FUNDAMENTALS OF N RSING "ADPIE" Assessment Gather information & review Verify the information collected is clear & accurate Diagnosis Interpret the information collected Identify & prioritize the problem through a nursing diagnosis Planning Set goals to solve the problem Prioritize the outcomes of care Implementation Evaluation Reaching those goals through performing the nursing action "Implementing" the goals set above in the planning stage Determine the outcome of the goals Evaluate the patient compliance Document client's response to pain Modify & assess for needed changes Promote 3C's Cooperation Compromise Collaboration Ethical Principles Autonomy respect for an individual's right to make their own decisions Nonmaleficence obligation to do & cause no harm to others Beneficence Justice do good to others Veracity obligation to tell the truth Fidelity following through with a promise fairness Patient Rights HIPAA Privacy The Health Insurance Portability & Accountability Act Considerate & respectful care Be informed Know the names & roles of the persons who are involved in care Consent or refuse a treatment Have an advance directive Obtain their own medical records & results Patient's records are private & they have the right to ensure the medical information is not shared without permission All health care professionals must inform the patient how their health information is used. The patient has the right to obtain a copy of their personal health information. Types of Consent Admission Agreement Immunization Consent Blood Transfusion Surgical Consent Research Consent Special Consent Treatment cannot be done without the patient's consent. In case of emergency when a patient cannot give consent, consent is implied through emergency laws. Those under 18 (minors), consent must be obtained from a parent or legal guardian. Take note: Before signing the consent, the patient must be informed of the ff risks & benefits of surgery, treatments, procedures, & plan of care in layman's terms so the patient understands clearly what is being done. Change agent Leader Manager Caregiver Communicator Teacher Case manager Client advocate Research consumer Counselor Abd A.B.G Arterial blood gas Activities of daily living ADL Before meals a.c A&O Alert & oriented Blood pressure BP Discontinue d/c H&H Hemoglobin & hematocrit DNR Do not resuscitate Diagnosis DX ECG Electrocardiogram Abdomen Fx h.s HOB HOH H&P HR ICU I&O IM IV NGT NPO CPR PPE Fracture At bedtime Head of bed Hard of hearing History & physical Heart rate Intensive care unit Intake & output intramuscular intravenous Nasogastric tube Nothing by mouth Cardiopulmonary resuscitation Personal protective equipment PO p.r.n ROM S&S Stat U/A VS PERRLA By mouth As needed Range of motion Signs & symptoms Immediately Urinalysis Vital signs Pupils Equal, Round, & Reactive to Light & Accomodation Vital Signs Blood pressure Systolic: 120 mmHg Diastolic: 80 mmHG Heart Rate: 60 - 100 BPM Respirations: 12 - 20 Breaths per min Oxygen: 95% - 100% Temperature: 36.537.7 °C (96.0-99.9 °F) RENAL COMPLETE BLOOD COUNT ( CBC ) Hemoglobin (Hgb) Female: 12 - 16 g/dL Male: 13 - 18 g/dL WBC: 4,500 - 11,000 RBC’s: 4.5 - 5.5 PLT: 150,000 - 450,000 BASAL METABOLIC PANEL (BMP) Sodium: 135 – 145 mEq/L Potassium: 3.5 – 5.0 mEq/L Chloride: 95 - 105 mEq/L Calcium: 9 - 11 mg/dL BUN: 7 - 20 mg/dL Creatinine: 0.6 – 1.2 mg/dL Albumin: 3.4 - 5.4 g/dL Total protein: 6.2 - 8.2 g/dL Calcium: 9 - 11 mg/dL Magnesium: 1.5 - 2.5 mg/dL Phosphorus: 2.5 - 4.5 mg/dL Specific gravity: 1.010 - 1.030 GFR: 90 - 120 mL/min/1.73 m2 BUN: 7 - 20 mg/dL Creatinine: 0.6 – 1.2 mg/dL Hematocrit (HCT) Female: 36% - 48% Male: 39% - 54% ABG’S HbA1c Non-diabetic: 4 - 5.6% Pre-diabetic: 5.7 - 6.4% Diabetic: > 6.5% (GOAL for diabetic: < 6.5%) LIPID PANEL LIVER FUNCTION TEST (LFT) ALT: 7 - 56 U/L AST: 5 - 40 U/L ALP: 40 - 120 U/L Bilirubin: 0.1 - 1.2 mg/dL Total cholesterol: <200 mg/dL Triglyceride: <150 mg/dL LDL: <100 mg/dL → Bad cholesterol HDL: >60/dL → Happy cholesterol PANCREAS Amylase: 30 - 110 U/L Lipase: 0 - 150 U/L PH: 7.35 - 7.45 PaCO2: 35 45 mmHg PaO2: 80 - 100 mmHg HCO3: 22 - 26 mEq/L ROME Respiratory Opposite Metabolic Equal COAGs HEPARIN PT: 10 - 13 sec PTT: 25 - 35 sec aPTT: 30 - 40 sec (heparin) INR -NOT ON Warfarin < 1 sec -ON Warfarin 2 - 3 sec measured with Therapeutic Range Antidote aPTT 1.5 - 2.0 x normal “control” value Protamine Sulfate Others MAP BMI PT/INR 1.5 - 2.0 x normal “control” value Vitamin K *The higher these numbers = higher chance of bleeding 18.5 - 24.9 Underweight <18.5 Overweight 25-29.9 Obese 30-34.9 Extremely Obese <35 GCS WARFARIN 70 - 100 mmHg Glascow coma scale: Best = 15 Mild: 13-15 Moderate: 9-12 Severe: 3-8 Sodium 135 - 145 Potassium 3.5 - 5 Phosphorus 2.5 - 4.5 BANANAS PHOR: 4 US: 2 (me + you = 2) There are about 3-5 in every bunch & you want them half ripe (1⁄2) So, think 3.5 - 5.0 Calcium 9 - 11 CALL 911 Magnesium 1.5 - 2.5 MAGnifying glass you see 1.5 - 2.5 bigger than normal Chloride 95 -105 Think of a chlorinated pool that you want to go in when it’s SUPER HOT: 95 - 105 °F CBC Hemoglobin (Hgb) Female: 12 - 16 g/dL Male: 13 - 18 g/dL Hematocrit (HCT) Female: 36% - 48% Male: 39% - 54% To remember HCT, multiply Hgb by 3 12 X 3 = 36 16 X 3 = 48 (Female) 13 X 3 = 39 18 X 3 = 54 (Male) Basal metabolic panel BUN: 7 - 20 mg/dL CREATININE: 0.6 – 1.2 mg/dL Think hamburger BUNs... Hamburgers can cost anywhere from $7 - $20 dollars This is the same value as LITHIUM’s therapeutic range (0.6 - 1.2 mmol/L) Lithium is excreted almost solely by the kidneys... And creatinine is a value that tests how well your kidneys filter Urine Specimen 1. Clean-Catch mid-stream urine -specimen for routine urinalysis, culture and sensitivity test Best time to collect is in the morning, first voided urine Provide sterile container Do perineal care before collection of the urine Discard the first flow of urine Label the specimen properly Send the specimen immediately to the laboratory Document the time of specimen collection and transport to the lab. Document the appearance, odor, and usual characteristics of the specimen. 2. 24-hour urine specimen Discard the first voided urine. Collect all specimens thereafter until the following day Soak the specimen in a container with ice Add preservative as ordered according to hospital policy 3. Second-Voided urine -required to assess glucose level and for the presence of albumen in the urine. Discard the first urine Give the patient a glass of water to drink After few minutes, ask the patient to void 4. Catheterized urine specimen Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen can be collected. Clamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary surgery Stool Specimen 1. Fecalysis -to assess gross appearance of stool and presence of ova or parasite Secure a sterile specimen container Ask the pt. to defecate into a clean, dry bed pan or a portable commode. Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial growth and paper towel contain bismuth which interfere with the test result. 2. Stool culture and sensitivity test -To assess specific etiologic agent causing gastroenteritis and various antibiotics. 3. Fecal Occult blood test bacterial sensitivity -Are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer, detecting melena stool to Hematest– (an Orthotolidin reagent tablet) Hemoccult slide– (filter paper impregnated with guaiac) *Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours. Colocare – a newer test, requires no smear Instructions Advise client to avoid ingestion of red meat for 3 days Patient is advice on a high residue diet Avoid dark food and bismuth compound If client is on iron therapy, inform the MD Make sure the stool in not contaminated with urine, soap solution or toilet paper Test sample from several portion of the stool. Venipuncture Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy or blood administration because it mat affect the result. Never collect venous sample from an infectious site because it may introduce pathogens into the vascular system Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury. Don’t wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine. If the patient has a clotting disorder or is receiving anticoagulant coagulant therapy, maintain pressure on the site for at least 5 min after withdrawing the needle. Arterial puncture for ABG test Before arterial puncture, perform Allen’s test first. If the patient is receiving oxygen, make sure that the patient’s therapy has been underway for at least 15 min before collecting arterial sample Be sure to indicate on the laboratory request slip the amount and type of oxygen therapy the patient is having. If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting the sample. Blood specimen No fasting for the following tests: CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes Fasting is required: FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride) Sputum specimen 1. Gross appearance of the sputum Collect early in the morning Use sterile container Rinse the mount with plain water before collection of the specimen Instruct the patient to hack-up sputum 2. Sputum culture and sensitivity test Use sterile container Collect specimen before the first dose of antibiotic 3. Acid-Fast Bacilli To assess presence of active pulmonary tuberculosis Collect sputum in three consecutive mornings 4. Cytologic sputum exam To assess for presence of abnormal or cancer cells. Plasma Antigens Proteins that elicit immune response Identifies the cell WBC's Plasma antibodies Protects body from “invaders” (think ANTI) RBC's Opposite of the type of antigen that is found on the RBC Has Rh on surface Does not have Rh on surface Can receive Can receive Advantages of blood component therapy Avoids the risk of sensitizing the patients to other blood components. Provides optimal therapeutic benefit while reducing risk of volume overload. Increases availability of needed blood products to larger population. Principles of blood transfusion therapy 1. Whole blood transfusion Indicated only for patients who need both increased oxygencarrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed. 2. Packed RBCs Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%. 3. Platelets Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension. 4. Granulocytes May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production 5. Plasma Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing. 6. Albumin Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure. 7. Cryoprecipitate Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding. 8. Factor IX concentrate Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors 9.Factor VIII concentrate Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission. 10. Indicated Prothrombin complex in congenital or acquired deficiencies of these factors. 1. Insert and IV line using an 18- or 19- gauge IV needle. 2. Run it with normal saline (keep vein open rate) 3. Use the largest catheter port available 4. Begin the transfusion slowly a. The first 15 min "MOST CRITICAL", monitor the patient for S/S of any transfusion reaction. b. Vital signs are monitored every 30 mins to 1 hour. c. After 15 mins, the flow can be increased unless transfusion reaction occurred. 5. Document the client's tolerance to the administration of blood product. Is an adverse reaction that happens as a result of receiving blood transfusion Immediate transfusion reaction chills, diaphoresis aches chest pain rash hives itching swelling rapid, thready pulse dyspnea cough or wheezing Circulatory overload Rise in venous pressure Dyspnea Crackles or rales Distended neck vein Cough Elevated BP Septicemia Rapid onset of chills Vomiting Marked Hypotension High fever Iron Overload Vomiting Diarrhea Hypotension Altered hematologic values 1. Stop the infusion 2. Change the IV tubing down to the IV site 3. Keep the IV open w/ normal saline 4. Notify the HCP and blood bank 5. Do not leave the client alone (monitor vs & continue to assess the patient Incubation interval between the pathogen entering the body & the presentation of the first symptom Prodromal Stage onset of the gen. symptoms to more distant symptoms; the pathogen is multiplying Illness Stage symptoms specific to the infection appear Convalescence acute symptoms disappear and recovery could take days to months total THEORETICAL FOUNDATION OF N RSING Nursing Theory It guides nurses in their practice knowing what is nursing and what is not nursing. It helps in the formulations of standards, policies and laws. It will help the people to understand the competencies and professional accountability of nurses. It will help define the role of the nurse in the multidisciplinary health care team. Four Major Concepts Person All human beings. People are the recipients of nursing care; they include individuals, families, communities, and groups Environment includes factors that affect individuals internally and externally. It means not only in the everyday surroundings but all setting where nursing care is provided. Health generally addresses the person’s state of well-being Nursing FLORENCE NIGHTINGALE Developed the first theory of nursing. Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. HILDEGARD PEPLAU Introduced the Interpersonal Model. She defined nursing as a therapeutic, interpersonal process which strives to develop a nurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate. FAYE ABDELLAH Defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people; developed list 21 nursing problem areas IDA JEAN ORLANDO Developed the three elements – client behavior, nurse reaction and nurse action – compose the nursing situation. She observed that the nurse provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. DOROTHY JOHNSON Developed the Behavioral System Model. 1. Patient’s behavior as a system that is a whole with interacting parts 2. how the client adapts to illness 3. Goal of nursing is to reduce so that the client can move more easily through recovery. IMOGENE KING Nursing process is defined as dynamic interpersonal process between nurse, client and health care system MARTHA ROGERS Conceptualized the Science of Unitary Human Beings. She asserted that human beings are more than different from the sum of their parts; the distinctive properties of the whole are significantly different from those of its parts. BETTY NEUMAN Neuman Systems Model presents a broad, holistic, and system-based method to nursing that maintains a factor of flexibility. Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention. SISTER CALLISTA ROY Presented the Adaptation Model. She viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. LYDIA HALL Introduced the notion that nursing centers around three components: person (core), pathologic state and treatment (cure) and body(care). JEAN WATSON Conceptualized the Human Caring Model. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony, which generates self-knowledge, self-control, self-care and self-healing. ROSEMARIE RIZZO PARSE Introduced the Theory of Human Becoming. She emphasized free choice of personal meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange with the environment and contranscending in many dimensions as possibilities unfold. MADELEINE LENINGER Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition. I can do all things through Christ who strengthens me. PHILIPPIANS 4:13 Good luck future RN! References 1. Genieieiop (2017). 6 factors that influence the infectious agent in infecting a human body. WikiMedia Commons. https://commons.wikimedia.org/wiki/File:Chain_of_Infection.png 2. RN Pedia (2021). Blood Transfusion Therapy. Retrieved from https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/blood-transfusiontherapy/ 3. RN Pedia (2021). Laboratory and Diagnostic Examination. Retrieved from https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/laboratorydiagnostic-examination/ 4. RN Pedia (2021). Roles and Function of a Nurse. Retrieved from https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/roles-functionnurse/ 5. RN Pedia (2021). Theoretical Framework of Nursing Practice. Retrieved from https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/theoreticalframework-nursing-practice/ 6. Tuttle, K. (2020). The Complete Nursing School Bundle. NurseInTheMaking LLC. By purchasing, you agree with the following terms and conditions: 1. You agree that this study guide are simply guides and should not be used over and above your course material and teacher instruction in nursing school. 2. These study guides are not intended to be used as medical advice or clinical practice, they are for educational use only. 3. You also agree NOT to distribute or share the materials under any circumstances.
