Promoting Wellness Through Life Span
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PROMOTING WELLNESS THROUGH LIFE SPAN
GROWTH AND DEVELOPMENT CONCEPTS
Theories of personality development Psychosexual Psychosocial Cognitive Developmental tasks Moral Interpersonal
Freuds psychosexual theory
Libido – inner drive Parts of body –focus of gratification Unsuccesful resolution - fixation Structures of personality
Id – pleasure principle-instinct
Ego – controls action and perception –reality principle
Superego – moral behavior - conscience
0-18 m0s ;oral – mouth – trust and discriminating 18 mos. – 3 years ; anal – bowels – holding on or letting go
Negativism and toilet training age
3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension)
Gender identification and genital awareness Oedipus and Electra complex // Castration anxiety and penis envy
6-12 years –latency (quiet stage) sexual energy diverted to play. Institution of superego…control of instinctual impulses 12 – young adult – genital ; reawakening of sexual drives – relationships
Sexual maturation Sexual identity ,ability to love and work
Psychosocial – Erickson developmental milestones //delay
0-12mos; 1-3y 3-6 6-12 12-18 18-25 25-60 60 and above
TRUST AUTONOMY INITIATIVE INDUSTRY IDENTITY INTIMACY GENERATIVITY EGO INTEGRITY
INFANCY
CONSISTENT MATERNAL –CHILD INTERACTION – TRUST INNER FEELING OF SELF WORTH
HOPE
ALLOW EXPLORATION PROVIDE FOR SAFETY
TODDLER
NO NO – NEGATIVISM OFFER CHOICES / REVERSE PSYCHOLOGY TOILET TRAINING – 18 MOS.-BOWEL
DAYTIME BLADDER -2 Y NIGHTIME BLADDER 3 Y
REWARD W/ PRAISE AND AFFECTION
INDEPENDENCE
PRE-SCHOOL
PROVIDE PLAY MATERIALS SATISFY CURIOSITY TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR) SIBLING RIVALRY
WILLPOWER
SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS CHUMS AND HOBBIES
NEEDS TO EXCEL/ACCOMPLISH NEED FOR PRIVACY AND PEER INTERACTION COMPETENCE
ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS BODY IMAGE CHANGES
NEED TO CONFORM BUT KEEP INDIVIDUALITY
SELF - AWARENESS
YOUNG ADULT COMMITMENT AND FIDELITY
RESPONSIBILITY
ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS MIDLIFE CRISIS
ADJUSTMENT AND COMPROMISE
MOST PRODUCTIVE AND CREATIVE
ALTRUISM
LATE ADULTHOOD
SELF ACCEPTANCE
SELF WORTH
WISDOM
PIAGET’S COGNITIVE THEORY 0-2 SENSORIMOTOR
REFLEXES IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING
2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC CANNOT CONCEPTUALIZE OTHER’S VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES)
7-12Y CONCRETE OPERATIONAL
LOGICAL CONCRETE THOUGHT INDUCTIVE RESAONING (SPECIFIC TO GENERAL) CAN RELATE ,PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION
12-ABOVE FORMAL OPERATIONAL THOUGHT
Abstract thinking Separation of fantasy and fact Reality oriented Deductive reasoning Apply scientific method
Havighurst Developmental Tasks Baby to early childhood
Right from wrong and Conscience
Late childhood
Physical skills,wholesome attitude,social roles Conscience morality and values
Fundamental skills in academics Personal independence
Adolescence
Sexual social roles Relationships Independence and ideology
Early adulthood
Career Selecting a mate Finding Civic or social responsibility
Middle age
Achieving Civic or social responsibility Adjusting to changes Satisfactory career performance Adjusting to aging parents Adjusting to parental roles
Old age
Adjusting to changes Establishing satisfactory living arrangements and affiliations
Kohlberg – MORAL DEVELOPMENT/ THINKING/ JUDGEMENT PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE OBEDIENCE TO RULES TO AVOID PUNISHMENT
CONVENTIONAL ( 6-12 )
MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY
SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE
POST –CONVENTIONAL (12 – 18 Y) PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS
SULLIVANS
INTERPERSONAL THEORY INFANCY
NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS
TODDLERHOOD / EARLY CHILDHOOD
CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT
PRE-SCHOOL
DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN
SCHOOL AGE
THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX
ADOLESCENCE
LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX
YOUNG ADULTHOOD
BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT
LATER ADULTHOOD
LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS
SENESCENCE
DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY
FORMATION OF PERSONALITY CERTAIN GOALS MUST BE ACCOMPLISHED, IF THIS GOALS ARE NOT ACCOMPLISHED AT A CERTAIN STAGE,….PERSONALITY WILL BE WEAKENED….
FACTORS IN EACH STAGE PERSISTS AS A PERMANENT PART OF PERSONALITY…. EACH STAGE HAS MAJOR TRAUMAS AND FRUSTRATIONS THAT MUST BE OVERCOME …….SUCCESSFUL RESOLUTION OF CONFLICTS ASSOCIATED WITH EACH STAGE IS ESSENTIAL TO DEVELOPMENT…..UNRESOLVED CONFLICTS REMAIN IN THE UNCONSCIOUS AND MAY, AT TIMES, RESULT IN MALADAPTIVE BEHAVIOR
PREVENTION AND EARLY DETECTION OF DISEASE GROWTH AND DEVELOPMENT
DEVELOPMENTAL TASKS---MILESTONES ---DELAYS(FIXATIONS/LAG)
IQ = MA / CA X 100
JUDGEMENT , COMPREHENSION AND LISTENING
DDST – BIRTH TO 6 YEARS
PERSONAL SOCIAL, FINE , GROSS MOTOR AND LANGUAGE SKILL AREAS
HEALTH SCREENING OB – GYNE / REPRODUCTIVE TESTS
UTZ-5 WKS CONFIRM PREGNANCY AND AOG AMNIOCENTESIS – 16 WKS-DETECT GENETIC DISORDERS – 30 WEEKS – L/S RATIO ( 2-4 WKS RESULT)(EMPTY Bladder) OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN 10 MINUTES- REACTIVE NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR ACCELERATION OF 15BPM/MORE LASTING 15 SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE – REACTIVE DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION) AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE DEFECTS – 16-18 WKS CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-12 WKS
NEWBORN/INFANT HEALTH SCREENING
PKU – GUTHRINE BLOOD TEST-EAT CHON FOR 2 DAYS MIN.(PHEONISTICS – DIAPER) SICKLE CELL DISEASE –ABNORMALLY SHAPED Hg , ELISA AND WESTERN BLOT CARRIER SCREENING FOR CYSTIC FIBROSIS AND SWEAT CHLORIDE TEST
SCHOOL AGE
HEARING AND VISION TESTS
ALLEN PICTURE CARDS SNELLEN CHART-20/40 AT TODDLER AND 20/20 AT SCHOOL AGE WEBER’S-SENSORINEURAL AND CONDUCTIVE RINNE’S- CONDUCTIVE DENTAL EXAM – STARTS AT 2 YEARS
ADOLESCENT
PPD – INDURATION – 72 HOURS BSE – (18-20 YRS.) POST MENSTRATION/MONTHLY TSE – MONTHLY (18-20 YRS) PELVIC EXAM WITH PAP SMEAR – IF SEXUALLY ACTIVE OR 18 Y.O. ANNUALLY
ADULT/ELDERLY
HPN , DM, HEARING AND VISION PROSTATE –ANNUALLY@40 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS FECAL OCCULT BLOOD TEST- > 50 = ANNUALLY DIGITAL RECTAL EXAM - > 40 Y.O. = YEARLY PELVIC EXAM – 18-40 Y.O. =PERFORMED Q 1 – 3 YEARS WITH PAP TEST MAMMOGRAM – 35-39 = BASELINE
40-49 = Q2Y 50 AND OLDER = QYEAR
BP SCREENING(mmHg) IMMUNITY pg 127-130
CONTRAINDICATIONS:
SEVERE FEBRILE ILLNESS LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED ALLERGIES RECENTLY ACQUIRED PASSIVE IMMUNITY(BLOOD TRANSFUSION AND IMMUNOGLOBULINS)
if child –no evidence of immunization <7 y.o. Give DPT,TOPV,TINE 4-6 WKS LATER MMR 1 MONTH AFTER DPT AND TOPV REPEATED IN ANOTHER MONTH AGAIN IN 10-16 MOS.
CAN GIVE DPT,MMR,TOPV, AND TINE SIMULTANEOUSLY
TD- 2 DOSES 4-8 WKS APART;3RD DOSE 6-12 MOS;BOOSTER AT 10 YRS FO LIFE RD OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3 DOSE 2 -12 MOS ND AFTER 2 (OPV NOT USED IN US) MMR-ONE DOSE – 12 MOS VARICELLA – TWO DOSES 4-8 WEEKS APART STARTS AT 12 MOS. ND HEPA B – 3 DOSES;2 1-2 MOS AFTER;3RD 4-6 MS AFTER PPV- ONE DOSE ;IF 65 AND RECEIVED > 5YEARS – ADMINISTER INFLUENZA –ANNUALLY EACH FALL
ALLERGY CONTRAINDICATIONS
EGGS – INFLUENZA , MMR NEOMYCIN – VARICELLA,IPV,MMR YEAST – HEPA-B GELATIN – VARICELLA
PREGNANCY C/I: MMR AND VARICELLA IMMUNOSUPPRESSED; VARICELLA WITH Ig or BT PREVIOUS 3-11 MOS – MMR AND VARICELLA
CONSIDERATIONS-IMMUNIZATION
DPT - IM – ANTERIOR OR LATERAL THIGH
FEVER AND SWELLING 24-48 H POTENTIAL SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC AND SCREAMING
MMR – SC – ANTERIOR OR LATERAL THIGH
RASH, FEVER ARTHRITIS-10DAYS-2 WKS
TRIVALENT OPV – PO
PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS – EVALUATED 48-72 HOURS
PHYSICAL ASSESSMENT
TEACHING OPPURTUNITY INSPECTION –VISUALLY PALPATION-WARM HANDS
DORSUM OF FINGERS FOR TEMP
PERCUSSION-DIRECT,INDIRECT,BLUNT
RESONANCE-MODERATE LOW PITCHED CLEAR HOLLOW(LUNG) HYPERRESONANCE-OVERINFLATED(EMPHYSEMA) TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL) DULL-SOFT MUFFLED,DENSE FLUID FILLED TISSUE(LIVER) FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-(MUSCLE/BONE)
AUSCULTATIONDIAPHRAGM-HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW PITCHED(HEART MURMURS)
TEMPERATURE:
VITAL SIGNS
ORAL – 98.6 ‘F / 37 ‘C RECTAL – 99.6 ‘F / 37.6’C AXILLARY – 97.6’F / 36.5’C
NORMAL VITAL SIGNS
NEWBORN=30 – 50 / MIN; 120 – 140 / MIN; 60/40 – 80/50 mmHg 1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN; 90/60 – 99/65 mmHg
5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60 mmHg
ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –140 / 90 mmHg
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 BIOT’S – SHALLOW BREATHS INTERRUPTED BY APNEA
NORMAL FINDINGS
PULSE PRESSURE – 30-40 mmHg Intracranial pressure – 10 mmHg PULSE DEFICIT – MINIMAL(3-5 ACCEPTABLE)
IDEAL BODY WEIGHT –
MALES -106 LBS FOR 1ST 5FT THEN ADD 6LBS/INCH ST FEMALE – 100LBS FOR 1 5 FT THEN ADD 5LBS/INCH ADD OR SUBTRACT 10% DEPENDING ON BODY FRAME. OBESE AND UNDERWEIGHT IF DEVIATION IS > 20%
SCARS,BRUISES AND LESIONS CHECK COLOR EDEMA – GRADING
SKIN
0-NO EDEMA 1-BARELY DETECTABLE 2-INDENTATION<5MM 3-INDENTATION 5-10MM 4-INDENTATION >10MM
PRESSURE SORE –GRADING
1-NONBLANCHABLE ERYTHEMA 2-EPIDERMIS,PARTIAL THICKNESS 3-FULL DERMIS AND SQ 4- SUPPORTING TISSUES AND BONES
TURGOR-PINCH SKIN TENTED 3 SECS NORMAL(ELDERLY-OVER STERNUM)
HAIR AND NAILS
HIRSUTISM-EXCESS
ALOPECIA-THINNING
SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING ANGLE > 180 DUE TO PROLONGED DECREASED OXYGENATION BLANCHING =< 3 SECS-NORMAL
HEAD
SYMMETRY, SIZE AND SHAPE CRANIAL NERVE ASSESSMENTS
OPTIC-SNELLEN OCULOMOTOR- PERRLA TRIGEMINAL – BITE DOWN AND STROKES WITH COTTON FACIAL – FACIAL MOVEMENT AND TASTE ACCOUSTIC – HEARING AND BALANCE(WATCH TICK TEST,OTOSCOPIC EXAMS AND POSTURE TESTS) GLOSSOPHARYGEAL-GAG AND SWALLOW VAGUS- SWALLOWING AND SPEAKING
EYES
PTOSIS-DROOPING OF THE UPPER EYELID ASTIGMATISM – UNEVEN CURVATURE OF CORNEA LEADING TO REFRACTION ERRORS NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE MOVEMENTS STRABISMUS-ASSYMETRICAL LIGHT EFLECTION ON EACH CORNEA RED REFLEX FROM RETINA-NORMAL COVER UNCOVER TEST – DET.EYE ALIGNMENT SNELLEN – FAR DISTANCE VISION/VISUAL ACUITY IOP-TONOMETRY TESTS INDENTATION(6-12)
EARS
PINNA BACK-UP-ADULT;DOWN-BACK-CHILD RINNE TEST – COMPARES AIR CONDUCTION WITH BONE CONDUCTION,VIBRATING FORK PLACED ON THE MASTOID IF SOUND NO LONGER HEARD POSITIONED IN FRONT OF EAR CANNAL. SHOULD HEAR A SOUND= 2:1 ; AIR CONDUCTION > THAN BONE CONDUCTION ;= POSITIVE RINNE
ASSESS CONDUCTIVE HEARING LOSS
EARS
WEBER – SENSORINEURAL AND CONDUCTIVE HEARING LOSS
FORK PLACED MIDDLE OF FORE HEAD,SHOULD BE HEARD EQUALLY=WEBER NEGATIVE IF NOT EQUAL=SENSORINEURAL HEARING LOSS. SOUND HEARD BETTER IN THE IMPAIRED EAR=BONE CONDUCTIVE HEARING LOSS, IF VICE VERSA = SENSORINEURAL DISTURBANCE
NECK,MOUTH AND PHARYNX
TEETH-32 TONSILS – NO TPC , + GAG REFLEX CERVICAL LYMPH NODES=<1CM CAROTID – PALPATE THRILL,LISTEN BRUIT JUGULAR VEINS – NOT DISTENDED TRACHEA-MIDLINE
THORAX AND LUNGS
APL DIAMETER-1:2 – 5:7
1:1 = BARREL CHEST
TACTILE FREMITUS NORMAL-BRONCHOPHONY,EGOPHONY AND WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGS BREATH SOUNDS
VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –PERIPHERAL LUNG SURFACES BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM BRONCHI BRONCHIAL- LOUD COARSE - TRACHEA
ADVENTITIOUS BREATH SOUNDS
RALES-FINE SHORT,CRACKLING OR HIGH PITCHED SOUNDS-INSPIRATION RHONCHI-CONTINOUS LOW PITCHED COARSEGURGLING HARSH SNORING BEST HEARD ON EXHALATION WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON INHALATION FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ LIKE VIBRATIONS – BOTH INHALATION AND EXHALATION
HEART SOUNDS
AORTIC AND PULMONIC VALVE AREAS- 2ND ICS, R AND L RESPECTIVEY RD ERBS POINT 3 ICS TH TRICUSPID AREA-4 / 5TH ICS TH MITRAL AREA – 5 ICS , LEFT MCL TH PMI-5 ICS MCL –(INFANTS-LATERAL TO LEFT NIPPLE-4TH ICS) S1LUBB-CLOSURE OFAV VALVES S2DUBB-CLOSURE OF SEMILUNAR VALVES MURMURS , GALLOP-ABNORMAL HEART SOUNDS
PERIPHERAL VASCULAR SYSTEM
ASSESS PAIN,PALLOR,PARALYSIS,PARESTHESIASAND PULSES. ASSESS HOMAN’S SIGN PULSE DEFICIT
BREASTS
START – UPPER OUTER CLOCKWISE ASSESS FOR SIZE,SHAPE,SYMMETRY AND NODES
ABDOMEN
DORSAL RECUMBENT INSPECT,AUSCULTATE,PERCUSS AND PALPATE BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 5-25/MIN NORMAL) IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS. MORE. SEQUENCE IS CLOCKWISE FROM RLQ
HYPOACTIVE < 3 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT TINKLING SOUND – BOWEL OBSTRUCTION
ABDOMEN
REBOUND TENDERNESS- INFLAMMATION OF PERITONEUM
KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLE
KIDNEY PUNCH TEST
MUSCULOSKELETAL SYSTEM
MUSCLE TONE AND STRENGTH
0=COMPLETE PARALYSIS 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT 3=50% - NORMAL MOVEMENT AGAINST GRAVITY 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE 5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE
JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS ARE ABNORMAL FASCICULATION ABNORMAL CONTRACTIONS AND SHORTENING OF MUSCLE FIBERS TREMOR-INVOLUNTARY TREMBLING TEST FOR ROM AND ASSESS FOR ATROPHY/HYPERTROPHY/CONTRACTURES
NEUROLOGIC TESTS
MENTAL STATUS-
LANGUAGE-CEREBRAL CORTEX-APHASIA ORIENTATION(TIME,PLACE,PERSON)(CONFUSION) MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY ATTENTION SPAN AND CALCULATION JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL VIEWS PERCEPTION – SENSORY ANALYSIS AND INTEGRATION
CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING MOVEMENTS,GAIT CRANIAL NERVE FUNCTIONS SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSERHOMBERG’S TEST)
NEUROLOGIC TESTS
DEEP TENDON REFLEX
0-NO REFLEX +1 – MINIMAL ACTIVITY(HYPOACTIVE) +2 – NORMAL RESPONSE +3 – MORE ACTIVE THAN NORMAL +4 – MAXIMUM ACTIVITY ( HYPERACTIVE)
PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY
LEVEL OF CONSCIOUSNESS
GLASGOW COMA SCALE=15 POINTS, 7 COMA
EYE OPENING
SPONTANEOUS=4 TO VERBAL COMMAND=3 TO PAIN=2 NO RESPONSE=1
MOTOR RESPONSE
TO VERBAL COMMAND=6 TO PAINFUL STIMULI/LOCALIZES PAIN=5 FLEXES AND WITHDRAWS=4 DECORTICATE=3 DECEREBRATE=2 NO RESPONSE=1
VERBAL RESPONSE
ORIENTED,CONVERSES=5 DISORIENTED,CONVERSES=4 USES INAPPROPRIATE WORDS=3 USES INCOMPREHENSIBLE SOUNDS=2 NO RESPONSE=1
ASSESSING MOTOR FUNCTION
WALKING GAITS
ROMBERGS TEST- STAND FEET TOGETHER ARMS RESTING AT THE SIDES,EYES OPEN THEN CLOSED. NEG. ROMBERG – MAY SWAY BUT KEEPS BALANCE.
SENSORY ATAXIA-CANNOT BALANCE EYES SHUT CEREBELLAR ATAXIA-CANNOT BALANCE EYES SHUT OR EPON
HEEL-TOE WALKING AND VICE VERSA FINGER TO NOSE TEST AND OTHER SENSORY FUNCTION TEST (ONE AND TWO POINT DISCRIMINATION) EXTINCTION PHENOMENON-SYMMETRICAL AREAS ARE TOUCHED BUT SENSATION ON ONE SIDE CANNOT BE FELT INDICATES LESIONS OF SENSORY CORTEX
GENITALIA , ANUS AND RECTUM
ASSESS APPEARANCE AND ORIFICES AND INGUINAL LYMPH NODES INSPECT CERVICAL OS AND VAGINA-SPECULUM DEVIATIONS
CYSTOCELE, RECTOCELE,ENTEROCELE HYPO AND EPISPADIAS-URETHRAL OPENING DISPLACED HERNIAS-DIRECT,INDIRECT , FEMORAL INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE
DIGITAL RECTAL EXAM –INSPECTION AND PALPATION –POSITION BOTH=SIM’S , FEMALES – LITHOTOMY;MALES =STAND AND BEND FORWARD PROSTATE GLAND-4 CM ;CERVIX = 2-3 CM HEMORRHOIDS =DILATED VEINS
STRESS , ANXIETY AND CRISIS SELF- AWARENESS
SELF CONCEPT – COLLECTION OF FEELING BELIEFS ABOUT ONE’S SELF SELF ESTEEM – CONFIDENCE IN ONE’S ABILITIES AND JUDGEMENT
ASSERTIVENESS
+ SELF - EVALUATION
STRESS
GAS – ALARM-RESISTANCE-EXHAUSTION COPING AND STRESS MANAGEMENT
ANXIETY-
MILD – SLIGHT AROUSAL AND INCREASED PERCEPTION MODERATE-INC. TENSION AND SELECTIVE INATT. SEVERE – DEC. PERCEPTION AND FOCUSSED ENERGY PANIC – OVERPOWERING AND LOSS OF CONTROL
STRESS MANAGEMENT
RELAXATION TECHNIQUES
RELAXATION BREATHING PROGRESSIVE MUSCLE SETTING AUTOGENIC TRAINING(SELF-SUGGESTIONS) IMAGERY(MENTAL VACATION) DISTRACTION
GRIEF AND LOSS Loss is a universal experience that occurs throughout life span Grief is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement Responses to loss are strongly influenced by one’s cultural background The grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss. Responses to loss and patterns of coping with loss are developed early in life.
Stages of Grieving (Kubler-Ross) Denial- refuses to believe that the loss has occurred Anger- the individual resists the loss and may “act out” feelings. Bargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss. Depression- overwhelming feeling of loneliness and withdrawal from others Acceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, and the interaction to other people resumed.
LOSS ,GRIEVING AND DEATH
DEATH CONCEPTS
1-5Y.O – IMMOBILITY AND INACTIVITY Wishes and unrelated action responsible for action 5-10 – final but can be avoided 9-12 – understands own mortality and fears death 12 – 18 – fears and fantasizes avoidance 18-45 – increased attitude awareness 45-65 – accepts mortality Above 65 – multiple meanings, encounters and fears
KUBLER ROSS – STAGES OF GRIEF
D – SUPPORTIVE
A- PROVIDE STRUCTURE AND CONTINUITY
B – LISTEN AND ENCOURAGE
D- ALLOW EXPRESSION AND PROVIDE FOR SAFETY
A- ENCOURAGE PARTICIPATION
CONCEPTS
6 MOS – 2 YEARS PROVISION OF DIGNIFIED PAIN FREE DEATH( QUEST. ANSWERED AND EMT. SUPPORT) DNR- COMFORT AND HYGIENE NEEDS ON-GOING CURE GOALS ----- COMFORT GOALS
CONCEPTS
HINDU – REINCARNATION , AUTOPSY , ORGAN DONATION, CREMATION ISLAM – NO TO ORGAN DONATION , CREMATION AND AUTOPSY …..CONFESS AND TURN TO MECCA JUDAISM – WASHED NATIVE AMERICAN – NOT TO AUTOPSY BUDDIST – OK – EUTHANASIA AND WITH LAST RITES
SAFETY AND INFECTION CONTROL
PROTECTING HEALTH
NON – SPECIFIC AND SPECIFIC CHAIN OF INFECTION
UNIVERSAL PRECAUTION PRINCIPLES OF SURGICAL ASEPSIS INFECTION CONTROL MEASURES
ISOLATION – CATEGORY SPECIFIC AND DISEASE SPECIFIC MEDICAL AND SURGICAL ASEPSIS
Universal Precautions
Strict Isolation-highly transmissible diseases by direct contact and airborne routes of transmission
Private room,gowns, mask , gloves, handwashing,double bagged techniques for soiled articles
Diptheria(pharyngeal),Herpes Zoster, Varicella , Pneumonia( S.Aureus , Strep,group A)
Universal Precautions
Respiratory Isolation-droplet transmission(3 feet)
Private rom,patient w/ same organism,mask,handwashing,labelled plastic bags for soiled articles
H. influenza, measles, mumps, N. Meningitidis
Universal Precautions
Tuberculosis/ AFB isolation-suspected / active TB
Private room with negative pressureventilation so that air room is vented outside, mask, handwashing, bronchoscopy and dental examination postponed until 2 weeks of antibiotic therapy
Tuberculosis
Universal Precautions
Contact Isolation – infectious disseases or multiple resistant microorganisms that are spread by direct contact or close contact
Private room , mask gown , gloves
diptheria( cutaneous), Herpes simplex, MRSA , Pediculosis , Scabies , Syphilis
Universal Precautions
Enteric Precautions – infectious diseases transmitted through direct or indirect contact with infected feces.
Handwashing , gloves , gowns worn only when handling contaminated objects with feces
Aseptic meningitis, AGE , Hepa A , Typhoid fever, diarrhea (CDT )
Universal Precautions
Drainage / Secretions precautions – patients with wound drainage or infected wounds
Gloves, gowns indicated if clothing is likely to be contaminated
Burns
Universal Precautions
Universal Blood and Body fluids precautions – blood borne , body fluids pathogens ( blood , semen , vaginal secretions , CSF , synovial fluid , pleural fluid , peritoneal fluid , pericardial fluid , amniotic fluid and tissues.
Gloves , mask, protective eyegears, gown , contaminated needles not recapped and sharps in puncture resistant containers
Aids , Hepatitis B and C , STD’s
Reverse Isolation
Patient is protected from pathogens and nosocomial infections by instituting reversed transmission precautions
Burns and open wounds, patients with artificial airway , immunocompromised patients – leukemia , AIDS , steroid therapy , radiation or cancer chemotherapy , medication effect of leukopenia or agranulocytosis
Infectious agents- pathogens (bacteria, fungi, virus, protozoa) ReservoirsReservoirs- sources or places for growth of the pathogens Portal of Exit and EntryEntry- provides the way for the pathogen to leave one host and enter another host Modes of transmissiontransmission- vehicles of transmission of the pathogens Susceptible HostHost- a carrier capable of supporting and transmitting microorganism
Body Defenses Against Infection
Normal Flora
Intact Skin Saliva and Mucus Membrane Cilia of the Upper Respiratory Tract Infection Inflammatory process Immune Response
Medical Asepsis/ Clean Technique Principles: Pathogens move through spaces or air current Pathogens are transferred from one surface to another whenever objects touch. Hand washing removes microorganism Pathogens are released into the air on droplet nuclei when person speaks, breaths, and sneeze. Pathogens are transferred by virtue of gravity Pathogens move slowly on dry surface but very quickly through moisture.
Surgical Asepsis/ Sterile Technique Areas of the body considered sterile are:
Blood stream Spinal Fluid Peritoneal Cavity Urinary Tract Muscles Bones Chamber of the Eyes
Sterile object remains sterile when touched by another sterile object Sterile objects or fields, which falls out of the range of vision or below one’s waist, are considered contaminated. Sterile items become contaminated when they come in contact with microorganism transported through the air. When sterile object/ field come in contact with another surface, it becomes contaminated. Fluids flows in the direction of gravity. The edges of the sterile field are considered unsterile.
Isolation Practices Strict Isolation- prevents transmission of highly communicable disease by contact and airborne transmission Respiratory isolation- prevents transmission by droplet Enteric precaution- prevents transmission through ingestion Wound and skin precaution- prevents cross-infection by direct contact with wounds and contaminated articles Discharge precaution- prevent cross-infection by secretions-contaminated articles Blood precaution- prevent transmission by contact with blood or items contaminated with blood
COMFORT AND PAIN *COMFORT AND PAIN
PQRST AND QUEST PHARMACOLOGICAL Tx PAIN GATEWAY CONTROL THEORY PLAN AND PREVENT INJURY/HARM PROVIDE ALTERNATIVE MEASURES PROPHYLACTIC/PREVENTIVE PCA PREFERENCE AND PARTICIPATION
Pain The noxious stimilation of threatened or actual tissue damage (Geach, 1987) Whatever the experiencing person says it is, existing whenever he or she says it does (McCaferry, 1979) It is highly subjective and individual and that is one of the body’s defense mechanism indicating that there is a problem. It is protective as it gives warning or signal for tissue injury
Assessment of Pain Precipitating Factors- “ What triggers the pain or makes it worse?” Quality of Pain- “Tell me what the pain feels like” Alleviating Factors- “What measures relieve your pain” Meaning of pain- “ How do you interpret the pain?”
Pattern Location Pain- “Where is your pain” Periodicity- “How long have you felt the pain sensation?”
REST AND SLEEP *REST AND SLEEP
REM – DREAM PARADOXICAL SLEEP PRIMARY AND SECONDARY SLEEP DISORDERS
RESTFUL ENVT. RITUALS RELAXATION RELEVANT MEDS AND RELATED THERAPY & NON PHARMACOLOGIC Tx RECORD ASSESSMENTS AND HISTORY
Stages of Sleep: Non-Rapid Eye Movement (NREM)- for body restoration
Very Light Sleep- drowsy, and readily awakened Light Sleep- Heart and respiratory rate decreases and the body temperature gradually falls. PNS domination- Difficult to arouse Deep Sleep- Decrease metabolism and very difficult to arouse
Rapid Eye movement (REM)- increase synthetic processes of the brain Paradoxical Sleep Dream state of the sleep Close to wakefulness but difficult to arouse
Common Sleep Disorders Insomia- sleeplessness Hypersomia- Excessive sleep at day time Narcolepsy- Sleep attack Parasomias
Somnambolism- sleep walking Soliloqy- Sleep talking Bruxism- clenching and grinding of teeth Night Terrors- bad dreams Nocturnal Erections- wet dreams
Nocturnal Enuresis - BEDWETTING
SAFETY Rest is the diminished state of activity Sleep is a state of decreased perception and reaction to the environment There are theories of sleep:
Active theory- there are parts of the brain that inhibit other brain parts Passive theory- the reticular activating system of the brain fatigues and becomes depressed, thus sleeps occurs
*SAFETY
TRIAGE DISASTER MANAGEMENT -=A,B,C
P REVENT ABSORPTION O FF AND OUT I DENTIFY S UPPORT AND SUPPLY ANTIDOTE O NGOING MONITORING N OTIFY
POISONING CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL THE NURSE SHOULD INTERVENE IF A MOTHER OF A VICTIM OF POISONING VERBALIZES TO DO THE FOLLOWING:
PLANS TO INDUCE VOMITING FOR PATIENT WITH ASPIRIN POISONING
PLANS TO INDUCE VOMITING WHEN SHE IS CERTAIN THAT HER CHILD’S GAG REFLEX AND LOC ARE INTACT WILL NOT GIVE IPECAC IF CHILD IS EXHIBITING NARROWED PULSE PRESSURE WILL WAIT FOR THE SEIZURE TO END BEFORE ADMINISTERING IPECAC
CONTRAINDICATIONS OF IPECAC / INDUCTION OF VOMITING
SEIZURE SUBNORMAL LOC AND GAG REFLEX SUBSTANCE CORROSIVE/PETROLEUM DISTILATE SHOCK-SEVERE
DISASTER PLANNING
TRIAGE-GREATEST GOOD FOR THE GREATEST NUMBER OF PEOPLE PRINCIPLES- ABCD , MASLOWS
RED-UNSTABLE – IMMEDIATE CARE YELLOW- STABLE – CAN WAIT 30-60 MIN GREEN –STABLE- CAN WAIT LONGER BLACK- UNSTABLE – FATAL, LAST SEEN DOA – SUPPORTIVE COMFORT MEASURES
DURING FIRE WHICH SET OF PATIENTS WILL THE NURSE MOBILIZE FIRST
AMBULATORY BEDRIDDEN CRITICAL TERMINAL
WHICH STEP IN FIRE MANAGEMENT COMES LAST?
ALARM CONTAIN MOBILIZE EXTINGUISH
READ ENSURE SUPERVISION LOCK AVOID TRANSFERING TEACH AND EDUCATE MANAGEMENT IPECAC ACTIVATED CHARCOAL H2O OR MILK NA SO4 SPECIFIC ANTIDOTE OR ANTAGONIST
POISONING CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL
SAFETY
FALLS(RAT) RISK ASSESSMENT TOOL
ALTERATION IN SENSATION AND PERCEPTION AWARENESS LEVEL ABILITY TO COMMUNICATE ALTERED GAIT AND POSTURE AMBULATION NEEDS ANXIETY AND EMOTIONAL STATE ASSOCIATED INJURY AND DISEASE ACCESS(LIFESTYLE)
BEDSIDE SAFETY/EMERGENCY MATERIALS / EQUIPMENTS
AMPUTATION – TOURNIQUET AUTONOMIS HYPERREFLEXIA – CATHETER
CHEST TUBE DRAINAGE- EXTRA BOTTLE- FORCEPS – VASELINIZED GAUZE CHOLINERGIC AND MYASTHENIC CRISIS – ENDOTRACHEAL TUBE / TRACHEOSTOMY SET EPIGLOTITIS - ENDOTRACHEAL TUBE / TRACHEOSTOMY SET PIH – PADDED MOUTH GAG PARKINSONS – SUCTION APPARATUS
BEDSIDE SAFETY/EMERGENCY MATERIALS / EQUIPMENTS
RADIUM IMPLANT – LEAD CONTAINER , FORCEPS SENGSTAKEN BLAKEMORE TUBE – SCISSORS SCI AND THYROIDECTOMY – TRACHEOSTOMY TONSILLECTOMY – FLASHLIGHT TRACHEOSTOMY TUBE – OBTURATOR , HEMOSTAT
PREVENTION OF FALLS
L IGHTING L OWER BED POSITION L OCATE GRAB BARS AND CALL BELL S UFFICIENT ORIENTATION S IDERAILS S UPERVISE AND ORIENT
RESTRAINTS
ASSIST FREQUENTLY ASSIGN HEALTH CARE PROCEDURES IN PAIRS AREA SUPERVISION ADIMINISTRATION ADJUSTMENTS ALLOW ROCKER CHAIR AND FREQUENT WALKS APPLY PILLOW,WEDGE , PADS AND PROPER POSITIONING ALLEVIATE AGITATION ASSESS AND MONITOR
RESTRAINTS-(HALF BOW KNOT/CLOVE HITCH,SQUARE OR REEF KNOT)
LIMB MUMMY ELBOW MITT OR HAND JACKET BELT OR SAFETY STRAP
CONFUSED AND COMBATIVE
CONTROL IMMEDIATE SITUATION OUT OF AREA MAINTAIN CALM BE FIRM AND SET LIMITS ALTERNATIVE TO RESTRAINTS,ASSESS AND ASSIST TRY POSITIVE CONSEQUENCES
HYGIENE *HYGIENE AND COMFORT
INFANT BATHING COMPLETE ADULT BED BATH TUB BATH THERAPEUTIC
SALINE OATMEAL CORNSTARCH NACHO3 KMnO4
HYGIENE AND COMFORT
PERINEAL / GENITAL CARE FOOT AND NAIL CARE HAIR CARE ORAL CARE BEDMAKING
PRESSURE ULCER
GRADING PREVENTION TREATMENT
ACTIVITY AND EXERCISE *ACTIVITY AND EXERCISE
ERGONOMICS
TYPES AND PRINCIPLES
ROM AND ISOMETRICS
PROBLEMS OF IMMOBILITY AND NURSING INTERVENTIONS
ACTIVITY ORDERS
*MOBILITY AND IMMOBILTY
POSITIONING MOVING AND LIFTING
AMBULATION AMBULATION AIDS
TRANSFERS TRANSFER AIDS
THERAPEUTIC EXERCISES
PASSIVE ROM-RETENTION OF ROM AND MAINTENANCE OF CIRCULATION ASSISTIVE- INCREASES MOTION , MAINTAINS MUSCLE TONE ACTIVE – MAINTAINS MOBILITY OF THE JOINT AND MAINTAINS MUSCLE STRENGTH RESISTIVE – INCREASES MUSCLE POWER ISOMETRICS- MAINTENANCE OF STRENGTH AND PREVENTS MUSCULAR ATROPHY
POSITIONING FOR SPECIAL CONDITIONS
ABDOMINAL ANEURYSM SURGERY-FOWLERS
ASTHMA – ORTHOPNEIC POSITION AUTNOMIC DYSREFLEXIA-HIGH FOWLERS POST BRONCHOSCOPY-SEMI FOWLERS
CARDIAC CATHETERIZATION-KEEP INSETION SITE EXTENDED FOR 4-6 HOURS TO PREVENT ARTERIAL OCCLUSION CAST – ELEVATE EXTREMITY CATARACT – SEMI FOWLERS CEREBRAL ANEURYSM – SEMI - FOWLERS
POSITIONING FOR SPECIAL CONDITIONS
CLEFT LIP – SUPINE CLEFT PALATE – PRONE CHF – HIGH FOWLERS CRANIOTOMY – SUPRATENTORIAL – SEMI FOWLERS ;INFRATENTORIAL – FLAT ICP – LEVATE HEAD DUMPING SYNDROME – SUPINE AFTER MEALS EPISTAXIS – LEAN FORWARD FLAIL CHEST – AFFECTED SIDE FEMORO-POPLITEAL BYPASS GRAFT – AFFECTED EXTREMITY EXTENDED
POSITIONING FOR SPECIAL CONDITIONS
GLAUCOMA(POST OP) – AFFECTED SIDE HEMORROIDECTOMY – SIDE LYING HIATAL HERNIA- UPRIGHT HIP SURGERY – LEGS IN ABDUCTION LAMINECTOMY – BACK AS STRAIGHT AS POSSIBLE LIVER BIOPSY – RIGHT SIDE LYING LOBECTOMY – SEMI FOWLERS POST LP – FLAT MASTECTOMY – ELEVATE EXTREMITY ON PILLOW MYELOGRAM – WATER BASED DYE – ELEVATE THE HEAD --- OIL BASED DYE - FLAT
POSITIONING FOR SPECIAL CONDITIONS
POSTURAL DRAINAGE – LUNG SEGMENT – UPPERMOST POSITION PROLAPSED CORD – KNEE-CHEST PULMONARY EDEMA – FOWLERS PYLORIC STENOSIS – RIGHT SIDE LYING RADIUM IMPLANT – FLAT ON BED RETINAL DETACHMENT – AFFECTED SIDE TOWARDS THE BED
POSITIONING FOR SPECIAL CONDITIONS
SEIZURE – SIDE-LYING
SHOCK – MODIFIED TRENDELENBURG SCI – IMMOBILIZE TONSILLECTOMY – SIDELYING / PRONE THYROIDECTOME – SEMI – FOWLERS THROMBOPHLEBITIS – ELEVATE LEG TPN – TRENDELENBURG – DURING INSERTION THORACENTESIS – FOWLER’S(DURING)
AFTER – POSITION OF COMFORT
MOBILITY AND IMMOBILITY
POSTURE AND BODY ALIGNMENT-ERECT JOINT MOVEMENTS=RANGE OF MOTION CONNECTIVE TISSUE
BONE TO BONE-LIGAMENT BONE TO MUSCLE – TENDON COVERS BONES/JOINTS - CARTILAGE
TYPES OF JOINT
SYNARTHROSES(CARTILAGENOUS) DIARTHROSES( SYNOVIAL) AMPIARTHROSES(FIBROUS)
ERGONOMICS-BODY POSITIONING AND MECHANICS
PRIORITY-ASSESS PERSONAL CAPACITY 1ST USE PROTECTIVE DEVICES/ TRANSFER AIDS CHANGE POSITION SLOWLY-ORTHOSTATIC HYPOTENSION(DANGLE LEGS FIRST) PIVOT ON THE STRONGER SIDE,MOVE PNT TOWARDS STRONGER SIDE USE LARGER MUSCLES OF THE BODY AND FACE THE DIRECTION OF THE MOVEMENT PULL SHEETS ARE BETTER METHOD THAN SLIDING ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE AN ASSISTANT STANDING BY. ROCK FROM FRONT TO BACK/VICE VERSA.WIDE BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF THE BODY.USE APPROPRIATE TRANSFER AND AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE BOARD, DRAW SHEET AND TRANSFER BELT
DANGERS OF IMMOBILITY
DECUBITUS ULCER-OSTEOMYELITIS OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND RENAL CALCULI INCREASED CARDIAC WORKLOAD- TACHYCARDIA CONTRACTURES- DEFORMITIES THROMBUS FORMATION-PULMONARY EMBOLISM ORTHOSTATIC HYPOTENSION-WEAKNESS,FAINTNESS AND DIZZINESS RESPIRATORY STASIS – HYPOSTATIC PNEUMONIA
CONSTIPATION – FECAL IMPACTION URINARY STASIS-URINARY RETENTION NEGATIVE NITROGEN BALANCE-WEIGHT LOSS/DEBILITATION
SPECIFIC THERAPEUTIC POSITION
HIGH FOWLERS-60-90’ FOWLER-45-60’ SEMI-FOWLERS-30-45’ LOW-FOWLERS-15-30’ SUPINE DORSAL RECUMBENT LITHOTOMY TRENDELENBURG SIMS LATERAL MODIFIED TRENDELENBURG PRONE KNEE-CHEST SIDE-LATERAL ORTHOPNEIC
CRUTCHES
ASSISTIVE DEVICES
CRUTCH HEIGHT-
STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 CM
TEACH MUSCLE STRENGTHENING EXERCISES PRIOR TO AMBULATION.WEIGHT ON THE HAND GRIP (TO AVOID CRUTCH PALSY) ELBOWS SHOULD BE FLEXED 20-30’ AND CRUTCHES SHOULD BE KEPT 6 INCHES LATERALLY AND 6 INCHES TO THE FRONT=TRIPOD POSITION(810 INCHES-OK) INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTURE
CRUTCH WALKING GAITS
FOUR POINT-SLOW SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS TWO POINT- FASTER SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS THREE-POINT-NON WEIGHT BEARING OF ONE LEG SWINGTO/SWINGTHROUGH-PARTIAL WEIGHT BEARING ALLOWED FOR BOTH LEGS GETTING INTO A CHAIR –BOTH CRUCHES TO THE WEAK SIDE , STRONGER ARM HOLDS THE ARMREST ST GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1 AND BAD GOES ST DOWN 1 .
WALKERPROVIDES STABILITY AND BALANCE MOVE WALKER AHEAD 15 CM (6INCHES-8-10 INCHES)WHILE WEIGHT IS BORNE BY BOTH LEGS.THEN ALTERNATE WEIGHT BEARING ASSISTED BY THE ARMS ELBOWS SHOULD BE FLEXED-20-30’ IF ONE LEG IS WEAKER MOVE THAT LEG TOGETHER WITH THE WALKER
CANE HOLD CANE ON THE STRONGER SIDE FLEX ELBOW 30’ AND TIP OF CANE 15 CM LATERAL TO THE SIDE OF THE 5TH TOE. ADVANCE CANE AND AFFECTED LEG ,WEIGHT ON CANE WHEN MOVING THE GOOD LEG BUT FOR MAXIMUM SUPPORT ADVANCE CANE 1 FEET ,MOVE AFFECTED LEG THEN THE STRONGER LEG GOING UP AND DOWN THE STAIRS –SAME WITH CRUTCHES
*NUTRITION *NUTRITION
PREMATURE INFANTS-LESS THAN37WKS/2,500G-100-200 CAL/KG/DAY AND HIGHER Na,Ca AND CHON FULL TERM-120 CAL/KG/DAY PREGNANCY + 300CAL/DAY LACTATION+ 500CAL/DAY
CONDITIONS
ENTERAL FEEDINGS
PREOPERATIVE NEED FOR NUTRITIONAL SUPPORT GI PROBLEMS ONCOLOGY THERAPY ALCOHOLISM,CHRONIC DEPRESSION AND EATING DISORDERS HEAD,NECK DISORDERS OR SURGERY
COMPLICATIONS
ASPIRATIONTUBE DISPLACEMENT CRAMPING,VOMITING,DIARRHEA HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE INTOLERANCE
NUTRITION
SPECIFIC NUTRIENT MODIFICATION CALORIC MODIFICATION CONSISTENCY
SPECIAL DIETS FOR SPECIFIC DISEASES DIETARY MODIFICATIONS FOR SPECIAL CONDITIONS
NUTRIENT MODIFICATION
INCREASE,DECREASE,RESTRICTED
CA,K,NA,Fe,FOLIC ACID,VIT C&B COM.,ADEK, CHOLESTEROL,GLUTEIN FIBER, PHENYLALAMINE,TYRAMINE CHO,FATS/LIPIDS,CHON
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
AGE – CLEAR LIQUID AGN – LOW NA , LOW CHON ADDISON’S – HIGH NA , LOW K ANEMIA , PERNICIOUS – HIGH CHON , VIT. B. ANEMIA SICKLE CELL – HIGH FLUID GOUT – PURINE RESTRICTED ADHD AND BIPOLAR – FINGER FOODS BURN – HIGH CAL. HIGH CHON CELIAC – GLUTEIN FREE CHOLECYSTITIS – HIGH CHON, HIGH CARB, LOW FAT CHF – LOW NA , LOW CHOL. CROHNS – HIGH CHON AND CHO, LOW FAT
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
CYSTIC FIBROSIS – HIGH CAL., HIGH NA LITHIASIS----ACID ASH FOR ALK. STONES------ALK. ASH FOR ACID STONES DECUBITUS ULCERS – HIGH CHON , HIGH VIT C DIARRHEA – HIGH K AND NA DUMPING SYNDROME – HIGH FAT, HIGH CHON,DRY HEPATIC ENCEPHALOPATHY-LOW CHON HEPATITIS – HIGH CHON,HIGH CAL.
HIRSPRUNGS – LOW RESIDUE, HIGH CHON AND CHO CIRRHOSIS – LOW CHON MENIERE’S LOW NA MI AND HPN – LOW CHOL.,FATS,NA HYPERTHYROIDISM- HIGH CAL. AND CHON HYPOTHYROIDISM – LOW CAL. , LOW CHOL, LOW SAT. FAT
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
NEPHROTIC SYNDROME – LOW NA, HIGH CHON , HIGH CAL. HYPERPARATHYROIDISM – LOW CALCIUM HYPOPARATHYROIDISM – HIGH CA, LOW PHOSPHORUS OSTEOPOROSIS – HIGH CALCIUM AND HIGH VIT. D PANCREATITIS – LOW FAT PUD – HIGH FAT, HIGH CARB. LOW CHON PKU – LOW CHON / PHENYLALANINE PIH – HIGH CHON
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
RENAL FAILURE (ACUTE) – LOW CHON,HIGH CARB
LOW NA (OLIGURIC PHASE) HIGH CHON , HIGH CAL AND RESTRICTED FLUID (DIURETIC PHASE
RENAL FAILURE (Chronic) – LOW CHON , LOW NA , LOW K
TOTAL PARENTERAL NUTRITION
TYPES OF SOLUTIONS
TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE BACTERIAL FILTER USED TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID, DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTER
PERIPHERAL=NO >10% DEXTROSE AND 2 WKS ONLY CENTRAL – INCOMPATIBLE WITH MEDS AND BLOOD IF SINGLE LUMEN USED ATRIAL-HICKMAN/BIOVAC AND GROSHONG- HUBBER NEEDLE USED TO ACCESS PORT THROUGH SKIN
TPN
INITIAL RATE OF INFUSION 50 ML/HR THEN 100-125/HR. COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS, PNEUMOTHORAX
FAST RATE=HYPEROSMOLAR STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS) SLOWED RATE=REBOUND HYPOGLYCEMIA
X-RAY CONFIRMS PLACEMENT ATTACH TO PUMP
IV TUBING AND FILTER CHANGED Q24 HOURS ALLOW SOLUTION TO WARM IMMEDIATELY BEFORE USE IF NO SOLUTION USE DEXTROSE 10% W SOLUTION
CHECK DAILY CBG,WEIGHT,TEMP. I AND O , CHECK 3X A WEEK BUN, ELECT, ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND PT,PTT
*ELIMINATION BOWEL ELIMINATION
TOILET TRAINING
FACTORS AFFECTING
PROBLEMS MANAGEMENT-CATHARTICS , ENEMA , SURGERY
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
ENEMA COLOSTOMY/ILEOSTOMY,OTHER SURGERIES BARIUM STUDIES SCOPIC EXAMS ROENTOLOGIC EXAMS
ENEMA They act by distending the intestines that increases peristalsis and expulsion of feces and flatus. Enemas serve the following purpose:
Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications
ENEMA
Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches Position: adult- left lateral; infants and children- dorsal recumbent
Administration- administer the enema in a minimum of 15 minutes duration. Conatainer’s Height- 12 inches above the rectum Temperature- 42°C or less
OSTOMIES
PERMANENT/TEMPORARY STOMA RED AND SLIGHT BLEEDING WHEN TOUCHEDBURNING SENSATION UNDER FACEPLATE INDICATES SKIN BREAKDOWN,REFER ABDL DISTENTION/DISCOMFORT, KARAYA POWDER(DEC.IRRITATION), CHARCOAL/BISMUTH CARBONATEDEODORIZER APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-72H AND 24-48H IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODED ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODOR COLOSTOMY-FORMED , CAN BE IRRIGATED 300-500ML AND REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCE
URINARY ELIMATION
BLADDER TRAINING
LABS AND DIAGNOSTIC TESTS
CONDITIONS
CATHETERIZATION AND IRRIGATIONS
URINARY ELIMINATION
BUN – 10-20 MG/DL CREA – 0.7 – 1.4 MG/DL 24 HOUR URINE PRODUCTION-1000-1500CC
ANURIA<100ML/24H OLIGURIA< 400 ML/24H POLYURIA > 2000 ML/24H
KEGELS –STRENGTHEN MUSCLES OF THE PELVIC FLOOR-TIGHTEN FOR 3 SECS THEN RELAX FOR 3 SECS PERFORM LYING DOWN, SITTING AND STANDING FOR TOTAL OF 45 BLADDER RETRAINING
INTERMITTENT CATHETERIZATION AFTER ATTEMPTING TO VOID Q 2-3H, TIME INCREASES GRADUALLY BUT NO MORE THAN 8 HOURS BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H THEN ATTEMP TO VOID 30 MINS LATER-TIME GRADUALLY INCREASED TRIGGERING TECHNIQUES-CREDES MANEUVER AND VALSALVA CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE TO VOID 3-4 HOURS AFETR REMOVAL
HEMODIALYSIS
DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS
PERITONEAL DIALYSIS
TENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES: CAPD(4-6H INDWELLING),AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING
OXYGENATION OXYGENATION
PULMONARY FUNCTION TESTS DIAGNOSTIC LABORATORIES(ABG, SPUTUM CS AND THROAT CULTURE) VISUALIZATION AUSCULTATION
OXYGEN DELIVERY EQUIPMENT CHEST PHYSIOTHERAPY ARTIFICIAL AIRWAYS THORACOCENTESIS,THORACOSTOMY.TRACHEOSTOMY AND ET INTUBATION SUCTIONING CHEST TUBES AND DRAINAGE SYSTEMS
CHEST PHYSIOTHERAPY
TURNING COUGHING DEEP BREATHING POSTURAL DRAINANGE PERCUSSION AND VIBRATION INCENTIVE SPIROMETRY SUCTIONING TRACHEOSTOMY CARE OXYGEN THERAPY VENTILATOR CARE AND MANAGEMENT
Chest Physiotherapy It is the combination of percussion, vibration, and postural drainage Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes Vibration is done during 5 exhalations Postural drainage is done for 15-20 minutes usually performed 3-4 times a day. Instruct the client to increase fluid intake to liquefy secretions This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery. This procedure is done before meal or 90 minutes after a meal
Oxygen Therapy Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen. Humidify the oxygen first before you administer. Check for bubbles in the humidifier to promote adequate flow of oxygen Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: “NO smoking: Oxygen is in used” Instruct the client not to use woolen blankets as this may create static electricity
pulmonary function tests
tidal volume- 500 residual volume- 1200 expiratory reserve volume –1200 inspiratory reserve volume – 3100
Vital Capacity- tidal volume + IRV + ERV = 4800 Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000
Forced Residual Capacity – ERV + RV
incentive spirometry – hold 2-6 sec; 4-5 times/H (TO MAXIMIZE RESP.&MOBILIZE SECRETIONS endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly visualization –
X ray Lung Scxan – 20-40mins isotopes in body for 8 H laryngoscopy Bronchoscopy Thoracentesis- consent, VS and baseline X-ray + post Procedural
Tracheostomy Care
tie new trache tie before removing the old tie to prevent accidental dislodgement.ALLOW 2 FINGERS TO BE INSERTED UNDER TIE use precut gauze and perform care OD at least. soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well suction prn, oral care prn(PROCEDURE DONE q8h AND PRN)
Oxygen Delivery Equipment
cannula – 2-6 LPM – 24-45% Mask – 5-8 LPM – 40-60% parial rebreather – 6-10 LPM – 60-90% non rebreather – 10-15 LPM – 95-100% tent – 4-8 LPM – 30-50 % Venturi mask –
2-3 LPM – 24-28% 4 LPM – 30% 6 LPM – 35% 8 LPM – 45% 14LPM – 55%
Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT: ASSESS BREATH SOUNDS
Hyperoxygenate the patient before and after the procedure. Apply intermittent suction on withdrawal of the catheter. Do not suction the patient for more than 15 seconds. IDEAL 10 SECS
Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space. space. NURSING ALERT: Check the consent. Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder. Instruct the patient not to cough, breath deeply or move during the procedure. After the procedure: Position the patient on the unaffected side/puncture site up. Check for bleeding at the puncture site and monitor the respiratory function. Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.
*PERI-OPERATIVE NURSING PREOP CARE
INFANT-DISTRACT TODDLER-ALLOW REGRESSION AND INVOLVE PARENTS,CONSISTENT CAREGIVER PRE-SCHOOL-LET CHILD HANDLE EQUIPMENT,EXPRESSION OF FEELINGS THROUGH PLAY DEMOFAMILIAR SORROUNDINGS SCHOOL AGE- EXPLAIN SIMPLY AND ALLOW CHOICES ADOLESCENTS- INVOLVE AND POINT OUT STRENGTHS AND BENEFITS,EXPECT RESISTANCE
PREOP CHECKLIST
CONSENT HEALTH TEACHING (SPEC. POST OP PROCEDURES) LAB TESTS,ECG,X-RAY SKIN PREP BOWEL PREP IV’S NPO PREOP MEDS,SEDATION AND ANTIBIOTICS REMOVAL OF DENTURES,NAILPOLISH AND JEWELRY NUTRITION-TPN OR ENTERAL FEEDINGS PREOP
INTRAOP- MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT STATUS,, APPROPRIATE GROUNDING DEVICES, FLUID BALANCE AND SPONGE/INSTRUMENT COUNT POST OP- MONITOR VS Q15X4;Q30X2;Q1HX2 THEN PRN MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC RESPIRATORY PHYSIOTHERAPY,TCBD INCENTIVE SPIROMETRY-20 SECS INHALATION ENCOURAGE AMBUALTION REFER IF UNABLE TO VOID IN 8 HOURS APPLY TED HOSE AND PNEUMATIC COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGN
WOUNDS NOTE DRESSING AND INCISION FEVER 1-2 DAYS POST OP-ATELECTASIS/ DEHYDRATION 3-7 DAYS – INFECTION UPPER GI TUBES-GASTRIC DECOMPRESSION LOWER GI TUBES – BOWEL DECOMPRESSION ST WOUND HEALING BY 1 INTENTION-SUTURED AND APPROXIMATED ; 3RD INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINS ND WOUND HEALING BY 2 INTENTION-INCREASED INCIDENCE OF INFECTION , INCREASED SCARRING AND LONGER HEALING TIME
POST-OP COMPLICATIONS
SHOCK PARALYTIC ILEUS ATELECTASIS AND PNEUMONIA - 2ND DAY EMBOLISM- 2ND DAY WOUND INFECTION-3-5D DEHISCENCE AND EVISCERATION-5-6D PSYCHOSIS CARDIOVASCULAR COMPROMISEURINARY RETENTION-8-12H URINARY INFECTION -5-8 D DVT-6-14 DAYS-1 YEAR
WOUND CARE WOUND TYPES AND
HEALING
DRESSING
DRAINS
SENSORY PERCEPTION AND COGNITION
SENSORY DEPRIVATION
SENSORY OVERLOAD
SENSORY DEFICITS
THERAPEUTICS
MEDICATION ADMINISTRATION
IVF INFUSIONS(INCLUDING MIO)
BLOOD TRANSFUSION
PHYSICAL AND OCCUPATIONAL THERAPY
SUPPLEMENTS
NORMAL VALUES
DIAGNOSTIC TESTS
THERAPEUTIC PROCEDURES
GROWTH AND DEVELOPMENT CONCEPTS
Theories of personality development Psychosexual Psychosocial Cognitive Developmental tasks Moral Interpersonal
Freuds psychosexual theory
Libido – inner drive Parts of body –focus of gratification Unsuccesful resolution - fixation Structures of personality
Id – pleasure principle-instinct
Ego – controls action and perception –reality principle
Superego – moral behavior - conscience
0-18 m0s ;oral – mouth – trust and discriminating 18 mos. – 3 years ; anal – bowels – holding on or letting go
Negativism and toilet training age
3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension)
Gender identification and genital awareness Oedipus and Electra complex // Castration anxiety and penis envy
6-12 years –latency (quiet stage) sexual energy diverted to play. Institution of superego…control of instinctual impulses 12 – young adult – genital ; reawakening of sexual drives – relationships
Sexual maturation Sexual identity ,ability to love and work
Psychosocial – Erickson developmental milestones //delay
0-12mos; 1-3y 3-6 6-12 12-18 18-25 25-60 60 and above
TRUST AUTONOMY INITIATIVE INDUSTRY IDENTITY INTIMACY GENERATIVITY EGO INTEGRITY
INFANCY
CONSISTENT MATERNAL –CHILD INTERACTION – TRUST INNER FEELING OF SELF WORTH
HOPE
ALLOW EXPLORATION PROVIDE FOR SAFETY
TODDLER
NO NO – NEGATIVISM OFFER CHOICES / REVERSE PSYCHOLOGY TOILET TRAINING – 18 MOS.-BOWEL
DAYTIME BLADDER -2 Y NIGHTIME BLADDER 3 Y
REWARD W/ PRAISE AND AFFECTION
INDEPENDENCE
PRE-SCHOOL
PROVIDE PLAY MATERIALS SATISFY CURIOSITY TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR) SIBLING RIVALRY
WILLPOWER
SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS CHUMS AND HOBBIES
NEEDS TO EXCEL/ACCOMPLISH NEED FOR PRIVACY AND PEER INTERACTION COMPETENCE
ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS BODY IMAGE CHANGES
NEED TO CONFORM BUT KEEP INDIVIDUALITY
SELF - AWARENESS
YOUNG ADULT COMMITMENT AND FIDELITY
RESPONSIBILITY
ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS MIDLIFE CRISIS
ADJUSTMENT AND COMPROMISE
MOST PRODUCTIVE AND CREATIVE
ALTRUISM
LATE ADULTHOOD
SELF ACCEPTANCE
SELF WORTH
WISDOM
PIAGET’S COGNITIVE THEORY 0-2 SENSORIMOTOR
REFLEXES IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING
2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC CANNOT CONCEPTUALIZE OTHER’S VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES)
7-12Y CONCRETE OPERATIONAL
LOGICAL CONCRETE THOUGHT INDUCTIVE RESAONING (SPECIFIC TO GENERAL) CAN RELATE ,PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION
12-ABOVE FORMAL OPERATIONAL THOUGHT
Abstract thinking Separation of fantasy and fact Reality oriented Deductive reasoning Apply scientific method
Havighurst Developmental Tasks Baby to early childhood
Right from wrong and Conscience
Late childhood
Physical skills,wholesome attitude,social roles Conscience morality and values
Fundamental skills in academics Personal independence
Adolescence
Sexual social roles Relationships Independence and ideology
Early adulthood
Career Selecting a mate Finding Civic or social responsibility
Middle age
Achieving Civic or social responsibility Adjusting to changes Satisfactory career performance Adjusting to aging parents Adjusting to parental roles
Old age
Adjusting to changes Establishing satisfactory living arrangements and affiliations
Kohlberg – MORAL DEVELOPMENT/ THINKING/ JUDGEMENT PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE OBEDIENCE TO RULES TO AVOID PUNISHMENT
CONVENTIONAL ( 6-12 )
MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY
SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE
POST –CONVENTIONAL (12 – 18 Y) PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS
SULLIVANS
INTERPERSONAL THEORY INFANCY
NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS
TODDLERHOOD / EARLY CHILDHOOD
CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT
PRE-SCHOOL
DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN
SCHOOL AGE
THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX
ADOLESCENCE
LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX
YOUNG ADULTHOOD
BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT
LATER ADULTHOOD
LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS
SENESCENCE
DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY
FORMATION OF PERSONALITY CERTAIN GOALS MUST BE ACCOMPLISHED, IF THIS GOALS ARE NOT ACCOMPLISHED AT A CERTAIN STAGE,….PERSONALITY WILL BE WEAKENED….
FACTORS IN EACH STAGE PERSISTS AS A PERMANENT PART OF PERSONALITY…. EACH STAGE HAS MAJOR TRAUMAS AND FRUSTRATIONS THAT MUST BE OVERCOME …….SUCCESSFUL RESOLUTION OF CONFLICTS ASSOCIATED WITH EACH STAGE IS ESSENTIAL TO DEVELOPMENT…..UNRESOLVED CONFLICTS REMAIN IN THE UNCONSCIOUS AND MAY, AT TIMES, RESULT IN MALADAPTIVE BEHAVIOR
PREVENTION AND EARLY DETECTION OF DISEASE GROWTH AND DEVELOPMENT
DEVELOPMENTAL TASKS---MILESTONES ---DELAYS(FIXATIONS/LAG)
IQ = MA / CA X 100
JUDGEMENT , COMPREHENSION AND LISTENING
DDST – BIRTH TO 6 YEARS
PERSONAL SOCIAL, FINE , GROSS MOTOR AND LANGUAGE SKILL AREAS
HEALTH SCREENING OB – GYNE / REPRODUCTIVE TESTS
UTZ-5 WKS CONFIRM PREGNANCY AND AOG AMNIOCENTESIS – 16 WKS-DETECT GENETIC DISORDERS – 30 WEEKS – L/S RATIO ( 2-4 WKS RESULT)(EMPTY Bladder) OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN 10 MINUTES- REACTIVE NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR ACCELERATION OF 15BPM/MORE LASTING 15 SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE – REACTIVE DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION) AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE DEFECTS – 16-18 WKS CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-12 WKS
NEWBORN/INFANT HEALTH SCREENING
PKU – GUTHRINE BLOOD TEST-EAT CHON FOR 2 DAYS MIN.(PHEONISTICS – DIAPER) SICKLE CELL DISEASE –ABNORMALLY SHAPED Hg , ELISA AND WESTERN BLOT CARRIER SCREENING FOR CYSTIC FIBROSIS AND SWEAT CHLORIDE TEST
SCHOOL AGE
HEARING AND VISION TESTS
ALLEN PICTURE CARDS SNELLEN CHART-20/40 AT TODDLER AND 20/20 AT SCHOOL AGE WEBER’S-SENSORINEURAL AND CONDUCTIVE RINNE’S- CONDUCTIVE DENTAL EXAM – STARTS AT 2 YEARS
ADOLESCENT
PPD – INDURATION – 72 HOURS BSE – (18-20 YRS.) POST MENSTRATION/MONTHLY TSE – MONTHLY (18-20 YRS) PELVIC EXAM WITH PAP SMEAR – IF SEXUALLY ACTIVE OR 18 Y.O. ANNUALLY
ADULT/ELDERLY
HPN , DM, HEARING AND VISION PROSTATE –ANNUALLY@40 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS FECAL OCCULT BLOOD TEST- > 50 = ANNUALLY DIGITAL RECTAL EXAM - > 40 Y.O. = YEARLY PELVIC EXAM – 18-40 Y.O. =PERFORMED Q 1 – 3 YEARS WITH PAP TEST MAMMOGRAM – 35-39 = BASELINE
40-49 = Q2Y 50 AND OLDER = QYEAR
BP SCREENING(mmHg) IMMUNITY pg 127-130
CONTRAINDICATIONS:
SEVERE FEBRILE ILLNESS LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED ALLERGIES RECENTLY ACQUIRED PASSIVE IMMUNITY(BLOOD TRANSFUSION AND IMMUNOGLOBULINS)
if child –no evidence of immunization <7 y.o. Give DPT,TOPV,TINE 4-6 WKS LATER MMR 1 MONTH AFTER DPT AND TOPV REPEATED IN ANOTHER MONTH AGAIN IN 10-16 MOS.
CAN GIVE DPT,MMR,TOPV, AND TINE SIMULTANEOUSLY
TD- 2 DOSES 4-8 WKS APART;3RD DOSE 6-12 MOS;BOOSTER AT 10 YRS FO LIFE RD OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3 DOSE 2 -12 MOS ND AFTER 2 (OPV NOT USED IN US) MMR-ONE DOSE – 12 MOS VARICELLA – TWO DOSES 4-8 WEEKS APART STARTS AT 12 MOS. ND HEPA B – 3 DOSES;2 1-2 MOS AFTER;3RD 4-6 MS AFTER PPV- ONE DOSE ;IF 65 AND RECEIVED > 5YEARS – ADMINISTER INFLUENZA –ANNUALLY EACH FALL
ALLERGY CONTRAINDICATIONS
EGGS – INFLUENZA , MMR NEOMYCIN – VARICELLA,IPV,MMR YEAST – HEPA-B GELATIN – VARICELLA
PREGNANCY C/I: MMR AND VARICELLA IMMUNOSUPPRESSED; VARICELLA WITH Ig or BT PREVIOUS 3-11 MOS – MMR AND VARICELLA
CONSIDERATIONS-IMMUNIZATION
DPT - IM – ANTERIOR OR LATERAL THIGH
FEVER AND SWELLING 24-48 H POTENTIAL SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC AND SCREAMING
MMR – SC – ANTERIOR OR LATERAL THIGH
RASH, FEVER ARTHRITIS-10DAYS-2 WKS
TRIVALENT OPV – PO
PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS – EVALUATED 48-72 HOURS
PHYSICAL ASSESSMENT
TEACHING OPPURTUNITY INSPECTION –VISUALLY PALPATION-WARM HANDS
DORSUM OF FINGERS FOR TEMP
PERCUSSION-DIRECT,INDIRECT,BLUNT
RESONANCE-MODERATE LOW PITCHED CLEAR HOLLOW(LUNG) HYPERRESONANCE-OVERINFLATED(EMPHYSEMA) TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL) DULL-SOFT MUFFLED,DENSE FLUID FILLED TISSUE(LIVER) FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-(MUSCLE/BONE)
AUSCULTATIONDIAPHRAGM-HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW PITCHED(HEART MURMURS)
TEMPERATURE:
VITAL SIGNS
ORAL – 98.6 ‘F / 37 ‘C RECTAL – 99.6 ‘F / 37.6’C AXILLARY – 97.6’F / 36.5’C
NORMAL VITAL SIGNS
NEWBORN=30 – 50 / MIN; 120 – 140 / MIN; 60/40 – 80/50 mmHg 1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN; 90/60 – 99/65 mmHg
5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60 mmHg
ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –140 / 90 mmHg
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 BIOT’S – SHALLOW BREATHS INTERRUPTED BY APNEA
NORMAL FINDINGS
PULSE PRESSURE – 30-40 mmHg Intracranial pressure – 10 mmHg PULSE DEFICIT – MINIMAL(3-5 ACCEPTABLE)
IDEAL BODY WEIGHT –
MALES -106 LBS FOR 1ST 5FT THEN ADD 6LBS/INCH ST FEMALE – 100LBS FOR 1 5 FT THEN ADD 5LBS/INCH ADD OR SUBTRACT 10% DEPENDING ON BODY FRAME. OBESE AND UNDERWEIGHT IF DEVIATION IS > 20%
SCARS,BRUISES AND LESIONS CHECK COLOR EDEMA – GRADING
SKIN
0-NO EDEMA 1-BARELY DETECTABLE 2-INDENTATION<5MM 3-INDENTATION 5-10MM 4-INDENTATION >10MM
PRESSURE SORE –GRADING
1-NONBLANCHABLE ERYTHEMA 2-EPIDERMIS,PARTIAL THICKNESS 3-FULL DERMIS AND SQ 4- SUPPORTING TISSUES AND BONES
TURGOR-PINCH SKIN TENTED 3 SECS NORMAL(ELDERLY-OVER STERNUM)
HAIR AND NAILS
HIRSUTISM-EXCESS
ALOPECIA-THINNING
SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING ANGLE > 180 DUE TO PROLONGED DECREASED OXYGENATION BLANCHING =< 3 SECS-NORMAL
HEAD
SYMMETRY, SIZE AND SHAPE CRANIAL NERVE ASSESSMENTS
OPTIC-SNELLEN OCULOMOTOR- PERRLA TRIGEMINAL – BITE DOWN AND STROKES WITH COTTON FACIAL – FACIAL MOVEMENT AND TASTE ACCOUSTIC – HEARING AND BALANCE(WATCH TICK TEST,OTOSCOPIC EXAMS AND POSTURE TESTS) GLOSSOPHARYGEAL-GAG AND SWALLOW VAGUS- SWALLOWING AND SPEAKING
EYES
PTOSIS-DROOPING OF THE UPPER EYELID ASTIGMATISM – UNEVEN CURVATURE OF CORNEA LEADING TO REFRACTION ERRORS NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE MOVEMENTS STRABISMUS-ASSYMETRICAL LIGHT EFLECTION ON EACH CORNEA RED REFLEX FROM RETINA-NORMAL COVER UNCOVER TEST – DET.EYE ALIGNMENT SNELLEN – FAR DISTANCE VISION/VISUAL ACUITY IOP-TONOMETRY TESTS INDENTATION(6-12)
EARS
PINNA BACK-UP-ADULT;DOWN-BACK-CHILD RINNE TEST – COMPARES AIR CONDUCTION WITH BONE CONDUCTION,VIBRATING FORK PLACED ON THE MASTOID IF SOUND NO LONGER HEARD POSITIONED IN FRONT OF EAR CANNAL. SHOULD HEAR A SOUND= 2:1 ; AIR CONDUCTION > THAN BONE CONDUCTION ;= POSITIVE RINNE
ASSESS CONDUCTIVE HEARING LOSS
EARS
WEBER – SENSORINEURAL AND CONDUCTIVE HEARING LOSS
FORK PLACED MIDDLE OF FORE HEAD,SHOULD BE HEARD EQUALLY=WEBER NEGATIVE IF NOT EQUAL=SENSORINEURAL HEARING LOSS. SOUND HEARD BETTER IN THE IMPAIRED EAR=BONE CONDUCTIVE HEARING LOSS, IF VICE VERSA = SENSORINEURAL DISTURBANCE
NECK,MOUTH AND PHARYNX
TEETH-32 TONSILS – NO TPC , + GAG REFLEX CERVICAL LYMPH NODES=<1CM CAROTID – PALPATE THRILL,LISTEN BRUIT JUGULAR VEINS – NOT DISTENDED TRACHEA-MIDLINE
THORAX AND LUNGS
APL DIAMETER-1:2 – 5:7
1:1 = BARREL CHEST
TACTILE FREMITUS NORMAL-BRONCHOPHONY,EGOPHONY AND WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGS BREATH SOUNDS
VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –PERIPHERAL LUNG SURFACES BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM BRONCHI BRONCHIAL- LOUD COARSE - TRACHEA
ADVENTITIOUS BREATH SOUNDS
RALES-FINE SHORT,CRACKLING OR HIGH PITCHED SOUNDS-INSPIRATION RHONCHI-CONTINOUS LOW PITCHED COARSEGURGLING HARSH SNORING BEST HEARD ON EXHALATION WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON INHALATION FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ LIKE VIBRATIONS – BOTH INHALATION AND EXHALATION
HEART SOUNDS
AORTIC AND PULMONIC VALVE AREAS- 2ND ICS, R AND L RESPECTIVEY RD ERBS POINT 3 ICS TH TRICUSPID AREA-4 / 5TH ICS TH MITRAL AREA – 5 ICS , LEFT MCL TH PMI-5 ICS MCL –(INFANTS-LATERAL TO LEFT NIPPLE-4TH ICS) S1LUBB-CLOSURE OFAV VALVES S2DUBB-CLOSURE OF SEMILUNAR VALVES MURMURS , GALLOP-ABNORMAL HEART SOUNDS
PERIPHERAL VASCULAR SYSTEM
ASSESS PAIN,PALLOR,PARALYSIS,PARESTHESIASAND PULSES. ASSESS HOMAN’S SIGN PULSE DEFICIT
BREASTS
START – UPPER OUTER CLOCKWISE ASSESS FOR SIZE,SHAPE,SYMMETRY AND NODES
ABDOMEN
DORSAL RECUMBENT INSPECT,AUSCULTATE,PERCUSS AND PALPATE BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 5-25/MIN NORMAL) IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS. MORE. SEQUENCE IS CLOCKWISE FROM RLQ
HYPOACTIVE < 3 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT TINKLING SOUND – BOWEL OBSTRUCTION
ABDOMEN
REBOUND TENDERNESS- INFLAMMATION OF PERITONEUM
KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLE
KIDNEY PUNCH TEST
MUSCULOSKELETAL SYSTEM
MUSCLE TONE AND STRENGTH
0=COMPLETE PARALYSIS 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT 3=50% - NORMAL MOVEMENT AGAINST GRAVITY 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE 5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE
JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS ARE ABNORMAL FASCICULATION ABNORMAL CONTRACTIONS AND SHORTENING OF MUSCLE FIBERS TREMOR-INVOLUNTARY TREMBLING TEST FOR ROM AND ASSESS FOR ATROPHY/HYPERTROPHY/CONTRACTURES
NEUROLOGIC TESTS
MENTAL STATUS-
LANGUAGE-CEREBRAL CORTEX-APHASIA ORIENTATION(TIME,PLACE,PERSON)(CONFUSION) MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY ATTENTION SPAN AND CALCULATION JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL VIEWS PERCEPTION – SENSORY ANALYSIS AND INTEGRATION
CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING MOVEMENTS,GAIT CRANIAL NERVE FUNCTIONS SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSERHOMBERG’S TEST)
NEUROLOGIC TESTS
DEEP TENDON REFLEX
0-NO REFLEX +1 – MINIMAL ACTIVITY(HYPOACTIVE) +2 – NORMAL RESPONSE +3 – MORE ACTIVE THAN NORMAL +4 – MAXIMUM ACTIVITY ( HYPERACTIVE)
PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY
LEVEL OF CONSCIOUSNESS
GLASGOW COMA SCALE=15 POINTS, 7 COMA
EYE OPENING
SPONTANEOUS=4 TO VERBAL COMMAND=3 TO PAIN=2 NO RESPONSE=1
MOTOR RESPONSE
TO VERBAL COMMAND=6 TO PAINFUL STIMULI/LOCALIZES PAIN=5 FLEXES AND WITHDRAWS=4 DECORTICATE=3 DECEREBRATE=2 NO RESPONSE=1
VERBAL RESPONSE
ORIENTED,CONVERSES=5 DISORIENTED,CONVERSES=4 USES INAPPROPRIATE WORDS=3 USES INCOMPREHENSIBLE SOUNDS=2 NO RESPONSE=1
ASSESSING MOTOR FUNCTION
WALKING GAITS
ROMBERGS TEST- STAND FEET TOGETHER ARMS RESTING AT THE SIDES,EYES OPEN THEN CLOSED. NEG. ROMBERG – MAY SWAY BUT KEEPS BALANCE.
SENSORY ATAXIA-CANNOT BALANCE EYES SHUT CEREBELLAR ATAXIA-CANNOT BALANCE EYES SHUT OR EPON
HEEL-TOE WALKING AND VICE VERSA FINGER TO NOSE TEST AND OTHER SENSORY FUNCTION TEST (ONE AND TWO POINT DISCRIMINATION) EXTINCTION PHENOMENON-SYMMETRICAL AREAS ARE TOUCHED BUT SENSATION ON ONE SIDE CANNOT BE FELT INDICATES LESIONS OF SENSORY CORTEX
GENITALIA , ANUS AND RECTUM
ASSESS APPEARANCE AND ORIFICES AND INGUINAL LYMPH NODES INSPECT CERVICAL OS AND VAGINA-SPECULUM DEVIATIONS
CYSTOCELE, RECTOCELE,ENTEROCELE HYPO AND EPISPADIAS-URETHRAL OPENING DISPLACED HERNIAS-DIRECT,INDIRECT , FEMORAL INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE
DIGITAL RECTAL EXAM –INSPECTION AND PALPATION –POSITION BOTH=SIM’S , FEMALES – LITHOTOMY;MALES =STAND AND BEND FORWARD PROSTATE GLAND-4 CM ;CERVIX = 2-3 CM HEMORRHOIDS =DILATED VEINS
STRESS , ANXIETY AND CRISIS SELF- AWARENESS
SELF CONCEPT – COLLECTION OF FEELING BELIEFS ABOUT ONE’S SELF SELF ESTEEM – CONFIDENCE IN ONE’S ABILITIES AND JUDGEMENT
ASSERTIVENESS
+ SELF - EVALUATION
STRESS
GAS – ALARM-RESISTANCE-EXHAUSTION COPING AND STRESS MANAGEMENT
ANXIETY-
MILD – SLIGHT AROUSAL AND INCREASED PERCEPTION MODERATE-INC. TENSION AND SELECTIVE INATT. SEVERE – DEC. PERCEPTION AND FOCUSSED ENERGY PANIC – OVERPOWERING AND LOSS OF CONTROL
STRESS MANAGEMENT
RELAXATION TECHNIQUES
RELAXATION BREATHING PROGRESSIVE MUSCLE SETTING AUTOGENIC TRAINING(SELF-SUGGESTIONS) IMAGERY(MENTAL VACATION) DISTRACTION
GRIEF AND LOSS Loss is a universal experience that occurs throughout life span Grief is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement Responses to loss are strongly influenced by one’s cultural background The grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss. Responses to loss and patterns of coping with loss are developed early in life.
Stages of Grieving (Kubler-Ross) Denial- refuses to believe that the loss has occurred Anger- the individual resists the loss and may “act out” feelings. Bargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss. Depression- overwhelming feeling of loneliness and withdrawal from others Acceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, and the interaction to other people resumed.
LOSS ,GRIEVING AND DEATH
DEATH CONCEPTS
1-5Y.O – IMMOBILITY AND INACTIVITY Wishes and unrelated action responsible for action 5-10 – final but can be avoided 9-12 – understands own mortality and fears death 12 – 18 – fears and fantasizes avoidance 18-45 – increased attitude awareness 45-65 – accepts mortality Above 65 – multiple meanings, encounters and fears
KUBLER ROSS – STAGES OF GRIEF
D – SUPPORTIVE
A- PROVIDE STRUCTURE AND CONTINUITY
B – LISTEN AND ENCOURAGE
D- ALLOW EXPRESSION AND PROVIDE FOR SAFETY
A- ENCOURAGE PARTICIPATION
CONCEPTS
6 MOS – 2 YEARS PROVISION OF DIGNIFIED PAIN FREE DEATH( QUEST. ANSWERED AND EMT. SUPPORT) DNR- COMFORT AND HYGIENE NEEDS ON-GOING CURE GOALS ----- COMFORT GOALS
CONCEPTS
HINDU – REINCARNATION , AUTOPSY , ORGAN DONATION, CREMATION ISLAM – NO TO ORGAN DONATION , CREMATION AND AUTOPSY …..CONFESS AND TURN TO MECCA JUDAISM – WASHED NATIVE AMERICAN – NOT TO AUTOPSY BUDDIST – OK – EUTHANASIA AND WITH LAST RITES
SAFETY AND INFECTION CONTROL
PROTECTING HEALTH
NON – SPECIFIC AND SPECIFIC CHAIN OF INFECTION
UNIVERSAL PRECAUTION PRINCIPLES OF SURGICAL ASEPSIS INFECTION CONTROL MEASURES
ISOLATION – CATEGORY SPECIFIC AND DISEASE SPECIFIC MEDICAL AND SURGICAL ASEPSIS
Universal Precautions
Strict Isolation-highly transmissible diseases by direct contact and airborne routes of transmission
Private room,gowns, mask , gloves, handwashing,double bagged techniques for soiled articles
Diptheria(pharyngeal),Herpes Zoster, Varicella , Pneumonia( S.Aureus , Strep,group A)
Universal Precautions
Respiratory Isolation-droplet transmission(3 feet)
Private rom,patient w/ same organism,mask,handwashing,labelled plastic bags for soiled articles
H. influenza, measles, mumps, N. Meningitidis
Universal Precautions
Tuberculosis/ AFB isolation-suspected / active TB
Private room with negative pressureventilation so that air room is vented outside, mask, handwashing, bronchoscopy and dental examination postponed until 2 weeks of antibiotic therapy
Tuberculosis
Universal Precautions
Contact Isolation – infectious disseases or multiple resistant microorganisms that are spread by direct contact or close contact
Private room , mask gown , gloves
diptheria( cutaneous), Herpes simplex, MRSA , Pediculosis , Scabies , Syphilis
Universal Precautions
Enteric Precautions – infectious diseases transmitted through direct or indirect contact with infected feces.
Handwashing , gloves , gowns worn only when handling contaminated objects with feces
Aseptic meningitis, AGE , Hepa A , Typhoid fever, diarrhea (CDT )
Universal Precautions
Drainage / Secretions precautions – patients with wound drainage or infected wounds
Gloves, gowns indicated if clothing is likely to be contaminated
Burns
Universal Precautions
Universal Blood and Body fluids precautions – blood borne , body fluids pathogens ( blood , semen , vaginal secretions , CSF , synovial fluid , pleural fluid , peritoneal fluid , pericardial fluid , amniotic fluid and tissues.
Gloves , mask, protective eyegears, gown , contaminated needles not recapped and sharps in puncture resistant containers
Aids , Hepatitis B and C , STD’s
Reverse Isolation
Patient is protected from pathogens and nosocomial infections by instituting reversed transmission precautions
Burns and open wounds, patients with artificial airway , immunocompromised patients – leukemia , AIDS , steroid therapy , radiation or cancer chemotherapy , medication effect of leukopenia or agranulocytosis
Infectious agents- pathogens (bacteria, fungi, virus, protozoa) ReservoirsReservoirs- sources or places for growth of the pathogens Portal of Exit and EntryEntry- provides the way for the pathogen to leave one host and enter another host Modes of transmissiontransmission- vehicles of transmission of the pathogens Susceptible HostHost- a carrier capable of supporting and transmitting microorganism
Body Defenses Against Infection
Normal Flora
Intact Skin Saliva and Mucus Membrane Cilia of the Upper Respiratory Tract Infection Inflammatory process Immune Response
Medical Asepsis/ Clean Technique Principles: Pathogens move through spaces or air current Pathogens are transferred from one surface to another whenever objects touch. Hand washing removes microorganism Pathogens are released into the air on droplet nuclei when person speaks, breaths, and sneeze. Pathogens are transferred by virtue of gravity Pathogens move slowly on dry surface but very quickly through moisture.
Surgical Asepsis/ Sterile Technique Areas of the body considered sterile are:
Blood stream Spinal Fluid Peritoneal Cavity Urinary Tract Muscles Bones Chamber of the Eyes
Sterile object remains sterile when touched by another sterile object Sterile objects or fields, which falls out of the range of vision or below one’s waist, are considered contaminated. Sterile items become contaminated when they come in contact with microorganism transported through the air. When sterile object/ field come in contact with another surface, it becomes contaminated. Fluids flows in the direction of gravity. The edges of the sterile field are considered unsterile.
Isolation Practices Strict Isolation- prevents transmission of highly communicable disease by contact and airborne transmission Respiratory isolation- prevents transmission by droplet Enteric precaution- prevents transmission through ingestion Wound and skin precaution- prevents cross-infection by direct contact with wounds and contaminated articles Discharge precaution- prevent cross-infection by secretions-contaminated articles Blood precaution- prevent transmission by contact with blood or items contaminated with blood
COMFORT AND PAIN *COMFORT AND PAIN
PQRST AND QUEST PHARMACOLOGICAL Tx PAIN GATEWAY CONTROL THEORY PLAN AND PREVENT INJURY/HARM PROVIDE ALTERNATIVE MEASURES PROPHYLACTIC/PREVENTIVE PCA PREFERENCE AND PARTICIPATION
Pain The noxious stimilation of threatened or actual tissue damage (Geach, 1987) Whatever the experiencing person says it is, existing whenever he or she says it does (McCaferry, 1979) It is highly subjective and individual and that is one of the body’s defense mechanism indicating that there is a problem. It is protective as it gives warning or signal for tissue injury
Assessment of Pain Precipitating Factors- “ What triggers the pain or makes it worse?” Quality of Pain- “Tell me what the pain feels like” Alleviating Factors- “What measures relieve your pain” Meaning of pain- “ How do you interpret the pain?”
Pattern Location Pain- “Where is your pain” Periodicity- “How long have you felt the pain sensation?”
REST AND SLEEP *REST AND SLEEP
REM – DREAM PARADOXICAL SLEEP PRIMARY AND SECONDARY SLEEP DISORDERS
RESTFUL ENVT. RITUALS RELAXATION RELEVANT MEDS AND RELATED THERAPY & NON PHARMACOLOGIC Tx RECORD ASSESSMENTS AND HISTORY
Stages of Sleep: Non-Rapid Eye Movement (NREM)- for body restoration
Very Light Sleep- drowsy, and readily awakened Light Sleep- Heart and respiratory rate decreases and the body temperature gradually falls. PNS domination- Difficult to arouse Deep Sleep- Decrease metabolism and very difficult to arouse
Rapid Eye movement (REM)- increase synthetic processes of the brain Paradoxical Sleep Dream state of the sleep Close to wakefulness but difficult to arouse
Common Sleep Disorders Insomia- sleeplessness Hypersomia- Excessive sleep at day time Narcolepsy- Sleep attack Parasomias
Somnambolism- sleep walking Soliloqy- Sleep talking Bruxism- clenching and grinding of teeth Night Terrors- bad dreams Nocturnal Erections- wet dreams
Nocturnal Enuresis - BEDWETTING
SAFETY Rest is the diminished state of activity Sleep is a state of decreased perception and reaction to the environment There are theories of sleep:
Active theory- there are parts of the brain that inhibit other brain parts Passive theory- the reticular activating system of the brain fatigues and becomes depressed, thus sleeps occurs
*SAFETY
TRIAGE DISASTER MANAGEMENT -=A,B,C
P REVENT ABSORPTION O FF AND OUT I DENTIFY S UPPORT AND SUPPLY ANTIDOTE O NGOING MONITORING N OTIFY
POISONING CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL THE NURSE SHOULD INTERVENE IF A MOTHER OF A VICTIM OF POISONING VERBALIZES TO DO THE FOLLOWING:
PLANS TO INDUCE VOMITING FOR PATIENT WITH ASPIRIN POISONING
PLANS TO INDUCE VOMITING WHEN SHE IS CERTAIN THAT HER CHILD’S GAG REFLEX AND LOC ARE INTACT WILL NOT GIVE IPECAC IF CHILD IS EXHIBITING NARROWED PULSE PRESSURE WILL WAIT FOR THE SEIZURE TO END BEFORE ADMINISTERING IPECAC
CONTRAINDICATIONS OF IPECAC / INDUCTION OF VOMITING
SEIZURE SUBNORMAL LOC AND GAG REFLEX SUBSTANCE CORROSIVE/PETROLEUM DISTILATE SHOCK-SEVERE
DISASTER PLANNING
TRIAGE-GREATEST GOOD FOR THE GREATEST NUMBER OF PEOPLE PRINCIPLES- ABCD , MASLOWS
RED-UNSTABLE – IMMEDIATE CARE YELLOW- STABLE – CAN WAIT 30-60 MIN GREEN –STABLE- CAN WAIT LONGER BLACK- UNSTABLE – FATAL, LAST SEEN DOA – SUPPORTIVE COMFORT MEASURES
DURING FIRE WHICH SET OF PATIENTS WILL THE NURSE MOBILIZE FIRST
AMBULATORY BEDRIDDEN CRITICAL TERMINAL
WHICH STEP IN FIRE MANAGEMENT COMES LAST?
ALARM CONTAIN MOBILIZE EXTINGUISH
READ ENSURE SUPERVISION LOCK AVOID TRANSFERING TEACH AND EDUCATE MANAGEMENT IPECAC ACTIVATED CHARCOAL H2O OR MILK NA SO4 SPECIFIC ANTIDOTE OR ANTAGONIST
POISONING CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL
SAFETY
FALLS(RAT) RISK ASSESSMENT TOOL
ALTERATION IN SENSATION AND PERCEPTION AWARENESS LEVEL ABILITY TO COMMUNICATE ALTERED GAIT AND POSTURE AMBULATION NEEDS ANXIETY AND EMOTIONAL STATE ASSOCIATED INJURY AND DISEASE ACCESS(LIFESTYLE)
BEDSIDE SAFETY/EMERGENCY MATERIALS / EQUIPMENTS
AMPUTATION – TOURNIQUET AUTONOMIS HYPERREFLEXIA – CATHETER
CHEST TUBE DRAINAGE- EXTRA BOTTLE- FORCEPS – VASELINIZED GAUZE CHOLINERGIC AND MYASTHENIC CRISIS – ENDOTRACHEAL TUBE / TRACHEOSTOMY SET EPIGLOTITIS - ENDOTRACHEAL TUBE / TRACHEOSTOMY SET PIH – PADDED MOUTH GAG PARKINSONS – SUCTION APPARATUS
BEDSIDE SAFETY/EMERGENCY MATERIALS / EQUIPMENTS
RADIUM IMPLANT – LEAD CONTAINER , FORCEPS SENGSTAKEN BLAKEMORE TUBE – SCISSORS SCI AND THYROIDECTOMY – TRACHEOSTOMY TONSILLECTOMY – FLASHLIGHT TRACHEOSTOMY TUBE – OBTURATOR , HEMOSTAT
PREVENTION OF FALLS
L IGHTING L OWER BED POSITION L OCATE GRAB BARS AND CALL BELL S UFFICIENT ORIENTATION S IDERAILS S UPERVISE AND ORIENT
RESTRAINTS
ASSIST FREQUENTLY ASSIGN HEALTH CARE PROCEDURES IN PAIRS AREA SUPERVISION ADIMINISTRATION ADJUSTMENTS ALLOW ROCKER CHAIR AND FREQUENT WALKS APPLY PILLOW,WEDGE , PADS AND PROPER POSITIONING ALLEVIATE AGITATION ASSESS AND MONITOR
RESTRAINTS-(HALF BOW KNOT/CLOVE HITCH,SQUARE OR REEF KNOT)
LIMB MUMMY ELBOW MITT OR HAND JACKET BELT OR SAFETY STRAP
CONFUSED AND COMBATIVE
CONTROL IMMEDIATE SITUATION OUT OF AREA MAINTAIN CALM BE FIRM AND SET LIMITS ALTERNATIVE TO RESTRAINTS,ASSESS AND ASSIST TRY POSITIVE CONSEQUENCES
HYGIENE *HYGIENE AND COMFORT
INFANT BATHING COMPLETE ADULT BED BATH TUB BATH THERAPEUTIC
SALINE OATMEAL CORNSTARCH NACHO3 KMnO4
HYGIENE AND COMFORT
PERINEAL / GENITAL CARE FOOT AND NAIL CARE HAIR CARE ORAL CARE BEDMAKING
PRESSURE ULCER
GRADING PREVENTION TREATMENT
ACTIVITY AND EXERCISE *ACTIVITY AND EXERCISE
ERGONOMICS
TYPES AND PRINCIPLES
ROM AND ISOMETRICS
PROBLEMS OF IMMOBILITY AND NURSING INTERVENTIONS
ACTIVITY ORDERS
*MOBILITY AND IMMOBILTY
POSITIONING MOVING AND LIFTING
AMBULATION AMBULATION AIDS
TRANSFERS TRANSFER AIDS
THERAPEUTIC EXERCISES
PASSIVE ROM-RETENTION OF ROM AND MAINTENANCE OF CIRCULATION ASSISTIVE- INCREASES MOTION , MAINTAINS MUSCLE TONE ACTIVE – MAINTAINS MOBILITY OF THE JOINT AND MAINTAINS MUSCLE STRENGTH RESISTIVE – INCREASES MUSCLE POWER ISOMETRICS- MAINTENANCE OF STRENGTH AND PREVENTS MUSCULAR ATROPHY
POSITIONING FOR SPECIAL CONDITIONS
ABDOMINAL ANEURYSM SURGERY-FOWLERS
ASTHMA – ORTHOPNEIC POSITION AUTNOMIC DYSREFLEXIA-HIGH FOWLERS POST BRONCHOSCOPY-SEMI FOWLERS
CARDIAC CATHETERIZATION-KEEP INSETION SITE EXTENDED FOR 4-6 HOURS TO PREVENT ARTERIAL OCCLUSION CAST – ELEVATE EXTREMITY CATARACT – SEMI FOWLERS CEREBRAL ANEURYSM – SEMI - FOWLERS
POSITIONING FOR SPECIAL CONDITIONS
CLEFT LIP – SUPINE CLEFT PALATE – PRONE CHF – HIGH FOWLERS CRANIOTOMY – SUPRATENTORIAL – SEMI FOWLERS ;INFRATENTORIAL – FLAT ICP – LEVATE HEAD DUMPING SYNDROME – SUPINE AFTER MEALS EPISTAXIS – LEAN FORWARD FLAIL CHEST – AFFECTED SIDE FEMORO-POPLITEAL BYPASS GRAFT – AFFECTED EXTREMITY EXTENDED
POSITIONING FOR SPECIAL CONDITIONS
GLAUCOMA(POST OP) – AFFECTED SIDE HEMORROIDECTOMY – SIDE LYING HIATAL HERNIA- UPRIGHT HIP SURGERY – LEGS IN ABDUCTION LAMINECTOMY – BACK AS STRAIGHT AS POSSIBLE LIVER BIOPSY – RIGHT SIDE LYING LOBECTOMY – SEMI FOWLERS POST LP – FLAT MASTECTOMY – ELEVATE EXTREMITY ON PILLOW MYELOGRAM – WATER BASED DYE – ELEVATE THE HEAD --- OIL BASED DYE - FLAT
POSITIONING FOR SPECIAL CONDITIONS
POSTURAL DRAINAGE – LUNG SEGMENT – UPPERMOST POSITION PROLAPSED CORD – KNEE-CHEST PULMONARY EDEMA – FOWLERS PYLORIC STENOSIS – RIGHT SIDE LYING RADIUM IMPLANT – FLAT ON BED RETINAL DETACHMENT – AFFECTED SIDE TOWARDS THE BED
POSITIONING FOR SPECIAL CONDITIONS
SEIZURE – SIDE-LYING
SHOCK – MODIFIED TRENDELENBURG SCI – IMMOBILIZE TONSILLECTOMY – SIDELYING / PRONE THYROIDECTOME – SEMI – FOWLERS THROMBOPHLEBITIS – ELEVATE LEG TPN – TRENDELENBURG – DURING INSERTION THORACENTESIS – FOWLER’S(DURING)
AFTER – POSITION OF COMFORT
MOBILITY AND IMMOBILITY
POSTURE AND BODY ALIGNMENT-ERECT JOINT MOVEMENTS=RANGE OF MOTION CONNECTIVE TISSUE
BONE TO BONE-LIGAMENT BONE TO MUSCLE – TENDON COVERS BONES/JOINTS - CARTILAGE
TYPES OF JOINT
SYNARTHROSES(CARTILAGENOUS) DIARTHROSES( SYNOVIAL) AMPIARTHROSES(FIBROUS)
ERGONOMICS-BODY POSITIONING AND MECHANICS
PRIORITY-ASSESS PERSONAL CAPACITY 1ST USE PROTECTIVE DEVICES/ TRANSFER AIDS CHANGE POSITION SLOWLY-ORTHOSTATIC HYPOTENSION(DANGLE LEGS FIRST) PIVOT ON THE STRONGER SIDE,MOVE PNT TOWARDS STRONGER SIDE USE LARGER MUSCLES OF THE BODY AND FACE THE DIRECTION OF THE MOVEMENT PULL SHEETS ARE BETTER METHOD THAN SLIDING ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE AN ASSISTANT STANDING BY. ROCK FROM FRONT TO BACK/VICE VERSA.WIDE BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF THE BODY.USE APPROPRIATE TRANSFER AND AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE BOARD, DRAW SHEET AND TRANSFER BELT
DANGERS OF IMMOBILITY
DECUBITUS ULCER-OSTEOMYELITIS OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND RENAL CALCULI INCREASED CARDIAC WORKLOAD- TACHYCARDIA CONTRACTURES- DEFORMITIES THROMBUS FORMATION-PULMONARY EMBOLISM ORTHOSTATIC HYPOTENSION-WEAKNESS,FAINTNESS AND DIZZINESS RESPIRATORY STASIS – HYPOSTATIC PNEUMONIA
CONSTIPATION – FECAL IMPACTION URINARY STASIS-URINARY RETENTION NEGATIVE NITROGEN BALANCE-WEIGHT LOSS/DEBILITATION
SPECIFIC THERAPEUTIC POSITION
HIGH FOWLERS-60-90’ FOWLER-45-60’ SEMI-FOWLERS-30-45’ LOW-FOWLERS-15-30’ SUPINE DORSAL RECUMBENT LITHOTOMY TRENDELENBURG SIMS LATERAL MODIFIED TRENDELENBURG PRONE KNEE-CHEST SIDE-LATERAL ORTHOPNEIC
CRUTCHES
ASSISTIVE DEVICES
CRUTCH HEIGHT-
STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 CM
TEACH MUSCLE STRENGTHENING EXERCISES PRIOR TO AMBULATION.WEIGHT ON THE HAND GRIP (TO AVOID CRUTCH PALSY) ELBOWS SHOULD BE FLEXED 20-30’ AND CRUTCHES SHOULD BE KEPT 6 INCHES LATERALLY AND 6 INCHES TO THE FRONT=TRIPOD POSITION(810 INCHES-OK) INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTURE
CRUTCH WALKING GAITS
FOUR POINT-SLOW SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS TWO POINT- FASTER SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS THREE-POINT-NON WEIGHT BEARING OF ONE LEG SWINGTO/SWINGTHROUGH-PARTIAL WEIGHT BEARING ALLOWED FOR BOTH LEGS GETTING INTO A CHAIR –BOTH CRUCHES TO THE WEAK SIDE , STRONGER ARM HOLDS THE ARMREST ST GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1 AND BAD GOES ST DOWN 1 .
WALKERPROVIDES STABILITY AND BALANCE MOVE WALKER AHEAD 15 CM (6INCHES-8-10 INCHES)WHILE WEIGHT IS BORNE BY BOTH LEGS.THEN ALTERNATE WEIGHT BEARING ASSISTED BY THE ARMS ELBOWS SHOULD BE FLEXED-20-30’ IF ONE LEG IS WEAKER MOVE THAT LEG TOGETHER WITH THE WALKER
CANE HOLD CANE ON THE STRONGER SIDE FLEX ELBOW 30’ AND TIP OF CANE 15 CM LATERAL TO THE SIDE OF THE 5TH TOE. ADVANCE CANE AND AFFECTED LEG ,WEIGHT ON CANE WHEN MOVING THE GOOD LEG BUT FOR MAXIMUM SUPPORT ADVANCE CANE 1 FEET ,MOVE AFFECTED LEG THEN THE STRONGER LEG GOING UP AND DOWN THE STAIRS –SAME WITH CRUTCHES
*NUTRITION *NUTRITION
PREMATURE INFANTS-LESS THAN37WKS/2,500G-100-200 CAL/KG/DAY AND HIGHER Na,Ca AND CHON FULL TERM-120 CAL/KG/DAY PREGNANCY + 300CAL/DAY LACTATION+ 500CAL/DAY
CONDITIONS
ENTERAL FEEDINGS
PREOPERATIVE NEED FOR NUTRITIONAL SUPPORT GI PROBLEMS ONCOLOGY THERAPY ALCOHOLISM,CHRONIC DEPRESSION AND EATING DISORDERS HEAD,NECK DISORDERS OR SURGERY
COMPLICATIONS
ASPIRATIONTUBE DISPLACEMENT CRAMPING,VOMITING,DIARRHEA HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE INTOLERANCE
NUTRITION
SPECIFIC NUTRIENT MODIFICATION CALORIC MODIFICATION CONSISTENCY
SPECIAL DIETS FOR SPECIFIC DISEASES DIETARY MODIFICATIONS FOR SPECIAL CONDITIONS
NUTRIENT MODIFICATION
INCREASE,DECREASE,RESTRICTED
CA,K,NA,Fe,FOLIC ACID,VIT C&B COM.,ADEK, CHOLESTEROL,GLUTEIN FIBER, PHENYLALAMINE,TYRAMINE CHO,FATS/LIPIDS,CHON
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
AGE – CLEAR LIQUID AGN – LOW NA , LOW CHON ADDISON’S – HIGH NA , LOW K ANEMIA , PERNICIOUS – HIGH CHON , VIT. B. ANEMIA SICKLE CELL – HIGH FLUID GOUT – PURINE RESTRICTED ADHD AND BIPOLAR – FINGER FOODS BURN – HIGH CAL. HIGH CHON CELIAC – GLUTEIN FREE CHOLECYSTITIS – HIGH CHON, HIGH CARB, LOW FAT CHF – LOW NA , LOW CHOL. CROHNS – HIGH CHON AND CHO, LOW FAT
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
CYSTIC FIBROSIS – HIGH CAL., HIGH NA LITHIASIS----ACID ASH FOR ALK. STONES------ALK. ASH FOR ACID STONES DECUBITUS ULCERS – HIGH CHON , HIGH VIT C DIARRHEA – HIGH K AND NA DUMPING SYNDROME – HIGH FAT, HIGH CHON,DRY HEPATIC ENCEPHALOPATHY-LOW CHON HEPATITIS – HIGH CHON,HIGH CAL.
HIRSPRUNGS – LOW RESIDUE, HIGH CHON AND CHO CIRRHOSIS – LOW CHON MENIERE’S LOW NA MI AND HPN – LOW CHOL.,FATS,NA HYPERTHYROIDISM- HIGH CAL. AND CHON HYPOTHYROIDISM – LOW CAL. , LOW CHOL, LOW SAT. FAT
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
NEPHROTIC SYNDROME – LOW NA, HIGH CHON , HIGH CAL. HYPERPARATHYROIDISM – LOW CALCIUM HYPOPARATHYROIDISM – HIGH CA, LOW PHOSPHORUS OSTEOPOROSIS – HIGH CALCIUM AND HIGH VIT. D PANCREATITIS – LOW FAT PUD – HIGH FAT, HIGH CARB. LOW CHON PKU – LOW CHON / PHENYLALANINE PIH – HIGH CHON
THERAPEUTIC DIET FOR SPECIFIC CONDITIONS
RENAL FAILURE (ACUTE) – LOW CHON,HIGH CARB
LOW NA (OLIGURIC PHASE) HIGH CHON , HIGH CAL AND RESTRICTED FLUID (DIURETIC PHASE
RENAL FAILURE (Chronic) – LOW CHON , LOW NA , LOW K
TOTAL PARENTERAL NUTRITION
TYPES OF SOLUTIONS
TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE BACTERIAL FILTER USED TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID, DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTER
PERIPHERAL=NO >10% DEXTROSE AND 2 WKS ONLY CENTRAL – INCOMPATIBLE WITH MEDS AND BLOOD IF SINGLE LUMEN USED ATRIAL-HICKMAN/BIOVAC AND GROSHONG- HUBBER NEEDLE USED TO ACCESS PORT THROUGH SKIN
TPN
INITIAL RATE OF INFUSION 50 ML/HR THEN 100-125/HR. COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS, PNEUMOTHORAX
FAST RATE=HYPEROSMOLAR STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS) SLOWED RATE=REBOUND HYPOGLYCEMIA
X-RAY CONFIRMS PLACEMENT ATTACH TO PUMP
IV TUBING AND FILTER CHANGED Q24 HOURS ALLOW SOLUTION TO WARM IMMEDIATELY BEFORE USE IF NO SOLUTION USE DEXTROSE 10% W SOLUTION
CHECK DAILY CBG,WEIGHT,TEMP. I AND O , CHECK 3X A WEEK BUN, ELECT, ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND PT,PTT
*ELIMINATION BOWEL ELIMINATION
TOILET TRAINING
FACTORS AFFECTING
PROBLEMS MANAGEMENT-CATHARTICS , ENEMA , SURGERY
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
ENEMA COLOSTOMY/ILEOSTOMY,OTHER SURGERIES BARIUM STUDIES SCOPIC EXAMS ROENTOLOGIC EXAMS
ENEMA They act by distending the intestines that increases peristalsis and expulsion of feces and flatus. Enemas serve the following purpose:
Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications
ENEMA
Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches Position: adult- left lateral; infants and children- dorsal recumbent
Administration- administer the enema in a minimum of 15 minutes duration. Conatainer’s Height- 12 inches above the rectum Temperature- 42°C or less
OSTOMIES
PERMANENT/TEMPORARY STOMA RED AND SLIGHT BLEEDING WHEN TOUCHEDBURNING SENSATION UNDER FACEPLATE INDICATES SKIN BREAKDOWN,REFER ABDL DISTENTION/DISCOMFORT, KARAYA POWDER(DEC.IRRITATION), CHARCOAL/BISMUTH CARBONATEDEODORIZER APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-72H AND 24-48H IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODED ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODOR COLOSTOMY-FORMED , CAN BE IRRIGATED 300-500ML AND REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCE
URINARY ELIMATION
BLADDER TRAINING
LABS AND DIAGNOSTIC TESTS
CONDITIONS
CATHETERIZATION AND IRRIGATIONS
URINARY ELIMINATION
BUN – 10-20 MG/DL CREA – 0.7 – 1.4 MG/DL 24 HOUR URINE PRODUCTION-1000-1500CC
ANURIA<100ML/24H OLIGURIA< 400 ML/24H POLYURIA > 2000 ML/24H
KEGELS –STRENGTHEN MUSCLES OF THE PELVIC FLOOR-TIGHTEN FOR 3 SECS THEN RELAX FOR 3 SECS PERFORM LYING DOWN, SITTING AND STANDING FOR TOTAL OF 45 BLADDER RETRAINING
INTERMITTENT CATHETERIZATION AFTER ATTEMPTING TO VOID Q 2-3H, TIME INCREASES GRADUALLY BUT NO MORE THAN 8 HOURS BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H THEN ATTEMP TO VOID 30 MINS LATER-TIME GRADUALLY INCREASED TRIGGERING TECHNIQUES-CREDES MANEUVER AND VALSALVA CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE TO VOID 3-4 HOURS AFETR REMOVAL
HEMODIALYSIS
DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS
PERITONEAL DIALYSIS
TENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES: CAPD(4-6H INDWELLING),AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING
OXYGENATION OXYGENATION
PULMONARY FUNCTION TESTS DIAGNOSTIC LABORATORIES(ABG, SPUTUM CS AND THROAT CULTURE) VISUALIZATION AUSCULTATION
OXYGEN DELIVERY EQUIPMENT CHEST PHYSIOTHERAPY ARTIFICIAL AIRWAYS THORACOCENTESIS,THORACOSTOMY.TRACHEOSTOMY AND ET INTUBATION SUCTIONING CHEST TUBES AND DRAINAGE SYSTEMS
CHEST PHYSIOTHERAPY
TURNING COUGHING DEEP BREATHING POSTURAL DRAINANGE PERCUSSION AND VIBRATION INCENTIVE SPIROMETRY SUCTIONING TRACHEOSTOMY CARE OXYGEN THERAPY VENTILATOR CARE AND MANAGEMENT
Chest Physiotherapy It is the combination of percussion, vibration, and postural drainage Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes Vibration is done during 5 exhalations Postural drainage is done for 15-20 minutes usually performed 3-4 times a day. Instruct the client to increase fluid intake to liquefy secretions This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery. This procedure is done before meal or 90 minutes after a meal
Oxygen Therapy Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen. Humidify the oxygen first before you administer. Check for bubbles in the humidifier to promote adequate flow of oxygen Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: “NO smoking: Oxygen is in used” Instruct the client not to use woolen blankets as this may create static electricity
pulmonary function tests
tidal volume- 500 residual volume- 1200 expiratory reserve volume –1200 inspiratory reserve volume – 3100
Vital Capacity- tidal volume + IRV + ERV = 4800 Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000
Forced Residual Capacity – ERV + RV
incentive spirometry – hold 2-6 sec; 4-5 times/H (TO MAXIMIZE RESP.&MOBILIZE SECRETIONS endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly visualization –
X ray Lung Scxan – 20-40mins isotopes in body for 8 H laryngoscopy Bronchoscopy Thoracentesis- consent, VS and baseline X-ray + post Procedural
Tracheostomy Care
tie new trache tie before removing the old tie to prevent accidental dislodgement.ALLOW 2 FINGERS TO BE INSERTED UNDER TIE use precut gauze and perform care OD at least. soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well suction prn, oral care prn(PROCEDURE DONE q8h AND PRN)
Oxygen Delivery Equipment
cannula – 2-6 LPM – 24-45% Mask – 5-8 LPM – 40-60% parial rebreather – 6-10 LPM – 60-90% non rebreather – 10-15 LPM – 95-100% tent – 4-8 LPM – 30-50 % Venturi mask –
2-3 LPM – 24-28% 4 LPM – 30% 6 LPM – 35% 8 LPM – 45% 14LPM – 55%
Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT: ASSESS BREATH SOUNDS
Hyperoxygenate the patient before and after the procedure. Apply intermittent suction on withdrawal of the catheter. Do not suction the patient for more than 15 seconds. IDEAL 10 SECS
Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space. space. NURSING ALERT: Check the consent. Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder. Instruct the patient not to cough, breath deeply or move during the procedure. After the procedure: Position the patient on the unaffected side/puncture site up. Check for bleeding at the puncture site and monitor the respiratory function. Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.
*PERI-OPERATIVE NURSING PREOP CARE
INFANT-DISTRACT TODDLER-ALLOW REGRESSION AND INVOLVE PARENTS,CONSISTENT CAREGIVER PRE-SCHOOL-LET CHILD HANDLE EQUIPMENT,EXPRESSION OF FEELINGS THROUGH PLAY DEMOFAMILIAR SORROUNDINGS SCHOOL AGE- EXPLAIN SIMPLY AND ALLOW CHOICES ADOLESCENTS- INVOLVE AND POINT OUT STRENGTHS AND BENEFITS,EXPECT RESISTANCE
PREOP CHECKLIST
CONSENT HEALTH TEACHING (SPEC. POST OP PROCEDURES) LAB TESTS,ECG,X-RAY SKIN PREP BOWEL PREP IV’S NPO PREOP MEDS,SEDATION AND ANTIBIOTICS REMOVAL OF DENTURES,NAILPOLISH AND JEWELRY NUTRITION-TPN OR ENTERAL FEEDINGS PREOP
INTRAOP- MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT STATUS,, APPROPRIATE GROUNDING DEVICES, FLUID BALANCE AND SPONGE/INSTRUMENT COUNT POST OP- MONITOR VS Q15X4;Q30X2;Q1HX2 THEN PRN MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC RESPIRATORY PHYSIOTHERAPY,TCBD INCENTIVE SPIROMETRY-20 SECS INHALATION ENCOURAGE AMBUALTION REFER IF UNABLE TO VOID IN 8 HOURS APPLY TED HOSE AND PNEUMATIC COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGN
WOUNDS NOTE DRESSING AND INCISION FEVER 1-2 DAYS POST OP-ATELECTASIS/ DEHYDRATION 3-7 DAYS – INFECTION UPPER GI TUBES-GASTRIC DECOMPRESSION LOWER GI TUBES – BOWEL DECOMPRESSION ST WOUND HEALING BY 1 INTENTION-SUTURED AND APPROXIMATED ; 3RD INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINS ND WOUND HEALING BY 2 INTENTION-INCREASED INCIDENCE OF INFECTION , INCREASED SCARRING AND LONGER HEALING TIME
POST-OP COMPLICATIONS
SHOCK PARALYTIC ILEUS ATELECTASIS AND PNEUMONIA - 2ND DAY EMBOLISM- 2ND DAY WOUND INFECTION-3-5D DEHISCENCE AND EVISCERATION-5-6D PSYCHOSIS CARDIOVASCULAR COMPROMISEURINARY RETENTION-8-12H URINARY INFECTION -5-8 D DVT-6-14 DAYS-1 YEAR
WOUND CARE WOUND TYPES AND
HEALING
DRESSING
DRAINS
SENSORY PERCEPTION AND COGNITION
SENSORY DEPRIVATION
SENSORY OVERLOAD
SENSORY DEFICITS
THERAPEUTICS
MEDICATION ADMINISTRATION
IVF INFUSIONS(INCLUDING MIO)
BLOOD TRANSFUSION
PHYSICAL AND OCCUPATIONAL THERAPY
SUPPLEMENTS
NORMAL VALUES
DIAGNOSTIC TESTS
THERAPEUTIC PROCEDURES
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