Health Promotion ; protects against specific problems (Immunizations)
+ dental Check-ups)
Secondary : Early identification + interventionto(Regular medical
[
return
optimal living Amputation support grpup)
to
+ Rehab ;
Primary
:
goal
Tertiary Restoration
:
infants : parent attachment
,
breastfeeding activity to
,
children : nutrition immunization ,
,
adores: communication , hormone
older adults sleep ,
:
Individualized
Holism
drug mangmnt
,
health
optimal
care
health
,
apply
preventative
services
needs :
physiological (5%9+6)
.
,
etc
areas that
taking
,
v
)
"" "
safety (R¥÷n
,
fitness
▪ Summarize health prevention: primary, secondary, and tertiary.
companion ,
(
▪ Differentiate life span considerations in health prevention and health Love love
considers all the
when
health ,
✓
context
spiritual
Physical emotional ,
principles +
mental
Ch 16
someone
,
care :
,
a
As A Whole Includes all
Total
screening
Unit 3-5 learning outcomes safety physical
caring for
:
Maslow's Basic
,
,
Individuality's o
attain , maintain
stimulate development
safety promotion
changes peer groups , self concepts sexuality
promotion.
self Esteem
)
▪ Differentiate holism, individual, and total care.
v1Respect
▪ Summarize Maslow’s basic needs model.
Self
▪ Discuss priority of patient needs using Maslow’s Basic Needs model Actualization
▪ Perform effective therapeutic communication.
( Potential lndep
-
ensure pts ability to
care of
perform tasks understand
establish goals, valves planned
,
how+
Why willing
,
,
,
to
self
Expression )
outcome
o Ch 17
age + condition ▪ Discuss ways to encourage motivation in noncompliant patients.
the
Why is the pt not following
▪ Explore reasons for patient nonadherence.
medication Nonadherence
regimen
Demonstrate caring
▪
Discuss
steps
to
take
in
the
care
of
a
nonadherent/noncompliant
Children Attitude towards medication
Encourage w/ positive reinforcement
past experience cost cultural issues patient.
Use aids for
number of doses taste
teaching
values
Establish therapeutic relationship
Adores Less often consider consequences rejecting adult
conforming to peers
allow pt to feel in control over
Older adults Longterm lifestyle choices limited / fixed income forgetfulness
their health
any
client of that
•
•
:
•
,
,
,
,
•
.
•
:
,
:
,
,
,
I. Assistive devices (lab) (Chapter 44)
needto
a. Cane – when would each one be used and rational
i. Standard straight cane (has one foot)
know !
ii. Tripod cane (has 3 feet)
Types Of Joint Movement
iii. Quad cane (has 4 feet as provides most support)
of
Flexion decreasing the angle
iv. Elbow slightly flexed
elbow )
the
(
bending
understand
joint
v. Cane on unaffected side or strong side
Extension increasing angle of
when they are
the
joint (straightening of arm b. Walker
used
at the elbow )
this
i. Elbow slightly flexed
back to
GO
further
extension
Hyperextension
ii. Hand bar just below client’s waist
or straightening of a joint (bending
c. Crutches
the head backwards)
i. Measure for correct use
Abduction movement away from
midline
1. 3 finger widths (2.5 to 5 cm below the axilla)
midline
towards
Adduction movement
2. Elbow 30* flexion
its
Rotation movement of the bone around
3. Crutch gaits
central axis
circum auction movement of the distal part of the a. Tripod position
bone in a circle while the proximal end remains fixed b. Four-point alternate gate
Eversion Sole of the foot outward by moving the
c. Three-point gait
ankle joint
the ankle d. Two-point alternate gate
Inversion sole of the foot inward by moving Joint
e. Swing-to gait
pronation moving bones in forearm ; palms of hands
f. Swing-through gait
Active ROM isotonic exercises (those
face down
hands g. Getting into a chair
initiated by the pt) include
in forearm : palms of
pushing /
bones
supination moving
h. Getting out of a chair pulling against a stationary object
face up
:
-
-
.
-
§
-
-
-
-
-
-
-
-
-
,
.
using
a
trapeze
to lift the
II. Range of Motion
off the bed lifting butt
a. Types of joint movements page 1012
by pushing hands against
b. Active ROM isotonic exercises where client moves each joint
,
body
off bed
mattress
BMI
underweight
18.5
normal
Overweight
Obesity
c. Passive ROM another person moves each of the client’s joints through its complete
range. maintain joint flexibility
i. Safety
ii. Firm grip
iii. Practice guidelines 1051
18.5
-
24.9
25.0 -29.9
30.0 34.9 I
35.0 -39.9 I
-
VI. Nutrition (Chapter 47)BMI weight in kilograms
(height in meters )Z
a. BMI page 1131
b. Factors that affect nutrition
healthier
nutrients older ; less calories
Lifespan considerations
diet
i. Development Age determines diet : youngera
more iron be mensuration
need
women
;
+
Children
ii. Sex men need ✗ calories proteins
are acceptable under different
Learned eating habits
circumstances
iii. Ethnicity and culture variations of intake
choices
can affect food
Adoles Who are vegan /
food
about
Beliefs
iv. Beliefs about food
on associations
vegetarians are at risk
v. Personal preferencespeople develop likes / dislikes based
""
"" " " de"""
""
starts
vi. Religious practices """""""" " "" """ °
fastfood )
P9 1132
Older Adults
vii. Lifestyle Lifestyle can be linked to eating habits Lex busy
Drug food interactions
viii. Economics socioeconomic status can affect acess to food options interaction
Drugs can increase /decrease
ix. Medications and therapy medication alter appetite taste ; drug food
appetite
x. Health missing teeth ill-fitting dentures sores in mouth dysphagia
+
Neuromuscular disorders
to weight gain
calories can lead
xi. Alcohol consumption Alcohol 1
dementia can make eating
ads
xii. Advertising Target
difficult
habits
xiii. Psychological factors stress depression can change eating
Dysphagia
factors
c. Life span considerations
Economic
caused by inadequate supply of iron
d. Deficiencies
i. Iron deficiency anemia for synthesis of hemoglobin
1. Teach iron-rich foods, organ meant, eggs, fish, poultry, leafy
extreme
Obesity
=
40.0+11=1
+
:
,
:
•
-
:
-
=
'
.
-
+
•
-
,
,
in
-
,
,
-
,
vegetables, dried fruits.
ii. Calcium deficiency needs vitamin D and it can come from the sun. Also
supplied in green leafy vegetables, soybean milk and tofu for vegans
iii. Promote healing.
1. Protein
2. Vitamin C
3. Zinc
iv. Dysphagia
1. Elevate HOB
2. Utilize thickening agents.
a. Thin
b. Nectar-like
c. Honey-like
d. Spoon-thick
v. Different diets and foods allowed.
1. Clear liquids coffee tea carbonated bevs clear juice gelatin
2. Full liquids all clear liquids + dairy drinks pudding icecream refined cereals
3. Soft diet chopped shredded meats mashed veg /fruit
4. Diet as tolerated when a pts appetite desire to eat + tolerance changes
5. Diet modification for disease meet requirements for diet base
on disease Clow
sugar+ diabetes)
vi. Enteral nutrition (lab)
1. HOB elevated.
percutaneous
endoscopic
2. Aspiration precautions and s/s aspiration
gastrostomy CPEG) 3. NGT (short term feedings)nasogastric tube
4. SBFT (short term feedings) small bore feeding tube
Percutaneous
5. PEG and PEJ (long term feedings, requires tube to be placed
endoscopic
PEJ
jejunostomy ( )
,
,
,
,
,
,
,
,
,
,
Enternal
Feedings
can be
given intermittently
feedings are the
continuously Intermittent
or
.
administration of 300 to 500mL Of enternal
formula several times per day
surgically)
a. Testing tube placement
deliver i. CXR initially
Bolus intermittent feedings
ii. Aspirate GI secretions
the formula to the stomach
iii. Measure the pH of aspirated fluid
continuous feedings are generally administered b. Enteral feedings
i. Bolus or intermittent (controlled by gravity)
over a 24-hour period Using an infusion pump
ii. Continuous feeding via pump
iii. Assess for aspiration
c. Parenteral nutrition
4ECF Extracellular
i. TPN Total parenteral Nutrition / IV hyperalimentation
fluid
injected into high flow
ii. Lipids
central veins where they
Infusion of
ICF Intracellular
are diluted by the
pts blood iii. Central venous site
water
are
done
via
to
syringe
.
-
-
~
,
-
dextrose
fluid
Leiegtroiytes
,
fat proteins vitamins
III. Fluid and electrolytes (Chapter 52)
excretion regulates ECF
+ trace
Renal reabsorption or
1315
a.
Sodium
Na+
135
145
distribution
PNOSP
v01
elements
pg
maintain ICF osmolality ; transmit nerve
excretion
;
Renal
b.
Potassium
K+
3.5
5
2- 4.5
Table
electron impulses
52-3
c. Calcium Ca+ 9.5 - 10 Redistribution between bones + ECF: form
+ teeth
bones
;
kidney
d. Magnesium Mg+ 1.5 – 2.5 Conserv. + excretion by
intracellular metabolism
WI
sodium
in
reabsorbed
i
HCl
kidneys
e. Chloride Cl- Excreted
production
see pg 1319
IV. Fluid volume deficit/ dehydration/ decrease ECF
occurs when the
hypovolemia
table 52-4
a. Hypovolemia/ clinical manifestations/nursing interventions body loses both water electrolytes
y
from the ECF
similar proportions
b. Third space syndrome fluid shifts from the
,
-
{
,
+
,
+
:
+
in
,
Vascular space to an area it is not
pg 1319
table 52-5
e
as ECF
readily available
hypervolemia
.
:
occurs when the
V. Fluid volume excess/ overhydration/ increase ECF
body retains both water sodium
a. Hypervolemia/ clinical manifestations/nursing interventions similar proportions to ECF
b. Edema both intravascular Interstitial spaces have increased water sodium Excess
+
+
+
in
.
.
interstitial fluid is edema
VI. Electrolyte imbalances Page 1322-1323
a. Clinical manifestations
b. Nursing interventions
VII. Lab values given in class on Galen sheet.
Table 52-6
add
normal
lab
values
urinary
Altered
Large
Amounts
off
-
urine
small / no
→
urine
•
elimination
containing
:
caffeine /
person bed diuretic ; presence of thirst alcohol
dehydration + weight loss , HX Of diabetes or
opolyuria : ingestion
of fluids
kidney disease
Oliguria anuria Decrease
:
,
dehydration
fluid intake ; sign of
of
shock
,
in
presence
hypotension
Urine elimination Chapter 48 (vocabulary words)
or heart failure
• Alterations in urine elimination, clinical manifestations and nursing measure/education
pg 1180 ; table
48-3
Frequency or nocturia pregnancy increase
• Assessment of urine
intake UTI
Normal Urine
• Diagnostic tests for urine
stress UTI
Urgency psychological
Amount 124hr) 1.200 -1.500mL
• Maintaining normal urinary elimination
color straw / amber / Clear
Dysuria VII /Injury/ inflammation
o Promoting fluid intake
hesitancy hematuria pyuria(pus in urine)
Odor Faint
o Maintaining normal voiding habits
frequency
Enuresis Hx of enuresis ,
Sterility No microorganisms
access to toilet home stress
o Assisting with toileting Water voiding
pH 4.5-8
avoid harsh soap tight
specific gravity 1.010-1.025 • Preventing UTI (page 1186) pants proper wiping
• Managing urinary incontinence (1187-89)
Glucose None
Ketones None
• External urinary device – skill 48-1
Blood None
• Managing urinary retention
o CAUTI catheter-associated urinary tract infection
o Box 48-3
o Skill 48-2
o Nursing interventions for clients with indwelling catheters
Fluids Dietary measures Peri care
▪ Removing indwelling catheters 1198
▪ Intermittent self-catherization
,
:
:
:
•
:
-
:
,
:
,
,
•
:
:
,
:
,
:
:
,
,
:
:
,
,
,
,
in
fl
Normal and Abnormal Feces
color : brown / Clay or white
Infant (yellow) Black + tarry
Fecal elimination Chapter 49 (vocabulary words)
Red Pale Orange Green
▪ Assessment of normal and abnormal feces consistency formed soft / Hard + dry
Coca ; color odor
▪ Clinical manifestations of colorectal cancer shape cylindrical / Narrow stringlike
consistency amt
o Risk factors Amount 100-400g / day
Odor Aromatic / Pungent
o Symptoms
▪ Fecal elimination problems/ clinical manifestations and nursing interventions
catheters
o Constipation <3 bowel movements per week ; dry hard
MAKES Insert
o Fecal impaction collection of hardened feces in rectum folds
to y bifurcation
o Diarrhea liquid feces ( loss of electrolytes sodium + Potassium)
to control fecal discharges
o Bowel incontinence loss of voluntary ability
Women 2-4 in
the chyme in the large , swallowed
on
of
bacteria
action
o Flatulence
intestines
air gas that diffuses between bloodstream and the
▪ Healthy defecation
▪ Enemas
Enema Solutions :
o Types and procedure Hypertonic Draws water into the colon
3- 4inch
soften feces
Hypotonic Distends colon stimulates peristalsis +
Insertion
o Skill 49-1
+ softens feces
(7- 10cm ) ▪ Lifespan considerations Isotonic Distends colon stimulates peristalsis
soapsuds Irritates mucosa distends colon
Hang bag no
oil ( mineral olive cottonseed ) Lubricates the feces and the colonic mucosa
,
,
.
:
,
+
:
,
,
:
.
:
,
:
-
:
,
-
.
-
•
-
,
-
-
,
-
,
-
more than 12 Inches
,
-
,
kayexalate TPot
(
-
.
-
-
)
(
Enemas with antibiotics
treat Ova +
parasites
(immediately to
lab)
Foods
high
calcium
In
milk , cheese,
yogurt, cream
:
Things
delegated
not
to UAPS
sterile procedures
Assessments
Evaluations
normal BMI 18.5
3. 5- 5 ( Iab)
Albumin
total
(1146)
over 5090
serum
Of the
proteins +
the most common visceral
associated
¥¥¥¥¥
Egg: ⑧fyq
soup
(promote caloric increases
accounts for
in
is
)
meds added
Enema
Diagnostic testing
to enema
medications
Gentamicin Surgery
▪ Urinary specimens
Antibiotic for parasites
o Clean voided urine specimens (routine)
bags
o Clean-catch or midstream urine specimen (C&S skill 34-2)
o Urine testing 735-736
gastro +
Looking for blood in stool nemo
▪ Stool specimens
o Occult blood (guaiac test)
o Steatorrhea excessive amount of fat in the stool due to a malaborption syndrome
or pancreatic
enzyme deficiency
o Ova and parasites
one of
proteins
nutrition assessment