(iccircu$#"ion "%#" su!!$is o*gn #n& nu"rin"s #n& r(o2#$ of 9#s" fro( "%(*oc#r&iu(

I2. S*s"(ic Circu$#"ion ) "% #r"ris #n& 2ins of "% s*s"(ic circu$#"ion &$i2rnu"rin"s #n& o*gn #n& r(o2 9#s"s fro( "% "issus. O*gn#"& 3$oo& f$o9sfro( "% $f" 2n"ric$ 3* 9#* of of "% #or"# #n& in"o "% $#rg s*s"(ic #r"ris

2. Rgu$#"ion of B$oo& F$o9 ) "% #(oun" of 3$oo& 5c"& fro( "% $f" 2n"ric$ #c%(inu" is "% c#r&i#c ou"!u". T% circu$#"ing 2o$u( of 3$oo& c%#ngs #ccor&ing "o"% o*gn #n& ("#3o$ic n&s of "% 3o&*. For #(!$> &uring rcis>!rgn#nc* #n& f2r> "% c#r&i#c ou"!u" incr#ss 3u" &uring s$!> "% c#r&i#cou"!u" &cr#ss.

D. Steps in the !rocess of ,0"genationI. Vn"i$#"ion ) !rocss 3* 9%ic% g#ss #r (o2& in"o #n& ou" of "% $ungs. A&/u#"

2n"i$#"ion r/uirs coor&in#"ion of "% (uscu$#r #n& $#s"ic !ro!r"is of "% $ung#n& "%or# #n& in"#c" innr2#"ion. T% (#5or ins!ir#"or* (usc$ is "% &i#!%r#g(9%ic% is innr2#"& 3* "% !%rnic nr2.

II. Prfusion ) "% !ri(#r* func"ion of !u$(on#r* circu$#"ion is "o (o2 3$oo& "o #n&fro( "% #$2o$#r=c#!i$$#r* ((3r#n so "%#" g#s c%#ng c#n occur

III. Ec%#ng of Rs!ir#"or* G#ss ) rs!ir#"or* g#ss #r c%#ng& in "% #$2o$i of"% $ungs #n& "% c#!i$$#ris of "% 3o&* "issus

a. 'iffusion ) (o2(n" of (o$cu$s fro( #n #r# of %ig%r concn"r#"ion "o #n#r# of $o9r concn"r#"ion

#. O*gn Tr#ns!or" ) &$i2r* &!n&s on "% #(oun" of o*gn n"ring "%$ungs +2n"i$#"ion,> 3$oo& f$o9 "o "% $ungs "issus +!rfusion,> #&/u#c* of&iffusion c#!#ci"* of "% 3$oo& "o c#rr* o*gn.

c. C#r3on 'ioi& Tr#ns!or" ) c#r3on &ioi& &iffuss in"o RBCs #n& I r#!i&$*%*&r#"& in"o c#r3onic #ci& 3c#us of "% !rsnc of c#r3onic %*&r#s

17. MEETING NUTRITIONAL NEEDSA. !rinciples of Nutrition

I. 'igs"ion ) !rocss 3* 9%ic% foo& su3s"#ncs #r c%#ng& in"o for(s "%#" c#n 3#3sor3& "%roug% c$$ ((3r#ns

II. A3sor!"ion ) "% "#1ing in of su3s"#nc 3* c$$s or ((3r#ns

III. M"#3o$is( ) su( of #$$ !%*sic#$ #n& c%(ic#$ !rocsss 3* 9%ic% # $i2ing org#nis(is for(& #n& (#in"#in& #n& 3* 9%ic% nrg* is (#& #2#i$#3$

I2. S"or#g ) so( nu"rin"s #r s"or& 9%n no" us& "o !ro2i& nrg* .g.c#r3o%*&r#"s #r s"or& i"%r #s g$*cogn or #s f#"

2. E$i(in#"ion ) !rocss of &isc#r&ing unncss#r* su3s"#ncs "%roug% 2#!or#"ion>cr"ion

B. N$trie!ts

24


25/30


I. C#r3o%*&r#"s ) "% !ri(#r* sourcs #r !$#n" foo&sT*!s of C#r3o%*&r#"s

a. Si(!$ +sug#rs, suc% #s g$ucos> g#$#c"os> #n& fruc"os#. Co(!$ suc% #s s"#rc%s +9%ic% #r !o$*s#cc%#ri&s, #n& fi3rs +su!!$is

3u$1 or roug%#g "o "% &i",

II. Pro"ins ) org#nic su3s"#ncs (#& u! of #(ino #ci&s

III. Li!i&s ) org#nic su3s"#ncs "%#" #r inso$u3$ in 9#"r 3u" so$u3$ in #$co%o$ #n&"%r.

a. Fatty acids) "% 3#sic s"ruc"ur#$ uni"s of #$$ $i!i&s #n& #r i"%r s#"ur#"& +#$$"% c#r3on #"o(s #r fi$$& 9i"% %*&rogn, or uns#"ur#"& +cou$& #cco((o"(or %*&rogn "%#n i" !rsn"$* con"#ins,

#. Foo& sourcs of $i!i&s #r #ni(#$ !ro&uc"s +(i$1> gg *o$1s #n& (#", #n&!$#n"s #n& !$#n" !ro&uc"s +s&s> nu"s> oi$s,

I2. Vi"#(ins ) org#nic co(!oun&s no" (#nuf#c"ur& in "% 3o&* #n& n&& in s(#$$/u#n"i"is "o c#"#$*; ("#3o$ic !rocsss

a. W#"r=so$u3$ 2i"#(ins inc$u& C #n& B=co(!$ 2i"#(ins#. F#"=so$u3$ 2i"#(ins inc$u& A> '> E> #n& K #n& "%s c#n 3 s"or& in $i(i"&

#(oun"s in "% 3o&*

2. Minr#$s ) co(!oun&s "%#" 9or1 9i"% o"%r nu"rin"s in (#in"#ining s"ruc"ur #n&func"ion of "% 3o&*

a. M#cronu"rin"s ) c#$ciu(> !%os!%#"> so&iu(> !o"#ssiu(> c%$ori&> (#gnsiu(#n& su$fur

#. Micronu"rin"s +"r#c $(n"s, ) iron> io&in> co!!r> ;inc> (#ng#ns #n&f$uori&

T% 3s" sourcs #r 2g"#3$s> $gu(s> (i$1 #n& so( (#"s

2I. W#"r ) "% 3o&*:s (os" 3#sic nu"rin" n& i" sr2s #s # (&iu( for ("#3o$icr#c"ions 9i"%in c$$s #n& # "r#ns!or"r fro nu"rin"s> 9#s" !ro&uc"s #n& o"%rsu3s"#ncs

1;. MEETING URINAR3 ELIMINATION NEEDSA. Normal 9rinar" Function

I. Nor(#$ urin ou"!u" is (L7%r or ?(L7* s%ou$& r(#in (L7%r "o nsurcon"inu& nor(#$ 1i&n* func"ion

II. Urin nor(#$$* consis"s of @ 9#"rIII. So$u"s foun& in urin inc$u&4

a. Org#nic so$u"s4 ur#> #((oni#> uric #ci& #n& cr#"inin#. Inorg#nic so$u"s4 so&iu(> !o"#ssiu(> c%$ori&> su$f#"> (#gnsiu(

!%os!%orus

B. Common Assessment FindingsI. Urgnc* ) s"rong &sir "o 2oi& (* 3 c#us& 3* inf$#((#"ions or infc"ions in "%

3$#&&r or ur"%r#II. '*suri# ) !#infu$ or &ifficu$" 2oi&ingIII. Fr/unc* ) 2oi&ing "%#" occurs (or "%#n usu#$ 9%n co(!#r& 9i"% "% !rson:s

rgu$#r !#""rn or "% gnr#$$* #cc!"& nor( of 2oi&ing onc 2r* "o %oursI2. Hsi"#nc* ) un&u &$#* #n& &ifficu$"* in ini"i#"ing 2oi&ing2. Po$*uri# ) # $#rg 2o$u( of urin or ou"!u" 2oi&& #" #n* gi2n "i(2I. O$iguri# ) # s(#$$ 2o$u( of urin or ou"!u" 3"9n ? "o (L7- %r2II. Noc"uri# ) cssi2 urin#"ion #" nig%" in"rru!"ing s$!2III.H(#"uri# ) RBCs in "% urin

1


26/30


S2r#$ BASIC FACTS #3ou" "% $o9r urin#r* "r#c" s*s"( s%ou$& 3 3orn in (in& 9%nconsi&ring c#"%"ri;#"ion.

B. Necessar" E1uipment for Catheteri)ation C#"%"rs #r gr#&& on "% Frnc% sc#$ #ccor&ing "o "% sie of the '$#e!. For "%

f(#$ #&u$"> No. ? #n& No. ? Frnc% c#"%"rs #r usu#$$* us&. S(#$$ c#"%"rs #r

gnr#$$* no" ncss#r* #n& "% si; of "% $u(n is #$so so s(#$$ "%#" i" incr#ss "%$ng"% of "i( ncss#r* for (!"*ing "% 3$#&&r. L#rgr c#"%"r &is"n&s "% ur"%r##n& "n&s "o incr#s "% &isco(for" of "% !roc&ur. For (#$ #&u$"> No.? #n& No.- Frnc% c#"%"rs usu#$$* us&> 3u" if "%is #!!#rs "o 3 "oo $#rg> s(#$$r c#"%"rs%ou$& 3 us&. No. #n& No. ? Frnc% c#"%"rs #r co((on$* us& for c%i$&rn.

C. !reparation of the !atientI. A&/u#" !$or#"ionII. Posi"ion ) &ors#$ rcu(3n" for "% f(#$ #n& su!in for "% (#$ using # fir(

(#""rss or "r#"(n" "#3$> Si(:s or $#"r#$ !osi"ion c#n 3 #n #$"rn#" for "%f(#$ !#"in"

III. Pro2ision for !ri2#c*

D. #etention or Ind'elling Catheter $Fole"%) A c#"%"r "o r(#in in !$#c for "% fo$$o9ing

!ur!oss4I. T% gr#&u#$ &co(!rssion of #n o2r &is"n&& 3$#&&rII. For in"r(i""n" 3$#&&r &r#in#gIII. For con"inuous 3$#&&r &r#in#g

An in&9$$ing c#"%"r %#s # 3#$$oon 9%ic% is inf$#"& #f"r "% c#"%"r is insr"& in"o "%3$#&&r. Bc#us "% inf$#"& 3#$$oon is $#rgr "%#n "% o!ning "o "% ur"%r#> "% c#"%"r isr"#in& in "% 3$#&&r.

E. !rocedure for InsertionI. Inf$#" "% 3#$$oon 9i"% "% !rfi$$& s*ring 3for insr"ing "% c#"%"r "o c%c1 for

3#$$oon !#"nc*. As!ir#" "% f$ui& 3#c1 in"o "% s*ring 9%n i" is &"r(in& "%#" "%3#$$oon is !#"n".

II. Ho$& "% c#"%"r 9i"% on %#n& #n& inf$#" "% 3#$$oon #ccor&ing "o "%(#nuf#c"urr:s ins"ruc"ions> #s soon #s "% c#"%"r is in "% 3$#&&r #n& urin %#s3gun "o &r#in fro( "% 3$#&&r. Usu#$$* ($ "o ? ($ of sterile wateris us&

III. If "% !#"in" co(!$#ins of !#in #f"r "% 3#$$oon is inf$#"&> #$$o9 i" "o (!"* #n&r!$#c "% c#"%"r 9i"% #no"%r on. T% 3#$$oon is !ro3#3$* $oc#"& in "% ur"%r##n& is c#using &isco(for" o9ing "o &is"n"ion of "% ur"%r#

I2. Er" s$ig%" "nsion on "% c#"%"r #f"r "% 3#$$oon is inf$#"& "o #ssur i"s !ro!r!$#c(n" in "% 3$#&&r

2. Connc" "% c#"%"r "o "% &r#in#g "u3ing #n& &r#in#g 3#g if no" #$r#&*connc"&

2I. T#! "% c#"%"r #$ong "% in"rior #s!c" of "% "%ig% fro # f(#$ !#"in". B sur"%r is no "nsion on "% c#"%"r 9%n i" is "#!& "o "% !#"in"

2II. H#ng "% &r#in#g 3#g on "% fr#( of "% 3& 3$o9 "% $2$ of "% 3$#&&r

F. Caring for the !atient 'ith an Ind'elling CatheterI. B sur "o 9#s% %#n&s 3for #n& #f"r c#ring for # !#"in" 9i"% #n in&9$$ing

c#"%"rII. C$#n "% !rin#$ #r# "%oroug%$*> s!ci#$$* #roun& "% (#"us> "9ic # * #n&

#f"r #c% 3o9$ (o2(n". T%is %$!s !r2n" org#nis(s for n"ring "% 3$#&&rIII. Us so#! or &"rgn" #n& 9#"r "o c$#n "% !rin#$ #r# #n& rins "% #r# 9$$I2. M#1 sur "%#" "% !#"in" (#in"#ins # gnrous f$ui& in"#1. T%is %$!s !r2n"

infc"ion #n& irrig#"s "% c#"%"r n#"ur#$$* 3* incr#sing urin#r* ou"!u"2. Encour#g "% !#"in" "o 3 u! #n& #3ou" #s or&r&2I. Rcor& "% !#"in":s in"#1 #n& ou"!u"2II. No" "% 2o$u( #n& c%#r#c"r of urin #n& rcor& o3sr2#"ions c#rfu$$*2III.T#c% "% !#"in" "% i(!or"#nc of !rson#$ %*gin> s!ci#$$* "% i(!or"#nc of

c#rfu$ c$#ning #f"r %#2ing 3o9$ (o2(n" #n& "%oroug% 9#s%ing of %#n&sfr/un"$*

I3. R!or" #n* signs of infc"ion !ro(!"$*. T%s inc$u& # 3urning sns#"ion #n&irri"#"ion #" "% (#"us> c$ou&* urin> # s"rong o&or "o "% urin> #n $2#"&"(!r#"ur #n& c%i$$s

3. P$#n "o c%#ng in&9$$ing c#"%"rs on$* #s ncss#r*. T% usu#$ $ng"% of "i(3"9n c#"%"r c%#ngs 2#ris #n& c#n 3 #n*9%r fro( *s "o - 91s. T%$ss of"n # c#"%"r is c%#ng&> "% $ss "% $i1$i%oo& "%#n #n infc"ion 9i$$ &2$o!

26


27/30


*. #emo-ing the Ind'elling Catheter and Aftercare of the !atientI. B sur "% 3#$$oon is &f$#"& 3for #""(!"ing "o r(o2 "% c#"%"r. T%is (#* 3

&on 3* insr"ing # s*ring in"o "% 3#$$oon 2#$2 or 3* cu""ing "% 3#$$oon 2#$2II. H#2 "% !#"in" "#1 s2r#$ &! 3r#"%s "o %$! %i( r$# 9%i$ gn"$* r(o2ing

"% c#"%"r. Wr#! "% c#"%"r in # "o9$ or &is!os#3$> 9#"r!roof &r#!III. C$#n "% #r# #" "% (#"us "%oroug%$* 9i"% #n"is!"ic s9#3s #f"r "% c#"%"r is

r(o2&I2. S "o i" "%#" "% !#"in":s f$ui& in"#1 is gnrous #n& rcor& "% !#"in":s in"#1 #n&

ou"!u". Ins"ruc" "% !#"in" "o 2oi& in"o "% 3&!#n or urin#$2. O3sr2 "% urin c#rfu$$* for #n* signs of #3nor(#$i"*2I. Rcor& #n& r!or" #n* usu#$ signs suc% #s &isco(for"> # 3urning sns#"ion 9%n

2oi&ing> 3$&ing #n& c%#ngs in 2i"#$ signs> s!ci#$$* "% !#"in":s "(!r#"ur. B#$r" "o #n* signs of infc"ion #n& r!or" "%( !ro(!"$*

1>. MEETING *OWEL ELIMINATION NEEDSA. Factors that influence Bo'el Elimination

I. AgII. 'i"III. Posi"ionI2. Prgn#nc*

2. F$ui& In"#12I. Ac"i2i"*2II. Ps*c%o$ogic#$2III.Prson#$ H#3i"sI3. P#in

3. M&ic#"ions3I. Surgr*7Ans"%si#

B. Characteristics of Normal StoolI. Co$or ) 2#ris fro( $ig%" "o r1 3ro9n foo&s (&ic#"ions (#* #ffc" co$orII. O&or ) #ro(#"ic> #ffc"& 3* ings"& foo& #n& !rson:s 3#c"ri#$ f$or#III. Consis"nc* ) for(&> sof"> s(i=so$i& (ois"I2. Fr/unc* ) 2#ris 9i"% &i" +#3ou" ? "o g7*,

2. Cons"i"un"s ) s(#$$ #(oun" of un&igs"& roug%#g> s$oug%& & 3#c"ri# #n&!i"%$i#$ c$$s> f#"> !ro"in> &ri& cons"i"un"s of &igs"i2 5uics +3i$ !ig(n"s,inorg#nic (#""r +c#$ciu(> !%os!%#"s,

C. Common Bo'el Elimination !roblemsI. Cons"i!#"ion ) #3nor(#$ fr/unc* of &fc#"ion #n& #3nor(#$ %#r&ning of s"oo$sII. I(!#c"ion ) #ccu(u$#"& (#ss of &r* fcs "%#" c#nno" 3 !$$&III. 'i#rr%# ) incr#s& fr/unc* of 3o9$ (o2(n"s +(or "%#n "i(s # *, #s

9$$ #s $i/ui& consis"nc* #n& incr#s& #(oun" #cco(!#ni& 3* urgnc*>&isco(for" #n& !ossi3$* incon"innc

I2. Incon"innc ) in2o$un"#r* $i(in#"ion of fcs2. F$#"u$nc ) !u$sion of g#s fro( "% rc"u(2I. H(orr%oi&s ) &i$#"& !or"ions of 2ins in "% #n#$ c#n#$ c#using i"c%ing #n& !#in

#n& 3rig%" r& 3$&ing u!on &fc#"ion.

1@. T3PES OF ENEMASA. Cleansing EnemasS"i(u$#" !ris"#$sis "%roug% irrig#"ion of co$on #n& rc"u( #n& 3*

&is"n"ionI. So#! Su&s4 Mi$& so#! so$u"ions s"i(u$#" #n& irri"#" in"s"in#$ (ucos#. 'i$u" ($ of

c#s"i$ so#! in ? ($ of 9#"rII. T#! 9#"r4 Gi2 c#u"ion o inf#n"s or "o #&u$"s 9i"% #$"r& c#r&i#c #n& rn#$ rsr2III. S#$in4 For nor(#$ s#$in n(#s> us s(#$$r 2o$u( of so$u"ionI2. Pr!#c1#g& &is!os#3$ n(# +F$",4 A!!roi(#"$* ?- cc> "i! is !r=$u3ric#"

#n& &os no" r/uir fur"%r !r!#r#"ion

B. ,il#etention EnemasLu3ric#"s "% rc"u( #n& co$on "% fcs #3sor3 "% oi$ #n& 3co(sof"r #n& #sir "o !#ss

C. Carminati-e Enema4 Pro2i&s r$if fro( g#sous &is"n"ion

D. Astri!)e!t E!e#&8Con"r#c"s "issu "o con"ro$ 3$&ingKe+ Poi!ts8 A,#i!isteri!) E!e#&

I. Fi$$ 9#"r con"#inr 9i"% "o ? cc of $u19#r( so$u"ion> + cc or $ss forc%i$&rn> - cc or $ss fro #n inf#n",> @@ &grs F "o ?- &grs F. So$u"ions "%#"

2+


28/30


#r "oo %o" or "oo co$&> or so$u"ions "%#" #r ins"i$$& "oo /uic1$*> c#n c#us cr#(!ing#n& (#g "o rc"#$ "issus

II. A$$o9 so$u"ion "o run "%roug% "% "u3ing so "%#" #ir is r(o2&III. P$#c c$in" on $f" si& in Si(:s !osi"ionI2. Lu3ric#" "% "i! of "% "u3ing 9i"% 9#"r=so$u3$ $u3ric#n"2. Gn"$* insr" "u3ing in"o c$in":s rc"u( + "o inc%s for #&u$"> ? inc% for inf#n"s> - "o

inc%s for c%i$&rn,> !#s" "% "rn#$ #n& in"rn#$ s!%inc"rs2I. R#is "% 9#"r con"#inr no (or "%#n ?- "o ? inc%s #3o2 "% c$in"2II.A$$o9 so$u"ion "o f$o9 s$o9$*. If "% f$o9 is s$o9> "% c$in" 9i$$ !rinc f9r

cr#(!s. T% c$in" 9i$$ #$so 3 #3$ "o "o$r#" #n& r"#in # gr#"r 2o$u( of so$u"ion2III.Af"r *ou %#2 ins"i$$& "% so$u"ion> ins"ruc" c$in" "o %o$& so$u"ion for #3ou" ? "o ?

(inu"sI3. Oi$ r"n"ion4 n(#s s%ou$& 3 r"#in& #" $#s" ? %our. C$#nsing n(#s #r

r"#in& ? "o ? (inu"s.

0. NASOGASTRIC &!, INTESTINAL TU*ES

A. Nasogastric &ubes

I. L2in Tu3 ) sing$ $u(n

a.Suc"ioning g#s"ric con"n"s#.A&(inis"ring "u3 f&ings

II. S#$( Su(! Tu3 ) &ou3$ $u(n +s(#$$r 3$u $u(n 2n"s "% "u3 !r2n"s suc"ionon "% g#s"ric (ucos#> (#in"#ins in"r(i""n" suc"ion rg#r&$ss of suc"ion sourc,

a. Suc"ioning g#s"ric con"n"s#. M#in"#ining g#s"ric &co(!rssion

K* Poin"s4#. Prior "o insr"ion> !osi"ion "% c$in" in Hig%=Fo9$r:s !osi"ion if !ossi3$.3. Us # 9#"r=so$u3$ $u3ric#n" "o f#ci$i"#" insr"ionc. M#sur "% "u3 fro( "% "i! of "% c$in":s nos "o "% #r$o3 #n& fro(

"% nos "o "% i!%oi& !rocss "o &"r(in "% #!!roi(#" #(oun" of

"u3 "o insr" "o r#c% "% s"o(#c%&. F$ "% c$in":s %#& s$ig%"$* for9#r& "%is 9i$$ &cr#s "% c%#nc of n"r*

in"o "% "r#c%#. Insr" "% "u3 "%roug% "% nos in"o "% n#so!%#r*ng$ #r# #s1 "% c$in"

"o s9#$$o9> #n& #s "% s9#$$o9 occurs> !rogrss "% "u3 !#s" "% #r# of"% "r#c%# #n& in"o "% so!%#gus #n& s"o(#c%. Wi"%&r#9 "u3i((&i#"$* if c$in" !rincs rs!ir#"or* &is"rss

f. Scur "% "u3 "o "% nos &o no" #$$o9 "% "u3 "o r" !rssur on "%u!!r innr !or"ion of "% n#rs

g. 2alidating !lacement of tu#e.

As!ir#" g#s"ric con"n"s 2i# # s*ring "o "% n& of "% "u3

M#sur !% of #s!ir#" f$ui&

P$#c "% s""%osco! o2r "% g#s"ric #r# #n& in5c" # s(#$$ #(oun"

of #ir "%roug% "% NGT. A c%#r#c"ris"ic soun& of #ir n"ring "%s"o(#c% fro( "% "u3 s%ou$& 3 %#r&

h. +haracteristics of nasogastric drainage,

Nor(#$$* is grnis%=*$$o9is%> 9i"% s"r#n&s of (ucous

Coff=groun& &r#in#g ) o$& 3$oo& "%#" %#s 3n 3ro1n &o9n

in "% s"o(#c%

Brig%" r& 3$oo& ) 3$&ing fro( "% so!%#gus> "% s"o(#c% or

s9#$$o9& fro( "% $ungs

Fou$=s($$ing +fc#$ o&or, ) occurs 9i"% r2rs !ris"#$sis in

3o9$ o3s"ruc"ion incr#s in #(oun" of &r#in#g 9i"%o3s"ruc"ion

B. In"s"in#$ Tu3s ) !ro2i& in"s"in#$ &co(!rssion !roi(#$ "o # 3o9$ o3s"ruc"ion.Pr2n"7&cr#s in"s"in#$ &is"n"ion. P$#c(n" of # "u3 con"#ining # (rcu

Documents

6541999 Fundamentals of Nursing p1