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GOSH Approach
Discover
Observe
Goal-oriented assessment
problem-solving Delve
Organized Go deeper
to go further
Steps, since it is called a process there are
different steps to be done.
Do the assessment, analyze and identify the
Decide
What needs to be done?
problem, proceed to the plan of care.
What do you have to do?
You cannot have an intervention if you do
not have a Nursing Diagnosis Do
Systematic Perform functions and actions/interventions
Done at an orderly function.
Organization Plan Evidenced-based
Discriminate
Critique
Humanistic Care Evaluation on the interventions.
Was it able to help the patient?
Involve patients
Address the concerns of your patient.
STEPS: ADPIE
Nurse + Patient
Assessment
Dorothy Johnson (A-D-N) A systematic and continuous collection,
Assessment validation and communication of client’s data
C-V-O-D-R
Decision – Decision will involve Plan a. Collection of Data
b. Validate the Data
Nursing Action c. Organization of Data
d. Data Analysis
e. Recording / Documentation
Purpose: Establish a Database
Types of Data
Subjective
Symptoms – pain, dizziness, vertigo
Objective
Signs – measured/observed; the patient
BP 120/80, pallor, redness
Sources of Data Shows transition from a specific level
Primary – Client/Patient of wellness to a higher level of
Secondary – Significant others, medical wellness
records, chart, other members of the health The patient has coped or adjusted to
care team, related health care literature his/her problem
PULSE
Wave of blood created by the contraction of RESPIRATION
the LV act of breathing
Regulate by the ANS inhalation and exhalation
60-100 bpm = NORMAL for Adults NORMAL = 16-20 cpm
120-160 bpm = NORMAL for pedia Medulla oblongata = primary responsible for
Sites: respiration
a) Temporal Pons
b) Carotid a) Pneumotaxic center (rhythmic quality
c) Apical of breathing
d) Brachial b) Apneustic center (for deep and
e) Radial prolonged respiration)
f) Femoral Types of breathing
g) Popliteal a) Thoracic
h) Posterior Tibial Chest
i) Pedal (Dorsalis Pedis) b) Diaphragmatic
AMPLITUDE (Volume) Abdomen
o Strength of the pulse NORMAL ADULT for stimulating of
o +4 (bounding/full/strong) respiration
o +3 (increased) o INCREASE CO2
o +2 (NORMAL)
o +1 (weak, thread. Feeble)
FACTORS AFFECTING RESPIRATION
o 0 (absent)
1) Increased altitude
RATE
2) Stress
RHYTHM
3) Environment
o Pattern and intervals of beats
a) Increase temp = decreased RR
PULSE DEFICIT b) Decreased temp = increased RR
c) Mountain climbers bring portable
oxygen for high altitudes to facilitate
FACTOR AFFECTING PULSE breathing
1) AGE
4) Exercise 4) Breathe in to expand chest fully
5) Medications 5) Avoid smoking
a) Narcotics = decrease RR 6) Eliminate/reduce use of chemicals
7) Support a pollution-free environment
ALTERATIONS IN RESPIRATIONS
A. RATE PULSE OXIMETRY
1) Apnea Measures O2 saturation
Cessation of breathing Percentage of Oxygenated Hgb in arterial
In newborns, periods of apnea in blood
newborns is considered NORMAL NORMAL = 95-100%
2) Bradypnea (low RR) 91-94% = MILD hypoxia
3) Tachypnea (high RR) 86-90% = MODERATE hypoxia
<85% = SEVERE hypoxia
B. VOLUME <70% = LIFE-THREATENING
1) Hyperventilation SITES:
Deep rapid respirations a) FINGERTIPS
CO2 excessively inhaled b) TOES
2) Hypoventilation c) EARLOBE
Decreased RR and decreased depth d) NOSE BRIDGE
CO2 excessively retained e) FOREHEAD
2) Reservoir
Natural habitat of microorganisms
Other humans, animals, soil, other
reservoir
How to break the CHAIN?
a) Environmental sanitation
b) Good health & hygiene Mostly, the reason is the break of
c) Decontamination/ Sterilization sterility
Stages of infection
1) Incubation period
3) Portal of Exit Exposed to potential carrier that
Through sneezing, coughing, waste, started to show signs and symptoms
secretions 2) Prodromal stage
How to break the CHAIN? Show characteristics symptoms
a) Control of secretions Viral infections must be
b) Hand hygiene pharmacologically managed in this
c) Proper waste disposal stage
3) FULL stage illness
4) Mode of Transmission Actual stage
a) Contact Signs and symptoms worsens
b) Droplet (larger prticles) Very infectious during this stage
c) Airborne (smaller particles) Signs and symptoms is specific to the
d) Vector-borne (mosquitoes) infection itself
e) Vehicle-borne Pathognomonic signs occur
How to break the CHAIN? Bacterial infections must be
a) Hand hygiene pharmacologically managed in this
b) Isolation precautions stage
c) Disinfection/sterilization 4) Convalescent period
Signs and symptoms abate
5) Portal of Entry Recovery period
Food ingested, inhaled
Skin, respiratory system, GI tract MEDICAL ASEPSIS SURGICAL ASEPSIS
How to break the CHAIN? REDUCES number of ELIMINATES/FREE OF
a) Hand hygiene pathogens ALL pathogens
b) Aseptic technique CLEAN TECHNIQUE STERILE TECHNIQUE
c) Wound care USES FOR:
Administration of DRESSING CHANGES
6) Susceptible Host MEDICATIONS
At risk: immune-compromised patients ENEMAS CATHETERIZATIONS
Considered as CARRIER TUBE FEEDING SURGICAL PROCEDURES
How to break the CHAIN? DAILY HYGIENE
a) Recognize high-risk patients
b) Prompt treatment
HAND WASHING
MOST IMPORTANT PART IN THE CHAIN OF 1. MEDICAL:
INFECTION NEEDS TO BE BROKEN TO Uses SOAP
PREVENT INFECTION Not less than 10 seconds
BETWEEN RESERVOIR AND PORTAL Recommendation: 20 seconds or
OF EXIT more
2. SURGICAL
NOSOCOMIAL INFECTIONS
Uses STERILIUM and BETADINE
Hospital acquired infections
Not less than 5 minutes
Most common HAI: UTI
Most common causative agent: S. aureus QUESTION: WHY DOES SURGICAL HANDWASHING
1) EXOGENOUS MAKES YOUR HANDS DRY?
Through environment or the people
2) ENDOGENOUS Microorganisms die out on DRY surroundings.
Patient harbors the microorganisms This is to dehydrate the microorganisms’
3) IATROGENIC nuclear envelope (nucleus) which makes the
Through medical treatments or RNA & DNA of the microorganisms be
procedures done by the patient destroyed.
CDC and Prevention Isolation Guidelines Upon REMOVING in SEQUENCE
A. Tier One (GlEGoMa)
1) Standard Precautions 1. Gloves
Designated for the care of ALL 2. Eyewear
hospital patients. 3. Gown
Hand hygiene 4. Mask
PPE (depending on the care B. Tier Two
rendered to a patient) 1) Transmission-based Precautions
Respiratory hygiene Airborne-precautions
Puncture-resistant containers Fine particles (<5 microns)
PROTECTION FROM NEEDLE PRICKS 1. Isolate (private room)
a) NEVER RECAP needles 1. Maintain 3 ft distance
b) Puncture-resistant containers 2. Negative air pressure
ENVIRONMENTAL CONTROL room
a) Routine cleaning 3. N95 mask/Hepa-filter
b) Waste disposal mask
4. E.g. Measles, TB, Varicella
Droplet precautions
larger particles (>5 microns)
2. Isolate (private room)
1. Ordinary Mask (not
necessarily N95)
2. Maintain 3 ft distance
3. E.g. Diphtheria, Rubella,
Pneumonia
Contact Precaution
Secretions, excretions, skin-
skin, blood and body fluids
3. Isolate (private room)
4. Avoid close intimate
contact
ROOM ASSIGMENTS 5. Wear PPE: gloves, gown,
Prevent contamination goggles
ASCEPTIC PRINCIPLES 6. E.g. scabies
a) CLEANING Protective environment
o Physical removal of dirt or 1. People underground gene
debris therapy, organ transplant
b) DISINFECTION 2. Administered drugs that
o Chemical or physical cause immunosuppression
processes used to reduce
the number of pathogens MAINTAINING A STERILE FIELD: STERILE
c) ISOLATION 1) STERILE TO STERILE ONLY
2) TUYO DAPAT (MUST BE DRY)
In PPE:
3) EDGE = 1 INCH OF THE TABLE: UNSTERILE
Upon WEARING in SEQUENCE:
4) REACHING ACROSS OR OVER IS AVOIDED
GoMEGlo
5) IF IN DOUBT, DISCARD
1. Gown
6) LEVEL UP IS STERILE, LEVEL DOWN IS
2. Mask UNSTERILE
3. Eyewear 7) EXPOSED MATERIALS = UNSTERILE
4. Gloves