PREBOARD Handout Revised

8/3/2019 PREBOARD Handout Revised

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PROFESSIONAL REVIEW NETWORK, INC.

COURSE AUDIT 2PREBOARD HANDOUT

NURSING PRACTICE I:

FOUNDATIONS OF NURSING PRACTICE

NURSING THEORIES

Faye Abdellah Identification of 21 NursingProblems

Lydia Hall Care, Core and Cure (3 Cs)

Virginia Henderson Identification of the 14 BasicNeeds

Imogene King Goal Attainment Theory

Madeleine Leininger Transcultural Nursing

Myra Levine FourConservationPrinciples

Florence Nightingale Environmental Theory

Betty Neuman Stress Reduction

Dorothea Orem Self-Care and Self-Deficit

Rosemarie Parse Human Becoming

Hildegard Peplau Interpersonal Relations Model

Martha Rogers Science of Unitary HumanBeings

Callista Roy Adaptation Model

Jean Watson Human Caring

Metaparadigm for Nursing Theories: CHEN (Client, Health,

Environment, Nursing)

CHAIN OF INFECTION

SIX LINKS

Host (susceptible)

Agent

Reservoir

Entry (mode of)

Transmission (mode of) direct, vehicle, vector

Exit (mode of)

SURGICAL VS MEDICAL ASEPSIS

Surgical sterile free from ALL microorganisms

Medical clean free from pathogenic microorganisms

ISOLATION PRECAUTIONS

Standard Precautions (Universal precautions)

Applies to ALL body fluids, secretions, blood, non-

intact skin and excretions except sweat

Includes hand washing, wearing clean gloves, maskand 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

Droplet used for clients with illnesses transmittedby droplet nuclei ( greater than 5 microns)

Examples: Diptheria, Pertussis, Meningitis,

Mumps

Wear mask when working within 3 feet

from the client

HANDWASHING

Should be done under stream of water or at least

20 seconds

Purpose: To reduce the number of microorganismon the hands and reduce transmission of

microorganisms to client.

Wash the hands in firm, rubbing, and circular

motion.

GLOVING

Purpose: To enable the nurse to handle or touch

sterile objects freely without contaminating them.

Sterile Gloving

Donned by the open method or closed method.

Open method is most frequently used outside theoperating room because the closed method requires

that the nurse wear a sterile gown.

After second glove is on, interlock hands together,

above waist level. Be sure to touch only sterile

sides

PERSONAL PROTECTIVE EQUIPMENT

Purpose: To protect health care workers and clients

from transmission of potentially infective materials.

STEPS:

1. Hand hygiene

2. Don a clean gown

- Overlap the gown at the back to cover the nurses

uniform.

3. A facemask and eye protection covering the

nose, mouth, and eye.

4. Don clean disposable gloves

- No special technique is required

Removing PPE

1. Remove the gloves first (most soiled)

2. Perform hand hygiene

3. Remove protective eyewear and dispose of

properly or place in the appropriate receptacle for

cleaning

4. Remove the mask (untie the top strings) and

dispose.

INSERTION OF NASOGASTRIC TUBE

Measure length of tube tip of the nose to

the tip of the earlobe to the xiphoid process

Position High Fowlers position with

neck hyperextended

Lubricate tip of tube with water soluble

lubricant

Instruct the client to swallow or drink from

a straw while the tube is being inserted

STOP and remove the tube if client

becomes cyanotic or coughs

Placement- check

- Aspirate gastric secretions measure pH

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- Auscultate and inject air into the tube(whooshing sound)

- X-ray best measure to determine properplacement (initial placement)

Secure tube using tape to the bridge of the

clients nose and to the clients gown

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

URINARY CATHETERIZATION

Sterile technique

Insertion

Male Female

Position Supine (legs

slightly abducted)

Penis at 90

degree angle

Supine (with

knees flexed

and externally

rotated)

Length to

be inserted

6-9 inches 2-3 inches

Length of

catheter

(Adult)

40 cm 22 cm

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, platelets

not more than 20 minutes

Rate: KVO

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

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

ASSISTIVE DEVICES

CANES

opposite the affected leg (C-O-A-L)

angle is 20 to 30 degrees

the length should permit the elbow to slightly flex

WALKERS

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.

SPECIAL DIETS

Diet Disorder

Low

carbohydrate

Dumping syndrome

Low protein Renal failure, Acute

glomerulonephritis, uremia, anuriaHigh protein Nephrotic syndrome

Low sodium Heart failure, CVDs, Nephrotic

syndrome

High fiber Constipation, hyperlipidemia

Low residue Bowel inflammation ( diverticulitis and


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ulcerative colitis)

Acid/Alkaline

ash

(depending on the lab analysis of the

stones)

Retard renal calculi formation

Clear liquid Following acute vomiting or diarrhea

Full liquid Gastrointestinal upsets, progression

from clear liquids

Gluten-free For clients with Celiac disease

Tyramine-free To prevent fermented and processedfoods for clients taking MAOIs

Purine

restricted

Gouty arthritis, uric acid stones

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

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

NURSING PROCESS

Assessment

Systematic and continuous collection, organization,

validation, and documentation of data

(information). Types of data:

- Subjective data/Symptoms /Covert data

- Objective data/Signs/Overt data

Sources of data:

- Primary: Client (best source of data)

- All other than the client

Conceptual Models/Frameworks

- Wellness models is use by the nurse to identify

health risk and to explore lifestyle habits and health

behaviors, beliefs, and values that influence levels

of wellness.

Nursing Diagnosis

Refers to a statement or conclusion regarding the

nature of phenomenon.

Types of nursing Diagnosis:

1. Actual diagnosis is a client problem that is

present at the time of the nursing assessment.

2. Risk Nursing Diagnosis- a clinical judgment that

a problem does not exist, but the presence of risk

factors indicate that a problem is likely to develop

unless nurses intervene.

3. Wellness Diagnosis

4. Possible Nursing Diagnosis

5. Syndrome Diagnosis

Problem-etiology-signs and symptoms format (PES

format)

VITAL SIGNS


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Ex. Older patients are more at risk for experiencing a fallthan younger patientsNondirectional hypothesis does not stipulate thedirection of the relationshipEx. There is a relationship between the age of a patient andthe risk for falling.Research hypothesis (also referred to as substantive,declarative, or scientific hypotheses) are statements ofexpected relationships between variables

Null hypothesis (or statistical hypotheses) states thatthere is no relationship between the independent anddependent variables.

Type I error by rejecting a null hypothesis that is, infact, TRUE leads to false positive conclusionType II error false negative conclusion

TRUE FALSE

True (Nullaccepted)

Correct decision Type II error(False negative)

False (Nullrejected)

Type I error(False positive)

Correct decision

B. DESIGN AND PLANNING PHASEStep 6: Selecting a Research design

RESEARCH DESIGNSResearch Design is a blueprint of conducting a studythat maximizes control over factors that could interferewith the validity of the findings.

Types of Designs according to Timeframesa. Cross-Sectional Design involve the collection of dataonce: the phenomena under study are captured during oneperiod of data collection. This design is appropriate fordescribing the status of phenomena or for describingrelationships among phenomena at fixed point in time

b. Longitudinal Design a study in which data arecollected at more than one point in time over an extendedperiod.c. Retrospective Design involves collecting data on anoutcome occurring in the present, and then linking itretrospectively to antecedents or determinants occurring inthe pastd. Prospective Design information is first collectedabout a presumed cause or antecedent, and thensubsequently the effect or outcome is measured.

RESEARCH METHODS

Quantitative Research - This applies to the manipulationand control of phenomena and verification of results, usingempirical data gathered through the senses. It is also calledas hard science, characterized by replicable and reliabledata.Qualitative Research Focuses on insights andunderstanding of individual perceptions on the phenomenonunder study. It is considered as a soft science, concernedwith the subjective meaning of experience to anindividual.

Types of QuantitativeResearch

1. Descriptive Research2. Correlational Research

3. Quasi-experimentalResearch4. Experimental Research

Types of QualitativeResearch1. PhenomenologicalResearch

2. Grounded TheoryResearch3. EthnographicResearch4. Historical Research5. Case studies

Experimental Research

an inquiry on cause-and-effect relationships. The

researcher controls and manipulates theindependent variable and randomly assigns thesubjects to different conditions or situations.

Strengths:

most powerful method available for testinghypotheses of cause-and-effect relationshipsbetween variables

considered the GOLD standard forintervention studies because it yields the highest-quality evidence regarding intervention effects

Limitations:HALO EFFECT - When researchers consider a person/respondent good (or bad) in one category, they are likelyto make a similar evaluation in other categories. It mayalso be connected with dissonance avoidance, as makingthem good at one thing and bad at another would makean overall evaluation difficult.HAWTHORNE EFFECT - describes a temporary change tobehavior or performance in response to a change in theenvironmental conditions; participants respond in a certainmanner because they are aware that they are beingobserved

Characteristics of a true experimental designManipulation (doing something to the study participants) the researcher manipulates he INDEPENDENT variable byadministering a treatment (intervention) to somesubjects and withholding it from others, or by administeringsome other treatment.Control the experimenter introduces controls over theexperimental situationControl group refers to a group of subjects whoseperformance on a dependent variable is used to evaluatethe performance of the treatment group on the same

dependent variable.Randomization (also called random assignment orrandom allocation) involves placing subjects into treatmentconditions at random.

Quasi-Experimental Research like true experiments,involve an intervention. However, quasi-experimentaldesigns lack randomization, the signature of a trueexperiment.Non-Experimental Research - the researcher does notinterfere with nature and the conditions for research arerealistic or uncontrolled. (Dr. CB Tan)Descriptive Research the purpose of descriptive studiesis to observe, describe and document aspects of a situationas it naturally occurs and sometimes to serve as a startingpoint for hypothesis generation or theory development.

Correlational Research the researcher study the effectof a potential cause that they cannot manipulate, they usedesigns that examine relationships between variables. Theresearcher does not control the independent variableAdditional: Outcomes Research is designed todocument the effectiveness of health care services and alsoplays an important role in policy research.

Outcomes of Patient, Provider, & Health Care System

Outcomes used to develop Policy

Change Practice based on ResearchPhenomenological Research asks the essence of a

phenomenon as experienced by the people and what doesit mean. Phenomenologists view human existence asmeaningful and interesting because of peoplesconsciousness of that existence.Ethnography involves description and interpretation ofcultural behavior.


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Fieldwork: is the process by which the ethnographerinevitably comes to understand a cultureStep 7: Developing protocols for the InterventionStep 8: Identifying the populationPopulation is the entire aggregation of cases in which aresearcher is interestedStep 9: Designing the sampling plan

SAMPLING

is the process of selecting a portion of the populationto represent the entire population so that inferencesabout the population can be made

Sample is a subset of population elements. An elementis the most basic unit about which information is collected.

SAMPLING METHODNon-Probability Sampling

Accidental also known as Convenience sampling, entailsusing the most conveniently available people as studyparticipantsQuota is one in which the researcher identifiespopulation strata and determines how many participantsare needed from each stratum

Purposive or Judgment based on the belief thatresearchers knowledge about the population can be usedto hand-pick sample membersSnowball or Network is a variant of conveni

encesampling. Early sample members (called seeds) are askedto refer other people who meet the eligibility criteriaProbability SamplingSimple random most basic type of probability sampling,fish ball methodStratified random the population is first divided intotwo or more strata. As with quota sampling, the aim of

stratified sampling is to enhance representativeness.Subdivide the population into homogenous subsets fromwhich an appropriate number of elements are selected at

randomCluster usual procedure in selecting samples from ageneral population is to states, census tracts, and thenhouseholdsSystematic involves the selection of every kth case froma list, such as every 10th person on a patient list or every100th person in a directory.

Ex. If we were seeking a sample of 200 from apopulation of 40,000, then our sampling intervalwould be as follows:

k = 40,000 = 200200

Step 10: Specifying Methods to measure the research

variablesStep 11: Developing Methods to safeguard Humanand Animal rightsStep 12: Reviewing and Finalizing the Research Plan

C. EMPIRICAL PHASEStep 13: Collecting data

CENTRAL TENDENCIES

MODE is the most frequency occurring score value in adistribution. Determined by inspecting a frequencydistributionMEDIAN is the point in a distribution above which andbelow which 50% of cases fall.

MEAN often symbolized as M or X is the sum of all scoresdivided by the number of scores what people usuallyrefer to as the average.

VARIABILITY

Range is simply the highest score minus the lowest scorein a distributionStandard Deviation used in interval-and-ration level data;indicates the average amount of deviation of values fromthe mean

Step 14: Preparing data for analysis

D. ANALYTIC PHASE

Step 15: Analyzing the DataStep 16: Interpreting the Results

E. DISSEMINATION PHASEStep 17: Communicating the findingsStep 18: Utilizing the findings in research

ETHICAL ISSUES IN RESEARCHAutonomy: informed consent.Right to privacy: The researcher should ensure theanonymity of the research participants and theconfidentiality of the data/information collected from them.Beneficence: the benefits of the research to the researchsubject/participants. should be adequately explained to the

participants.Nonmaleficence: avoidance of harm or reduction of risksto the research subject.

Social Justice: right to be represented in the sample,equal access to knowledge, right not to be discriminatedagainst

NURSING PRACTICE II:

CARE OF MOTHER AND CHILD AND COMMUNITY

HEALTH NURSING

COMMUNITY HEALTH NURSING

Community Health NursingThe utilization of the nursing process in the different levelsof clientele-individuals, families, population groups andcommunities, concerned with the promotion of health,prevention of disease and disability and rehabilitation.GoalTo raise the level of citizenry by helping communities andfamilies to cope with the discontinuities in and threats tohealth in such a way as to maximize their potential forhigh-level wellness.

Public HealthThe science and art ofpreventing disease, prolonginglife, promoting health and efficiency through organized

community effort for the: Sanitation of the environment

Control of communicable diseases

Education of individuals in personal hygiene

Organization of medical and nursingservices

Early diagnosis and preventive treatment ofdisease

Development of social machineryTo ensure everyone a standard of living adequate for themaintenance of health, so organizing these benefits as toenable every citizen to realize his birthright of healthand longetivity (Dr. C. E. Winslow definition)

The art of applying science in the context of politics so asto reduce inequalities in health while ensuring the besthealth for greatest number. (WHO definition)

Core business of public health


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Disease control

Injury prevention

Health protection

Healthy public policy including those in relation toenvironmental hazards such as in workplace,housing, food, water, etc.

Promotion of health and equitable health gain

THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

Department of Health (DOH) is mandated as the

lead agency in health at the national level

With the devolution of health services:

The local health system is run by the LocalGovernment Units (LGUs)

The provincial and districts hospital are under theprovincial government

The city/municipal government manages the healthcenters/rural health units (RHUs) and barangayhealth stations (BHSs).

Vision

The DOH is the leader, staunch advocate and model inpromoting Health for All in the Philippines.

MissionGuarantee equitable, sustainable and quality health for allFilipinos, especially the poor and shall lead the quest forexcellence in health.

GoalHealth Sector Reform Agenda through sound organizationaldevelopment, strong policies, systems and procedures,capable human resources and adequate financial resources.

FOURmula ONE for Health

- The implementation framework for healthsector reforms- It intends to implement critical

interventions as a single package backed byeffective management infrastructure and financingarrangements following a sector wide approach

Goals of FOURmula ONE for Health

Better health outcomes

More responsive health systems

Equitable health care financing

Four elements of FOURmula ONE

Health financing

Health regulation Health service delivery

Good governance

National Objectives for Health 2005 to 2010Provides the road map for stakeholders in health and health related sectors to intensify and harmonize their efforts toattain its time honored vision of health for all Filipinos.

Primary Health Care

Essential health care made universally accessible toindividuals and families in the community by meansacceptable to them through their full participation and at acost that the community and country can afford at every

stage of development. (WHO definition)

Partnership and empowerment of the people is thecore strategy in the effective provision of essential

health services that are community based,accessible, acceptable and sustainable at a cost

which the community and the government canafford.

Elements/Components of Primary Health Care

Environmental Sanitation

Control of Communicable diseases

Immunization

Health Education

Maternal and Child Health and Family Planning

Adequate Food and Proper Nutrition

Provision of Medical Care and EmergencyTreatment

Treatment of Locally Endemic Diseases

Provision of Essential Drugs

The framework for meeting the goal of primaryhealth care is organizational strategy, which callsfor active and continuing partnership among thecommunities.

Four Cornerstones/Pillars in Primary Health care

Active community participation

Intra and inter sectoral linkages

Use of appropriate technology

Support mechanism made available

Two levels of primary health care workers

Village or Barangay Health Workers- Refers to trained community health workers or

volunteer, traditional birth attendant or healer

Intermediate level health workers- Refers to general medical practitioners, public

health nurse and midwives.

Levels of Health Care and Referral system

Levelof Care

Definition

Service Type Example

Primary Providedat healthcare/RHU, Brgy.Healthstations,communityhospitals

Healthpromotion,preventivecare

Healthpromotionand illnessprevention

Informationdissemination

Secondary

Referralis madetoinfirmari

es,municipal &districthospitalsandoutpatient dept.ofprovincialhospitals,

Surgery,medicalservicesby

specialist

Diagnosisandtreatment

Screeningprocedures

Tertiary Highly

specializedmedicalcare isnecessary.Referrals

Advanced

specialized,diagnostic,therapeutic &rehabilitat

Rehabilitat

ion

PT/OT


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made tomedical

centersandspecializedhospitalse.g.Heart

Center.

ive care

Epidemiology

The study of distribution of disease or physiologiccondition among human populations and the factorsaffecting such distribution

The study of the occurrence and distribution of health

conditions such as disease, death, deformities or disabilities

on human population

Patterns of Disease Occurrence:

Epidemic

A situation when there is a high incidence

of new cases of a specific disease in excess of theexpected.

When the proportion of the susceptible arehigh compared to the proportion of the immunes.

Endemic

Habitual presence of a disease in a givengeographic location accounting for the low numberof both immunes and susceptible.e.g Schistosomiasis in Leyte and Samar

Sporadic

Disease occurs every now and thenaffecting only a small number of people relative tothe total populatione.g. Rabies

Pandemic Global occurrence of disease

Vital StatisticsRefers to the systemic study of vital events such as birthsillnesses, marriages, divorce, separation and deaths.

StatisticsRefers to a systematic approach of obtaining, organizingand analyzing numerical facts so that the conclusion maybe drawn from them.

Use of vital statistics

Indices of the health and illness status of the

community Serves as bases for planning, implementing,

monitoring and evaluating community healthnursing programs and services

INTEGRATED MANAGEMENT OF CHILDHOOD

ILLNESSES

Methods that are being utilized in managing

childhood illnesses are:Assess the client taking the history of the patientis one way of getting information about the disease

condition. This can be done by asking andobserving the patients condition to explore thepossible causes.Classify the disease a thorough assessmentsupported with laboratory results is necessary forclassification of illnesses and confirmation of thedisease. Classification of the disease are: 1) mild,2) moderate, 3) severe.Treat the patient treatment is a curative methodof treating diseases. This vary on the condition ofthe patientCounsel the patient providing health education toclients promotes health and avoid risk of infection.these are important for parents/caregivers

especially who lack knowledge on health practicesand risks factors that contribute to diseaseailments.

To assess for danger signs, the nurse should:

Look if the child is lethargic or unconscious

Ask the mother or adult with the child:

Is the child able to drink or breastfeed?

Does the child vomit everything?

Has the child had convulsions?

In the presence of any danger sign, make sure thechild is referred after first dose of an appropriateantibiotic and other urgent treatment.

DEHYDRATION

Severe Dehydration

2 of the following signs

abnormally sleepy or difficult to awaken

sunken eyes

not able to drink or drinking poorly

skin pinch goes back very slowly

Treatment

If the patient has no other severe

classification- PLAN C

If the patient has another severe

classification- refer URGENTLY, with mother

giving frequent sips of ORS on the way

If the child is 2 years or older and there is

cholera in the area, give antibiotic for

cholera

Some Dehydration

2 of the following signs

Restless, irritable


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Incidence rateNo. of new cases of a given disease

_____________________ x 1,000Estimated midyear population

Swaroops IndexNo. of deaths 50 y/o and above_____________________ x 100

Total no. of deaths

Crude Birth rateTotal no. of registered live births _____________________ x 1,000Total no. of population

Crude Death rate

Total no. of deaths

_____________________ x 1,000Total no. of population

Maternal death rate

Total no. of deaths____ x 1,000

Total no. of live births


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Sunken eyes

Drinks eagerly, thirsty

Skin pinch goes back slowly

Treatment

Give ORS, zinc supplements and food for

some dehydration (PLAN B)

If the child has other severe classification

refer URGENTLY, with mother giving

frequent sips of ORS on the way

Advise mother to continue breastfeeding

Follow up in 5 days if not improving

No Dehydration

-Not enough signs

Treatment

PLAN A

Follow-up in 5 days if not improving

Severe Persistent Diarrhea

-Dehydration present

Treat dehydration before referral unless the

child has another severe classification

Give Vitamin A

Refer to hospital

Persistent Diarrhea

- No dehydration

Advise mother on feeding

Give Vitamin A

Give multivitamins and minerals (inc

luding

zinc) for 14 days

Dysentery

-blood in the stool

Give ciprofloxacin for 3 days

PNEUMONIA

Severe Pneumonia or Very Severe Disease-Any general danger signs, or chest indrawing, or

stridor

Give first dose of an appropriate antibititic

Give Vitamin A

If chest indrawing and wheeze, go directly

to treat wheezing

Treat the child to prevent low blood sugar

Urgent referral

Pneumonia

-fast breathing

Give an appropriate antibiotic for 3 days

Soothe the throat and relieve the cough If coughing for more than 3 weeks or if

having recurrent wheezing, refer for

assessment of TB or asthma

No Pneumonia: Cough or cold

-No signs of pneumonia or very severe disease

Soothe the throat and relieve the cough

If coughing for more than 30 days, refer for

assessment

MALARIA

(Malaria-Risk)

Very Severe Febrile Disease/Malaria

Give first dose of quinine Treat child to prevent low blood sugar

Give one dose of paracetamol for fever

(38.5 C or above)

Send blood smear with the patient

Refer URGENTLY

Malaria

-blood smear (+); if blood smear is not done: NO

runny nose, and No measles, and NO other causes

of fever

Treat the child with an oral antimalarial

Give dose of paracetamol

If fever is present for more than 7 days,

refer for assessment

Fever: Malaria unlikely

- Blood smear (-), or runny nose, or measles, or

other causes of fever

Give one dose of paracetamol for high fever

(38.5C and above)

Treat other causes of fever

(No Malaria-risk)

Very Severe Febrile Disease

- any general danger sign, or stiff neck

Give dose of antibiotic

Treat the child to prevent low blood sugar Give dose of paracetamol

Refer urgently

Fever: No Malaria

-No signs of severe febrile disease

Give one dose of paracetamol

MEASLES

Severe Complicated Measles

-Any general danger sign, or clouding of the

cornea, or deep or extensive mouth ulcers

Give Vitamin A

Give first dose of antibiotic If there is clouding of the cornea, apply

TETRACYCLINE

Refer URGENTLY

Measles with Eye or Mouth Complications

- Puss draining from the eye, or mouth ulcers

Give Vitamin A

If puss is draining from the eye, apply

tetracycline

Measles

-Measles now or within the last three months

Give Vitamin A

Mastoiditis-tender swelling behind the ear

Give first dose of antibiotic

Give first dose of paracetamol for pain

Refer URGENTLY to hospital

Acute Ear Infection

- Puss is seen draining from the ear and discharge

is less than 14 days

- Ear pain

Give antibiotic for 5 days

Give paracetamol for pain

Dry the ear by wicking

Chronic Ear Infection-Puss is seen draining from the ear and discharge is

14 days or more

Dry the ear by wicking

Instill quinolone otic drops for 2 weeks

No ear infection


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- No ear pain and no puss is seen draining from the

ear

No additional treatment

Severe Malnutrition

- Severe muscle wasting, or edema of both feet

Treat the child to prevent low blood sugar

Give Vitamin A

Refer URGENTLY

Very Low Weight

-Very low weight for age

Assess the childs feeding and counsel the

mother

Give Vitamin A

Follow-up in 30 days

Not Very Low Weight

- Not very low weight for age and no other signs of

malnutrition

If the child is less than 2 years old, assess

the childs feeding.

If feeding is a problem, follow-up in 5 days

Severe Anemia-Severe palmar pallor

Refer urgently

Anemia

-Some palmar pallor

Give iron

Give Albendazole/MEbendazole if the

child

is 1 year or older and has not had a dose in

the previous 6 months

No Anemia

- No palmar pallor

Assess the childs feeding and counsel the

mother

ORAL ANTIBIOTICS FOR PNEUMONIA,

MASTOIDITIS/ACUTE EAR INFECTION, OR

VERY SEVERE DISEASE:

First-line antibiotic: Amoxicillin

Second-line antibiotic: Cotrimoxazole

NURSING PRACTICE III-V:

CARE OF CLIENTS WITH PHYSIOLOGIC AND

PSYCHOSOCIAL ALTERATIONS

MEDICAL SURGICAL NURSING

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 toback

Angina Stab-like pain, , radiates

from chest to jaw to left

shoulder and arm

Hypertension / Pounding pain

hypertensive

crisis

Ectopic

pregnancy

Knife-like pain

Gastric ulcer Gnawing pain

UTI Flank pain

Pancreatitis Radiates from Left upper

quadrant to left shoulder

PERIOPERATIVE PRINCIPLES

PREOPERATIVE CAREInformed Consent

Physician: gives the client a full explanation of theprocedure, including complications, risks, andalternatives

Should be signed by the physician, the client, and awitness (usually the staff nurse)

Informed consent is part of the chart record andshould accompany the nurse to the operating room

INTRAOPERATIVE CARE

The Surgical TeamThe Scrubbed Sterile Team

Operatingsurgeon

- Serves as the leader of the team- Sees to it that all team members areaware of the needs of the procedureand the patient- Performs the surg

ery

Assistant/sto thesurgeon

- assist the surgeon- holds retractor, places clamps onblood vessels, assists in suturing and

ligating light bleeders

Scrubnurse

- set up sterile supplies andinstruments- assists surgeon

- assists in gowning and gloving ofsurgical team- assists in draping- hands instruments, sutures, sponges- keeps operative field tidy- keeps close watch on needles,instruments and sponges- keep accurate needle/instrument

count- discards soil linen

The Unscrubbed Unsterile Team

Anesthesiologist

- gives and controls the anestheticfor the patient- must see to it that all suppliesneeded for anesthesia induction isavailable- gives signal to surgeon orcirculating nurse to proceed withpositioning and preparing theoperative site- monitors vital sign during operation- informs surgeon about patientscondition- determine when the patient maybe moved to PACU after theoperation has been completed

Circulating nurse - functions as overseer of roomduring operation- sends for the patient at theappropriate time- receives, greets, identifies thepatient- check chart for completeness


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- checks operating room lights inadvance for good working order

- prepares operative site- does sponge count with scrubnurse- fills out required operation recordscompletely and legibly

Pathologist

- consulted by the surgeon duringand after surgery for a diagnosis by

gross or microscopic of any tissueremoved- consulted by the surgeonconcerning treatment of somediseases

POSTOPERATIVE CARE

Nursing Management

Full system assessment of the patient

Monitor vital signs q 15 min x 4, q 30 min x 2, q 1hour x 2 then as needed

Position the patient on the side, with face slightlydown.

Elevate upper arm on a pillow maximize chestexpansion

Leave airway in place until pharyngeal reflex hasreturned; suction as needed

Help the client to turn, cough and take deepbreaths

Check bowel sounds in 4 quadrants for 5 minutes(high-pitched tympany is abnormal)

Apply ant embolic stockings (TED hose) before

getting out of bed

Monitor for Homans sign (pain with dorsiflexion onfood)

Possible Complications

POTENTIAL COMPLICATIONS OF SURGERY

COMPLICATION ASSESSMENT NURSINGCONSIDERATIONS

Hemorrhage Decreased BP,increasedpulsed cold,clammy skin

Replace bloodvolumeMonitor vital signs

Shock Decreased Bp.Increasedpulse Cold,clammy skin

Treat causeOxygenIV fluids

Atelectasis andpneumonia

Dyspneacyanosis,

coughTachycardiaElevatedtemperaturePain onaffected side

Experienced secondday postop

SuctioningPosturalDrainageAntibioticsCough and turn

Embolism Dyspnea,Pain,hemoptysisRestleness

ABG-low 02,Hig

h C02,

Experienced secondday postop OxygenAnticoagulants(heparin)

IV fluids

Deep veinthrombosis

PositiveHomans sign

Experienced 6-14days up to 1 year

laterAnticoagulanttherapy

Paralytic ileus Absent bowelsounds noflatus or stool

Nasogastric suctionIV fluidsDecompression Fluid

Infection ofwound

Absent bowelWBC and

temperaturePositivecultures

Experienced 3-5days postop

AntibioticsAseptic techniqueGood nutrition

Dehiscence Disruption of surgicalincision orwound

Experienced 5-6days postop LowFowlers position, nocoughing

NPONotify physician

Evisceration Protrusion of wouldcontents

Experienced 5-6days postop LowFowlers position, nocoughingNPOCover viscera withsterile salinedressing or waxpaper(if a home)notify physician

Urinary retention Unable to voidafter surgery

bladderdistension

Experienced 8-12hours postop

Catheterize asneeded

Urinary Infection Foul-smellingurine ElevatedWBC

Experienced 5-8days postopAntibioticsForce Fluids

Psychosis Inappropriate TherapeuticcommunicationMedication

TYPES OF ANGINA

Stable occurs during exertion,

unchanging severity, relieved by drugs and rest

Unstable unpredictable occurrence,

severity increases with time, not relieved by drugs

and rest

Prinzmetal (also known as variant

angina)results from coronary artery vasospasms

Intractable or refractory severe

incapacitating chest pain

EMERGENCY AND DISASTER NURSING

Triage Categories

Catego

ry

Prio

rity

Colo

r

Example

Immedi

ate

1 Red Sucking chest wounds, airway

obstruction, tension

pneumothorax, 2nd/3rd degree

burns of 15-40% TBSA

Delaye

d

2 Yello

w

Stable abdominal wounds,

soft tissue injuries,

maxillofacial wounds

Minimal 3 Gree

n

Upper extremity fractures,

minor burns, sprains, small

lacerations

Expect

ant

4 Black Unresponsive clients with

penetrating head wounds,

high spinal cord injuries,

2nd/3rd degree burns of more

than 60% TBSA, profound

shock


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FIRST AID

Snake Bite- have patient lie down,

remove constrictive clothing, clean and

cover the wound then immobilize

injured body part below heart level

Jelly fish sting- application of acetic

acid / vinegar to the wound

Insect sting- remove sting and washwound with soap and water (do not

scrape)

Poisoning-(depends on what

substance was taken) if corrosive, do

not induce vomiting- water or milk is

given for dilution. Other gastric

emptying procedures: syrup of ipecac,

activated charcoal, cathartic, gastric

lavage

Heat stroke-remove patients clothing

first then apply cooling blankets or

immerse in cold water bath if possible

Chemical burn drench skin

immediately with running water.

PSYCHIATRIC NURSING

PSYCHOPHARMACOLOGY

ANTIPSYCHOTICS

also known as neuroleptics; major tranquillizer -essentially dopamine receptor blockers, are used totreat disorders that involve thought processes

Traditional/conventional/Typical antipsychotics ( -

azine, -ridol, and thixene) Haloperidol (Haldol) can be used IM during

emergencies, Chlorpromazine (Thorazine) reduces seizure threshold

Increase the risk for extra pyramidal side-effects;and only effective in (+) symptoms

Non-traditional/ Atypical antipsychotics ( - zapine/-apine, - done)

Clozapine (Clozaril), Olanzapine (Zyprexa),Risperidone (Risperdal) DOC for Korsakoffspsychosis

Decrease risk for extra pyramidal side effects

(caused by imbalance between Ach and Dopamine,reversible except for Tardive Dyskinesia

effective both for (+) and (-) symptoms WOF : Agranulocytosis (fever, sore throat),

seizures, hypotension, oversedation

Common Anti-cholinergic side-effects of Anti-psychotics BUCO PanDan

Blurring of Vision pupils are dilate however, hasdecrease accommodation and lens are not so reactiveUrinary RetentionConstipationOrthostatic HypotensionPhotosensitivityDry mouth offer sugarless candy, ice chip, inc. FluidIntake, oral care

ANTIPSYCHOTICS

Taken with Antacids

Non-adherence most common

cause of

exacerbation/rehospitalization;anti-psychotics are taken at NIGHT

Can Trigger Arrythmias: Torsades

de Ponte (HYpomagnesemia) DOC:Magnesium sulfate

Injectables: DECANOATE clients

with notorious non-complinae

Dose: once a weeko Duration: 1-2 week

Prostatic hypertrophy

contraindication, as it canexacerbate urinary retention

Side-effects

* MAJOR EPSEs involuntary spontaneousmotor movements

a. pseudoparkinsonisms: mask-like face,pill-rolling or resting tremors, stoop posture,shuffling, festinating propulsive gait

b. Dystonia: increase muscle tone,musclespasm of the tongue, face, neck, back,laryngospasm and extraocular muscle spasmDOC: Benadryl or Cogentin

1. oculogyric crisis most common; fixedstare2. Torticollis wry neck3. Opisthotonus arching of the back

4. Pisa Syndrome leaning on one side,common in elders

c. Akathisia: inner subjectivefeeling of RESTLESSNESSAntidote: Propranolol

Tardive dyskinesia: late adverse effect ; appearsafter 6 months of taking neuroleptics

Lip smacking, Tongue protruding, Cheek

puffing and Fly-catchers mouth

Vermiform movement of the tongue early

signAkinesia: decrease or absent of movement

Yes to straw

Syrup antipsychotic: s/e CONTACT DERMATITISGive 1 full glass of water after to dilute the drug

Change position slowly: prevent orthostatic hypotension

High protein Bound

Drug bounded in CHON in blood can decrease potency ofdrug/becoming less effective

Decrease CHON level Increase free dopamine in the

blood, though risk for TOXICITYIncrease CHON level decrease effect of the drug

Ocular pressure (dilated) occlusion of the canal of schlemcausing acute glaucoma

Orange-urine

Therapeutic effect

3 6 weeks lag period

Increase Prolactin inversely proportional with Dopamine

Causing: decrease libido, gynecomastia

Can cause NMS rare, life=threatening, extreme agency;

notify the physician

Hyperthermia/Fever 42 degree Celsius (Hallmark sign)DOC: Bromocriptine (Parlodel)

Dantrolene (Dantrium)

Sensitivity: PHOTO

Wear hats, long sleeves, sunglasses

ANXIOLYTICS (- zepam, - barbital) act in the limbicsystem and the RAS to make gamma-aminobutyric acid(GABA) more effective, causing interference with neuronfiring. Minor tranquilizers.


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Benzodiazepines (-zepam, -pam) - the most frequentlyused anxiolytic drugs, prevent anxiety without causingmuch associated sedation.

Less likely to cause physicaldependence

Side-effects: Dry mouth, constipation, blurredvision, nausea and vomiting, elevated liverenzymes

: RESPIRATORYN DEPRESSION:

monitor respiratory rateChlordiazepoxide (Librium) DOC for Deliriumtremens

Avoid use of OTC medications andherbal therapies

Avoid alcohol while taking thisdrug

Antidote: Flumazenil (Romazicon)Barbiturates (barbital) increase risk for addiction anddependence

TRIAD Symptom of Barbiturate Toxicitya. Respiratory depressionb. Pinpoint pupilsc. Coma

ANTIDEPRESSANTSSELECTIVE SEROTONIN REUPTAKE INHIBITOR firstline of treatment

Fluoxetine (Prozac), Paroxetine (Paxil), Sertral

ine(Zoloft)

(- xetine, - zodone, -xamine, - line, - xine, -pram)

Side-effects: weight loss most common side-effect; insomnia (single Am dose); causes sexual

dysfunction and impotence

4 weeks lag period

SSRI to MAOIs: wait for at least 2 t o4 weeksTRICYCLIC ANTIDEPRESSANT increase norepinephrineand serotonin

Clomipramine hydrochloride (Anafranil) DOC for OCDImipramine (Tofranil) best drug for enuresis (bedwetting)Norpramine for elderly depressionide-effects: GIanticholinergic

EffectsNote: causes cardiac toxicity (amitryptyline most

cardio toxic), C/I in clients with MI or anypre-existing cardiac problems, can causearrhythmias, MI, angina, palpitations andstroke

MONOAMINE OXIDASE INHIBITORS

MAOI to SSRI:a period of 6 weeks should elapse

after stopping an SSRI before beginning therapy

with an MAOI Isocarboxacid (Marplan); Phenelzine(Nardil); Tranylcypromine (Parnate)

C/I: pheochromocytoma, CAD, angina, CHF w/c could be exacerbated by increasedlevel

Hypertensive Crisis most fatal a/echaracterized by occipital headache,palpitations, neck stiffness, nausea,vomiting, sweating, dilated pupils,photophobia, tachycardia, and chest pain.It may progress to intracranial bleeding andfatal stroke.

1. Avoid tyramine rich foods can cause

hypertensive criEx. Aged cheese, cheddar cheese, fermentedmeats, brewer yeast, smoked or pickledmeats, fish or poultry, Low amounts oftyramine: soy sauce, sour cream, yogurt,chocolate, grapes, pineapple, raisins,oranges

ANTIMANICLithium salts (Lithane, Lithotabs) are taken orally for themanagement of manic episodes and prevention of futureepisodes.

for treatment of manic episodes of manic-depression or bipolar illness and for themaintenance therapy to prevent or diminish thefrequency and intensity of future manic episodes.

Therapeutic Serum Lithium level: 0.6 to 1.2 mEq/LLithium Carbonate: therapeutic level in 2

weeks

sodium depletion or dehydration kidney reabsorbs more lithiuminto the serum, leading totoxicity.

Teratogenic: advice women touse birth control while taking thedrug

Lithium Levels:1. Serum levels of less than 1.5 mEq/L: CNS problems(lethargy, slurred speech, muscle weakness and finetremor); gastric toxicity (nausea, vomiting and diarrhea)

2. Serum levels of 1.5 to 2 mEq/L: intensification of all ofthe above reactions, with ECG changes

3. Serum levels of 2 to 2.5 mEq/L: ataxia, clonicmovemenst, hyperreflexia and seizures, CV: hypotension,dieresis

4. Serum levels greater than 2.5 mEq/L: complexmultiorgan toxicity, with a significant risk of death

ANTIDOTE: osmotic diuretics excrete excess lithium( Diamox (Acetazolamide); Mannitol (Osmitrol) )

Nursing Management:Increase fluid

Kidney test to determine for nephrotoxicityb. Have normal sodium intake (the kidney cannot

differentiate sodium from lithium)> Increase lithium : dec. lithium = inc.

reabsorption of lithium = inc. toxicity> Inc. sodium intake = decrease the

potency of lithiumc. Lithium level checked every 6 to 8 weeks

ANTI-DEMENTIA

Work by blockingacetylcholinesterase at the synaptic cleft. Thisblocking allows the accumulation of Ach releasedfrom the nerve endings and leads to increased andprolonged stimulation of Ach receptor sites at all of

the postsynaptic cholinergic junctions

Tacrine (Cognex) - * Monitor liverenzymes

Donepezil

DEFENSE MECHANISM UTILIZE BY DIFFERENTPSYCHIATRIC DISORDERS

1. Alcoholics: Denial2. Paranoid: Projection3. Bipolar: Reaction Formation4. Anxiety, Stress, anorexia, psychosis: Regression

5. OCD: Undoing6. Depression: Introjection7. Phobia: Displacement8. Conversion d/o: conversion, symbolism, repression

Personality DisordersCluster A (Odd, eccentric)Paranoid: Hallmark suspiciousness and hypervigilancePersecutory delusion


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No jokes/chit chatDistant friendliness (being available when patientapproaches you)Schizoid (Loners)No pleasure in the company of othersSchizotypal premorbid characteristic of schizophreniaBest therapy cognitive therapyStereotype mad scientistMagical thinking

Cluster B (erratic and emotional)Antisocial: Hallmark sign lack of Remorse

Manipulative behavior: Thrill or fulfillment breaking thelawBehavioral therapy setting limitsBorderline: Hallmark unstable and instabilityRisk for depression inc. risk for suicide

Defense mechanism: Splitting

Histrionic: Hallmark Attention seekerTheatrical: Flamboyant, highly exaggerated inappearance and clothingNarcissistic extreme love to self

f. Hallmark: lack of empathy (egocentric);sense of entitlement (being superior)g. Nurse Approach: Matter of fact way

Cluster C (anxious and fearful)

Avoidant high incidence for depressionEgocentric dec. self esteem, avoid other personsMajor intervention: Role play

ing to increase self-esteemDependent: Hallmark extreme dependence to otherpeopleNeeds attention/assistance : clinging behaviorObsessive-compulsive behaviorHallmark : perfectionistExpect monologues, rigidityTherapy: occupational therapyGoal: completion of tasks

Love means living the way God commanded us to live. As you have heard from the beginning, His command is this: Live

a life ofLOVE 2 John 1: 6

We wish you good luck and congratulations future COLLEAGUE in the NURSING PROFESSION!

-TEAM PRN


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