Fundamental of Nursing P- wellness; yet vulnerable

Nursing 1. Health promotion- maintenance, support,client has no

dse orientation
Fr. Nutritious
2. Specific protection- illness prevention;injury and illness
Services offered to clients/ patients oriented

Leninger- transcultural nursing- individual, family, community S- has intervention, Dse. Illness; stop dse. Prevent disability and
further complication
4 scopes
1. Promote health – models 1.Early Dx

>Clinical –s/sx 2.Early treatment and intervention

+s/sx = client is ill; stop occurrence of s/sx T-Dse, Illness- stabilized, cannot be fixed already.

>Adaptive model- Sr. Roy(adaptation theory) –make use of conscious mind in 1.Restoration
order to balance in his environment
2. Rehabilitaion(upon admission already starts but stabilize
:Illness-responses of the client based on the given dse. the px)

:Diseases- alteration in body function Roles

>Role performance model- client is able to perform his task for adl even if ill Care provider- spirit of nursing, welfare of the patients

d. orem –self care-capable to perform adl Communicator- vital responsibility of the nurse; helps us assess,
identify needs of us our clients, and establish relationship with clients
self deficit- disability adl
4 phases of nurse client relationship
self care deficit- assist client in achieving health care;
Preorientation- self awareness
wholly compensatory(dependent client) , partially
compensatory (collaboration between nurse and client), supportive Orientation- contract, identification and trust
and educative (focus on motivation by inC awareness)
Working- longest
;health education is the best way to promote health
Termination – end of contract; goal may/not be met
>eudemonistic model- Self Actualization (non nursing model)- client is able to
maximize potential Interpersonal model- Hildegard Peplau

V. Henderson- 14 fundamental needs- lack of any need could lead Orientation

to illness
Identification- needs
- assist clients toward recovery; and gain independence
Exploitation- implementation
B. neuman
Resolution
3 levels of health
Interpersonal process theory- ida jean Orlando VS peplau
health care delivery system

KenSanRN
 Dynamic nurse client relationship competent 2-3 yr of experience(planning and organizing act
for the unit)
Joyce Travelbee- impt. Of communication proficient 3-5 yr of experience(holistic understanding and
perception on their client )
Nursing is a human to human interaction expert 5yrs of experience (fluid)analytical and intuitive

Advocate Expanded role of nurses

Advocacy- Action that shows concern to other people or Expert nurses- adv level of education/ training
interaction
-nurse educator- in academe or teaching institution (MAN, 1
 Patient is the main focus yr)
 Intercede in behalf of the client (put yourself in the shoe of
the patient t understand the patient) Nurse midwife-

Change agent- Goal oriented; looking for change – modify client behavior Nurse entrepreneur- health related business
and environment
Nurse practitioner- 2 yrs.- primary ambulatory care- chronic and acute
Teacher- impart knowledge to our client illnesses

Manager- delegation and budgeting Clinical nurse specialist- expert

Collaborator- work with other health care team/ hosp. Nurse anesthetist- icu/rr

Leader- influence our client Nurse traveler- floaters

Nurse counselor- client to modify their behavior(guide and listen but not to 2. Prevention of illness and occurrence of dse.
decide for the client) 5 stages of illness behavior
>s/sx experiences-
1. physical changes/ alteration in body fx.,
2. cognitive- we tend to interpret the problem
Imogene King- goal attainment theory (transaction process) 3. emotional- anxiety / fear is N
>assumption of sick role-teNd to confirm the problem
transaction is needed bet. Nurse and patient in order to achieve
the goal > medical care contact- Validate, understand, Reassure

decision making but final decision should come to the patient >dependent client role- Px gives up independence

>Recovery/rehabilitation- abatement of s/sx

nurses are allowed to decide for px in crises mgt. :Promotion/Prevention/Rehabilitation/Care of Dying

Researcher- update ourselves with the trends

CPE- enhancement, updates trend and tech, expertise Hx:

5 stages- P. Benner (based on yrs. ) INTUITIVE

novice- inflexible nurses (knowledge, skills )
adv. Beginner 1-2 yr of experience (clinical judgment; knows to shaman= white magic
prioritize)
trephening- first operation

KenSanRN
 code of Hammurabi- first document that governs the practice of medicine PERIOD OF CONTEMPORARY NURSING

concept of cleanliness- handwashing / basis of specialization/  After world war II – present

service charges  Scientific and technological development and social changes marks this period.
 Events and trends; technology
china= material medica- pharma  WHO was established
 Readjustment in the curriculum
india= male nurses-knowledge, clever, devoted, purity of mind and body(no sex
including masturbation)
Data collection- Base line data
shushurutu= design that req. for aspiring nurses Subjective- verbalized by patient, symptom, covert, illness
Objective- observable and measurable data, sign, objective, dse.
Israel= moses father of sanitation
Sources of data
Egypt= art of embalming/ recognized 250 dse. Primary= client/px
Secondary= significant others, consultation, record and report

Documentation
APPRENTICE SOMR-Source Oriented Medical Record- traditional
Narrative format
OJT period POMR-Problem Oriented Medical Record- 4 components
Baseline data; problem list; plan of care; progress notes
>Crimean war- SOAP/IE/R
FOCUS –Dx Action Response
>Florence nightingale- environmental theory- Lady with Lamp PIE
Kardex- concise documentation that is used for indorsement
>training school- pastor t. fliedner- germany
Report being verbalized
Dark (reformation) Change of shift report- endorsement/ end of shift
- continuity of care/ legalities & liabilities
>martin luther Nursing rounds- endorsement on bedside( assess before indorse)
Telephone order- between 2 health care professional MD-RN,
>nurse- unwanted women- prosti and prisoners document @ once (signed by nurse and cosigned by MD W/in 24
hrs.) basic orders
JOHN HOWARD- prison reformer Telephone report- md-rn-rn-md-md
 teacher of the prosti and prisoner Methods of data collection
Interview- plan communication
PERIOD OF EDUCATED NURSING Open ended and close ended- open (therapeutic, explore and expound of
data)
 Began on June 15, 1860 Directive approach- nurse manipulated- close ended
 Opened Florence Nightingale School of Nursing at St, Thomas Hospital in Indirect approach- client manipulated-
London. Observation- physical senses= objective data
 Arousal of Social consciousness Increase the clinical eye level of the nurse
 Facts about Florence Nightingale: Examination- gather objective data
o “Mother of Modern Nursing” 1. Health assessment- vital signs
o “Lady with a Lamp” a. Temp= balance in heat loss and heat production
 England pioneer country in modern nursing i. Core – underlying organ. 37.5‟ c
 Resident physician- instructor; ii. Surface- skin and underlying tissue- 36.5-37.5
 standard curriculum- 6 months; >rectal- 1-3 min; ci: hemorrhoid, diarrhea, rectal operation:
 clinical training/ expansion of roles last option
KenSanRN
 th
>oral - .5‟ c of 1‟ f lower than rectal, ci: too young, Apical-lying position; after radial identical with radial, 3yrs below (4 ics) ,
unconscious, vomits, prone in having seizure attack, angry
irritable or confused, contraption Brachial- cardiac arrest kids
> axilla; 1.1 „c or 2-3‟ f lower than rectal-6-9 mins
>tympanic- core- one of safest Radial(most accessible)
Basal Metabolic Rate- amt of heat needed by the body in order to perform vital
process; the younger the higher Femoral-cardiac arrest
Direct- respiratory chamber- heat evolving is measured.
Indirect – get rr,- 12 – 16 hours after eating, resting or sleeping, Posterior Tibial,
Diurnal- most at 6 pm and 8-12 mm
- Least -6 am 1-4 am Pedal (dorsalis pedis),
Hormones
Inc EE, nor epi, proges Popliteal- circulation of blood to lower legs
Dec estrogen
Stress Radial-apical assessment- two nurse method
SAMR: inc in epi and nor epi One nurse method
A>R- refer immediately, indication for cardio prob
Hypothermia- lower than N. 36 below Pulse deficit = difference of two pulse
Mild- 32-37
Moderate- 28-32 BLOOD PRESSURE
Severe -22-28
Pyrexia- fever higher than 38.1 centigrade • Determinants of Blood Pressure
Intermittent- fluctuation normal to Blood volume- increase causes increase
fever.
Remittent always above 38.1 Viscosity- hematocrit
Relapsing fever-
Constant/ high fever- remittent with Peripheral Resistance- vasoconstriction or vasodilation
fluctuation up to 41‟c
Hyperthermia- above 41‟c Cardiac output

Respiration- controlled by medulla oblongata- fx as primary receptor(cpu), pons Elasticity or Compliance

rhythmic act of respiration, if pons and medulla fails carotid and aortic bodies take
over(limited time can cause alkalosis) • Factors Affecting Blood Pressure
• Three processes: Age= y, dec BP
Ventilation, Diffusion, Perfusion
Exercise
• Types of breathing:
Costal (thoracic) and Diaphragmatic(abdominal) Stress- could increase or decrease

• Factors affecting respiratory rate Race

Exercise, Stress, Environment, Increased
altitude, medication Obesity
Pulse- autonomic nervous system
• Factors Affecting Pulse Rate Sex/Gender- f 65 inc Bp
Age , Sex/Gender, Exercise, Fever, Medications, Hemorrhage, Stress, Position
Medications
Changes
Diurnal Variations-4-6 pm high 7-9pm; early am low or upon awakening..
• Pulse Sites
Temporal (brain circulation),
Disease Process
Carotid- cardiac arrest adult
KenSanRN
 Position- lying best position.. level with heart. Fasting blood sugar- 6-8 hours NPO, side of the fingers, 70-110mg/dl
Somogyi rule - 60-100mg/dl
Orthostatic blood pressure measurement- drop of BP to prevent positional Fulin‟s- 80-120mg/dl
hypotension.., lying then sitting then standing with 5 mins interval Wu‟s- 80-120mg/dl
Vanillymandelic acid test- urine; to check tumor, cancer cells in adrenal
Hypertensive- 2-3 times 140/90 area, avoid vanilla rich food and aspirin
Urine- normal pH 4.6-8
Sp. Gravity-1.010-1.035
2. Physical assessment- validate or refuse certain data Color of urine- amber to straw
Consent must be secured Red- inc. CHON, hematuria, black or brown-
Non invasive and invasive requires consent bleeding, white- infection pus.
Verbal consent is impt. Volume-30-60ml/hr
Poly- excessive urination more than 100ml/hr
Empty the bladder twice, before doing the assessment and before (hypercalcemia, hyperparathyroid, diabetes, diuretics); oli- less than 30
assessing the abdomen ml/hr but higher than 10 ml(500ml/day)(renal failure hypertension ,
Position must be considered- best is either standing or sitting; all neprhotic syndrome ); anuria-absence or always <10 ml/ hr(100ml/day),
area are accessible (hemorrhage, metal poisoning)
Gown
Observe privacy- proper draping, area only to be assessed Methods
- age Clean catch- culture and sensitivity (5-10ml), routine
-gender urinalysis(10ml, (30-50ml), 24hr collection, catheterized collection
4 modes of PA ; (clamp for a minimum of 30mins to 2hours)
system,
cephalocaudal- age, severity, protocol Stool- fecalysis, culture and sensitivity ,
I- well lighted and ventilated area occult blood (GUIAC)- peptic ulcer determination,
P- light(suoerficial), deep ( size, mobility consistency of organ or mass) ; gastric ca analysis, no: red meat, iron, dark
finger pads, colored food, hgb. (2-3days)
P- flat(muscles and bones), tympanic sounds (stomach), dull(hollow pea size is enough
organ, liver pancreas heart), resonance (normal lungs),hyper resonance .
increase level of secretion(normal if 3 y.o.) Sputum – culture sensitivity, acid fast bacilli staining-TB
A- direct – unaided ear (collected 3 consecutive moring)
indirect- gadget or instrument -early morning collection
Battery- touched, assault- verbalized -avoid commercial mouth wash
3. Lab procedure -before giving any type of antibiotic
Use of diff. specimen; blood semen urine stool sputum >deep breathing and cough exercise-able to
Huhner‟s Test-post coital examination.(sperm as specimen) use to cough/expectorate
determine the motility of the sperm. 2-3 hours prior to collect -cascade-able to cough and expectorate
Arterial blood gas- most recommended radial artery, 10 ml pre- with minimal effort
heparinized syringe; placed on ice filled container -pursed lip technique; inhale
pH: 7.35-7.45 7.31-7.41 thru nose hold for 5 sec., exhale thru pursed lips
pO2: 80-100 30-40 3x. then inhale thru nose and hold and cough
pCO2: 35-45 41-45 -huff able to cough and expectorate but
HCO3: 22-26 21-29 max effort is needed
o2sat: 95 60-80 - inhale thru nose hold for 5
sec., exhale while stating huff 3x. then inhale thru
respiratory acidosis: rr decrease; temp decrease; bp decrease, pulse nose and hold and cough
increasedisoriented, depress, apathetic, confused quad- person wchich need effort in
metabolic acidosis; nausea, mild to moderate dehydration, abdominal terms of respiration. inhale inward upward
cramping, diarrhea exhale release. Inhale inward upward hold and
metabolic alkalosis; vomiting, nausea cough release
respiratory alkalosis; fever, anxiety >suctioning- able to cough but not expectorate
KenSanRN
 -naso/oro pharyngeal- able to  Preschool 300-500ml, fr 16-18, 2-3in
cough and expectorate  School age to adult- 500-1000ml, fr22-30, 3-
-naso oro thracheal- not able to 4in
cough and not able to expectorate  Solution
Rule of thumb- nose  Water- to lower temperature
to earlobe  Soap-sud- cleansing enema to stimulate
-tracheal- artificial airway peristalsis
>CPT- if the client cant expectorate at least 30 ml  Castile soap, 20cc:1000ml Nsaline/
of secretion, nebulization before cpt, ci; water
emaciated  Sodium phosphate- constipation
-chest percussion- lower to upper  Commercially prepared solution
-chest vibration  Fleet enema
-postural drainage- high fowlers‟ (upper  Saline based solution-0.9% NaCl
lobe), trendelenburg (lower lobe),
 Oil-retention enema
superior(supine), posterior(prone) 15 -20 mins/
position
 Cleansing enema- allowed to perform to a max of 3time , 5-10
4. Visualization
mins
o High cleansing- 1000 ml, 12-18inch above the
>direct- invasive procedure, obtain consent, NPO for atleast 6-8‟,
rectum
sedation
o Low cleansing- 500ml, <12 in
>indirect- use of x ray to visualize, remove all metal,
 Carminative enema-expel flatus, 80 -100 ml,water
- dye- assess for allergy
 Oil retention enema- best to relieve fecal impaction, 5-6x,
-electrical impulse- remove all metal
Fullness stop and kink lower the irrigation and
unkink after 30 secs.
Elimination
1. Constipation
2. Fecal impaction- defecation is absent for 3-5 day
a. High fiber diet
i. Best removal-is manual; oil retention before digital removal
b. Increase fluid intake
3. Flatulence – too much air swallowed, blood diffusion, bacterial action
c. Exercise
i. Avoid gas forming food
d. Respond immediately for any urge to defecate
ii. Avoid the use of straw
e. Laxative as ordered.
iii. Avoid chewing gum
i. Can cause diarrhea
iv. Provide warm fluid
ii. Could destroy normal defecatingreflexes
v. Proper positioning- knee chest position, prone position
Bulk forming –psyllium- increase solid liquid gas- increase fluid
(place a small pillow under the stomach)
intake, It‟ll take 3 days.
4. Diarrhea
Saline based- (salt) fluin retention- form bulk e.g. milk of magnesia,
i. Place in low fiber diet
Not to be used for too young and too old.
ii. Replace all fluid and electrolyte loss
Stool softener- colace- 1-3 days before effect, allows water to enter
iii. Conserve energy
dtool, delays drying of stool
iv. Encourage increase potassium intake
Chemical irritant- castor oil- increases gastric motility to empty
a. Gatorade-small frequent sip
bowel
v. BRAT diet
Can lead to fluid and electrolyte imbalance.
vi. Bland diet
Lubricant- mineral oil
 Softens the stool while lubricating the anal canal Urinary elimination
f. Enema 1. Dysuria- painful voiding
i. Evacuation, empty bowel of content esp. prior operation 2. Hematuria- blood in urine
ii. Lower body temperature 3. Enuresis- frequent urination
a. Nocturnal enuresis- night
 Age- volume, catheter size and total length b. Diurnal enuresis-day
 Infant 50-200ml, fr 10-12, 1-1.5 in c. Primary enuresis- didn‟t learn how to control
 Toddler 200-300ml, fr 14-16, 2-3 in
KenSanRN
 d. Secondary enuresis- assoc. with dse. - Ointment- inner to outer (close eyes wipe the excess
4. Incontinence- not capable to control voiding med)
a. Functional- aware of urge– unpredictable passage of urine Otic- straighten the ear canal
b. Urge – aware of the urge- minimal warning- uncontrollable Adult –up and back
passage of urine Child- down and back (3yo below)
i. Place a client on toilet training, discipline the client, Nasal installation- supine pos., slightly hyperextend neck,
teach how to control; days-every two hours, night- gently lift nose and drop medication maintain pos. 3-5
every 4 hours mins
c. Stress incontinence- increase abdominal pressure- leakage of Rectal – sims lateral
urine/ uncontrollable passage of urine; dribbling urine Vaginal-dorsal recumbal
i. Lessen the pressure= pelvic exercise=keggel Injection- im -90 „
d. Reflex- is not aware of any urge to void; uncontrollable feeling -1 – 3 ml max per injection
i. Catheter Sites
- deltoid
Catheterization = last option and priority - vastus lateralis (7 mo below), mid leg
Aseptic technique; -ventro gluteal (7 mo above)
 consider for the gender; - dorso gluteal (3yrs old above)(has been
Male= fr. 16- 18, supine, 6-9 in, lower abdomen, walking for 1 yr)
Female= fr. 12-14, dorsal recumbent, 3-4 in, upper inner thigh - deep Im- Z track – prevent leakage of med back
to subQ
 type - slow admin; 0.1ml:1sec.
o straight catheterization-1 way foley catheter Id- just beneath the skin(5-15”), skin test and
 gradual decompression, at level of symphysis pubis, not tuberculin test
more than 1000 ml/ per irrigation= can cause Skin test
hypovolemic shock -to identify whether a client is having allergic
 repeat after 2-3 hours reaction towards any medication
o retention catheter -hairless(left is for tuberculin, right for skin test)
 2way foley- inflate with 5-10 ml of water - bevel up, form bleb, and outline with blue or
 3 way foley- continous bladder irrication- Cystoclysis black and place a micropore near a site for infos.
 - assess for temp, rashes, itchiness after 30 mins
MEDICATION Mantoux test
Chemical substances that are used to treat diagnose and cure -for tb
- tuberculin syringe
Administration - PPD 1 cc
Right client- ask to state name -assess for induration, measure in (mm) after 12
Right drug- hours; peak of interpretation after 48 to 72
Right dose- 5-9 mm= ?= tx; 10 mm= + =tx
Age Subq
Height and weight -administered in fat layer
Right time- can be 30 mins before or after the time - 45 or 90‟
Right documentation - 0.5ml-1.5 ml; if more than= pain
Right route- - insulin- never massage site might cause hypogly
Internal- - regular, short, clear first, air intro start
Oral with the other.
Buccal - anticoagulant- avoid green leafy veg., never
Sublingual massage, no aspiration
Topical – IV
Through our skin (hairless) Isotonic - equilibrium
Eyes-drops- lower conjunctival sac 1-2cm (press - inc. extra cellular fluid
nasolacrimal) .9 NaCl- isotonicity of blood

KenSanRN
 .5% dextrose- when it enters body >initiate after 30 min
changes to hypertonic >stay with client for first 15-30 min.
Ringer- Na Cl K Ca >4 hours
Lactated Ringer- has lactic acid and
forms bicarbonate- and is for metabolic acidosis Whole blood- 300-400- 4 hours
Hypotonic- lesser con. than body fluid Packed RBC-250-300- 4hours
- Lowers osmotic pressure Albumin- 10-20- 20 mins
- O.45 % NaCl- nutrient solution – rich in water and carbo Plasma-300ml- 3 hours
- 0.33% NaCl- FFP- 6 hours
- 2.5% Dextrose
Hypertonic- greater con. than body fluid Complications
- Increase osmotic pressure Allergic reaction
- Increase extra cellular fluid Mild- hyper sensitivity of the plasma of the donor
- D5LR, D5W, D5NaCl, D25W >rashes, urticaria, itchiness
Severe- antigen antibody formation
Complications with IV: >hypotension, DOB, chest pain
Infection: iv tubing, cannula should be replaced Septic Reaction
every 2-3days >contaminated blood
: iv dressing site should be replaced >nausea, vomiting, hypotension,
every shift, 8‟ , headache, drowsiness, dizziness, DOB, Chest pain
Infiltration: out of vein; dislodge, pallor, cold Hemolytic Reaction
: remove cannula, and apply warm >incompatible blood
compress > tachycardia, hypotension, DOB, chest
Phlebitis: inflammation of the vein pain, lower back pain, hematuria
: caused by over use of vein, irritation of Febrile reaction
the vein due to overdose or over concentration of med, >non hemolytic reaction
warm, red >hypersensitivity to plasma, rbc, wbc
:cold; and warm compress (if swelling >fever, hypotension,
goes away)
Circulatory overload
>hypertension
5 cardinal signs :Inflammation > distended neck vein
Rubor- red- increase blood volume
Calor-heat- increase blood volume SToP infusion, and start 0.9% NaCl (fast drip), monitor V/S,
Tumor-swelling administer antihistamine/ antibiotic/ bronchodilator/
Dolor-pain antipyretic
Functio laesa- loss of function
Comfort measure
Rest- Free from any form of anxiety
Blood transfusion Sleep- State of consciousness the individual perception and responses to
Restores blood volume stimuli is decrease
Improve o2carrying capacity NREM- a very light sleep to deepest stage of sleep
>aseptic technique - To conserve energy
>proper documentation REM - dream state of sleep
>secure consent - Increase synthesis processes in our brain
>V/s monitoring
>type, cross matching, serial code, expiration 5 Stages of Sleep
>before and after infuse .9naCl- KVO (10ml) 1- very light sleep= 5-10 min muscle relaxation till s.4, easily
>18/19 gauge arousable till s 2
>label blood 2- sound sleep= 10-20 min, normal-slow
>warm blood @ room temp 3- initial stage of deep sleep= 15-30min, slow-decline
KenSanRN
 4- deep sleep=
5- dream state= 90 min after sleep, loosing of skeletal tone Vitamins
Water soluble
insomnia- Vit. C –ascorbic acid: antioxidant, boost immune system
initial- problem in initiating sleep X= scurvy
terminal- early awakening B1- thiamine carbohydrate metabolism
intermittent- difficulty in staying asleep X=beriberi
hypersomnia B2-riboflavin protein synthesis
prolong sleep X=skin lesion
narcolepsy B3- niacin skin and cellular respiration
sleep attack, uncontrollable sleepiness X= dermatitis, pellagra
sleep apnea B6 pyridoxine calcium reabsorption, growth and devt
difficulty in sleeping due cessation of breathing X=peripheral neuritis
sleep deprivation B9 folic carbohydrate metabolism
disturbed sleep pattern X=megaloblastic anemia
B12cobalamin
Parasomnia X= pernicious anemia
Bruxism- grinding of teeth Biotin/panthotenic acid fat metabolism
Somnambulism- sleep walk X=muscle weakness, fatigue
>companionship, check client, assign near station Fat soluble
Soliloquy- sleep talker A retinol
Nocturnal enuresis- bedwetting X=night blindness
Nocturnal erection/ emission- D ergocalciferol
x= rickets
Drugs E tocoferol
Alcohol- speed onset of sleep; easily arousable X= anemia
Caffeine-CNS stimulant, increase alertness, prolong use increases the K menadione
alertness X=bleeding
Diuretics- take/give during morning
Hypnotics- interferes reaching deep sleep Anorexia- fear of eating
Nasal decongestant- drowsiness Gradual approach= small frequent feeding
Anti histamine- drowsiness, prolong day time sleepiness Trace any anxiety
Narcotics- suppress REM N/V= metabolic alkalosis
Beta adrenergic blocker- causes nightmare Ice chips, Hot ginger ale/kalamansi/lemo/honey
Anti depressant- suppress REM Crackers or Toast
Benzodiazepam- Prolong sleepiness Prevent aspiration; position
Remove sources of unpleasant odor
Promote sleep: Replace fluid and electrolyte
Increase protein intake: high in tryptopan Clear diet diet
Exercise before 2 hours sleep
Conducive environment for rest and sleep Bulimia- eat purge cycle
Provide relaxation technique Psychological approach
Attend to bed time rituals
Malnutrition
Nutrition Over or under nutrition
Organic and inorganic chemicals found in food that are converted to energy
and is expressed as calories IBW- 1-10%
:water 1kg= 1kcal
:carbohydrates I gm=4cal Over nutrition
;CHON 1gm=4cal Overweight 11-20%
:fats 1gm=9cal Obese
KenSanRN
 Mild21-40% moderate 41-100% severe 100% and -measure- anterior aspect of axilla to the foot +2.5 cm (lying);
above anterior aspect of axilla to the foot 3+4 finger (standing)
Under Nutrition - stand- promote tripod position( place crutches 6 inch forward and
Kwashiorkor sideward)(max 1ft.)
Marasmus -Walk >gaits
 4 point gait- min of 3 bearing point- right crutch-
>Consider for the preference left foot-left crutch-right foot
>age of the patient  3point/orthopedic gait -weaker extremity that
>culture can bear weight- both crutch and weak leg
>practices followed by the strong leg
>recommended diet  2point gait – modification of 4 point gait- right
>liquid diet- clear- acute and chronic/ vomited/ post or crutch&left foot-left crutch&right foot
(short term therapy)  Swinging gait- crutches first then legs
-Full/ transitional diet- post or/ (long term o Swing to: safer, maximize tripod- swing
therapy) high in CHO, fat and H2O min of CHON towards the level of crutch
>soft- for those with dysphagia o Swing through: swing towards the level
- Pureed (head/neck injury) and beyond of crutch
-mechanical (stomatitis) -stairs: going up good leg bad leg crutches
Special diets : going down crutch bad leg good leg
>diabetic diet- small frequent feeding: high in fiber, -sitting
CHO(50-60% of intake) >cane
>BRAT diet- diarrhea -measure- level of the greater trochanter
>bland diet- no spices- a gastric/bowel irritable syndrome -support- stronger side of the body
>DAT- -walk –cane-weaker-stronger (great stability)
>low cholesterol diet- heart‟s meal diet- max 300mg/day -cane & weaker- stronger (lesser)
>low Na- no salt added- renal, cardiac, hpn >walker
_ measure- level of the greater trochanter
>Stimulate appetite --walk –walker-weaker-stronger (great stability)
> Food safety -walker & weaker- stronger (lesser)
>perform/encourage hand washing
>wash food: food bleach: 1cc:100ml >restraint
>discard / refrigerate - to limit the client‟s physical activity
>expiration date - client should be free from any form of restraint; restraint if to
>assist in feeding transport, procedure, has disruptive behavior
>NGT-Lavage, (NEX) -secure doctor‟s order within 25 hours
>NET- Gavage (NEX+12-20cm) -consent
>aseptic >elevate - restraint should be anchored to the bed frame
head of bed - adequate ventilation
>measure of length of catheter >lubricate - free movement as possible
with water based - assess every 2 hours, V/S
>advance(hyperextend-nose-nasopharynx-tilt- -check site every 15 min to 1 hour
oropharynx) - remove restraint every two hours
- remove one at a time with 30 min interval
Proper Placement • Mechanical- gadget/ instruments attached to client
>X-ray >Auscultate >Aspirate • Chemical- drug/medication
>Immersion >pressure sore
 Pressure
Safety and mobility  Friction
>crutches  Shearing force
-pair  Malnourish
o Obese
KenSanRN
 o Emaciated
o Decrease CHON
 Immobile
 Bowel and bladder incontinence
 Decrease mental capacity
 Diminished sensation
 Increased temperature

Stages of pressure sore

 One-non blanchable erythema of the intact skin(epidermis)
 Two- Partial skin thickness loss, bleeding, hollow crater formation
(dermis)
 Three - Full thickness skin loss crater formation, (epi,dermis, subq)
 Four- Full thickness skin loss crater formation (epi,dermis, subq,
bones, muscles)

KenSanRN