Fundamentals Saci

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Fundamentals SACI

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TABLE OF CONTENTS

I.THEORETICAL FRAMEWORK of NURSING PRACTICE

A. NURSING……………………………….1ProfessionBenner Level of Proficiency

B. Nursing History…………………………1

Intuitive PeriodApprentice PeriodDark PeriodEducative PeriodContemporary PeriodNursing in the Philippine Setting

C. Nursing Theories & Theorists………..2-34 Concepts of Nursing TheoriesClassifications of Theories(Nursing Theorists)

II. STRESS & COPING A.Localized Adaptiation Syndrome (LAS)

…..3B.Generalized Adaptation Syndrome (GAS)

…..3

III. INFECTION CONTROL A.Airborne……………..4B.Droplet………………..4C.Contact………………4D.Enteric………………..4E.Neutropenic precaution….4F. Bleeding precaution………4

IV. FUNDAMENTAL HUMAN NEEDS A. OXYGENATION…………………

……4-6Normal breath soundsAdventitious breath soundsAltered breathing pattern

PROCEDURESi. SUCTIONING

b. Oropharyngealc.Nasopharyngeald. Endotracheale. Tracheostomy

ii. OXYGEN THERAPYa. Low Flow System

b. High Flow Systemiii. CHEST PHYSIOTHERAPYiv. CHEST DRAINAGEv. ABG INTERPRETATION

B. NUTRITION……………………….7Vitamins

Water SolubleFat-soluble

PROCEDURESi. NASOGASTRIC TUBE

C. BOWEL/FECAL ELIMINATION…….7

PROCEDURES:EnemaStoma Care

D.URINARY ELIMINATION…………….8 Urinary Incontinence

PROCEDURES:CatheterizationContinuous bladder irrigation

V. FLUIDS & ELECTROLYTESFLUID VOLUME………………………..8

Fluid volume excessFluid volume deficit

ELECTROLYTES………………………..9 Sodium

HyponatremiaHypernatremia

PotassiumHypokalemiaHyperkalemia

CalciumHypercalcemia

Hypocalcemia

VI.GERIATRIC NURSING………….10

VII. MEDICATION--------------10 VIII. DEATH & DYING ………….10Post Mortem Care

FUNDAMENTALS OF NURSING

NURSING

BENNER’S LEVEL OF PROFICIENCY

NURSING HISTORY

1. I _____________________ -

Babylonia

Egypt

Israel

China

India

Greece

Rome2. A ______________________-

3. D ______________________-

4. E _______________________-

5. C _____________________-

NURSING IN THE PHILIPPINE SETTING

“Commit to the Lord whatever you do and your plans will succeed’ Prov. 16:3 FUNDAMENTALS OF NURSINGMs. Christy Bustillo RN USRN CRCP

LEVELS OF PROFICIENCY EXPERIENCE

RULES/MAXIMS

ORGANIZATIONAL ABILITY

SPEED/FLEXIBILIT

Y

HOLISTIC

I. THEORETICAL FRAMEWORK of NURSING PRACTICE

FLORENCE NIGHTINGALE VIRGINIA HENDERSON

MARTHA ROGER

SISTER CALLISTA ROY

1577 – ______________________________- first hospital for the Spanish wounded soldiers 1578 – ______________________________- Hospital by Bro. Juan Clemente (Leprosy) 1906 – ______________________________-first Nursing school 1907

o _________________________o _________________________o _________________________o _________________________

______________________________- Philippine Nurses Association by Anastacia Giron-Tupas

A. GENERAL THEORIES

B. SYSTEM THEORIES

“Commit to the Lord whatever you do and your plans will succeed’ Prov. 16:3 FUNDAMENTALS OF NURSINGMs. Christy Bustillo RN USRN CRCP

DOROTHY JOHNSON

IMOGENE KING

BETTY NEUMAN

NURSING THEORIES

DOROTHEA OREM

PAGE 1

IDA JEAN ORLANDO

C. INTERPERSONAL THEORIES

D. CLIENT-CENTERED THEORIES

___________________________________

LOCALIZED ADAPTATION SYNDROME

GENERALIZED ADAPTATION SYNDROME

“Commit to the Lord whatever you do and your plans will succeed’ Prov. 16:3 FUNDAMENTALS OF NURSINGMs. Christy Bustillo RN USRN CRCP

JEAN WATSON

LYDIA HALL

MADELEINE LEININGERHILDEGARD PEPLAU

FAYE GLEN ABDELLAH MYRA LEVINE

NOLA PENDER

PAGE 2

II. STRESS AND COPING

FIRST TIER: STANDARD PRECAUTION SECOND TIER: TRANSMISSION-BASED PRECAUTION

Guidelines: HANDWASHING GLOVES GOWN GOGGLES

Diseases:

H-A-L-L-

P-A-T-I-E-N-T-

O X Y G E N A T I O N

“Commit to the Lord whatever you do and your plans will succeed’ Prov. 16:3 FUNDAMENTALS OF NURSINGMs. Christy Bustillo RN USRN CRCP

PAGE 3III. INFECTION CONTROL

IV. FUNDAMENTAL HUMAN NEEDS

SUCTIONING

GUIDELINES DISORDERSAIRBORNE M-

T-V-HZ-

DROPLET D-R-O-p-L-E-T-I-S-M-

CONTACT C-R-I-B-M-V-H-

ENTERIC

SUCTIONIN

“Commit to the Lord whatever you do and your plans will succeed’ Prov. 16:3 FUNDAMENTALS OF NURSINGMs. Christy Bustillo RN USRN CRCP

PAGE 4

Tracheobronchial Secretions

ENDOTRACHEAL TUBE TRACHEOSTOMY TUBE TRACHEOSTOMY CARE

OXYGEN THERAPY

CHEST PHYSIOTHERAPYPercussion Vibration Postural Drainage

CHEST PHYSIOTHERAPY CHEST DRAINAGE SYSTEM

ABG INTERPRETATION

Test: _______________________

RESPIRATORY METABOLIC

ACIDOSIS

ALKALOSIS PAGE 5

Normal Values:Ph PaCO2

mmHg

HCO3 mEq/L

paO2 mmHg

SaO2 %

N U T R I T I O NMACRONUTRIENTS - Carbohydrates/ Protein/ Fats

Diet Indication Purpose Limit Encourage

LOW PROTEINMeat, eggs, milk products

Carbohydrates and supplement with amino acids.

HIGH PROTEIN Meat, fish, dairy products.

LOW CHOLESTEROL

Fried food, egg yolk, shellfish, liver, pork.

Broiled or steamed food, fruits, vegetables, chicken meat, vegetable oils.

LOW FAT DIET

Fatty meat, gravy, cream, chocolate, nuts.

Vegetable, fruits, lean meats, fish.

BALANCED DIET

Principle: All meals should contain all three main groups. Avoid skipping or delaying meals. Frequent, small meals are better.

 

**Bland Diet Hot spices, raw foods. Milk, butter, eggs, white bread, broiled potatoes.

MICRONUTRIENTS - Vitamins & Minerals“FAT-SOLUBLE VITAMINS”

VITAMINS DEFICIENCY FOOD SOURCESA Liver, egg yolk, carrots

D Milk, sunshineE Vegetable oilsK Liver, egg yolk, green leafy vegetables

“WATER-SOLUBLE VITAMINS”VITAMINS DEFICIENCY FOOD SOURCES

C Citrus fruits

B1 (Thiamine) Liver, meat

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B2 (RIBOFLAVIN0 Liver, meat

B3 (NIACIN) Liver, meat

B6 (PYRIDOXINE) Rice, wheat

B9 (FOLIC ACID) Green Leafy vegetables

B12 (CYANOCOBALAMIN) Liver, meat

NASOGASTRIC TUBE

B O W E L E L I M I N A T I O N

ENEMA

NON-RETENTION

RETENTION

SOLUTION USEDHEIGHT

TEMPERATURE

TIME OF RETENTION

CARE OF THE CLIENTS WITH STOMA

U R I N A R Y E L I M I N A T I O N

URINARY INCONTINENCE URINARY RETENTION CONTINUOUS BLADDER IRRIGATION

Stress: CATHETERIZATION

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Urge:

Mixed:

Overflow:

Functional:

B O D Y F L U I D S

TONICITY OF INTRAVENOUS SOLUTIONS

HYPOTONIC ISOTONIC HYPERTONIC

FLUID IMBALANCES

FLUID VOLUME DEFICIT FLUID VOLUME EXCESS

E L E C T R O L Y T E SCATIONS (+) ANIONS (-)

Sodium (Na) mEq/L

Potassium (K) mEq/L

Calcium (Ca) mg/dl

Magnesium (Mg) mg/Dl

Phosphate (P04) mg/Dl

Chloride (Cl) mmOL/L

Bicarbonate (HCO3)

SODIUM Food sources:

HYPONATREMIA HYPERNATREMIA

V. FLUIDS AND ELECTROLYTES

PAGE 8

POTASSIUMFood Sources:

HYPOKALEMIA HYPERKALEMIA

CNS

GITMUSCLES Skeletal: Smooth:MGT

CNS

GITMUSCLES Skeletal: Smooth:MGT

CALCIUMFood sources:

HYPOCALCEMIA HYPERCALCEMIA

GERIATRIC NURSING OVERVIEW

Dev’t Task:________________________________A.Cognitive decline: ______________________B.___ Visual acuity: ________________________C.___Hearing: _____________________________D.___Lung Residual volume: ________________E.___Clotting: ______________________________

F.COLOR difficult to be distinguished: _______G.Bone deminiralization:____________________H.____ Gastric enzymes: ___________________I. ____ BLADDER CAPACITY: _________________J. ____ GFR: ________________________________K. ____ NO. of TASTE BUDS

PARENTERAL MEDICATIONS

Injection Route Best Site Angle Gauge

(needle)Intradermal (ID) G 25-27

VI. GERIATRIC NURSING

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VII. MEDICATIONS

Subcutaneous (SQ)

G 23-25

Intramuscular (IM)

G 20-22

Intravenous (IV) VARIES

Z TRACK METHOD

INTRAVENOUS FLUIDS

Complications of IV Infusion (CHEMOTHERAPEUTIC drugs

NON-VESICANT VESICANT

BLOOD TRANSFUSION

FRESH WHOLE BLOOD/PACKED RBC

PLATELET & FRESH FROZEN

PLASMA

PRE:

INTRA:

POST:

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VIII. PRINCIPLES OF DEATH & DYING (POST MORTEM CARE)