Autonomic dysreflexia – High fowler’s

Post-bronchoscopy – Semi-fowler’s
TYPES OF ISOLATION Cardiac catheterization – Keep insertion site extended
Strict Isolation – highly transmissible diseases by direct for 4-6 hours to prevent arterial
contact and airborne routes of transmission occlusion
Private rooms, gowns, mask, gloves Cast – Elevate extremity
handwashing, double bagged Cataract – Semi-fowler’s
techniques for soiled articles Cerebral Aneurysm – Semi-Fowler’s
Ex. Diphtheria(pharyngeal), Herpes Cleft Lip – Supine
Zoster, Varicella, Pneumonia (S. Cleft Palate – Prone
Aureus, Strep group A) Congestive Heart Failure – High-Fowler’s
Respiratory Isolation – droplet transmission (3 feet) Craniotomy – Supratentorial:Semi-Fowler’s;
Private room, patient w/ same Infratentorial: Flat
organism, handwashing, labeled Increased ICP – Elevate Head
plastic bags for soiled articles Dumping Syndrome – Supine after meals
Ex. H. influenza, measles, mumps, N. Epistaxis – Lean forward
meningitidis Flail Chest – Affected Side
Tuberculosis/ AFB isolation – suspected/active TB Femoro-Popliteal Bypass Graft – Affected extremity
Private room with negative pressure extended
ventilation, mask, handwashing, Glaucoma(post-op) – Affected side
bronchoscopy and dental examination Hemorrhoidectomy – Side-lying
postponed until 2 weeks of antibiotic Hiatal Hernia – Upright
therapy Hip Surgery – Legs in Abduction
Contact isolation – infectious diseases or multiple Laminectomy – Back as straight as possible
resistant microorganisms that are Liver Biopsy – Right side-lying
spread by direct contact or close Lobectomy – Semi-Fowler’s
contact. Mastectomy – Elevate extremity on pillow
Private room, mask, gown, gloves Myelogram – Water-based dye:Elevate the head;
Ex. Diphtheria (cutaneous), Herpes Oil-based dye: Flat
simplex, MRSA, Pediculosis, Scabies, Prolapsed cord – Knee-chest position
Syphilis Pulmonay edema – Fowler’s
Enteric precautions – infectious diseases transmitted Pyloric stenosis – Right side-lying
through direct or indirect contact with Radium implant – Flat on bed
infected feces Retinal detachment – Affected side towards the bed
Handwashing, gloves, gowns worn Seizure – Side-lying
only when handling contaminated Shock except Cardiogenic shock – Modified
objects with feces Trendelenburg
Ex. Aseptic meningitis, AGE, Hepa A, Cardiogenic Shock – Semi-Fowler’s
Typhoid fever, diarrhea Spinal Cord Injury – Immobilize
Drainage/Secretions precautions – patient with wound Tonsillectomy – Side-lying/Prone
drainage or infected wounds Throidectomy – Semi-Fowler’s
Gloves, gowns indicated if clothing is Thrombophlebitis – Elevate Leg
likely to be contaminated Total Parenteral Nutrition – Trendelenburg – During
Ex. Burns insertion
Thoracentesis – Fowler’s (During procedure)
Position of comfort (After procedure)
Universal Blood and Bloody Fluids Precautions – blood- THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
borne, body fluids (blood, semen, AGE- Clear liquids
vaginal secretions, CSF, synovial fluid, AGN – Low Na, Low CHON
pleural fluid, peritoneal fluid, Addisons’s Disease – High Na, Low K
pericardial fluid, amniotic fluid) Anemia, Pernicious – High CHON, Vit B
Gloves, mask, protective eyegears, Anemia, Sickle Cell – High Fluid
gown, contaminated needles not Gout – Purine Restricted
recapped and sharps in puncture ADHD and Bipolar Disorder – Finger foods
resistant containers Burn – High calorie, High CHON
Ex. AIDS, Hepatitis B and C, STD’s Celiac Disease – Glutein-free
Reversed Isolation – patient is protected from Cholecystitis – High CHON, High CHO, Low Fat
pathogens and nosocomial infections Congestive Heart Failure – Low Na, Low Cholesterol
by instituting reversed transmission Crohn’s Disease – High CHON and CHO, Low Fat
precautions Cystic Fibrosis – High Calorie, High Na
Burns and open wounds, patients Urolithiasis – Acid ash for alkaline stones; Alkaline ash
with artificial airway, for acid stones
immunocompromised patients – Decubitus ulcers – High CHON, High Vitamin C
leukemia, AIDS, steroid therapy, Diarrhea – High K, High Na
radiation or cancer chemotherapy, Dumping syndrome – High Fat, High Protein, Low CHO
medication effect of leucopenia or Hepatic Encephalopathy – Low CHON
agranuloctosis Hepatitis – High CHON, High calorie
Hirschprung’s Disease – Low Residue, High CHON and
POSITIONING FOR SPECIAL CONDITIONS CHO
Abdominal aneurysm surgery – Fowler’s Cirrhosis – Low CHON
Asthma – Orthopneic position Meniere’s Disease – Low Na

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Myocardial Infarction&Hypertension – Low Cholesterol,  Focus: to rehabilitate & restore client to
Fats & Na optimum level of functioning w/in the
Hyperthyroidism – High calorie and CHON constraints of disability
Hypothyroidism – Low Calorie, Low Cholesterol, Low E.g.
Saturated Fat a. Referring a client w/ colostomy to a support
Nephrotic syndrome – Low Na, High CHON, High Calorie group
Hyperparathyroidism – Low Calcium b. Teaching clients w/ DM to administer insulin
Hypoparathyroidism – High Calcium, Low Phosphorus c. Physical therapy to post amputation client
Osteoporosis – High Calcium, High Vitamin D
Pancreatitis – Low Fat OVERVIEW OF NURSING THEORIES
PUD – High fat, High CHO, Low CHON 1. FLORENCE NIGHTINGALE, 1850’s – Mother of Modern
PKU – Low CHON/Phenylalanine Nursing
PIH – Hign CHON THEORY:Environmental Theory
Renal Failure (Acute) – Low CHON, High CHO NURSING: Provision of optimal conditions to enhance the
(Oliguric Phase) – Low Na person’s reparative process and prevent the reparative
(Diuretic Phase) – High CHON, High Calorie, process of being interrupted.
and restricted fluid Nursing is religious calling for women.
Renal Failure (Chronic) – Low CHON, Low Na, Low K
2. VIRGINIA HENDERSON, 1966
THREE LEVELS OF PREVENTION
THEORY: Definition of Nursing
PERSON: A whole, complete and independent being who
I. PRIMARY PREVENTION has 14 fundamental needs.
 Applied to generally healthy individuals/groups 1. to breathe
 Generalized health promotion (mother’s class) 2. eat and drink
 Specific protection against disease 3. eliminate
(immunization) 4. move and maintain posture
 Precedes (before) disease or dysfunction 5. sleep and rest
E.g. 6. dress and undress
1. HEALTH EDUCATION about 7. maintain body temperature
a. prevention of accidents 8. keep clean
b. standards of nutrition 9. avoid danger
c. growth & development 10. communicate
d. exercise 11. worship
e. stress management 12. work
f. protection against occupational 13. play
hazards 14. learn
NURSING: The unique function of the nurse is to assist
2. Immunization (active)
clients, sick or well, in performing those activities
3. Risk assessment of specific disease
contributing to health, its recovery, or peaceful death –
4. Family planning services & marriage
activities clients would perform unaided if they have the
counseling necessary strength, will or knowledge.
5. Environmental sanitation & provision of GOAL – to gain independence as soon as possible
adequate housing, recreation  This definition was a major stepping-stone in the
emergence of nursing as a discipline separate
from medicine.
II. SECONDARY PREVENTION  Nurse has complimentary and supplementary
 Emphasizes on early detection of roles
disease/diagnosis (case finding)  He/she can be a partner, a helper, or a substitute
 Prompt intervention / treatment (passive-- for the client.
immunoglobulin)
 health maintenance for individuals
experiencing health problems 3. MARTHA ROGERS,1970
 includes prevention of complication & THEORY: Unitary Human Beings as an Energy Field
disabilities (turn side-to-side, increase fluid NURSING: A humanistic science dedicated to
intake) compassionate concern with maintaining and promoting
E.g. health, preventing illness, and caring for and rehabilitating
the sick and disabled. Seeks to promote symphonic
1. SCREENING
interaction between the environment and the person.
2. Encouraging regular checkups
3. Teaching BSE & TSE
4. Nursing assessment & CARE provided (home, 4. DOROTHEA OREM, 1980
hospital, agency) THEORY: SELF-CARE DEFICIT THEORY
1. Self-care Theory
2. Self-care Deficit Theory
III. TERTIARY PREVENTION 3. Nursing System Theory
 Begins after illness NURSING: A helping or assisting service to persons who are
 When a defect/disability is fixed, stabilized or wholly or partly dependent when they (to include others)
irreversible are no longer able to give or supervise their care. Nursing is
 Support for the client to achieve a deliberate action.
a. successful adaptation to known risk
b. optimal reconstitution 5. SISTER CALLISTA ROY, 1976
c. re-establishment of high level wellness THEORY: Adaptation Model
NURSING: A theoretical system of knowledge that
prescribes a process of analysis and action related to the

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care of the ill or potentially ill person. Nursing is a science
and a practice discipline. There are Ten (10) Carative Factors
1. Formation of a Humanistic-Altruistic
6. IMOGENE KING, 1971 Value System
THEORY: Goal Attainment Theory 2. Faith-Hope
NURSING: A helping profession that assists individuals and 3. Cultivation of Sensitivity to Self and
groups in society to attain, maintain and restore health. If Others
this is not possible, nurses help individuals die with dignity. 4. Establishing a Helping-Trust
Nurses interact with clients to communicate information Relationship
needed to establish mutual goals and to explore and agree 5. Expression of Feelings, Both Positive
on means to achieve goals (Transaction). and Negative
6. Research and Systematic Problem-
7. BETTY NEUMAN, 1972 Solving
THEORY: Health Care Systems Model 7. Promotion of Interpersonal Teaching-
NURSING: A unique profession in that it is concerned with Learning
all the variables affecting an individual’s response to 8. Provision for a Supportive, Protective,
stressors, which are intra-, inter-, and extrapersonal in and/or Corrective Mental, Physical,
nature. The concern of nursing is to prevent stress invasion, Sociocultural and Spiritual Environment
or, following stress invasion, to protect the client’s basic 9. Gratification of Human Needs (low and
structure and obtain or maintain a maximum level of high order needs) – survival, functional,
wellness. The nurse helps the client through primary, integrative and growth-seeking needs.
secondary, and tertiary prevention modes, to adjust to 10. Allowance for Existential
environmental stressors and maintain client system Phenomenological Force
stability.
12. FAYE ABDELLAH, 1960
8. DOROTHY JOHNSON, 1968 THEORY: Typology of Nursing Problems
THEORY: Behavioral System Model NURSING: Promotion of wholeness for all whether well or
NURSING: An external regulatory force that acts to preserve ill. Must use a problem-solving approach.
the organization and integration of the client’s behavior at Lists 21 Nursing Problems that fall into one of the three
an optimal level under those conditions in which the categories.
behavior constitutes a threat to physical or social health or 1. Physical, emotional, social needs
in which illness is found. 2. Interpersonal needs
3. Common elements of client care.
9. HILDEGARD PEPLAU, 1952
THEORY: Psychodynamic Nursing Theory and Interpersonal
Relations Theory 13. ERNESTINE WIEDENBACH, 1964
NURSING: A maturing force that is realized as the THEORY: Helping Art of Clinical Nursing
personality develops through educational, therapeutic and NURSING: An art based on goal-directed care. Nursing
interpersonal processes. It involves four phases consists of identifying a “need for help” which is desired by
(Orientation, Identification, Exploitation, Resolution) The the individual, ministering to the need, and validating that
nurse acts as a resource person, a counselor, and a the need was met.
surrogate.
Psychodynamic nursing is defined as understanding one’s 14. Joyce Travelbee, 1966
own behavior to help others identify felt difficulties and
applying principles of human relations to problems arising THEORY: Human to Human Relationship Model
during the experience. NURSING: Nursing is accomplished through human-to-
human relationships. She defined Empathy as the ability to
10. MADELEINE LEININGER, 1978 share in the patient’s experience, and thus be able to
THEORY: Transcultural Care Theory or Culture Care predict the behavior of the patient. She defined Sympathy
Diversity and Universality Theory as going beyond empathy and occurring when the nurse
NURSING: She found it senseless to define “nursing” as a desires to alleviate the cause of patient’s suffering and is
distinct concept. “involved but incapacitated”.
 However, these are some of her concepts with regards Her works are applicable to psychiatric nursing and greatly
to culture care. influenced hospice movement.
 “There can be no cure without caring, but there may
be caring without curing.” 15. LYDIA HALL, 1960’S
 Caring is the essence of nursing. THEORY: Theory of Care, Core and Cure
 Nursing care that is not congruent with beliefs, values NURSING: Nursing is helping clients move in the direction of
of a patient’s culture will lead to noncompliance and self-awareness. Nursing care is given exclusively by nurses
stress. educated in the behavioral sciences who take the
 Through the three types of nursing care decisions and responsibility and opportunity to coordinate and deliver the
actions (Cultural Care Preservation, Cultural Care total care of their patients. This includes nursing, teaching,
Accommodation and Cultural Care Restructuring), it is and advocacy in fostering healing.
possible to provide culture congruent care that is
beneficial, satisfying and meaningful to people. 16. IDA ORLANDO, 1961
THEORY: Dynamic Nurse-Patient Relationship or
Deliberative Process of Nursing
11. JEAN WATSON, 1979 NURSING: Nurse’s reaction to patient behavior forms the
THEORY: Philosophy and Science of Nursing basis for nurse actions. It can be Automatic or Deliberative.
NURSING: The purpose of caring is to assist the person in Orlando emphasized patient participation in planning care
gaining control and becoming knowledgeable, and in the by allowing the patient to give feedback.
process promote health changes.
17. MYRA LEVINE, 1969
The science of caring is complementary THEORY: Four Conservation Principles of Nursing
to science of curing.

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NURSING: Nursing is a human interaction designed to  REM –deep sleep, depressed muscle tone and
promote “wholeness” through adaptation. Nursing care is possibly irregular heart and respiratory rates
seen as both supportive and therapeutic. The supportive  NON-REM SLEEP is a deep restful sleep without
aspect is designed to maintain a state of wholeness in the dreaming
face of a client’s failing health. The therapeutic aspect is  DELTA STAGE OR SLOW WAVE SLEEP – non-REM
designed to promote adaptation that contributes to health stage III and IV –quiet sleep
or restoration of health of clients.  napping in the afternoon – not conducive to
KEY CONCEPTS
nightime sleeping
1. Conservation of Energy
 pain is whatever the patient says it is , exists
2. Conservation of Structural Integrity
whenever she says it does
3. Conservation of Personal Integrity
4. Conservation of Social Integrity  preventing pain is always easier than relieving it
 bedrail only a reminder not to leave bed
18. ROSEMARY RIZZO PARSE, 1981 SPECIAL NEEDS
THEORY: Theory of Human Becoming  Aging decreased elasticity of blood vessels,
NURSING: Focuses on man as “living unity”. Goal is to guide increased peripheral resistance and decreased
individuals and families uncover the meaning and relate it blood flow
to their present situation. Parse sees nursing as a human  Azheimer’s Disease – loss of short term memory
science rather than one founded on the natural sciences.  sensory deprivation- involuntary loss of physical
awareness caused by detachment from external
19. MARGARET NEWMAN, 1979 sensory stimuli – isolation
THEORY: Energy Field Theory – “Health as Expanding  speak directly in front and enunciate well- hearing
Consciousness” impaired
NURSING: A partner in the process of expanding  “devoid of feelings” – acceptance in the grieving
consciousness. The nursing process is one of pattern process nurse can help ensure a peaceful death by
recognition. providing dignified support
 high protein diet – acidic urine ; vegetarian diet –
20. PATERSON AND ZDERAD, 1976
alkaline urine
THEORY: Humanistic Nursing
NURSING: The nurturing response of one person (the nurse)
 TPN CONSIDERATIONS: GENERAL COND;- LOSS OF
to another in need (the client), by performing actions to 7% OF USUAL BODY WEIGHT OVER 2 MONTHS,
increase the possibility that the client will make responsible LACK OF ORAL NUTRITION FOR 5 DAYS, PRE-OP.
choices. PREPARATION OF SEVERELY MALNOURISHED
PATIENTS, CA in the GIT and IBD
MAINTAINING ASEPSIS  Soft diet – no fried foods , organ or red meats,
 organisms mode of transmission determines isolation whole grain breads and seasoning
precautions  Bland – no gastric irritants and seasonings, fruit
 barrier used to break the chain of infection between juice OK
mode of transmission and susceptible host  Venturi mask – precise o2 concentration.
 sterile items can be only stored for 1 -2 months  Humidification of O2 – distilled H2O
 handwashing not less than 30 seconds  Vomiting of fluids for 3 days – loss of fluids
 autoclave – kills all micorbes including spores –  Lungs and kidneys - body’s homeostatic regulators
penetrate thick linen  Hypertonic solution enema-120 ml left in place for 7
 patient in isolation – need sensory stimulation – 10 minutes
 soaps and detergents – remove bacteria – lower  Cleansing enema – 1000 ml.
surface tension of water and act as emulsifying MOBILITY
agents  INCREASED ADRENALIN PRODUCTION IN IMMOBILE
 antiseptic – inhibit growth PATIENTS – DECREASED PERISTALSIS
 bactericides and disinfectants – detsroy pathogens  Anorexia – depleted protein stores
 exudate – clear protein rich fluid  Anatomic alignment prevents strain on body parts,
 good nutrition - crucial in the healing of pressure amintains balance and promotes physiologic
ulcers functioning
THERAPIES AND TREATMENTS  Drawsheet is the best device to use when moving a
 phlebitis – warmth and burning sensation patient up in bed
 Z – track - prevent skin staining and irritation  Virchow’s triad- collectively predispose a ptient to
 mid – deltoid - can accommodate only 1 ml. of thrombophlebitis , impaired venous return to the
medication heart , blood hypercoagubility and injury to to blood
 insulin injection- validate dose accuracy vessel wall.
 insulin injection – G25 , 5/8 “ needle  Valsalva maneuver – forced expiratory effort against
 G20 – IM oil based a closed glottis
 22G 1 ½”– im meds.  Oxygen improves respiratory function only if he has
 G26 – intradermal symptoms of hypoxia
 length of tubing should make no influence in how the  Cold skin and impalpable pulse in the leg – refer
infusion flows ASAP (embolus)
COMFORT AND SAFETY MEASURES  Pulse rate – most reliable indicator of activity
 lotions containing lanolin – preferred for backrub tolerance
 sleep deprivation causes behavior and personality  Complication of immobility – foot drop
changes. adequate sleep maintains coordination
and perception and decreases restlessness
HEMATOLOGY

DETERMINATION REFERENCE RANGE CLINICAL SIGNIFICANCE

Bleeding Time 1.5-9.5 min Prolonged in thromcytopenia,

________________________________________________________
 defective platelet function and aspirin
therapy.
Factor VIII Assay 60% - 140 % Deficient in Classical Hemophilia
PTT (Activated) 25-45 sec Prolonged deficiency of fibrinogen
PTT (normal 2.5x control) factors II, V, VIII, IX, X , XI and XII and
60-70 sec in heparin therapy
PT 9-14 sec Prolonged by deficiency of Factos I, II,
V, VII and X, fat malabsorption, severe
liver disease, Coumarin anticoagulant
therapy
INR 1.0 Used to standardize the prothrombin
time and anticoagulation therapy.
Erythrocyte count M: 4.6-6.2 x 1012/L Increased in severe diarrhea and
F: 4.2-5.4 x 1012/L dehydration, polycythemia, acute
poisoning, pulmonary fibrosis
Decreased in all anemias, in leukemia
and after hemorrhage when blood
volume has been restored
ESR Westergren Method <15-200 mm/h Increased in tissue destruction,
ESR Zeta Centrifuge Method <0.40-0.60 whether inflammatory or
degenerative, during menstruation
and pregnancy and in acute febrile
illness
Hematocrit M: 42-52% Increased in erythrocytosis of any
F: 35-47% cause and in dehydration or
hemoconcentration associated with
shock.
Decreased in severe anemias, anemia
of pregnancy, acute massive blood
loss.
Hemoglobin M: 13-18 g/dL Increased in polycythemia, COPD,
F: 12-16 g/dL failure of oxygenation because of CHF
and normally in people living at high
altitudes
Decreased in various anemias,
pregnancy, severe or prolonged
hemorrhage, with excessive fluid
intake
WBC/Leukocytes 5 000-10 000/cu mm Increased in various infections

Neutrophils 45%-73% Neutrophils increased with acute

Eosinophils 0%-4% infections, trauma or surgery,
Basophils 0%-1% leukemia, malignant disease, necrosis;
Lymphocytes 20%-40% Decreased with viral infections, bone
Monocytes 2%-8% maroow suppression, primary bone
marrow disease
Eosinophils increase in allergies,
parasitic disease, collagen disease,
subacute infections, decreased with
stress, use of some medications
(ACTH, epinephrine, thyroxine)
Basophils increased with acute
leukemia and following surgery or
trauma, decreased with allergic
reactions, stress, parasitic disease, use
of corticosteroids.
Lymphocytes increased with
infectious mononucleosis, viral and
some bacterial infections, hepatitis,
decreased in aplastic anemia, SLE,
immunodeficiency including AIDS
Monocytes increased with viral
infections, parasitic disease, collagen
and haemolytic disorders, decreased
with use of corticosteroids, RA, HIV
infection
Platelet count 150 000-450 000/cu mm Decreased in thrombocytopenic
purpura, acute leukemia, aplastic
anemia and during cancer
chemotherapy

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SERUM, PLASMA AND WHOLE BLOOD CHEMISTRIES

DETERMINATION REFERENCE RANGE INCREASED DECREASED

Conventional Units SI Units
Acid, total M: 2-12 U/L M: 2-12 U/L Carcinoma of prostate
phosphatase F: 0.3-9.2 U/L F: 0.3-9.2 U/L Advanced Paget’s
Disease
Hyperparathyroidism
Gaucher’s Disease
Alkaline phosphatase Adults: 50-120 U/L 50-10 U/L Conditions reflecting
increased osteoblastic
activity if the bone
Rickets
Hyperparathyroidism
Hepatic Disease
Bone disease
Ammonia (plasma) 15-45 ug/dL (varies 11-32 umol/L Severe liver disease
with method) Hepatic
decompensation
Amylase 60-a60 Somogyi 111-296 U/L Acute pancreatitis Chronic pancreatitis
U/dL Mumps Pancreatic fibrosis
Duodenal ulcer and atrophy
Carcinoma of head of Cirrhosis of liver
pancreas Pregnancy (2nd and
Prolonged elevation 3rd trimester)
with pseudocyst of
pancreas
Increased by
medications that
constrict pancreatic
duct sphincters
(morphine, codeine,
cholinergics)

AST (Aspartate M: 10-40 U/L M: 0.34-0.68 µkat/L Myocardial infarction

aminotrnasferase) F: 15-30 U/L F: 0.25-.0.51 µkat/L Skeletal muscle disease
formerly SGOT Liver disease
ALT(Alanine M: 10-40 U/ml M: 0.17-0.6 µkat/L Same conditions as AST
aminotransferase) F: 8-35 U/ml F: 0.14-0.60 µkat/L (SGOT) but increase is
formerly SGPT more marked in liver
disease than AST
Bilirubin Total: 0.3-1.0 mg/dL 5-17 µmol/L Hemolytic
Direct: 0.1-0.4 mg/dL anemia(indirect)
Indirect: 0.1-0.4 1.7-3.7 µmol/L Biliary obstruction and
mg/dL disease
3.4-11.2 µmol/L Hepatocellular
damage(hepatitis)
Pernicious anemia
Hemoltic disease of
newborn

BLOOD GASES

Oxygen, arterial 85-95 mm Hg 10.64-12.64 kPa Polycythemia Anemia

(whole blood) Cardiac or
Partial pressure (PaO- pulmonary disease
2)

Saturation (SaO2) 95%-99% Volume fraction: Cardiac

0.95-0.99 decompensation
Chronic obstructive
lung disease
Carbon dioxide, 35-45 m Hg 4.66-5.99 kPa Respiratory acidosis Respiratory alkalosis
arterial (whole blood) Metabolic alkalosis Metabolic acidosis
Partial pressure
(PaCO2)
pH (whole blood, 7.35-7.45 7.35-7.45 Vomiting Uremia
arterial) Hyperventilation Diabetic acidosis

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  The goal of listening- identify problems and needs
and a supportive act.
 Delegating responsibility shows respect for the staff
NURSING PROCESS members abilities to solve problems on their own
 Nursing processp provides continuity of care and  The nurse managers function is to guide , direct and
patient participation in health care coordinate patient care, not to provide it.
 Care plans should never be unchangeable and  Primary nursing – comprehensive form of nursing in
revised prn which one nurse is responsible for comprehensive
 NANDA – responsible for formulating taxonomies or care of a given patient
classifications  Evaluation of staff members must be based on
 Nursing order should include the date, the specific performance criteria as established by professional
nursing action, time / length of time and signature standards and the job description.
 Provide safety from falls – keep bed in lowest level  Poor performance stems from poor morale
and locking wheels  Trust is the foundation of positive nurse patient
 The point at which the brachial pulse can no longer relationship
be palpated provides an estimate of the maximum  Therapeutic communication – two way , deliberative
pressure required to measure systolic blood interaction between the patient and nurse in which
pressure. they establish mutually acceptable, achievable goals
 Last Korotkoff sound heard on auscultation with a ---fundamental component at all phases of the
stethoscope is the diastolic pressure nursing process
 The primary reason for bedrest is to decrease  Problem orientedmedical record- information is
metabolic activity, which reduces the cells need for recorded as prob.,observations and plan
oxygen.secondary is to conserve energy and  Narrative chart – decriptive storylike record
decrease cardiac output  A positive change in the patient’s behavior is the best
 The normal APTT is 16 – 25 seconds and PT is 12 – 15 way to identify learning
seconds, these levels must remain within two to two  Teacher should always try to involve the learner
½ the normal levels  Asking questions shows that the patient is interested
 Negligence – failure to act as an ordinary prudent in learning
person would.  Maintaining independence, a need common to
 Malpractice – professional misconduct, improper patients of all age-groups, fosters the elderly
discharge of professional duties or failure to meet person’s feelings of self worth
standards of care NURSING ASSESSMENT
 Three elements necessary to establish nursing  Too much Yin causes digestive disorders and
malpractice – nursing error , injury and proximal nervousness and too much yang causes dehydration ,
cause fever and irritability.
 A DNR order means that basic and advanced life  Correct sequence in abdl. Assessment is RLQ, RUQ,
support measures won’t be initiated if respiratory or LUQ and LLQ
cardiac arrest occurs. It does not mean that ordinary  Guaiac – hemoccult test
treatment measures or nursing care is stopped  Rectal examination – sims , genupectoral and dorsal
COMMUNICATION SKILLS recumbent
Nursing theory – one that generates knowledge in  Romberg test – test for sensory or cerebellar ataxia
nursing  Narrowed pulse pressure less than 30 – hypovolemia
 Conceptual model – group of general ideas that  Oral temp.-36.1- 37.8’C (axillary 1‘deg.lower) (rectal
serves as framework upon which nursing theories -1’higher)
can be developed and tested.  BP cuff small – false high readings
 In 1960, Nursing schools adopted theories from the  Rectal temp – 3 to 5 mins. And axillary 10 mins.
biological and psychosocial sciences to serve as  Rinne hearing tests compare sound conduction
conceptual frameworks through air and bone.air conduction greater than
 Four concepts – person, environment – health and bone conduction normal hearing or sensorineural
nursing(actions) hearing loss. Vice versa conductive hearing loss
 Martha Rogers – life process model – evolving  Weber’s – determine if patient hears better in one
creature interacting with the environment in an ear or to differentiate sensorineural hearing loss
open, adaptive manner-achieve maximum health in from conductive hearing loss
his environment  Level of consciousness is the most important
 Dorothea Orem – persons need to achieve self care. element in assessing the patient’s mental status
Goal of nursing is to help patient develop self- care  Lethargic patient sleep’s on and off but will respond
activities to maintain maximum wellness to verbal or tactile stimuli. Stupor – needs constant
 High level wellness - OLOF stimulation
 Maslow – a need as a satisfaction whose absence can  Brain highly sensitive to inadequate oxygenation
cause illness ( mental changes – hypoxia – first sign)
 Safest way to identify patient is checking  Body’s response to elevated temperature –
identification band on his wrist tachycardia and peripheral vasodilation(inc.
 Diagnosis and Tx of human responses to actual or metabolism) - hypotension
potential health problems  Crisis – turning point in the course of a disease
 Profession – requires specialized knowledge with usually indicated by a rapid decrease in temperature
long and intensive academic preparation  Lysis – gradual improvement in condition
 Student nurses do not provide services, they are INFORMED CONSENT
solely on the unit to learn  Capacity and competence
 Patient safety is a major concern in all situations  Includes explanation of

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  Benefits, expected results,alternatives and risk  Biot’s – shallow breaths interrupted by apnea
 Voluntary THERAPEUTIC EXERCISES
 Information understood  Passive ROM-retention of rom and maintenance of
 Cannot sign if under alcohol or premedicated circulation
MANAGED CARE  Assistive- increases motion , maintains muscle tone
 Work allocation  Active – maintains mobility of the joint and
 Patient needs and conditions maintains muscle strength
 Abilities of staff  Resistive – increases muscle power
 Continuity of care  Isometrics- maintenance of strength and prevents
 Knowledge of staff and qualifications\ muscular atrophy
 Right task- function , activity , DANGERS OF IMMOBILITY
decision…….information , supervision , follow-up  Decubitus ulcer-osteomyelitis
 Don’t delegate assessment,teaching  Osteoporosis-pathological fractures and renal calculi
evaluation,planning  Increased cardiac workload- tachycardia
 Contractures- deformities
SCOPE  Thrombus formation-pulmonary embolism
 RN  Orthostatic hypotension-weakness,faintness and
 Planning and health teaching dizziness
 Licensure requirements  Respiratory stasis – hypostatic pneumonia
 Assessment and evaluation  Constipation – fecal impaction
 Need for knowledge and skill  Urinary stasis-urinary retention
 LPN/LVN-  Negative nitrogen balance-weight loss/debilitation
 Stable patients
 Standard unchanging procedures NUTRITION
 Simple monitoring and implementation  PREMATURE INFANTS-less than37wks/2,500g-100-
 Sequenced/predictable outcomes 200 cal/kg/day and higher na,ca and chon
 State practice act inclusion  FULL TERM-120 cal/kg/day
 UAP-direct patient care activity and standard  Pregnancy + 300cal/day
operating unchanging procedures  Lactation+ 500cal/day
RESTRAINTS
 Liable for false imprisonment
 Last resort
 Informed consent(proxy)
 Alternative measures first
 Benefits> risks
 Length of time and circumstances specified
 Ensure safety – circulation checks,skin care, rom and
remove q2h
RESTRAINTS IS USED FOR:
 The purpose of discipline
 Comfort and convenience of provider
 Required to treat medical symptoms
 Ensure used to control behavior
 Prevent breach in safe and effective delivery of
medical therapy.
 Ensure safety of other patients
 Medium of limit setting and provision of external
controls
COMPLAINTS
 Compromise / collaborative agreement
 Listen attentively
 Explain scopes and limitations
 Ask and relay expected solutions and terms
 Non-defensive
HEALTH TEACHING
 C-consider support systems / compliance
 H- olds motivation and insight
 A- allow feedback
 N-needs met and assured
 G- goals and priorities set w/ pnt.
 E- empathetic and ensures collaboration
BREATHING PATTERNS
 Cheyne stokes – periodic breathing characterized by
rhytmic waxing and waning
 Dyspnea - labored painful breathing
 Hyperventilation – abnormally rapid deep prolonged
breathing
 Kussmauls – air hunger , marked increase in depth
and rate
 Tachypnea – fast shallow breathing
 Paradoxical – flail chest , deflates during inhalation

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