Supplements For Theoretical Foundations

SUPPLEMENTS FOR THEORETICAL FOUNDATIONS SAFE AND EFFECTIVE CARE ENVIRONMENT HEALTH PROMOTION AND MAINTENANCE FUNDAMENTAL CONCEPTS REDUCTION OF RISK POTENTIAL THERAPIES AND PROCEDURES

MANAGEMENT OF CARE 

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COMPETENCE,CONFIDENTIALITY AND PRIVACY ADVOCACY AND ACCOUNTABILITY RESPECTFUL CARE AND RESPONSIBILITY PROTECTED ELATIONSHIP AND PROMOTION OF PUBLIC HEALTH ETHICAL STANDARDS OF CARE

INFORMED CONSENT  

CAPACITY AND COMPETENCE INCLUDES EXPLANATION OF 

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BENEFITS, EXPECTED RESULTS,ALTERNATIVES AND RISK

VOLUNTARY INFORMATION UNDERSTOOD CANNOT SIGN IF UNDER ALCOHOL OR PREMEDICATED

Which statement about consent is not accurate: 

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It includes explanation of benefits and disadvantages It states that consent cannot be withdrawn anytime It requires a competent adult who can make voluntary choices Married minors and pregnant minors can sign own consent for treatment

MANAGED CARE 

WORK ALLOCATION    

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PATIENT NEEDS AND CONDITIONS ABILITIES OF STAFF CONTINUITY OF CARE KNOWLEDGE OF STAFF AND QUALIFICATIONS\

RIGHT TASK- FUNCTION , ACTIVITY , DECISION…….INFORMATION , SUPERVISION , FOLLOW-UP DON’T DELEGATE ASSESSMENT,TEACHING EVALUATION,PLANNING

DELEGATION      

BUILDS TRUST EMPOWERS OTHERS TEACHES AN MOTIVATES TEAMWORK DEVELOPS ENHANCE COMMUNICATION RAPID PRODUCTIVITY AND RAISED SKILL

WHICH OF THE FOLLOWING IS NOT TRUE ABOUT MANAGED CARE? 

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In delegation , responsibility is transferred, accountability is shared Responsibility is determined by Nurse practice acts, standards of care, job description and policy statement In delegating identify variables nevertheless this would not change authority and responsibility Delegate to the lowest person on heirarchy that has the required skills and abilities who is allowed to do the task

Example: “ feed client if coherent and awake, if confused do not feed and notify me asap.

SCOPE  R.N.   

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LPN/LVN    

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PLANNING AND HEALTH TEACHING LICENSURE REQUIREMENTS ASSESSMENT AND EVALUATION NEED FOR KNOWLEDGE AND SKILL STABLE PATIENTS STANDARD UNCHANGING PROCEDURES SIMPLE MONITORING AND IMPLEMENTATION SEQUENCED/PREDICTABLE OUTCOMES STATE PRACTICE ACT INCLUSION

UAP-DIRECT PATIENT CARE ACTIVITY AND STANDARD OPERATING UNCHANGING PROCEDURES

INCIDENT REPORTS 

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SEQUENCE-UNEXPECTED OR UNPLANNED OCCURENCE RISK MANAGER SITUATIONS-STATEMENT OF FACTS AND PATIENT PHYSICAL RESPONSE ACTUAL AND POTENTIAL-REPORT WITHIN 24 HOURS-INVESTIGATION OF REFERRING TEAM MANAGEMENT(RISK MANAGER)

In writing an incident report the nurse manager should state the following guidelines on charting  Don’t include except words such as error or 

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inappropriate Don’t include judgemental statements Only actual risks should be reported within 24 hours to the risk manager Documentation of clients status should be continuous

RESTRAINTS 

LIABLE FOR FALSE IMPRISONMENT

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LAST RESORT INFORMED CONSENT(PROXY) ALTERNATIVE MEASURES FIRST BENEFITS> RISKS LENGTH OF TIME AND CIRCUMSTANCES SPECIFIED ENSURE SAFETY – CIRCULATION CHECKS,SKIN CARE, ROM AND REMOVE Q2H

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RESTRAINTS IS USED FOR:       

THE PURPOSE OF DISCIPLINE COMFORT AND CONVENIENCE OF PROVIDER REQUIRED TO TREAT MEDICAL SYMPTOMS ENSURE USED TO CONTROL BEHAVIOR PREVENT BREACH IN SAFE AND EFFECTIVE DELIVERY OF MEDICAL THERAPY. ENSURE SAFETY OF OTHER PATIENTS MEDIUM OF LIMIT SETTING AND PROVISION OF EXTERNAL CONTROLS

COMPLAINTS 

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COMPROMISE / COLLABORATIVE AGREEMENT LISTEN ATTENTIVELY EXPLAIN SCOPES AND LIMITATIONS ASK AND RELAY EXPECTED SOLUTIONS AND TERMS NON-DEFENSIVE

A CLIENT WHO IS ABOUT TO BE BATHED BY A NURSE STATES;”You are too young to know how to do this, get me someone who knows what they are doing”.the nurse best response is: 

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We do this procedure daily, I have done this several times, tell me what are you afraid of? I can see you are upset , can we talk about it? You’re concerns show you are upset, we will talk about this after I have demonstrated the procedure. Can you be more specific about you’re concerns?

Health teaching 

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C-CONSIDER SUPPORT SYSTEMS / COMPLIANCE H- olds MOTIVATION AND INSIGHT A- ALLOW FEEDBACK N-NEEDS MET AND ASSURED G- GOALS AND PRIORITIES SET w/ pnt. E- EMPATHETIC AND ENSURES COLLABORATION

Patient Education Type of learning:

Cognitive Psychomotor Affective Patients motivation –PRIORITY FACTORS – DURATION , COMPLEXITY AND SIDE EFFECTS Discharge planning  Begins with first encounter 

Functional level considered Referrals and preferrences  Compromised plan

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WHAT IS THE BEST GAUGE THAT THE CLIENT UNDERSTANDS DISCHARGE TEACHING? PATIENT VERBALIZES INTEREST PATIENT ASKS QUESTIONS RELATED TO ADAPTATION TO NEEDED CHANGE IN BEHAVIOR ACCURATE DEMONSTRATION OF PROCEDURE PLANS FOR PRACTICE SESSIONS RELATED TO HEALTH CARE SUGGESTIONS TAUGHT BY THE R.N.

SAFETY AND INFECTION CONTROL pg.27-49 

UNIVERSAL PRECAUTIONS 

STANDARD PRECAUTIONS – BARRIER

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COMMUNICABLE DISEASE CONCEPTS CLINICAL MANIFESTATIONSINITIAL,PATHOGNOMONIC/OUTSTANDING  DIAGNOSTIC TESTS AND ETIOLOGY  CARE ESSENTIALS AND IMPLICATIONS 

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MANAGEMENT SEQUELAE

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:  

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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   

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SEIZURE SUBNORMAL LOC AND GAG REFLEX SUBSTANCE CORROSIVE/PETROLEUM DISTILATE SHOCK-SEVERE

DISASTER PLANNING  

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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

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AMBULATORY BEDRIDDEN CRITICAL TERMINAL

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WHICH STEP IN FIRE MANAGEMENT COMES LAST?

ALARM CONTAIN MOBILIZE EXTINGUISH

PREVENTION AND EARLY DETECTION OF DISEASE

GROWTH AND DEVELOPMENT 

DEVELOPMENTAL TASKS---MILESTONES ---DELAYS(FIXATIONS/LAG)

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IQ = MA / CA X 100 

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JUDGEMENT , COMPREHENSION AND LISTENING

DDST – BIRTH TO 6 YEARS 

PERSONAL SOCIAL, FINE , GROSS MOTOR AND LANGUAGE SKILL AREAS

HEALTH SCREENING 

OB – GYNE / REPRODUCTIVE TESTS  

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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 1520 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- 1012 WKS

NEWBORN/INFANT HEALTH SCREENING 

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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  

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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

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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) SYSTOLIC

DIASTOLIC

FOLLOW-UP

< 130

<85

2 YEARS

130-139

85-89

1 YEAR

140-159

90-99

2 MOS.

160-179

100-109

EVALUATE AND REFER 1 MOS.

180-209 >210

110-119 120

1 WEEK IMMEDIATELY

IMMUNITY pg 127-130

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CONTRAINDICATIONS:    

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if child –no evidence of immunization <7 y.o.     

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SEVERE FEBRILE ILLNESS LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED ALLERGIES RECENTLY ACQUIRED PASSIVE IMMUNITY(BLOOD TRANSFUSION AND IMMUNOGLOBULINS)

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

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TD- 2 DOSES 4-8 WKS APART;3RD DOSE 612 MOS;BOOSTER AT 10 YRS FO LIFE OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3RD DOSE 2 -12 MOS AFTER 2ND(OPV NOT USED IN US) MMR-ONE DOSE – 12 MOS VARICELLA – TWO DOSES 4-8 WEEKS APART STARTS AT 12 MOS. HEPA B – 3 DOSES;2ND 1-2 MOS AFTER;3RD 4-6 MS AFTER PPV- ONE DOSE ;IF 65 AND RECEIVED > 5YEARS – ADMINISTER INFLUENZA –ANNUALLY EACH FALL

ALLERGY CONTRAINDICATIONS    

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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

CONSIDERATIONSIMMUNIZATION 

DPT - IM – ANTERIOR OR LATERAL THIGH  

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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

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TRIVALENT OPV – PO

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PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS – EVALUATED 48-72 HOURS

PHYSICAL ASSESSMENT   

TEACHING OPPURTUNITY INSPECTION –VISUALLY PALPATION-WARM HANDS 

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PERCUSSION-DIRECT,INDIRECT,BLUNT     

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DORSUM OF FINGERS FOR TEMP

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

VITAL SIGNS 

TEMPERATURE: ORAL – 98.6 ‘F / 37 ‘C  RECTAL – 99.6 ‘F / 37.6’C  AXILLARY – 97.6’F / 36.5’C 

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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

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5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60 mmHg

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ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 60 –140 / 90 mmHg

BREATHING PATTERNS 

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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   

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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 FEMALE – 100LBS FOR 1ST 5 FT THEN ADD 5LBS/INCH ADD OR SUBTRACT 10% DEPENDING ON BODY FRAME. OBESE AND UNDERWEIGHT IF DEVIATION IS > 20%

SKIN   

SCARS,BRUISES AND LESIONS CHECK COLOR EDEMA – GRADING     

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PRESSURE SORE –GRADING    

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0-NO EDEMA 1-BARELY DETECTABLE 2-INDENTATION<5MM 3-INDENTATION 5-10MM 4-INDENTATION >10MM

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  

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HIRSUTISM-EXCESS ALOPECIA-THINNING SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING ANGLE > 180 DUE TO PROLONGED DECREASED OXYGENATION BLANCHING =< 3 SECS-NORMAL

HEAD

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SYMMETRY, SIZE AND SHAPE CRANIAL NERVE ASSESSMENTS     

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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 

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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    

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TEETH-32 TONSILS – NO TPC , + GAG REFLEX CERVICAL LYMPH NODES=<1CM CAROTID – PALPATE THRILL,LISTEN BRUIT JUGULAR VEINS – NOT DISTENDED TRACHEA-MIDLINE

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THORAX AND LUNGS APL DIAMETER-1:2 – 5:7 

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TACTILE FREMITUS NORMALBRONCHOPHONY,EGOPHONY AND WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGS BREATH SOUNDS   

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1:1 = BARREL CHEST

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 ERBS POINT 3RD ICS TRICUSPID AREA-4TH / 5TH ICS MITRAL AREA – 5TH ICS , LEFT MCL PMI-5TH 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 

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ASSESS PAIN,PALLOR,PARALYSIS,PARESTHESI ASAND PULSES. ASSESS HOMAN’S SIGN PULSE DEFICIT

BREASTS  

START – UPPER OUTER CLOCKWISE ASSESS FOR SIZE,SHAPE,SYMMETRY AND NODES

ABDOMEN   

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DORSAL RECUMBENT INSPECT,AUSCULTATE,PERCUSS AND PALPATE BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 525/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 TENDERNESSINFLAMMATION OF PERITONEUM 

KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLE

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KIDNEY PUNCH TEST

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MUSCULOSKELETAL SYSTEM MUSCLE TONE AND STRENGTH      

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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

NEUROLOGIC TESTS 

MENTAL STATUS     

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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. PROPRIOCEPTIONPOSITION SENSE- RHOMBERG’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) 

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PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY

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LEVEL OF CONSCIOUSNESS GLASGOW COMA SCALE=15 POINTS, 7 COMA 

EYE OPENING    

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MOTOR RESPONSE      

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SPONTANEOUS=4 TO VERBAL COMMAND=3 TO PAIN=2 NO RESPONSE=1 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.  

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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

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

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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

THERAPEUTIC EXERCISES 

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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

DANGERS OF IMMOBILITY          

DECUBITUS ULCER-OSTEOMYELITIS OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND RENAL CALCULI INCREASED CARDIAC WORKLOAD- TACHYCARDIA CONTRACTURES- DEFORMITIES THROMBUS FORMATION-PULMONARY EMBOLISM ORTHOSTATIC HYPOTENSIONWEAKNESS,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

ASSISTIVE DEVICES 

CRUTCHES 

CRUTCH HEIGHT

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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(8-10 INCHES-OK) INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTURE

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CRUTCH WALKING GAITS     

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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 GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1ST AND BAD GOES DOWN 1ST.

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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

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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 

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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

ENTERAL FEEDINGS 

CONDITIONS     

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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

TOTAL PARENTERAL NUTRITION 

TYPES OF SOLUTIONS  

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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 GROSHONGHUBBER NEEDLE USED TO ACCESS PORT THROUGH SKIN

TPN

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INITIAL RATE OF INFUSION 50 ML/HR THEN 100125/HR. COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS, PNEUMOTHORAX  

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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

OSTOMIES  

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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 CARBONATE-DEODORIZER APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q4872H AND 24-48H IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODED ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODOR COLOSTOMY-FORMED , CAN BE IRRIGATED 300500ML AND REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCE

URINARY ELIMINATION   

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BUN – 10-20 MG/DL CREA – 0.7 – 1.4 MG/DL 24 HOUR URINE PRODUCTION-10001500CC ANURIA<100ML/24H OLIGURIA< 400 ML/24H POLYURIA > 2000 ML/24H

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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 

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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,MUS CLE CRAMPS,AIR EMBOLISM AND SEPSISCOMPLICATIONS

PERITONEAL DIALYSIS   

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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

PREOP CARE  

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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

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PREOP CHECKLIST  

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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

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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 WOUND HEALING BY 1ST INTENTION-SUTURED AND APPROXIMATED ; 3RD INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINS WOUND HEALING BY 2ND 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