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COURSE AUDIT 2 PREBOARD HANDOUT NURSING PRACTICE I: FOUNDATIONS OF NURSING PRACTICE NURSING THEORIES Faye Abdellah Identification of 21 Nursing Problems Lydia Hall Care, Core and Cure (3 Cs) Virginia Henderson Identification of the 14 Basic Needs Imogene King Goal Attainment Theory Madeleine Leininger Transcultural Nursing Myra Levine Four Conservation Principles Florence Nightingale Environmental Theory Betty Neuman Stress Reduction Dorothea Orem Self-Care and Self-Deficit Rosemarie Parse Human Becoming Hildegard Peplau Interpersonal Relations Model Martha Rogers Science of Unitary Human Beings Callista Roy Adaptation Model Jean Watson Human Caring Metaparadigm for Nursing Theories: CHEN (Client, Health, Environment, Nursing) CHAIN OF INFECTION SIX LINKS HANDWASHING Should be done under stream of water or at least 20 seconds Purpose: To reduce the number of microorganism on the hands and reduce transmission of microorganisms to client. Wash the hands in firm, rubbing, and circular motion. GLOVING Purpose: To enable the nurse to handle or touch sterile objects freely without contaminating them. Sterile Gloving Donned by the open method or closed method. Open method is most frequently used outside the operating room because the closed method requires that the nurse wear a sterile gown. After second glove is on, interlock hands together, above waist level. Be sure to touch only sterile sides

PERSONAL PROTECTIVE EQUIPMENT Purpose: To protect health care workers and clients from transmission of potentially infective materials. Host (susceptible) STEPS: Agent 1. Hand hygiene Reservoir 2. Don a clean gown - Overlap the gown at the back to cover the nurses Entry (mode of) uniform. Transmission (mode of) direct, vehicle, vector 3. A facemask and eye protection covering the Exit (mode of) nose, mouth, and eye. SURGICAL VS MEDICAL ASEPSIS 4. Don clean disposable gloves Surgical sterile free from ALL microorganisms - No special technique is required Medical clean free from pathogenic microorganisms Removing PPE 1. Remove the gloves first (most soiled) ISOLATION PRECAUTIONS 2. Perform hand hygiene Standard Precautions (Universal precautions) 3. Remove protective eyewear and dispose of Applies to ALL body fluids, secretions, blood, nonproperly or place in the appropriate receptacle for intact skin and excretions except sweat cleaning Includes hand washing, wearing clean gloves, mask 4. Remove the mask (untie the top strings) and and gown dispose. Transmission Based Precautions Airborne used for clients with INSERTION OF NASOGASTRIC TUBE illnesses transmitted by airborne Measure length of tube tip of the nose to droplets (less than 5 microns) the tip of the earlobe to the xiphoid process Examples: Tuberculosis, Chickenpox, Measles Position High Fowlers position with Place client in private room but if no private neck hyperextended room is available place client in a room with Lubricate tip of tube with water soluble another client infected with the same lubricant microorganism Instruct the client to swallow or drink from Wear N95 respirator a straw while the tube is being inserted Droplet used for clients with illnesses transmitted STOP and remove the tube if client by droplet nuclei ( greater than 5 microns) becomes cyanotic or coughs Examples: Diptheria, Pertussis, Meningitis, Placement- check Mumps - Aspirate gastric secretions measure pH Wear mask when working within 3 feet from the client

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- Auscultate and inject air into the tube


(whooshing sound)

Tube becomes disconnected from the client cover wound with sterile dressing Water seal has vigorous bubbling there is a leak clamp tube nearest the client (intermittent bubbling normal, vigorous/continuous bubbling-abnormal) Transporting the client bottle below chest level and upright

- X-ray best measure to determine proper


placement (initial placement) Secure tube using tape to the bridge of the clients nose and to the clients gown TUBE FEEDINGS

Assessment: Check patency of tube and Aspirate residual contents before feeding (if opposite the affected leg (C-O-A-L) 100 ml or more than 50% of last feeding angle is 20 to 30 degrees withheld and check) the length should permit the elbow to slightly flex For feeding bags: Hang bag from infusion WALKERS pole HEIGHT: 12 inches Hand bar below the clients waist and the elbow is slightly flexed Complications: Dumping syndrome, aspiration pneumonia, diarrhea, CRUTCHES Angle of elbow flexion 30 hyperglycemia, nausea and vomiting degrees URINARY CATHETERIZATION -weight of the body should be Sterile technique

Position: Fowlers position

ASSISTIVE DEVICES CANES

Insertion
Position Male Supine (legs slightly abducted) Penis at 90 degree angle 6-9 inches 40 cm Female Supine (with knees flexed and externally rotated) 2-3 inches 22 cm

borne by the arms not the axilla to prevent CRUTCH PALSY

Crutches are placed 6 inches in front and 6 inches laterally the feet should be slightly apart, hips and knees extended and back is straight Four point gait right crutch, left foot, left crutch, right foot Three point gait right and left crutch with weak leg, stronger leg Two point gait- right crutch and left foot together, left crutch and right foot Swing to gait- move both crutches forward, lift body weight and swing to crutches -Swing through gait - move both crutches forward, lift body weight and swing through beyond the crutches Going up the stairs (remember: all good people go to heaven) when going up, lift (good) unaffected leg first followed by the crutch, affected leg.

Length to be inserted Length of catheter (Adult)

BLOOD TRANSFUSION

FIRST: Check if properly typed and cross matched Gauge of needle: g #18 Drop factor: 10 gtts/min (1st 30 mins.) Duration: RBCs and whole blood 4 hours, FFP Fresh frozen plasma, platelets not more than 20 minutes Rate: KVO IVF: Plain NSS Monitor: vital signs (every 15 minutes for 1st hour), any adverse reactions When reaction happens: STOP transfusion and notify the physician the

Common blood transfusion reactions: SPECIAL DIETS Diet Low carbohydrate Low protein High protein Low sodium High fiber Low residue

Anaphylactic reaction s/sx: rashes and hives Hemolytic reaction s/sx: flank/back pain Pyrogenic reaction s/sx: fever, headache Cardiogenic reaction - s/sx: dyspnea

Disorder Dumping syndrome Renal failure, Acute glomerulonephritis, uremia, anuria Nephrotic syndrome Heart failure, CVDs, Nephrotic syndrome Constipation, hyperlipidemia Bowel inflammation ( diverticulitis and

CHEST TUBES What to do if: Tube becomes disconnected from the bottle place end of tube in a bottle with NSS

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Acid/Alkaline ash Clear liquid Full liquid Gluten-free Tyramine-free Purine restricted

ulcerative colitis) (depending on the lab analysis of the stones) Retard renal calculi formation Following acute vomiting or diarrhea Gastrointestinal upsets, progression from clear liquids For clients with Celiac disease To prevent fermented and processed foods for clients taking MAOIs Gouty arthritis, uric acid stones

- All other than the client Conceptual Models/Frameworks - Wellness models is use by the nurse to identify health risk and to explore lifestyle habits and health behaviors, beliefs, and values that influence levels of wellness.

Nursing Diagnosis

Refers to a statement or conclusion regarding the nature of phenomenon.

Types of nursing Diagnosis: 1. Actual diagnosis is a client problem that is DEGREES OF BURNS present at the time of the nursing assessment. Superficial Partial Thickness 2. Risk Nursing Diagnosis- a clinical judgment that a problem does not exist, but the presence of risk area involved: epidermis factors indicate that a problem is likely to develop tingling, erythema, minimal or no edema unless nurses intervene. Deep Partial Thickness 3. Wellness Diagnosis area involved: 4. Possible Nursing Diagnosis epidermis, dermis 5. Syndrome Diagnosis w/ PAIN, Problem-etiology-signs and symptoms format (PES hyperesthesia, format) BLISTERS, edema, weeping surface, VITAL SIGNS mottled and red base Full Thickness

area involved: epidermis, dermis, may involve subcutaneous and connective tissue, muscle and bone

PAIN FREE, shock, dry, PALE, WHITE leathery or charred skin, broken skin with fat exposed, edema

PRESSURE ULCERS (STAGES)

Stage 1 ERYTHEMA(redness), elevated temperature, patient complains of discomfort Stage 2 Skin breaks, abrasions, BLISTERS, shallow crater, edema, infection may develop Stage 3 ulcer extends into the subcutaneous tissue, necrosis and drainage, infection develops Stage 4- ulcer extends into the muscle and bone, deep pockets of infection develop

NURSING PROCESS Assessment Systematic and continuous collection, organization, validation, and documentation of data (information). Types of data: - Subjective data/Symptoms /Covert data - Objective data/Signs/Overt data Sources of data: - Primary: Client (best source of data)

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TEMP NV (Adult) 36.0-37.5 0 C Oral-2-3 mins Rectal 2-3 mins (most accurate) Axillary 6-9 mins (least accurate) Tympanic

PR 60-100 bpm

RR 12-20 bpm

BP 120/80 mmHg

developing specific principles. Assembled information Disciplined research

Deductive reasoning is the process of


predictions from

general

Ang PET Mo A- pical P-ulmonic E-rbs pt. T-ricuspid M- itral Others: Brachial BP Apical used for children below 3 y/o

Monitor in clients who are/has: immunosu ppressed, receiving chemo, etc

Bleeding, taking digitalis, has DVT or thrombophl ebitis

Breath Sounds: Stridorshrill and harsh ( laryngeal obstruction ) Wheeze high pitched/mu sical (Asthma) Volume: Hypoventil ation-slow and shallow (Respirator y acidosis pursed lip) Hyperventil ation-deep and rapid (Respirator y alkalosis brown paper bag) Anxious, receiving morphine and Magnesium sulfate

-cover about PURPOSES OR NURSING RESEARCH 2/3 of the limb Basic research undertaken to extend the base of Position: knowledge in a discipline, or to formulate or refine a theory sitting Applied research focuses on finding solutions to Release valve existing problems and thus tends to be of greater on cuff carefully immediate utility for EBP. -2-3 mmHg/sec Wait 1-2 min VARIABLES qualities, properties, or characteristics of before taking persons, things, or situations that change or vary and are another BP manipulated or measured in research BP Independent variable is a stimulus or activity that erroneously is manipulated or varied to create an effect on the high-Cuff too dependent variable narrow, arm Dependent variable the response, the behavior, or unsupported, no outcome that the researcher wants to predict or explain rest before Extraneous variables variables other than the assessment, dependent and independent which can affect the cuff wrapped measurement of study variables loosely, Demographic variables characteristics or deflating too attributes of subjects that are collected to describe the slowly (high sample diastolic), assessing MAJOR STEPS IN A QUANTITATIVE STUDY immediately after a meal A. CONCEPTUAL PHASE BP erroneously lowStep 1: Formulating and delimiting the problem cuff too Research problem is an enigmatic, perplexing or wide, arm above heart troubling condition; a situation in need of solution, level improvement, or alteration or a discrepancy between the Cardiac way things are and the way they ought to be. problems, DM, RF Research Question are the specific queries researchers want to answer in addressing the research problem. Research questions guide the types of data to be collected in a study. Step 2: Reviewing the related literature

LITERATURE REVIEW: Summary of theoretical and empirical sources to generate a picture of what is known NURSING RESEARCH BULLETS and not known about a particular problem. RESEARCH is systematic inquiry that uses disciplined PURPOSE: to find, read, and analyze the body of literature methods to answer questions or solve problems. published on a particular topic, primarily in a particular field, for its particular trends and gaps. NURSING RESEARCH is systematic inquiry designed to develop trustworthy evidence about issues of importance to Step 3: Undertaking clinical fieldwork the nursing profession, including nursing practice, Step 4: Defining the framework and developing education, administration and informatics. Conceptual Definitions Trial and error alternatives are tried successively until a solution to a problem is found. Intuition is a type of knowledge that cannot be explained on the basis of reasoning or prior instruction. Logical reasoning as a problem solving method combines experience, intellectual faculties, and formal systems of thought Inductive reasoning - is the process of developing generalizations from specific observations. Step 5: Formulating hypothesis Research Hypothesis is a prediction about the relationship between two or more variables. Simple hypothesis a hypothesis that expresses an expected relationship between one independent and one dependent variable Complex hypothesis is a prediction of a relationship between two (or more) independent variables and/or two (or more) dependent variables. Directional hypothesis is one that specifies not only the existence but also the expected direction of the relationship between variables

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Ex. Older patients are more at risk for experiencing a fall Experimental Research than younger patients an inquiry on cause-and-effect relationships. The Nondirectional hypothesis does not stipulate the researcher controls and manipulates the direction of the relationship independent variable and randomly assigns the Ex. There is a relationship between the age of a patient and subjects to different conditions or situations. the risk for falling. Strengths: Research hypothesis (also referred to as substantive, most powerful method available for testing declarative, or scientific hypotheses) are statements of hypotheses of cause-and-effect relationships expected relationships between variables between variables Null hypothesis (or statistical hypotheses) states that considered the GOLD standard for there is no relationship between the independent and intervention studies because it yields the highestdependent variables. quality evidence regarding intervention effects Limitations: Type I error by rejecting a null hypothesis that is, in HALO EFFECT - When researchers consider a person/ fact, TRUE leads to false positive conclusion respondent good (or bad) in one category, they are likely Type II error false negative conclusion to make a similar evaluation in other categories. It may also be connected with dissonance avoidance, as making TRUE FALSE them good at one thing and bad at another would make True (Null Correct decision Type II error an overall evaluation difficult. accepted) (False negative) HAWTHORNE EFFECT - describes a temporary change to False (Null Type I error Correct decision behavior or performance in response to a change in the rejected) (False positive) environmental conditions; participants respond in a certain manner because they are aware that they are being B. DESIGN AND PLANNING PHASE observed Step 6: Selecting a Research design Characteristics of a true experimental design RESEARCH DESIGNS Manipulation (doing something to the study participants) Research Design is a blueprint of conducting a study the researcher manipulates he INDEPENDENT variable by that maximizes control over factors that could interfere administering a treatment (intervention) to some with the validity of the findings. subjects and withholding it from others, or by administering some other treatment. Types of Designs according to Timeframes Control the experimenter introduces controls over the a. Cross-Sectional Design involve the collection of data experimental situation once: the phenomena under study are captured during one Control group refers to a group of subjects whose period of data collection. This design is appropriate for performance on a dependent variable is used to evaluate describing the status of phenomena or for describing the performance of the treatment group on the same relationships among phenomena at fixed point in time dependent variable. b. Longitudinal Design a study in which data are Randomization (also called random assignment or collected at more than one point in time over an extended random allocation) involves placing subjects into treatment period. conditions at random. c. Retrospective Design involves collecting data on an outcome occurring in the present, and then linking it Quasi-Experimental Research like true experiments, retrospectively to antecedents or determinants occurring in involve an intervention. However, quasi-experimental the past designs lack randomization, the signature of a true d. Prospective Design information is first collected experiment. about a presumed cause or antecedent, and then Non-Experimental Research - the researcher does not subsequently the effect or outcome is measured. interfere with nature and the conditions for research are realistic or uncontrolled. (Dr. CB Tan) RESEARCH METHODS Descriptive Research the purpose of descriptive studies Quantitative Research - This applies to the manipulation is to observe, describe and document aspects of a situation and control of phenomena and verification of results, using as it naturally occurs and sometimes to serve as a starting empirical data gathered through the senses. It is also called point for hypothesis generation or theory development. as hard science, characterized by replicable and reliable Correlational Research the researcher study the effect data. Qualitative Research Focuses on insights and of a potential cause that they cannot manipulate, they use understanding of individual perceptions on the phenomenon designs that examine relationships between variables. The under study. It is considered as a soft science, concerned researcher does not control the independent variable with the subjective meaning of experience to an Additional: Outcomes Research is designed to document the effectiveness of health care services and also individual. plays an important role in policy research. Outcomes of Patient, Provider, & Health Care System Types of Quantitative Types of Qualitative Outcomes used to develop Policy Research Research Change Practice based on Research 1. Descriptive Research 1. Phenomenological Phenomenological Research asks the essence of a 2. Correlational Research Research phenomenon as experienced by the people and what does 3. Quasi-experimental 2. Grounded Theory it mean. Phenomenologists view human existence as Research Research meaningful and interesting because of peoples 4. Experimental Research 3. Ethnographic consciousness of that existence. Research Ethnography involves description and interpretation of 4. Historical Research cultural behavior. 5. Case studies

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Fieldwork: is the process by which the ethnographer inevitably comes to understand a culture Step 7: Developing protocols for the Intervention Step 8: Identifying the population Population is the entire aggregation of cases in which a researcher is interested Step 9: Designing the sampling plan SAMPLING is the process of selecting a portion of the population to represent the entire population so that inferences about the population can be made Sample is a subset of population elements. An element is the most basic unit about which information is collected. SAMPLING METHOD Non-Probability Sampling Accidental also known as Convenience sampling, entails using the most conveniently available people as study participants Quota is one in which the researcher identifies population strata and determines how many participants are needed from each stratum Purposive or Judgment based on the belief that researchers knowledge about the population can be used to hand-pick sample members Snowball or Network is a variant of convenience sampling. Early sample members (called seeds) are asked to refer other people who meet the eligibility criteria Probability Sampling Simple random most basic type of probability sampling, fish ball method Stratified random the population is first divided into two or more strata. As with quota sampling, the aim of stratified sampling is to enhance representativeness. Subdivide the population into homogenous subsets from which an appropriate number of elements are selected at random Cluster usual procedure in selecting samples from a general population is to states, census tracts, and then households Systematic involves the selection of every kth case from a list, such as every 10th person on a patient list or every 100th person in a directory. Ex. If we were seeking a sample of 200 from a population of 40,000, then our sampling interval would be as follows: k = 40,000 = 200 200

Range is simply the highest score minus the lowest score in a distribution Standard Deviation used in interval-and-ration level data; indicates the average amount of deviation of values from the mean Step 14: Preparing data for analysis D. ANALYTIC PHASE Step 15: Analyzing the Data Step 16: Interpreting the Results E. DISSEMINATION PHASE Step 17: Communicating the findings Step 18: Utilizing the findings in research ETHICAL ISSUES IN RESEARCH Autonomy: informed consent. Right to privacy: The researcher should ensure the anonymity of the research participants and the confidentiality of the data/information collected from them. Beneficence: the benefits of the research to the research subject/participants. should be adequately explained to the participants. Nonmaleficence: avoidance of harm or reduction of risks to the research subject. Social Justice: right to be represented in the sample, equal access to knowledge, right not to be discriminated against NURSING PRACTICE II: CARE OF MOTHER AND HEALTH NURSING

CHILD

AND

COMMUNITY

COMMUNITY HEALTH NURSING Community Health Nursing The utilization of the nursing process in the different levels of clientele-individuals, families, population groups and communities, concerned with the promotion of health, prevention of disease and disability and rehabilitation. Goal To raise the level of citizenry by helping communities and families to cope with the discontinuities in and threats to health in such a way as to maximize their potential for high-level wellness.

Public Health The science and art of preventing disease, prolonging Step 10: Specifying Methods to measure the research life, promoting health and efficiency through organized variables community effort for the: Step 11: Developing Methods to safeguard Human Sanitation of the environment and Animal rights Control of communicable diseases Step 12: Reviewing and Finalizing the Research Plan Education of individuals in personal hygiene Organization of medical and nursing C. EMPIRICAL PHASE services Step 13: Collecting data Early diagnosis and preventive treatment of disease CENTRAL TENDENCIES Development of social machinery MODE is the most frequency occurring score value in a To ensure everyone a standard of living adequate for the distribution. Determined by inspecting a frequency maintenance of health, so organizing these benefits as to distribution enable every citizen to realize his birthright of health MEDIAN is the point in a distribution above which and and longetivity (Dr. C. E. Winslow definition) below which 50% of cases fall. MEAN often symbolized as M or X is the sum of all scores The art of applying science in the context of politics so as divided by the number of scores what people usually to reduce inequalities in health while ensuring the best refer to as the average. health for greatest number. (WHO definition) VARIABILITY Core business of public health

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Disease control Injury prevention Health protection Healthy public policy including those in relation to environmental hazards such as in workplace, housing, food, water, etc. Promotion of health and equitable health gain

THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM Department of Health (DOH) is mandated as the lead agency in health at the national level With the devolution of health services: The local health system is run by the Local Government Units (LGUs) The provincial and districts hospital are under the provincial government The city/municipal government manages the health centers/rural health units (RHUs) and barangay health stations (BHSs). Vision The DOH is the leader, staunch advocate and model in promoting Health for All in the Philippines. Mission Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health. Goal Health Sector Reform Agenda through sound organizational development, strong policies, systems and procedures, capable human resources and adequate financial resources. FOURmula ONE for Health The implementation framework for health sector reforms It intends to implement critical interventions as a single package backed by effective management infrastructure and financing arrangements following a sector wide approach Goals of FOURmula ONE for Health Better health outcomes More responsive health systems Equitable health care financing

which the community and the government can afford. Elements/Components of Primary Health Care Environmental Sanitation Control of Communicable diseases Immunization Health Education Maternal and Child Health and Family Planning Adequate Food and Proper Nutrition Provision of Medical Care and Emergency Treatment Treatment of Locally Endemic Diseases Provision of Essential Drugs The framework for meeting the goal of primary health care is organizational strategy, which calls for active and continuing partnership among the communities.

Four Cornerstones/Pillars in Primary Health care Active community participation Intra and inter sectoral linkages Use of appropriate technology Support mechanism made available Two levels of primary health care workers Village or Barangay Health Workers Refers to trained community health workers or volunteer, traditional birth attendant or healer Intermediate level health workers Refers to general medical practitioners, public health nurse and midwives. Levels of Health Care and Referral system Level of Care Primary Definiti on Provided at health care/RH U, Brgy. Health stations, communi ty hospitals Referral is made to infirmari es, municipa l& district hospitals and outpatie nt dept. of provincia l hospitals , Highly specializ ed medical care is necessar y. Referrals Service Health promotion , preventive care Type Health promotion and illness prevention Example Informatio n disseminati on

Seconda ry

Four elements of FOURmula ONE Health financing Health regulation Health service delivery Good governance National Objectives for Health 2005 to 2010 Provides the road map for stakeholders in health and health related sectors to intensify and harmonize their efforts to attain its time honored vision of health for all Filipinos. Primary Health Care Essential health care made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and country can afford at every stage of development. (WHO definition) Partnership and empowerment of the people is the core strategy in the effective provision of essential health services that are community based, accessible, acceptable and sustainable at a cost

Surgery, medical services by specialist

Diagnosis and treatment

Screening procedures

Tertiary

Advanced specialize d, diagnostic , therapeuti c& rehabilitat

Rehabilitat ion

PT/OT

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made to medical centers and specializ ed hospitals e.g. Heart Center.

ive care

Epidemiology The study of distribution of disease or physiologic condition among human populations and the factors affecting such distribution The study of the occurrence and distribution of health conditions such as disease, death, deformities or disabilities on human population Patterns of Disease Occurrence: Epidemic A situation when there is a high incidence of new cases of a specific disease in excess of the expected. When the proportion of the susceptible are high compared to the proportion of the immunes. Endemic Habitual presence of a disease in a given geographic location accounting for the low number of both immunes and susceptible. e.g Schistosomiasis in Leyte and Samar Sporadic Disease occurs every now and then affecting only a small number of people relative to the total population e.g. Rabies Pandemic Global occurrence of disease

INTEGRATED ILLNESSES

MANAGEMENT

OF

CHILDHOOD

Vital Statistics Refers to the systemic study of vital events such as births illnesses, marriages, divorce, separation and deaths. Statistics Refers to a systematic approach of obtaining, organizing and analyzing numerical facts so that the conclusion may be drawn from them. Use of vital statistics Indices of the health and illness status of the community Serves as bases for planning, implementing, monitoring and evaluating community health nursing programs and services Incidence rate No. of new cases of a given disease _____________________ x 1,000 Estimated midyear population Swaroops Index No. of deaths 50 y/o and above _____________________ x 100 Total no. of deaths Crude Birth rate Total no. of registered live births _____________________ x 1,000 Total no. of population Crude Death rate Total no. of deaths _____________________ x 1,000 Professional Review Network, Inc. Copyright Total no. of population Maternal death rate Total no. of deaths____ Total no. of live births x 1,000

Methods that are being utilized in managing childhood illnesses are: Assess the client taking the history of the patient is one way of getting information about the disease condition. This can be done by asking and observing the patients condition to explore the possible causes. Classify the disease a thorough assessment supported with laboratory results is necessary for classification of illnesses and confirmation of the disease. Classification of the disease are: 1) mild, 2) moderate, 3) severe. Treat the patient treatment is a curative method of treating diseases. This vary on the condition of the patient Counsel the patient providing health education to clients promotes health and avoid risk of infection. these are important for parents/caregivers especially who lack knowledge on health practices and risks factors that contribute to disease ailments. To assess for danger signs, the nurse should: Look if the child is lethargic or unconscious Ask the mother or adult with the child: Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions? In the presence of any danger sign, make sure the child is referred after first dose of an appropriate antibiotic and other urgent treatment. DEHYDRATION Severe Dehydration 2 of the following signs abnormally sleepy or difficult to awaken sunken eyes not able to drink or drinking poorly skin pinch goes back very slowly Treatment If the patient has no other severe classification- PLAN C If the patient has another severe classification- refer URGENTLY, with mother giving frequent sips of ORS on the way If the child is 2 years or older and there is cholera in the area, give antibiotic for cholera Some Dehydration 2 of the following signs Restless, irritable

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Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly Treatment Give ORS, zinc supplements and food for some dehydration (PLAN B) If the child has other severe classification refer URGENTLY, with mother giving frequent sips of ORS on the way Advise mother to continue breastfeeding Follow up in 5 days if not improving No Dehydration -Not enough signs Treatment PLAN A Follow-up in 5 days if not improving Severe Persistent Diarrhea -Dehydration present Treat dehydration before referral unless the child has another severe classification Give Vitamin A Refer to hospital Persistent Diarrhea - No dehydration Advise mother on feeding Give Vitamin A Give multivitamins and minerals (including zinc) for 14 days Dysentery -blood in the stool Give ciprofloxacin for 3 days PNEUMONIA Severe Pneumonia or Very Severe Disease -Any general danger signs, or chest indrawing, or stridor Give first dose of an appropriate antibititic Give Vitamin A If chest indrawing and wheeze, go directly to treat wheezing Treat the child to prevent low blood sugar Urgent referral Pneumonia -fast breathing Give an appropriate antibiotic for 3 days Soothe the throat and relieve the cough If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment of TB or asthma No Pneumonia: Cough or cold -No signs of pneumonia or very severe disease Soothe the throat and relieve the cough If coughing for more than 30 days, refer for assessment MALARIA (Malaria-Risk) Very Severe Febrile Disease/Malaria Give first dose of quinine Treat child to prevent low blood sugar Give one dose of paracetamol for fever (38.5 C or above) Send blood smear with the patient

Refer URGENTLY Malaria -blood smear (+); if blood smear is not done: NO runny nose, and No measles, and NO other causes of fever Treat the child with an oral antimalarial Give dose of paracetamol If fever is present for more than 7 days, refer for assessment Fever: Malaria unlikely - Blood smear (-), or runny nose, or measles, or other causes of fever Give one dose of paracetamol for high fever (38.5C and above) Treat other causes of fever (No Malaria-risk) Very Severe Febrile Disease - any general danger sign, or stiff neck Give dose of antibiotic Treat the child to prevent low blood sugar Give dose of paracetamol Refer urgently Fever: No Malaria -No signs of severe febrile disease Give one dose of paracetamol MEASLES Severe Complicated Measles -Any general danger sign, or clouding of the cornea, or deep or extensive mouth ulcers Give Vitamin A Give first dose of antibiotic If there is clouding of the cornea, apply TETRACYCLINE Refer URGENTLY Measles with Eye or Mouth Complications - Puss draining from the eye, or mouth ulcers Give Vitamin A If puss is draining from the eye, apply tetracycline Measles -Measles now or within the last three months Give Vitamin A Mastoiditis -tender swelling behind the ear Give first dose of antibiotic Give first dose of paracetamol for pain Refer URGENTLY to hospital Acute Ear Infection - Puss is seen draining from the ear and discharge is less than 14 days - Ear pain Give antibiotic for 5 days Give paracetamol for pain Dry the ear by wicking Chronic Ear Infection -Puss is seen draining from the ear and discharge is 14 days or more Dry the ear by wicking Instill quinolone otic drops for 2 weeks No ear infection

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INTRAOPERATIVE CARE The Surgical Team The Scrubbed Sterile Team Operating - Serves as the leader of the team surgeon - Sees to it that all team members are aware of the needs of the procedure and the patient - Performs the surgery Assistant/s - assist the surgeon to the - holds retractor, places clamps on surgeon blood vessels, assists in suturing and ligating light bleeders Scrub - set up sterile supplies and nurse instruments - assists surgeon - assists in gowning and gloving of surgical team - assists in draping ORAL ANTIBIOTICS FOR PNEUMONIA, - hands instruments, sutures, sponges MASTOIDITIS/ACUTE EAR INFECTION, OR - keeps operative field tidy VERY SEVERE DISEASE: - keeps close watch on needles, First-line antibiotic: Amoxicillin instruments and sponges Second-line antibiotic: Cotrimoxazole - keep accurate needle/instrument count NURSING PRACTICE III-V: - discards soil linen CARE OF CLIENTS WITH PHYSIOLOGIC AND The Unscrubbed Unsterile Team PSYCHOSOCIAL ALTERATIONS Anesthesi - gives and controls the anesthetic ologist for the patient MEDICAL SURGICAL NURSING - must see to it that all supplies needed for anesthesia induction is PAIN available Study: Gate control theory (Substantia - gives signal to surgeon or circulating nurse to proceed with gelatinosa) positioning and preparing the Analgesics, patient controlled analgesia (PCA), operative site transcutaneous electrical nerve stimulation (TENS), - monitors vital sign during operation imagery, massage - informs surgeon about patients Pain assessment (some common indicators) condition MI Crushing pain, (someone sitting in my chest), radiates from chest to back Stab-like pain, , radiates from chest to jaw to left shoulder and arm Pounding pain - determine when the patient may be moved to PACU after the operation has been completed - functions as overseer of room during operation - sends for the patient at the appropriate time - receives, greets, identifies the patient - check chart for completeness

- No ear pain and no puss is seen draining from the ear No additional treatment Severe Malnutrition - Severe muscle wasting, or edema of both feet Treat the child to prevent low blood sugar Give Vitamin A Refer URGENTLY Very Low Weight -Very low weight for age Assess the childs feeding and counsel the mother Give Vitamin A Follow-up in 30 days Not Very Low Weight - Not very low weight for age and no other signs of malnutrition If the child is less than 2 years old, assess the childs feeding. If feeding is a problem, follow-up in 5 days Severe Anemia -Severe palmar pallor Refer urgently Anemia -Some palmar pallor Give iron Give Albendazole/MEbendazole if the child is 1 year or older and has not had a dose in the previous 6 months No Anemia - No palmar pallor Assess the childs feeding and counsel the mother

hypertensive crisis Ectopic pregnancy Gastric ulcer UTI Pancreatitis

Knife-like pain Gnawing pain Flank pain Radiates from Left upper quadrant to left shoulder

PERIOPERATIVE PRINCIPLES PREOPERATIVE CARE Informed Consent Physician: gives the client a full explanation of the procedure, including complications, risks, and alternatives Should be signed by the physician, the client, and a witness (usually the staff nurse) Informed consent is part of the chart record and should accompany the nurse to the operating room

Circulatin g nurse

Angina

Hypertension /

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Pathologi st

- checks operating room lights in advance for good working order - prepares operative site - does sponge count with scrub nurse - fills out required operation records completely and legibly - consulted by the surgeon during and after surgery for a diagnosis by gross or microscopic of any tissue removed - consulted by the surgeon concerning treatment of some diseases

Infection of wound

Dehiscence

Absent bowel WBC and temperature Positive cultures Disruption of surgical incision or wound Protrusion of would contents

Evisceration

POSTOPERATIVE CARE Nursing Management Full system assessment of the patient Monitor vital signs q 15 min x 4, q 30 min x 2, q 1 hour x 2 then as needed Position the patient on the side, with face slightly down. Elevate upper arm on a pillow maximize chest expansion Leave airway in place until pharyngeal reflex has returned; suction as needed Help the client to turn, cough and take deep breaths Check bowel sounds in 4 quadrants for 5 minutes (high-pitched tympany is abnormal) Apply ant embolic stockings (TED hose) before getting out of bed Monitor for Homans sign (pain with dorsiflexion on food) Possible Complications POTENTIAL COMPLICATIONS OF SURGERY COMPLICATION ASSESSMENT NURSING CONSIDERATIONS Hemorrhage Decreased BP, Replace blood increased volume pulsed cold, Monitor vital signs clammy skin Shock Decreased Bp. Treat cause Increased Oxygen pulse Cold, IV fluids clammy skin Atelectasis and Dyspnea Experienced second pneumonia cyanosis, day postop cough Suctioning Tachycardia Postural Elevated Drainage temperature Antibiotics Pain on Cough and turn affected side Embolism Dyspnea, Experienced second Pain, day postop Oxygen hemoptysis Anticoagulants Restleness (heparin) ABG-low 02, IV fluids High C02, Deep vein Positive Experienced 6-14 thrombosis Homans sign days up to 1 year later Anticoagulant therapy Paralytic ileus Absent bowel Nasogastric suction sounds no IV fluids flatus or stool Decompression Fluid

Urinary retention

Urinary Infection

Unable to void after surgery bladder distension Foul-smelling urine Elevated WBC Inappropriate

Psychosis

Experienced 3-5 days postop Antibiotics Aseptic technique Good nutrition Experienced 5-6 days postop Low Fowlers position, no coughing NPO Notify physician Experienced 5-6 days postop Low Fowlers position, no coughing NPO Cover viscera with sterile saline dressing or wax paper(if a home) notify physician Experienced 8-12 hours postop Catheterize as needed Experienced 5-8 days postop Antibiotics Force Fluids Therapeutic communication Medication

TYPES OF ANGINA

Stable occurs during exertion, unchanging severity, relieved by drugs and rest Unstable unpredictable occurrence, severity increases with time, not relieved by drugs and rest Prinzmetal (also known as variant angina)results from coronary artery vasospasms Intractable or incapacitating chest pain refractory severe

EMERGENCY AND DISASTER NURSING Triage Categories Catego Prio Colo Example ry rity r Immedi 1 Red Sucking chest wounds, airway ate obstruction, tension pneumothorax, 2nd/3rd degree burns of 15-40% TBSA Delaye 2 Yello Stable abdominal wounds, d w soft tissue injuries, maxillofacial wounds Minimal 3 Gree Upper extremity fractures, n minor burns, sprains, small lacerations Expect 4 Black Unresponsive clients with ant penetrating head wounds, high spinal cord injuries, 2nd/3rd degree burns of more than 60% TBSA, profound shock

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FIRST AID

Snake Bite- have patient lie down, remove constrictive clothing, clean and cover the wound then immobilize injured body part below heart level Jelly fish sting- application of acetic acid / vinegar to the wound Insect sting- remove sting and wash wound with soap and water (do not scrape)

exacerbation/rehospitalization; anti-psychotics are taken at NIGHT Can Trigger Arrythmias: Torsades de Ponte (HYpomagnesemia) DOC: Magnesium sulfate Injectables: DECANOATE clients with notorious non-complinae Dose: once a week o Duration: 1-2 week

Prostatic hypertrophy contraindication, as it can exacerbate urinary retention Poisoning-(depends on what Side-effects substance was taken) if corrosive, do * MAJOR EPSEs involuntary spontaneous not induce vomiting- water or milk is motor movements given for dilution. Other gastric a. pseudoparkinsonisms: mask-like face, emptying procedures: syrup of ipecac, pill-rolling or resting tremors, stoop posture, shuffling, festinating propulsive gait activated charcoal, cathartic, gastric b. Dystonia: increase muscle tone, muscle lavage spasm of the tongue, face, neck, back, Heat stroke-remove patients clothing laryngospasm and extraocular muscle spasm first then apply cooling blankets or DOC: Benadryl or Cogentin immerse in cold water bath if possible 1. oculogyric crisis most common; fixed stare Chemical burn drench skin 2. Torticollis wry neck immediately with running water. 3. Opisthotonus arching of the back 4. Pisa Syndrome leaning on one side, PSYCHIATRIC NURSING common in elders c. Akathisia: inner subjective PSYCHOPHARMACOLOGY feeling of RESTLESSNESS Antidote: Propranolol ANTIPSYCHOTICS Tardive dyskinesia: late adverse effect ; appears also known as neuroleptics; major tranquillizer after 6 months of taking neuroleptics essentially dopamine receptor blockers, are used to Lip smacking, Tongue protruding, Cheek treat disorders that involve thought processes puffing and Fly-catchers mouth Traditional/conventional/Typical antipsychotics ( Vermiform movement of the tongue early azine, -ridol, and thixene) sign Haloperidol (Haldol) can be used IM during Akinesia: decrease or absent of movement emergencies, Chlorpromazine (Thorazine) Yes to straw reduces seizure threshold Syrup antipsychotic: s/e CONTACT DERMATITIS Increase the risk for extra pyramidal side-effects; Give 1 full glass of water after to dilute the drug and only effective in (+) symptoms Change position slowly: prevent orthostatic hypotension Non-traditional/ Atypical antipsychotics ( - zapine/apine, - done) High protein Bound Clozapine (Clozaril), Olanzapine (Zyprexa), Drug bounded in CHON in blood can decrease potency of Risperidone (Risperdal) DOC for Korsakoffs drug/becoming less effective psychosis Decrease CHON level Increase free dopamine in the Decrease risk for extra pyramidal side effects blood, though risk for TOXICITY (caused by imbalance between Ach and Dopamine, Increase CHON level decrease effect of the drug reversible except for Tardive Dyskinesia Ocular pressure (dilated) occlusion of the canal of schlem effective both for (+) and (-) symptoms causing acute glaucoma WOF : Agranulocytosis (fever, sore throat), Orange-urine seizures, hypotension, oversedation Therapeutic effect 3 6 weeks lag period Common Anti-cholinergic side-effects of Antipsychotics BUCO PanDan Increase Prolactin inversely proportional with Dopamine Blurring of Vision pupils are dilate however, has Causing: decrease libido, gynecomastia decrease accommodation and lens are not so reactive Can cause NMS rare, life=threatening, extreme agency; Urinary Retention notify the physician Constipation Hyperthermia/Fever 42 degree Celsius (Hallmark sign) Orthostatic Hypotension DOC: Bromocriptine (Parlodel) Photosensitivity Dantrolene (Dantrium) Dry mouth offer sugarless candy, ice chip, inc. Fluid Sensitivity: PHOTO Intake, oral care Wear hats, long sleeves, sunglasses ANTIPSYCHOTICS ANXIOLYTICS (- zepam, - barbital) act in the limbic Taken with Antacids system and the RAS to make gamma-aminobutyric acid Non-adherence most common (GABA) more effective, causing interference with neuron cause of firing. Minor tranquilizers.

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Benzodiazepines (-zepam, -pam) - the most frequently used anxiolytic drugs, prevent anxiety without causing much associated sedation. Less likely to cause physical dependence Side-effects: Dry mouth, constipation, blurred vision, nausea and vomiting, elevated liver enzymes : RESPIRATORYN DEPRESSION: monitor respiratory rate Chlordiazepoxide (Librium) DOC for Delirium tremens Avoid use of OTC medications and herbal therapies Avoid alcohol while taking this drug Antidote: Flumazenil (Romazicon) Barbiturates (barbital) increase risk for addiction and dependence TRIAD Symptom of Barbiturate Toxicity a. Respiratory depression b. Pinpoint pupils c. Coma ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE INHIBITOR first line of treatment Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft) (- xetine, - zodone, -xamine, - line, - xine, -pram) Side-effects: weight loss most common sideeffect; insomnia (single Am dose); causes sexual dysfunction and impotence 4 weeks lag period SSRI to MAOIs: wait for at least 2 t o4 weeks TRICYCLIC ANTIDEPRESSANT increase norepinephrine and serotonin Clomipramine hydrochloride (Anafranil) DOC for OCD Imipramine (Tofranil) best drug for enuresis (bedwetting) Norpramine for elderly depressionide-effects: GI anticholinergic Effects Note: causes cardiac toxicity (amitryptyline most cardio toxic), C/I in clients with MI or any pre-existing cardiac problems, can cause arrhythmias, MI, angina, palpitations and stroke MONOAMINE OXIDASE INHIBITORS MAOI to SSRI: a period of 6 weeks should elapse after stopping an SSRI before beginning therapy with an MAOI Isocarboxacid (Marplan); Phenelzine (Nardil); Tranylcypromine (Parnate) C/I: pheochromocytoma, CAD, angina, CHF w/c could be exacerbated by increased level Hypertensive Crisis most fatal a/e characterized by occipital headache, palpitations, neck stiffness, nausea, vomiting, sweating, dilated pupils, photophobia, tachycardia, and chest pain. It may progress to intracranial bleeding and fatal stroke. 1. Avoid tyramine rich foods can cause hypertensive cri Ex. Aged cheese, cheddar cheese, fermented meats, brewer yeast, smoked or pickled meats, fish or poultry, Low amounts of tyramine: soy sauce, sour cream, yogurt, chocolate, grapes, pineapple, raisins, oranges

ANTIMANIC Lithium salts (Lithane, Lithotabs) are taken orally for the management of manic episodes and prevention of future episodes. for treatment of manic episodes of manicdepression or bipolar illness and for the maintenance therapy to prevent or diminish the frequency and intensity of future manic episodes. Therapeutic Serum Lithium level: 0.6 to 1.2 mEq/L Lithium Carbonate: therapeutic level in 2 weeks sodium depletion or dehydration kidney reabsorbs more lithium into the serum, leading to toxicity. Teratogenic: advice women to use birth control while taking the drug Lithium Levels: 1. Serum levels of less than 1.5 mEq/L: CNS problems (lethargy, slurred speech, muscle weakness and fine tremor); gastric toxicity (nausea, vomiting and diarrhea) 2. Serum levels of 1.5 to 2 mEq/L: intensification of all of the above reactions, with ECG changes 3. Serum levels of 2 to 2.5 mEq/L: ataxia, clonic movemenst, hyperreflexia and seizures, CV: hypotension, dieresis 4. Serum levels greater than 2.5 mEq/L: complex multiorgan toxicity, with a significant risk of death ANTIDOTE: osmotic diuretics excrete excess lithium ( Diamox (Acetazolamide); Mannitol (Osmitrol) ) Nursing Management: Increase fluid Kidney test to determine for nephrotoxicity b. Have normal sodium intake (the kidney cannot differentiate sodium from lithium) > Increase lithium : dec. lithium = inc. reabsorption of lithium = inc. toxicity > Inc. sodium intake = decrease the potency of lithium c. Lithium level checked every 6 to 8 weeks ANTI-DEMENTIA Work by blocking acetylcholinesterase at the synaptic cleft. This blocking allows the accumulation of Ach released from the nerve endings and leads to increased and prolonged stimulation of Ach receptor sites at all of the postsynaptic cholinergic junctions Tacrine (Cognex) - * Monitor liver enzymes Donepezil DEFENSE MECHANISM UTILIZE BY DIFFERENT PSYCHIATRIC DISORDERS 1. Alcoholics: Denial 2. Paranoid: Projection 3. Bipolar: Reaction Formation 4. Anxiety, Stress, anorexia, psychosis: Regression 5. 6. 7. 8. OCD: Undoing Depression: Introjection Phobia: Displacement Conversion d/o: conversion, symbolism, repression

Personality Disorders Cluster A (Odd, eccentric) Paranoid: Hallmark suspiciousness and hypervigilance Persecutory delusion

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No jokes/chit chat Distant friendliness (being available when patient approaches you) Schizoid (Loners) No pleasure in the company of others Schizotypal premorbid characteristic of schizophrenia Best therapy cognitive therapy Stereotype mad scientist Magical thinking

Histrionic: Hallmark Attention seeker Theatrical: Flamboyant, highly exaggerated in appearance and clothing Narcissistic extreme love to self f. Hallmark: lack of empathy (egocentric); sense of entitlement (being superior) g. Nurse Approach: Matter of fact way

Cluster C (anxious and fearful) Avoidant high incidence for depression Cluster B (erratic and emotional) Egocentric dec. self esteem, avoid other persons Antisocial: Hallmark sign lack of Remorse Major intervention: Role playing to increase self-esteem Dependent: Hallmark extreme dependence to other Manipulative behavior: Thrill or fulfillment breaking the people law Needs attention/assistance : clinging behavior Behavioral therapy setting limits Obsessive-compulsive behavior Borderline: Hallmark unstable and instability Hallmark : perfectionist Risk for depression inc. risk for suicide Expect monologues, rigidity Therapy: occupational therapy Defense mechanism: Splitting Goal: completion of tasks

Love means living the way God commanded us to live. As you have heard from the beginning, His command is this: Live a life of LOVE 2 John 1: 6

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