Callista Roy Adaptation model

Dorothea Orem Self care and self deficit

Faye Abdellah 21 nursing problems
Florence Nightingale Manipulation of environment
Hildegard Peplau Interpersonal model
Imogene King Goal attainment theory
Lydia Hall Car, core and cure
Madeleine Leininger Transcultural Nursing
Martha Rogers Science of unitary human beings
Myra Levine Four conservation principles
Rosemarie Parse Human becoming
Virginia Genderson 14 basic needs
Nursing Process

 A cognitive process
 C lient centered
 O outcome directed, systematic approach
 D ynamic and cyclic
 E encourages medical diagnosis
NGT

 Assessment
 Principles
 Position
 Measurement
 Lubrication
 Placement
Gastroenteral Feedings
 Enteral nutrition entails running of formula through
a tube placed into the GIT either by NG route or
surgically through abdominal wall
 Complications
 Dumping syndrome
 Obstructed tubing
 Nausea and vomiting
 Tubing inadvertently pulled out
 Diarrhea
 Aspiration pneumonia
 Stoma and skin infection
 Hyperglycemia
 Principles
 Position
 Aspirate residual feeding to assess absorption
 Check patency prior to feeding
▪ Height of container
▪ Temperature
▪ Duration of delivery
Parenteral Nutrition
 Aka intravenous hyperalimentation
 Concern: infection control
 Site: right subclavian vein
 Complication
 hyperglycemia
 Solutions
 Dextrose
 Water
 Fats
 Proteins
 Electrolytes
 Vitamins
Insulin Administration

 Purpose
 Principles
INSULIN ADMINISTRATION

onset peak duration

rapid 1-2 2-4 4-6

Intermediate 1-2 4-6 16-20

Long acting 6-8 12-16 20-30

Visualization Procedures

 Direct
 oscopies
 Indirect
 Gram/graphy
Specimen Collection
 Urine
 Clean catch
 24 h
 2nd voided urine
 Indwelling
 Stool
 Fecalysis
 Occult blood
 Sputum
Ostomy care

 Color
 Functioning
 Diet
 Foods to avoid
Blood transfusion
 Priority
 Gauge
 Duration
 Crucial time
 Reactions
 Hemolytic
 Cardiogenic
 Anaphylactic
Chest Physiotherapy

 Purpose
 Considerations
Suctioning

 Considerations
 Position
 Oro
 Naso
 Duration
 Oro
 Naso
 Tracheo
Oxygenation

 Position
 Equipments
 Clothing
 Lab
 Toys
Assistive Devices

Cane Crutches
 Position  Position
 Handle  Weight
 Measurement
Pain

 Theory  Radiation
 DOC ▪ Angina
 Pain Assessment ▪ MI
▪ Cholecystitis
 Precipitating
▪ Renal Colic
 Quality ▪ Pancreatitis
▪ Crushing  Severity
▪ Pounding
▪ 0-3
▪ Knife like
▪ 4-7
▪ Gnawing
▪ 8-10
Serum Electrolytes
 Magnesium = 1.5-2.5 mg/dL
 Calcium = 8.6-10.2 mg/dL
 Sodium = 135-145 mEq/L
 Phosphorus = 2.5-4.5 mg/dL
 Chloride = 95-105 mEq/L
 Potassium = 3.5-5 mEq/L
Blood Gases

 PaO2 = 85-95 mmHg

 SaO2 = 95-99%
 PaCO2 = 35-45 mmHg
 pH = 7.35-7.45
Salad Bowl
 Cholesterol level =<200 mg/dL
 Creatinine =0.5-1.5 mg/dL
 BUN =10-20 mg/dL
 IOP =12-21mmHg
CBC
 RBC = 4.6-6.2x1012
 WBC = 4.5-11x109
 Platelets = 150,000-450,000
 PTT = 60-70 sec
 PT = 11-12 sec
 Clotting time = 6-9 sec
 Bleeding time = 1.5-9.5 min
Test for Conditions

 Heparin therapy  Hepatic

 Warfarin encephalopthy
 Diabetic client  Acute renal failure
 Leukemia
 Diuretics
 Sickle Cell
 Gout
 Syphillis
 Pancreatitis
 ITP
 Liver failure
 MI
 RA
Antidotes

Magnesium sulfate
Heparin
Coumadin
Acetaminophen
Lead poisoning
Morphine sulfate
Penicillin
Positioning

 Supine  Genupectoral
 Prone  Jack knife
 Sims  Affected
 Lateral  Unaffected
 Right  Fowler’s
 Left  Low fowlers
Diet
 MAO’I inhibitor
 Leukopenia
 Gout
 Celiac
 Cancer
 Cirrhosis
 CRF
 Ulcer
 CVA
 Tonsillectomy
 CHF
Things commonly asked..
 Acetone
 Airport
 Asepto syringe
 Ball cap
 Band aid
 Bath tub
 Bed cradle
 Belt
 Bottle
 BP cuff
Cont…
 Brown bottle
 Cigarette
 Clamp
 Coffee
 Cotton shirt
 Deodorant
 Elastic stockings
 Electric razor
Cont..

 Flowers
 Goniometer
 High rise toilet seat
 Jewelries
 Keys
 Lead container
 Mall
 Microwave
Test commonly asked..

 Benedict’s test
 CD4determinatioon
 Coomb’s test
 ELISA test
 Sweat chloride test
 Torniquet test
 Western blot test
Cont..

 Heat and acetic acid

 Liver enzyme test
 Mantoux test
 Romberg test
 Schilling test