FUNDAMENTALS OF NURSING

I. Nursing Theorists Identification of 21 Nursing Problems Care, Core and Cure (3 Cs) Identification of the 14 Basic Needs Goal Attainment Theory Transcultural Nursing Four Conservation Principles Environmental Theory Stress Reduction Self-Care and Self-Deficit Human Becoming o Interpersonal Relations Model Science of Unitary Human Beings Adaptation Model Human Caring o

Agent Reservoir Entry (mode of) Transmission (mode of) direct, vehicle, vector Exit (mode of)

Faye Abdellah Lydia Hall Virginia Henderson Imogene King Madeleine Leininger Myra Levine Florence Nightingale Dorothea Orem Rosemarie Parse Hildegard Peplau Martha Rogers Callista Roy Jean Watson

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Surgical vs. Medical Asepsis Surgical Sterile Free from ALL microorganisms Medical Clean Free from pathogenic microorganisms

III. ISOLATION PRECAUTIONS o Standard Precautions (Universal precautions) Applies to ALL body fluids, secretions, blood, nonintact skin and excretions except sweat Includes hand washing, wearing clean gloves, mask and gown Transmission Based Precautions Airborne used for clients with illnesses transmitted by airborne droplets (less than 5 microns) Examples: Tuberculosis, Chickenpox, Measles Place client in private room but if no private room is available place client in a room with another client infected with the same microorganism Wear N95 respirator

Betty Neuman

Metaparadigm for Nursing Theories: CHEN (Client, Health, Environment, Nursing)

II. CHAIN OF INFECTION o Six links Host (susceptible) IV. PERSONAL PROTECTIVE EQUIPMENT (PPE) o Sequence of removing (PPE) Gloves Mask Gown Eyewear

Droplet used for clients with illnesses transmitted by droplet nuclei (greater than 5 microns) Examples: Diptheria, Pertussis, Meningitis, Mumps Wear mask when working within 3 feet from the client

VII. INTESTINAL OSTOMIES Assessment: color should be bright red ( not purple, bluish, pale, etc.), peristomal skin, amount and type of feces (Ileostomy liquid feces / acidic, ascending semi-liquid, transverse semi formed, descending and sigmoidostomy formed feces / aromatic and smelly) Empty bag when it is 1/3 full Apply a barrier (i.e. Karaya gum) over the skin around the stoma to prevent skin breakdown Control Odors (deodorizers, charcoal disks, prevent odor-causing foods) Complications: Fluid and Electrolyte imbalance, skin breakdown, constipation, infection

V. INSERTION OF NASOGASTRIC TUBE cyanotic or coughs Placement- check Aspirate gastric secretions measure pH Auscultate and inject air into the tube (whooshing sound) X-ray best measure to determine proper placement (initial placement) Secure tube using tape to the bridge of the client nose and to the client gown Measure length of tube tip of the nose to the tip of the earlobe to the xiphoid process Position High Fowler position with neck hyperextended Lubricate tip of tube with water soluble lubricant while the tube is being inserted

VI. TUBE FEEDINGS Position: Fowlers position Assessment: Check patency of tube and Aspirate residual contents before feeding (if 100 ml or more than 50% of last feeding withheld and check) For feeding bags: Hang bag from infusion pole HEIGHT: 12 inches Complications: Dumping syndrome, aspiration pneumonia, diarrhea, hyperglycemia, nausea and vomiting

VIII. ENEMAS Classified into FOUR: Cleansing, Carminative, Retention and Return Flow Position: Left Lateral position Protection: Wear clean gloves Lubrication: lubricate with water soluble lubricant Insertion: Insert 3-4 inches (adult), 2-3 inches (children) Administration: administer gradually IX. URINARY CATHETERIZATION Sterile technique Insertion

Male Position Supine (legs slightly abducted) Penis at 90 degree angle Length to be inserted Length of catheter (Adult) X. TRACHEOSTOMY 6-9 inches

Female Supine (with knees flexed and externally rotated)

IVF: Plain NSS Monitor: vital signs (every 15 minutes for 1st hour), any adverse reactions When reaction happens: STOP the transfusion and notify the physician Common blood transfusion reactions: Anaphylactic reaction s/sx: rashes and hives Hemolytic reaction s/sx: flank/back pain Pyrogenic reaction s/sx: fever, headache Cardiogenic reaction s/sx: dyspnea

2-3 inches

40 cm

22 cm

XIV. CHEST TUBES What to do if: Tube becomes disconnected from the bottle place end of tube in a bottle with NSS Tube becomes disconnected from the client cover wound with sterile dressing Water seal has vigorous bubbling there is a leak clamp tube nearest the client (intermittent bubbling normal, vigorous/continuous bubbling-abnormal) Transporting the client bottle below chest level and upright

Position: (during insertion) Fowlers position Use: Sterile gloves Time: 2-3 minutes between suctions when possible, suction applied for 5-10 seconds to minimize oxygen loss Clean with: After removing the inner cannula it is soaked in full strength hydrogen peroxide to moisten and loosen dried secretions. After cleaning the cannula, it should be rinsed with sterile normal saline to remove traces of hydrogen peroxide from the cannula before replacing it and securing it in place again. When changing the ties: tie one end of the new tie to the eye of the flange while leaving old ties in place Before tying the tapes: be able to put two fingers under the tapes before tying it Parts: Inner cannula, outer cannula and obturator Object at bedside: Obturator (for reinsertion), suction machine/apparatus (for removing secretions)

XV. PAIN Study: Gate control theory (Substantia gelatinosa) Analgesics, patient controlled analgesia (PCA), transcutaneous electrical nerve stimulation (TENS), imagery, massage Pain assessment (some common indicators) MI Crushing pain, (someone sitting in my chest), radiates from chest to back Stab-like pain, , radiates from chest to jaw to left shoulder and arm Pounding pain Knife-like pain Gnawing pain Flank pain Radiates from Left upper quadrant to left shoulder

Angina Hypertension / hypertensive crisis Ectopic pregnancy Gastric ulcer UTI Pancreatitis

XI. CHEST PHYSIOTHERAPY (PVP) done before meals (but not immediately before meals) or 2 hours after meals increase fluid intake to liquefy secretions Percussion Vibration Postural drainage

XII. ANTIEMBOLISM STOCKINGS Indication: to prevent thrombophlebitis by promoting venous return from the legs The client must be measured to ensure proper fit of the stockings When to apply: during the morning before the client gets out of bed (elevate for at least 15 minutes) When to remove: remove 20-30 minutes every 8 hours Assess skin for breakdown

XVI. ASSISTIVE DEVICES CANES WALKERS opposite the affected leg (C-O-A-L) angle is 20 to 30 degrees the length should permit the elbow to slightly flex

XIII. BLOOD TRANSFUSION FIRST: Check if properly typed and cross matched Gauge of needle: g #18 Drop factor: 10 gtts/min (1st 30 mins.) Duration: RBCs and whole blood 4 hours, FFP Fresh frozen plasma, platelet not more than 20 minutes Rate: KVO

Hand bar below the clients waist and the elbow is slightly flexed CRUTCHES Angle of elbow flexion 30 degrees weight of the body should be borne by the arms not the axilla to prevent CRUTCH PALSY Crutches are placed 6 inches in front and 6 inches laterally the feet should be slightly apart, hips and knees extended and back is straight Four point gait right crutch, left foot, left crutch, right foot Three point gait right and left crutch with weak leg, stronger leg Two point gait- right crutch and left foot together, left crutch and right foot Swing to gait- move both crutches forward, lift body weight and swing to crutches

Swing through gait - move both crutches forward, lift body weight and swing through beyond the crutches Going up the stairs (remember: all good people go to heaven) when going up, lift (good) unaffected leg first followed by the crutch, affected leg.

XVIII. DEGREES OF BURNS Superficial Partial Thickness area involved: epidermis tingling, erythema, minimal or no edema Deep Partial Thickness area involved: epidermis, dermis w/ PAIN, hyperesthesia, BLISTERS, edema, weeping surface, mottled and red base Full Thickness area involved: epidermis, dermis, may involve subcutaneous and connective tissue, muscle and bone PAIN FREE, shock, dry, PALE, WHITE leathery or charred skin, broken skin with fat exposed, edema

XVII. SPECIAL DIETS DISORDER DIET Low carbohydrate Low protein High protein Low sodium High fiber Low residue Acid/Alkaline ash Clear liquid Full liquid Gluten-free Tyramine-free Purine restricted Dumping syndrome Renal failure, Acute glomerulonephritis, uremia, anuria Nephrotic syndrome Heart failure, CVDs, Nephrotic syndrome Constipation, hyperlipidemia Bowel inflammation ( diverticulitis and ulcerative colitis) (depending on the lab analysis of the stones) Retard renal calculi formation Following acute vomiting or diarrhea Gastrointestinal upsets, progression from clear liquids For clients with Celiac disease To prevent fermented and processed foods for clients taking MAOIs Gouty arthritis, uric acid stones

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

]XX. VITAL SIGNS TEMP NV (Adult) 36.0-37.5 0 C Oral: 2-3 mins Rectal: 2-3 mins (most accurate Axillary: 6-9 mins (least accurate) Tympanic PR 60-100 bpm Ang PET Mo: A-pical P-ulmonic E-rbs pt. T-ricuspid M- itral Others: Brachial BP Apical used for children below 3 y/o RR 12-20 bpm Breath Sounds: Stridor- shrill and harsh ( laryngeal obstruction) Wheeze high pitched/musical (Asthma) Volume: Hypoventilation-slow and shallow (Respiratory acidosis pursed lip) Hyperventilation-deep and rapid (Respiratory alkalosis brown paper bag) BP 120/80 mmHg -cover about 2/3 of the limb Position: Sitting Release valve on cuff carefully -2-3 mmHg/sec Wait 1-2 min before taking another BP BP erroneously high: Cuff too narrow, arm unsupported, no rest before assessment, cuff wrapped loosely, deflating too slowly (high diastolic), assessing immediately after a meal

BP erroneously low: cuff too wide, arm above heart level Monitor in clients who are/has: Immune-suppressed, receiving chemo, etc Bleeding, taking digitalis, has DVT or thrombophlebitis Anxious, receiving morphine and Magnesium sulfate Cardiac problems, DM, RF

10 HERBAL PLANTS (Advocated by DOH) Lagundi Yerba Buena Sambong Tsaang Gubat Niyug-niyugan Asthma, cough, fever Pain, headache, stomachache, toothache, mens-trual and gas pain Anti-edema, anti-urolithiasis Diarrhea,stomachache Anti-helminthic Bayabas Akapulko Ulasimang Bato Bawang Ampalaya For washing wounds mouthwash/ gargle, toothache Anti-fungal Lowers uric acid For hypertension/ toothache To lower blood sugar levels