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8/3/2019 PREBOARD Handout Revised
1/14
PROFESSIONAL REVIEW NETWORK, INC.
COURSE AUDIT 2PREBOARD HANDOUT
NURSING PRACTICE I:
FOUNDATIONS OF NURSING PRACTICE
NURSING THEORIES
Faye Abdellah Identification of 21 NursingProblems
Lydia Hall Care, Core and Cure (3 Cs)
Virginia Henderson Identification of the 14 BasicNeeds
Imogene King Goal Attainment Theory
Madeleine Leininger Transcultural Nursing
Myra Levine FourConservationPrinciples
Florence Nightingale Environmental Theory
Betty Neuman Stress Reduction
Dorothea Orem Self-Care and Self-Deficit
Rosemarie Parse Human Becoming
Hildegard Peplau Interpersonal Relations Model
Martha Rogers Science of Unitary HumanBeings
Callista Roy Adaptation Model
Jean Watson Human Caring
Metaparadigm for Nursing Theories: CHEN (Client, Health,
Environment, Nursing)
CHAIN OF INFECTION
SIX LINKS
Host (susceptible)
Agent
Reservoir
Entry (mode of)
Transmission (mode of) direct, vehicle, vector
Exit (mode of)
SURGICAL VS MEDICAL ASEPSIS
Surgical sterile free from ALL microorganisms
Medical clean free from pathogenic microorganisms
ISOLATION PRECAUTIONS
Standard Precautions (Universal precautions)
Applies to ALL body fluids, secretions, blood, non-
intact skin and excretions except sweat
Includes hand washing, wearing clean gloves, maskand gown
Transmission Based Precautions
Airborne used for clients with
illnesses transmitted by airborne
droplets (less than 5 microns)
Examples: Tuberculosis, Chickenpox, Measles
Place client in private room but if no private
room is available place client in a room with
another client infected with the same
microorganism
Wear N95 respirator
Droplet used for clients with illnesses transmittedby droplet nuclei ( greater than 5 microns)
Examples: Diptheria, Pertussis, Meningitis,
Mumps
Wear mask when working within 3 feet
from the client
HANDWASHING
Should be done under stream of water or at least
20 seconds
Purpose: To reduce the number of microorganismon the hands and reduce transmission of
microorganisms to client.
Wash the hands in firm, rubbing, and circular
motion.
GLOVING
Purpose: To enable the nurse to handle or touch
sterile objects freely without contaminating them.
Sterile Gloving
Donned by the open method or closed method.
Open method is most frequently used outside theoperating room because the closed method requires
that the nurse wear a sterile gown.
After second glove is on, interlock hands together,
above waist level. Be sure to touch only sterile
sides
PERSONAL PROTECTIVE EQUIPMENT
Purpose: To protect health care workers and clients
from transmission of potentially infective materials.
STEPS:
1. Hand hygiene
2. Don a clean gown
- Overlap the gown at the back to cover the nurses
uniform.
3. A facemask and eye protection covering the
nose, mouth, and eye.
4. Don clean disposable gloves
- No special technique is required
Removing PPE
1. Remove the gloves first (most soiled)
2. Perform hand hygiene
3. Remove protective eyewear and dispose of
properly or place in the appropriate receptacle for
cleaning
4. Remove the mask (untie the top strings) and
dispose.
INSERTION OF NASOGASTRIC TUBE
Measure length of tube tip of the nose to
the tip of the earlobe to the xiphoid process
Position High Fowlers position with
neck hyperextended
Lubricate tip of tube with water soluble
lubricant
Instruct the client to swallow or drink from
a straw while the tube is being inserted
STOP and remove the tube if client
becomes cyanotic or coughs
Placement- check
- Aspirate gastric secretions measure pH
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- Auscultate and inject air into the tube(whooshing sound)
- X-ray best measure to determine properplacement (initial placement)
Secure tube using tape to the bridge of the
clients nose and to the clients gown
TUBE FEEDINGS
Position: Fowlers position
Assessment: Check patency of tube and
Aspirate residual contents before feeding (if
100 ml or more than 50% of last feeding
withheld and check)
For feeding bags: Hang bag from infusion
pole HEIGHT: 12 inches
Complications: Dumping syndrome,
aspiration pneumonia, diarrhea,
hyperglycemia, nausea and vomiting
URINARY CATHETERIZATION
Sterile technique
Insertion
Male Female
Position Supine (legs
slightly abducted)
Penis at 90
degree angle
Supine (with
knees flexed
and externally
rotated)
Length to
be inserted
6-9 inches 2-3 inches
Length of
catheter
(Adult)
40 cm 22 cm
BLOOD TRANSFUSION
FIRST: Check if properly typed and
cross matched
Gauge of needle: g #18
Drop factor: 10 gtts/min (1st 30 mins.)
Duration: RBCs and whole blood 4
hours, FFP Fresh frozen plasma, platelets
not more than 20 minutes
Rate: KVO
IVF: Plain NSS
Monitor: vital signs (every 15 minutes for
1st hour), any adverse reactions
When reaction happens: STOP the
transfusion and notify the physician
Common blood transfusion reactions:
Anaphylactic reaction s/sx: rashes and hives
Hemolytic reaction s/sx: flank/back pain
Pyrogenic reaction s/sx: fever, headache
Cardiogenic reaction - s/sx: dyspnea
CHEST TUBES
What to do if:
Tube becomes disconnected from the bottle place
end of tube in a bottle with NSS
Tube becomes disconnected from the client cover
wound with sterile dressing
Water seal has vigorous bubbling there is a leak
clamp tube nearest the client (intermittent bubbling
normal, vigorous/continuous bubbling-abnormal)
Transporting the client bottle below chest level
and upright
ASSISTIVE DEVICES
CANES
opposite the affected leg (C-O-A-L)
angle is 20 to 30 degrees
the length should permit the elbow to slightly flex
WALKERS
Hand bar below the clients waist and the elbow is slightly
flexed
CRUTCHES
Angle of elbow flexion 30
degrees
-weight of the body should be
borne by the arms not the axilla
to prevent CRUTCH PALSY
Crutches are placed 6 inches in
front and 6 inches laterally
the feet should be slightly
apart, hips and knees extended
and back is straight
Four point gait right crutch,
left foot, left crutch, right foot
Three point gait right and
left crutch with weak leg,stronger leg
Two point gait- right crutch
and left foot together, left
crutch and right foot
Swing to gait- move both
crutches forward, lift body
weight and swing to crutches
-Swing through gait - move
both crutches forward, lift body
weight and swing through
beyond the crutches
Going up the stairs
(remember: all good people
go to heaven) when going
up, lift (good) unaffected leg
first followed by the crutch,
affected leg.
SPECIAL DIETS
Diet Disorder
Low
carbohydrate
Dumping syndrome
Low protein Renal failure, Acute
glomerulonephritis, uremia, anuriaHigh protein Nephrotic syndrome
Low sodium Heart failure, CVDs, Nephrotic
syndrome
High fiber Constipation, hyperlipidemia
Low residue Bowel inflammation ( diverticulitis and
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ulcerative colitis)
Acid/Alkaline
ash
(depending on the lab analysis of the
stones)
Retard renal calculi formation
Clear liquid Following acute vomiting or diarrhea
Full liquid Gastrointestinal upsets, progression
from clear liquids
Gluten-free For clients with Celiac disease
Tyramine-free To prevent fermented and processedfoods for clients taking MAOIs
Purine
restricted
Gouty arthritis, uric acid stones
DEGREES OF BURNS
Superficial Partial Thickness
area involved: epidermis
tingling, erythema, minimal or no edema
Deep Partial Thickness
area involved:
epidermis, dermis
w/ PAIN,
hyperesthesia,
BLISTERS, edema,
weeping surface,
mottled and red
base
Full Thickness
area involved:
epidermis, dermis,
may involve
subcutaneous and
connective tissue,
muscle and bone
PAIN FREE, shock, dry, PALE, WHITE
leathery or charred skin, broken skin with
fat exposed, edema
PRESSURE ULCERS (STAGES)
Stage 1 ERYTHEMA(redness),
elevated temperature, patient
complains of discomfort
Stage 2 Skin breaks, abrasions,
BLISTERS, shallow crater, edema,
infection may develop Stage 3 ulcer extends into the
subcutaneous tissue, necrosis and
drainage, infection develops
Stage 4- ulcer extends into the muscle
and bone, deep pockets of infection
develop
NURSING PROCESS
Assessment
Systematic and continuous collection, organization,
validation, and documentation of data
(information). Types of data:
- Subjective data/Symptoms /Covert data
- Objective data/Signs/Overt data
Sources of data:
- Primary: Client (best source of data)
- All other than the client
Conceptual Models/Frameworks
- Wellness models is use by the nurse to identify
health risk and to explore lifestyle habits and health
behaviors, beliefs, and values that influence levels
of wellness.
Nursing Diagnosis
Refers to a statement or conclusion regarding the
nature of phenomenon.
Types of nursing Diagnosis:
1. Actual diagnosis is a client problem that is
present at the time of the nursing assessment.
2. Risk Nursing Diagnosis- a clinical judgment that
a problem does not exist, but the presence of risk
factors indicate that a problem is likely to develop
unless nurses intervene.
3. Wellness Diagnosis
4. Possible Nursing Diagnosis
5. Syndrome Diagnosis
Problem-etiology-signs and symptoms format (PES
format)
VITAL SIGNS
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Ex. Older patients are more at risk for experiencing a fallthan younger patientsNondirectional hypothesis does not stipulate thedirection of the relationshipEx. There is a relationship between the age of a patient andthe risk for falling.Research hypothesis (also referred to as substantive,declarative, or scientific hypotheses) are statements ofexpected relationships between variables
Null hypothesis (or statistical hypotheses) states thatthere is no relationship between the independent anddependent variables.
Type I error by rejecting a null hypothesis that is, infact, TRUE leads to false positive conclusionType II error false negative conclusion
TRUE FALSE
True (Nullaccepted)
Correct decision Type II error(False negative)
False (Nullrejected)
Type I error(False positive)
Correct decision
B. DESIGN AND PLANNING PHASEStep 6: Selecting a Research design
RESEARCH DESIGNSResearch Design is a blueprint of conducting a studythat maximizes control over factors that could interferewith the validity of the findings.
Types of Designs according to Timeframesa. Cross-Sectional Design involve the collection of dataonce: the phenomena under study are captured during oneperiod of data collection. This design is appropriate fordescribing the status of phenomena or for describingrelationships among phenomena at fixed point in time
b. Longitudinal Design a study in which data arecollected at more than one point in time over an extendedperiod.c. Retrospective Design involves collecting data on anoutcome occurring in the present, and then linking itretrospectively to antecedents or determinants occurring inthe pastd. Prospective Design information is first collectedabout a presumed cause or antecedent, and thensubsequently the effect or outcome is measured.
RESEARCH METHODS
Quantitative Research - This applies to the manipulationand control of phenomena and verification of results, usingempirical data gathered through the senses. It is also calledas hard science, characterized by replicable and reliabledata.Qualitative Research Focuses on insights andunderstanding of individual perceptions on the phenomenonunder study. It is considered as a soft science, concernedwith the subjective meaning of experience to anindividual.
Types of QuantitativeResearch
1. Descriptive Research2. Correlational Research
3. Quasi-experimentalResearch4. Experimental Research
Types of QualitativeResearch1. PhenomenologicalResearch
2. Grounded TheoryResearch3. EthnographicResearch4. Historical Research5. Case studies
Experimental Research
an inquiry on cause-and-effect relationships. The
researcher controls and manipulates theindependent variable and randomly assigns thesubjects to different conditions or situations.
Strengths:
most powerful method available for testinghypotheses of cause-and-effect relationshipsbetween variables
considered the GOLD standard forintervention studies because it yields the highest-quality evidence regarding intervention effects
Limitations:HALO EFFECT - When researchers consider a person/respondent good (or bad) in one category, they are likelyto make a similar evaluation in other categories. It mayalso be connected with dissonance avoidance, as makingthem good at one thing and bad at another would makean overall evaluation difficult.HAWTHORNE EFFECT - describes a temporary change tobehavior or performance in response to a change in theenvironmental conditions; participants respond in a certainmanner because they are aware that they are beingobserved
Characteristics of a true experimental designManipulation (doing something to the study participants) the researcher manipulates he INDEPENDENT variable byadministering a treatment (intervention) to somesubjects and withholding it from others, or by administeringsome other treatment.Control the experimenter introduces controls over theexperimental situationControl group refers to a group of subjects whoseperformance on a dependent variable is used to evaluatethe performance of the treatment group on the same
dependent variable.Randomization (also called random assignment orrandom allocation) involves placing subjects into treatmentconditions at random.
Quasi-Experimental Research like true experiments,involve an intervention. However, quasi-experimentaldesigns lack randomization, the signature of a trueexperiment.Non-Experimental Research - the researcher does notinterfere with nature and the conditions for research arerealistic or uncontrolled. (Dr. CB Tan)Descriptive Research the purpose of descriptive studiesis to observe, describe and document aspects of a situationas it naturally occurs and sometimes to serve as a startingpoint for hypothesis generation or theory development.
Correlational Research the researcher study the effectof a potential cause that they cannot manipulate, they usedesigns that examine relationships between variables. Theresearcher does not control the independent variableAdditional: Outcomes Research is designed todocument the effectiveness of health care services and alsoplays an important role in policy research.
Outcomes of Patient, Provider, & Health Care System
Outcomes used to develop Policy
Change Practice based on ResearchPhenomenological Research asks the essence of a
phenomenon as experienced by the people and what doesit mean. Phenomenologists view human existence asmeaningful and interesting because of peoplesconsciousness of that existence.Ethnography involves description and interpretation ofcultural behavior.
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Fieldwork: is the process by which the ethnographerinevitably comes to understand a cultureStep 7: Developing protocols for the InterventionStep 8: Identifying the populationPopulation is the entire aggregation of cases in which aresearcher is interestedStep 9: Designing the sampling plan
SAMPLING
is the process of selecting a portion of the populationto represent the entire population so that inferencesabout the population can be made
Sample is a subset of population elements. An elementis the most basic unit about which information is collected.
SAMPLING METHODNon-Probability Sampling
Accidental also known as Convenience sampling, entailsusing the most conveniently available people as studyparticipantsQuota is one in which the researcher identifiespopulation strata and determines how many participantsare needed from each stratum
Purposive or Judgment based on the belief thatresearchers knowledge about the population can be usedto hand-pick sample membersSnowball or Network is a variant of conveni
encesampling. Early sample members (called seeds) are askedto refer other people who meet the eligibility criteriaProbability SamplingSimple random most basic type of probability sampling,fish ball methodStratified random the population is first divided intotwo or more strata. As with quota sampling, the aim of
stratified sampling is to enhance representativeness.Subdivide the population into homogenous subsets fromwhich an appropriate number of elements are selected at
randomCluster usual procedure in selecting samples from ageneral population is to states, census tracts, and thenhouseholdsSystematic involves the selection of every kth case froma list, such as every 10th person on a patient list or every100th person in a directory.
Ex. If we were seeking a sample of 200 from apopulation of 40,000, then our sampling intervalwould be as follows:
k = 40,000 = 200200
Step 10: Specifying Methods to measure the research
variablesStep 11: Developing Methods to safeguard Humanand Animal rightsStep 12: Reviewing and Finalizing the Research Plan
C. EMPIRICAL PHASEStep 13: Collecting data
CENTRAL TENDENCIES
MODE is the most frequency occurring score value in adistribution. Determined by inspecting a frequencydistributionMEDIAN is the point in a distribution above which andbelow which 50% of cases fall.
MEAN often symbolized as M or X is the sum of all scoresdivided by the number of scores what people usuallyrefer to as the average.
VARIABILITY
Range is simply the highest score minus the lowest scorein a distributionStandard Deviation used in interval-and-ration level data;indicates the average amount of deviation of values fromthe mean
Step 14: Preparing data for analysis
D. ANALYTIC PHASE
Step 15: Analyzing the DataStep 16: Interpreting the Results
E. DISSEMINATION PHASEStep 17: Communicating the findingsStep 18: Utilizing the findings in research
ETHICAL ISSUES IN RESEARCHAutonomy: informed consent.Right to privacy: The researcher should ensure theanonymity of the research participants and theconfidentiality of the data/information collected from them.Beneficence: the benefits of the research to the researchsubject/participants. should be adequately explained to the
participants.Nonmaleficence: avoidance of harm or reduction of risksto the research subject.
Social Justice: right to be represented in the sample,equal access to knowledge, right not to be discriminatedagainst
NURSING PRACTICE II:
CARE OF MOTHER AND CHILD AND COMMUNITY
HEALTH NURSING
COMMUNITY HEALTH NURSING
Community Health NursingThe utilization of the nursing process in the different levelsof clientele-individuals, families, population groups andcommunities, concerned with the promotion of health,prevention of disease and disability and rehabilitation.GoalTo raise the level of citizenry by helping communities andfamilies to cope with the discontinuities in and threats tohealth in such a way as to maximize their potential forhigh-level wellness.
Public HealthThe science and art ofpreventing disease, prolonginglife, promoting health and efficiency through organized
community effort for the: Sanitation of the environment
Control of communicable diseases
Education of individuals in personal hygiene
Organization of medical and nursingservices
Early diagnosis and preventive treatment ofdisease
Development of social machineryTo ensure everyone a standard of living adequate for themaintenance of health, so organizing these benefits as toenable every citizen to realize his birthright of healthand longetivity (Dr. C. E. Winslow definition)
The art of applying science in the context of politics so asto reduce inequalities in health while ensuring the besthealth for greatest number. (WHO definition)
Core business of public health
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Disease control
Injury prevention
Health protection
Healthy public policy including those in relation toenvironmental hazards such as in workplace,housing, food, water, etc.
Promotion of health and equitable health gain
THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM
Department of Health (DOH) is mandated as the
lead agency in health at the national level
With the devolution of health services:
The local health system is run by the LocalGovernment Units (LGUs)
The provincial and districts hospital are under theprovincial government
The city/municipal government manages the healthcenters/rural health units (RHUs) and barangayhealth stations (BHSs).
Vision
The DOH is the leader, staunch advocate and model inpromoting Health for All in the Philippines.
MissionGuarantee equitable, sustainable and quality health for allFilipinos, especially the poor and shall lead the quest forexcellence in health.
GoalHealth Sector Reform Agenda through sound organizationaldevelopment, strong policies, systems and procedures,capable human resources and adequate financial resources.
FOURmula ONE for Health
- The implementation framework for healthsector reforms- It intends to implement critical
interventions as a single package backed byeffective management infrastructure and financingarrangements following a sector wide approach
Goals of FOURmula ONE for Health
Better health outcomes
More responsive health systems
Equitable health care financing
Four elements of FOURmula ONE
Health financing
Health regulation Health service delivery
Good governance
National Objectives for Health 2005 to 2010Provides the road map for stakeholders in health and health related sectors to intensify and harmonize their efforts toattain its time honored vision of health for all Filipinos.
Primary Health Care
Essential health care made universally accessible toindividuals and families in the community by meansacceptable to them through their full participation and at acost that the community and country can afford at every
stage of development. (WHO definition)
Partnership and empowerment of the people is thecore strategy in the effective provision of essential
health services that are community based,accessible, acceptable and sustainable at a cost
which the community and the government canafford.
Elements/Components of Primary Health Care
Environmental Sanitation
Control of Communicable diseases
Immunization
Health Education
Maternal and Child Health and Family Planning
Adequate Food and Proper Nutrition
Provision of Medical Care and EmergencyTreatment
Treatment of Locally Endemic Diseases
Provision of Essential Drugs
The framework for meeting the goal of primaryhealth care is organizational strategy, which callsfor active and continuing partnership among thecommunities.
Four Cornerstones/Pillars in Primary Health care
Active community participation
Intra and inter sectoral linkages
Use of appropriate technology
Support mechanism made available
Two levels of primary health care workers
Village or Barangay Health Workers- Refers to trained community health workers or
volunteer, traditional birth attendant or healer
Intermediate level health workers- Refers to general medical practitioners, public
health nurse and midwives.
Levels of Health Care and Referral system
Levelof Care
Definition
Service Type Example
Primary Providedat healthcare/RHU, Brgy.Healthstations,communityhospitals
Healthpromotion,preventivecare
Healthpromotionand illnessprevention
Informationdissemination
Secondary
Referralis madetoinfirmari
es,municipal &districthospitalsandoutpatient dept.ofprovincialhospitals,
Surgery,medicalservicesby
specialist
Diagnosisandtreatment
Screeningprocedures
Tertiary Highly
specializedmedicalcare isnecessary.Referrals
Advanced
specialized,diagnostic,therapeutic &rehabilitat
Rehabilitat
ion
PT/OT
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made tomedical
centersandspecializedhospitalse.g.Heart
Center.
ive care
Epidemiology
The study of distribution of disease or physiologiccondition among human populations and the factorsaffecting such distribution
The study of the occurrence and distribution of health
conditions such as disease, death, deformities or disabilities
on human population
Patterns of Disease Occurrence:
Epidemic
A situation when there is a high incidence
of new cases of a specific disease in excess of theexpected.
When the proportion of the susceptible arehigh compared to the proportion of the immunes.
Endemic
Habitual presence of a disease in a givengeographic location accounting for the low numberof both immunes and susceptible.e.g Schistosomiasis in Leyte and Samar
Sporadic
Disease occurs every now and thenaffecting only a small number of people relative tothe total populatione.g. Rabies
Pandemic Global occurrence of disease
Vital StatisticsRefers to the systemic study of vital events such as birthsillnesses, marriages, divorce, separation and deaths.
StatisticsRefers to a systematic approach of obtaining, organizingand analyzing numerical facts so that the conclusion maybe drawn from them.
Use of vital statistics
Indices of the health and illness status of the
community Serves as bases for planning, implementing,
monitoring and evaluating community healthnursing programs and services
INTEGRATED MANAGEMENT OF CHILDHOOD
ILLNESSES
Methods that are being utilized in managing
childhood illnesses are:Assess the client taking the history of the patientis one way of getting information about the disease
condition. This can be done by asking andobserving the patients condition to explore thepossible causes.Classify the disease a thorough assessmentsupported with laboratory results is necessary forclassification of illnesses and confirmation of thedisease. Classification of the disease are: 1) mild,2) moderate, 3) severe.Treat the patient treatment is a curative methodof treating diseases. This vary on the condition ofthe patientCounsel the patient providing health education toclients promotes health and avoid risk of infection.these are important for parents/caregivers
especially who lack knowledge on health practicesand risks factors that contribute to diseaseailments.
To assess for danger signs, the nurse should:
Look if the child is lethargic or unconscious
Ask the mother or adult with the child:
Is the child able to drink or breastfeed?
Does the child vomit everything?
Has the child had convulsions?
In the presence of any danger sign, make sure thechild is referred after first dose of an appropriateantibiotic and other urgent treatment.
DEHYDRATION
Severe Dehydration
2 of the following signs
abnormally sleepy or difficult to awaken
sunken eyes
not able to drink or drinking poorly
skin pinch goes back very slowly
Treatment
If the patient has no other severe
classification- PLAN C
If the patient has another severe
classification- refer URGENTLY, with mother
giving frequent sips of ORS on the way
If the child is 2 years or older and there is
cholera in the area, give antibiotic for
cholera
Some Dehydration
2 of the following signs
Restless, irritable
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Incidence rateNo. of new cases of a given disease
_____________________ x 1,000Estimated midyear population
Swaroops IndexNo. of deaths 50 y/o and above_____________________ x 100
Total no. of deaths
Crude Birth rateTotal no. of registered live births _____________________ x 1,000Total no. of population
Crude Death rate
Total no. of deaths
_____________________ x 1,000Total no. of population
Maternal death rate
Total no. of deaths____ x 1,000
Total no. of live births
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Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
Treatment
Give ORS, zinc supplements and food for
some dehydration (PLAN B)
If the child has other severe classification
refer URGENTLY, with mother giving
frequent sips of ORS on the way
Advise mother to continue breastfeeding
Follow up in 5 days if not improving
No Dehydration
-Not enough signs
Treatment
PLAN A
Follow-up in 5 days if not improving
Severe Persistent Diarrhea
-Dehydration present
Treat dehydration before referral unless the
child has another severe classification
Give Vitamin A
Refer to hospital
Persistent Diarrhea
- No dehydration
Advise mother on feeding
Give Vitamin A
Give multivitamins and minerals (inc
luding
zinc) for 14 days
Dysentery
-blood in the stool
Give ciprofloxacin for 3 days
PNEUMONIA
Severe Pneumonia or Very Severe Disease-Any general danger signs, or chest indrawing, or
stridor
Give first dose of an appropriate antibititic
Give Vitamin A
If chest indrawing and wheeze, go directly
to treat wheezing
Treat the child to prevent low blood sugar
Urgent referral
Pneumonia
-fast breathing
Give an appropriate antibiotic for 3 days
Soothe the throat and relieve the cough If coughing for more than 3 weeks or if
having recurrent wheezing, refer for
assessment of TB or asthma
No Pneumonia: Cough or cold
-No signs of pneumonia or very severe disease
Soothe the throat and relieve the cough
If coughing for more than 30 days, refer for
assessment
MALARIA
(Malaria-Risk)
Very Severe Febrile Disease/Malaria
Give first dose of quinine Treat child to prevent low blood sugar
Give one dose of paracetamol for fever
(38.5 C or above)
Send blood smear with the patient
Refer URGENTLY
Malaria
-blood smear (+); if blood smear is not done: NO
runny nose, and No measles, and NO other causes
of fever
Treat the child with an oral antimalarial
Give dose of paracetamol
If fever is present for more than 7 days,
refer for assessment
Fever: Malaria unlikely
- Blood smear (-), or runny nose, or measles, or
other causes of fever
Give one dose of paracetamol for high fever
(38.5C and above)
Treat other causes of fever
(No Malaria-risk)
Very Severe Febrile Disease
- any general danger sign, or stiff neck
Give dose of antibiotic
Treat the child to prevent low blood sugar Give dose of paracetamol
Refer urgently
Fever: No Malaria
-No signs of severe febrile disease
Give one dose of paracetamol
MEASLES
Severe Complicated Measles
-Any general danger sign, or clouding of the
cornea, or deep or extensive mouth ulcers
Give Vitamin A
Give first dose of antibiotic If there is clouding of the cornea, apply
TETRACYCLINE
Refer URGENTLY
Measles with Eye or Mouth Complications
- Puss draining from the eye, or mouth ulcers
Give Vitamin A
If puss is draining from the eye, apply
tetracycline
Measles
-Measles now or within the last three months
Give Vitamin A
Mastoiditis-tender swelling behind the ear
Give first dose of antibiotic
Give first dose of paracetamol for pain
Refer URGENTLY to hospital
Acute Ear Infection
- Puss is seen draining from the ear and discharge
is less than 14 days
- Ear pain
Give antibiotic for 5 days
Give paracetamol for pain
Dry the ear by wicking
Chronic Ear Infection-Puss is seen draining from the ear and discharge is
14 days or more
Dry the ear by wicking
Instill quinolone otic drops for 2 weeks
No ear infection
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- No ear pain and no puss is seen draining from the
ear
No additional treatment
Severe Malnutrition
- Severe muscle wasting, or edema of both feet
Treat the child to prevent low blood sugar
Give Vitamin A
Refer URGENTLY
Very Low Weight
-Very low weight for age
Assess the childs feeding and counsel the
mother
Give Vitamin A
Follow-up in 30 days
Not Very Low Weight
- Not very low weight for age and no other signs of
malnutrition
If the child is less than 2 years old, assess
the childs feeding.
If feeding is a problem, follow-up in 5 days
Severe Anemia-Severe palmar pallor
Refer urgently
Anemia
-Some palmar pallor
Give iron
Give Albendazole/MEbendazole if the
child
is 1 year or older and has not had a dose in
the previous 6 months
No Anemia
- No palmar pallor
Assess the childs feeding and counsel the
mother
ORAL ANTIBIOTICS FOR PNEUMONIA,
MASTOIDITIS/ACUTE EAR INFECTION, OR
VERY SEVERE DISEASE:
First-line antibiotic: Amoxicillin
Second-line antibiotic: Cotrimoxazole
NURSING PRACTICE III-V:
CARE OF CLIENTS WITH PHYSIOLOGIC AND
PSYCHOSOCIAL ALTERATIONS
MEDICAL SURGICAL NURSING
PAIN
Study: Gate control theory (Substantia
gelatinosa)
Analgesics, patient controlled analgesia (PCA),
transcutaneous electrical nerve stimulation (TENS),
imagery, massage
Pain assessment (some common indicators)
MI Crushing pain, (someone
sitting in my chest),
radiates from chest toback
Angina Stab-like pain, , radiates
from chest to jaw to left
shoulder and arm
Hypertension / Pounding pain
hypertensive
crisis
Ectopic
pregnancy
Knife-like pain
Gastric ulcer Gnawing pain
UTI Flank pain
Pancreatitis Radiates from Left upper
quadrant to left shoulder
PERIOPERATIVE PRINCIPLES
PREOPERATIVE CAREInformed Consent
Physician: gives the client a full explanation of theprocedure, including complications, risks, andalternatives
Should be signed by the physician, the client, and awitness (usually the staff nurse)
Informed consent is part of the chart record andshould accompany the nurse to the operating room
INTRAOPERATIVE CARE
The Surgical TeamThe Scrubbed Sterile Team
Operatingsurgeon
- Serves as the leader of the team- Sees to it that all team members areaware of the needs of the procedureand the patient- Performs the surg
ery
Assistant/sto thesurgeon
- assist the surgeon- holds retractor, places clamps onblood vessels, assists in suturing and
ligating light bleeders
Scrubnurse
- set up sterile supplies andinstruments- assists surgeon
- assists in gowning and gloving ofsurgical team- assists in draping- hands instruments, sutures, sponges- keeps operative field tidy- keeps close watch on needles,instruments and sponges- keep accurate needle/instrument
count- discards soil linen
The Unscrubbed Unsterile Team
Anesthesiologist
- gives and controls the anestheticfor the patient- must see to it that all suppliesneeded for anesthesia induction isavailable- gives signal to surgeon orcirculating nurse to proceed withpositioning and preparing theoperative site- monitors vital sign during operation- informs surgeon about patientscondition- determine when the patient maybe moved to PACU after theoperation has been completed
Circulating nurse - functions as overseer of roomduring operation- sends for the patient at theappropriate time- receives, greets, identifies thepatient- check chart for completeness
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- checks operating room lights inadvance for good working order
- prepares operative site- does sponge count with scrubnurse- fills out required operation recordscompletely and legibly
Pathologist
- consulted by the surgeon duringand after surgery for a diagnosis by
gross or microscopic of any tissueremoved- consulted by the surgeonconcerning treatment of somediseases
POSTOPERATIVE CARE
Nursing Management
Full system assessment of the patient
Monitor vital signs q 15 min x 4, q 30 min x 2, q 1hour x 2 then as needed
Position the patient on the side, with face slightlydown.
Elevate upper arm on a pillow maximize chestexpansion
Leave airway in place until pharyngeal reflex hasreturned; suction as needed
Help the client to turn, cough and take deepbreaths
Check bowel sounds in 4 quadrants for 5 minutes(high-pitched tympany is abnormal)
Apply ant embolic stockings (TED hose) before
getting out of bed
Monitor for Homans sign (pain with dorsiflexion onfood)
Possible Complications
POTENTIAL COMPLICATIONS OF SURGERY
COMPLICATION ASSESSMENT NURSINGCONSIDERATIONS
Hemorrhage Decreased BP,increasedpulsed cold,clammy skin
Replace bloodvolumeMonitor vital signs
Shock Decreased Bp.Increasedpulse Cold,clammy skin
Treat causeOxygenIV fluids
Atelectasis andpneumonia
Dyspneacyanosis,
coughTachycardiaElevatedtemperaturePain onaffected side
Experienced secondday postop
SuctioningPosturalDrainageAntibioticsCough and turn
Embolism Dyspnea,Pain,hemoptysisRestleness
ABG-low 02,Hig
h C02,
Experienced secondday postop OxygenAnticoagulants(heparin)
IV fluids
Deep veinthrombosis
PositiveHomans sign
Experienced 6-14days up to 1 year
laterAnticoagulanttherapy
Paralytic ileus Absent bowelsounds noflatus or stool
Nasogastric suctionIV fluidsDecompression Fluid
Infection ofwound
Absent bowelWBC and
temperaturePositivecultures
Experienced 3-5days postop
AntibioticsAseptic techniqueGood nutrition
Dehiscence Disruption of surgicalincision orwound
Experienced 5-6days postop LowFowlers position, nocoughing
NPONotify physician
Evisceration Protrusion of wouldcontents
Experienced 5-6days postop LowFowlers position, nocoughingNPOCover viscera withsterile salinedressing or waxpaper(if a home)notify physician
Urinary retention Unable to voidafter surgery
bladderdistension
Experienced 8-12hours postop
Catheterize asneeded
Urinary Infection Foul-smellingurine ElevatedWBC
Experienced 5-8days postopAntibioticsForce Fluids
Psychosis Inappropriate TherapeuticcommunicationMedication
TYPES OF ANGINA
Stable occurs during exertion,
unchanging severity, relieved by drugs and rest
Unstable unpredictable occurrence,
severity increases with time, not relieved by drugs
and rest
Prinzmetal (also known as variant
angina)results from coronary artery vasospasms
Intractable or refractory severe
incapacitating chest pain
EMERGENCY AND DISASTER NURSING
Triage Categories
Catego
ry
Prio
rity
Colo
r
Example
Immedi
ate
1 Red Sucking chest wounds, airway
obstruction, tension
pneumothorax, 2nd/3rd degree
burns of 15-40% TBSA
Delaye
d
2 Yello
w
Stable abdominal wounds,
soft tissue injuries,
maxillofacial wounds
Minimal 3 Gree
n
Upper extremity fractures,
minor burns, sprains, small
lacerations
Expect
ant
4 Black Unresponsive clients with
penetrating head wounds,
high spinal cord injuries,
2nd/3rd degree burns of more
than 60% TBSA, profound
shock
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FIRST AID
Snake Bite- have patient lie down,
remove constrictive clothing, clean and
cover the wound then immobilize
injured body part below heart level
Jelly fish sting- application of acetic
acid / vinegar to the wound
Insect sting- remove sting and washwound with soap and water (do not
scrape)
Poisoning-(depends on what
substance was taken) if corrosive, do
not induce vomiting- water or milk is
given for dilution. Other gastric
emptying procedures: syrup of ipecac,
activated charcoal, cathartic, gastric
lavage
Heat stroke-remove patients clothing
first then apply cooling blankets or
immerse in cold water bath if possible
Chemical burn drench skin
immediately with running water.
PSYCHIATRIC NURSING
PSYCHOPHARMACOLOGY
ANTIPSYCHOTICS
also known as neuroleptics; major tranquillizer -essentially dopamine receptor blockers, are used totreat disorders that involve thought processes
Traditional/conventional/Typical antipsychotics ( -
azine, -ridol, and thixene) Haloperidol (Haldol) can be used IM during
emergencies, Chlorpromazine (Thorazine) reduces seizure threshold
Increase the risk for extra pyramidal side-effects;and only effective in (+) symptoms
Non-traditional/ Atypical antipsychotics ( - zapine/-apine, - done)
Clozapine (Clozaril), Olanzapine (Zyprexa),Risperidone (Risperdal) DOC for Korsakoffspsychosis
Decrease risk for extra pyramidal side effects
(caused by imbalance between Ach and Dopamine,reversible except for Tardive Dyskinesia
effective both for (+) and (-) symptoms WOF : Agranulocytosis (fever, sore throat),
seizures, hypotension, oversedation
Common Anti-cholinergic side-effects of Anti-psychotics BUCO PanDan
Blurring of Vision pupils are dilate however, hasdecrease accommodation and lens are not so reactiveUrinary RetentionConstipationOrthostatic HypotensionPhotosensitivityDry mouth offer sugarless candy, ice chip, inc. FluidIntake, oral care
ANTIPSYCHOTICS
Taken with Antacids
Non-adherence most common
cause of
exacerbation/rehospitalization;anti-psychotics are taken at NIGHT
Can Trigger Arrythmias: Torsades
de Ponte (HYpomagnesemia) DOC:Magnesium sulfate
Injectables: DECANOATE clients
with notorious non-complinae
Dose: once a weeko Duration: 1-2 week
Prostatic hypertrophy
contraindication, as it canexacerbate urinary retention
Side-effects
* MAJOR EPSEs involuntary spontaneousmotor movements
a. pseudoparkinsonisms: mask-like face,pill-rolling or resting tremors, stoop posture,shuffling, festinating propulsive gait
b. Dystonia: increase muscle tone,musclespasm of the tongue, face, neck, back,laryngospasm and extraocular muscle spasmDOC: Benadryl or Cogentin
1. oculogyric crisis most common; fixedstare2. Torticollis wry neck3. Opisthotonus arching of the back
4. Pisa Syndrome leaning on one side,common in elders
c. Akathisia: inner subjectivefeeling of RESTLESSNESSAntidote: Propranolol
Tardive dyskinesia: late adverse effect ; appearsafter 6 months of taking neuroleptics
Lip smacking, Tongue protruding, Cheek
puffing and Fly-catchers mouth
Vermiform movement of the tongue early
signAkinesia: decrease or absent of movement
Yes to straw
Syrup antipsychotic: s/e CONTACT DERMATITISGive 1 full glass of water after to dilute the drug
Change position slowly: prevent orthostatic hypotension
High protein Bound
Drug bounded in CHON in blood can decrease potency ofdrug/becoming less effective
Decrease CHON level Increase free dopamine in the
blood, though risk for TOXICITYIncrease CHON level decrease effect of the drug
Ocular pressure (dilated) occlusion of the canal of schlemcausing acute glaucoma
Orange-urine
Therapeutic effect
3 6 weeks lag period
Increase Prolactin inversely proportional with Dopamine
Causing: decrease libido, gynecomastia
Can cause NMS rare, life=threatening, extreme agency;
notify the physician
Hyperthermia/Fever 42 degree Celsius (Hallmark sign)DOC: Bromocriptine (Parlodel)
Dantrolene (Dantrium)
Sensitivity: PHOTO
Wear hats, long sleeves, sunglasses
ANXIOLYTICS (- zepam, - barbital) act in the limbicsystem and the RAS to make gamma-aminobutyric acid(GABA) more effective, causing interference with neuronfiring. Minor tranquilizers.
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Benzodiazepines (-zepam, -pam) - the most frequentlyused anxiolytic drugs, prevent anxiety without causingmuch associated sedation.
Less likely to cause physicaldependence
Side-effects: Dry mouth, constipation, blurredvision, nausea and vomiting, elevated liverenzymes
: RESPIRATORYN DEPRESSION:
monitor respiratory rateChlordiazepoxide (Librium) DOC for Deliriumtremens
Avoid use of OTC medications andherbal therapies
Avoid alcohol while taking thisdrug
Antidote: Flumazenil (Romazicon)Barbiturates (barbital) increase risk for addiction anddependence
TRIAD Symptom of Barbiturate Toxicitya. Respiratory depressionb. Pinpoint pupilsc. Coma
ANTIDEPRESSANTSSELECTIVE SEROTONIN REUPTAKE INHIBITOR firstline of treatment
Fluoxetine (Prozac), Paroxetine (Paxil), Sertral
ine(Zoloft)
(- xetine, - zodone, -xamine, - line, - xine, -pram)
Side-effects: weight loss most common side-effect; insomnia (single Am dose); causes sexual
dysfunction and impotence
4 weeks lag period
SSRI to MAOIs: wait for at least 2 t o4 weeksTRICYCLIC ANTIDEPRESSANT increase norepinephrineand serotonin
Clomipramine hydrochloride (Anafranil) DOC for OCDImipramine (Tofranil) best drug for enuresis (bedwetting)Norpramine for elderly depressionide-effects: GIanticholinergic
EffectsNote: causes cardiac toxicity (amitryptyline most
cardio toxic), C/I in clients with MI or anypre-existing cardiac problems, can causearrhythmias, MI, angina, palpitations andstroke
MONOAMINE OXIDASE INHIBITORS
MAOI to SSRI:a period of 6 weeks should elapse
after stopping an SSRI before beginning therapy
with an MAOI Isocarboxacid (Marplan); Phenelzine(Nardil); Tranylcypromine (Parnate)
C/I: pheochromocytoma, CAD, angina, CHF w/c could be exacerbated by increasedlevel
Hypertensive Crisis most fatal a/echaracterized by occipital headache,palpitations, neck stiffness, nausea,vomiting, sweating, dilated pupils,photophobia, tachycardia, and chest pain.It may progress to intracranial bleeding andfatal stroke.
1. Avoid tyramine rich foods can cause
hypertensive criEx. Aged cheese, cheddar cheese, fermentedmeats, brewer yeast, smoked or pickledmeats, fish or poultry, Low amounts oftyramine: soy sauce, sour cream, yogurt,chocolate, grapes, pineapple, raisins,oranges
ANTIMANICLithium salts (Lithane, Lithotabs) are taken orally for themanagement of manic episodes and prevention of futureepisodes.
for treatment of manic episodes of manic-depression or bipolar illness and for themaintenance therapy to prevent or diminish thefrequency and intensity of future manic episodes.
Therapeutic Serum Lithium level: 0.6 to 1.2 mEq/LLithium Carbonate: therapeutic level in 2
weeks
sodium depletion or dehydration kidney reabsorbs more lithiuminto the serum, leading totoxicity.
Teratogenic: advice women touse birth control while taking thedrug
Lithium Levels:1. Serum levels of less than 1.5 mEq/L: CNS problems(lethargy, slurred speech, muscle weakness and finetremor); gastric toxicity (nausea, vomiting and diarrhea)
2. Serum levels of 1.5 to 2 mEq/L: intensification of all ofthe above reactions, with ECG changes
3. Serum levels of 2 to 2.5 mEq/L: ataxia, clonicmovemenst, hyperreflexia and seizures, CV: hypotension,dieresis
4. Serum levels greater than 2.5 mEq/L: complexmultiorgan toxicity, with a significant risk of death
ANTIDOTE: osmotic diuretics excrete excess lithium( Diamox (Acetazolamide); Mannitol (Osmitrol) )
Nursing Management:Increase fluid
Kidney test to determine for nephrotoxicityb. Have normal sodium intake (the kidney cannot
differentiate sodium from lithium)> Increase lithium : dec. lithium = inc.
reabsorption of lithium = inc. toxicity> Inc. sodium intake = decrease the
potency of lithiumc. Lithium level checked every 6 to 8 weeks
ANTI-DEMENTIA
Work by blockingacetylcholinesterase at the synaptic cleft. Thisblocking allows the accumulation of Ach releasedfrom the nerve endings and leads to increased andprolonged stimulation of Ach receptor sites at all of
the postsynaptic cholinergic junctions
Tacrine (Cognex) - * Monitor liverenzymes
Donepezil
DEFENSE MECHANISM UTILIZE BY DIFFERENTPSYCHIATRIC DISORDERS
1. Alcoholics: Denial2. Paranoid: Projection3. Bipolar: Reaction Formation4. Anxiety, Stress, anorexia, psychosis: Regression
5. OCD: Undoing6. Depression: Introjection7. Phobia: Displacement8. Conversion d/o: conversion, symbolism, repression
Personality DisordersCluster A (Odd, eccentric)Paranoid: Hallmark suspiciousness and hypervigilancePersecutory delusion
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No jokes/chit chatDistant friendliness (being available when patientapproaches you)Schizoid (Loners)No pleasure in the company of othersSchizotypal premorbid characteristic of schizophreniaBest therapy cognitive therapyStereotype mad scientistMagical thinking
Cluster B (erratic and emotional)Antisocial: Hallmark sign lack of Remorse
Manipulative behavior: Thrill or fulfillment breaking thelawBehavioral therapy setting limitsBorderline: Hallmark unstable and instabilityRisk for depression inc. risk for suicide
Defense mechanism: Splitting
Histrionic: Hallmark Attention seekerTheatrical: Flamboyant, highly exaggerated inappearance and clothingNarcissistic extreme love to self
f. Hallmark: lack of empathy (egocentric);sense of entitlement (being superior)g. Nurse Approach: Matter of fact way
Cluster C (anxious and fearful)
Avoidant high incidence for depressionEgocentric dec. self esteem, avoid other personsMajor intervention: Role play
ing to increase self-esteemDependent: Hallmark extreme dependence to otherpeopleNeeds attention/assistance : clinging behaviorObsessive-compulsive behaviorHallmark : perfectionistExpect monologues, rigidityTherapy: occupational therapyGoal: completion of tasks
Love means living the way God commanded us to live. As you have heard from the beginning, His command is this: Live
a life ofLOVE 2 John 1: 6
We wish you good luck and congratulations future COLLEAGUE in the NURSING PROFESSION!
-TEAM PRN
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