Uploaded by Anne Caluya

FUNDAMENTALS-OF-NURSING-1

advertisement
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.
Download
Study collections