CA1-DAY 1 Fundamental of Nursing PDF

D. Period of Educated Nursing COMPETENCY APPRAISAL 1 - Florence Nightingale School of DAY 1 | Fundamental of Nursing Nursing - opened...

D. Period of Educated Nursing COMPETENCY APPRAISAL 1 - Florence Nightingale School of DAY 1 | Fundamental of Nursing Nursing - opened St. Thomas By: JK - Lei - Iris - Maria Hospital in London. - Florence Nightingale History of Nursing in the Philippines Mother of modern nursing A. Early Beliefs and Practices Born May 12, 1820 in - Cause by enemy or evil spirits Florence, Italy B. Early Care of the Sick Raise in England - Herbicheros “one who practice Entered Deaconess School at witchcraft” Kaiserworth C. Spanish Regime Took care in Crimean War - Hospitals established: E. Period of Contemporary Nursing 1st Hospital: Hospital Real de - World War II to present Manila - World Health Organization (WHO) 2nd Hospital: San Lazaro Hospital Roles of Nurses - Josephine Bracken (Wife of Rizal) - 1. Caregiver - Care physically and prominent nurse in the philippines. psychologically. - Hospital and School of Nursing - 2. Communicator - Identify and communicate Iloilo Mission Hospital School of verbally or write the problems. Nursing (1906). 3. Client Advocate - Protect the client. - First Nursing Law Act # 2808. 4. Counselor - Recognize and cope with stress. - University of Santo Tomas (1946) - 5. Change Agent - Make behavioral 1st College of Nursing. modifications. - Other Prominent data: 6. Case Manager - Measure the effectiveness of Anastacia Tupas (Founder of case management plan. PNA) 7. Leader - Influences others to work for a goal. “Nurses Week” (Last Week 8. Manager - Delegates nursing activities. of October) since Carlos P. 9. Teacher - Learn about their health. Garcia proclamation 539 October 17, 1958. Nursing Theories Hospicio de San Jose (Early - Metaparadigm - Major concepts and scope of child welfare) a certain discipline. History of Nursing A. Period of Intuitive Nursing - Black Magic and Voodoo belief - “Shaman” (Heals ill) - Egypt (Embalming) - Israel (Father of sanitation) - China (“Materia Medica” Pharmacology) B. Period of Apprentice - Kaiserworth Institute - for the training of Deaconess (Training School for Nurses). - Crusades - Knight of Lazarus “Lepers”. - St. Elizabeth of Hungary - Secular Orders: Patron Saint of Nurses. C. Dark Period of Nursing - No nurse to take care due to the civil war. 1 | PRELIMS CA1 2 | PRELIMS CA1  JEAN WATSON “10 Carative Factors” 1. Formation of a humanistic-altruistic system of values. 2. Instillation of faith-hope. 3. Cultivation of sensitivity to one’s self and others. 4. Development of a helping-trust relationship. 5. Promotion and acceptance of the expression of positive and negative feelings. 6. Systematic use of the scientific problem-solving method for decision making. 7. Promotion of interpersonal teaching-learning. 8. Provision for a supportive, protective, and/or corrective mental, physical, sociocultural, and spiritual environment. 9. Assistance with the gratification of human needs. 10. Allowance for existential phenomenological forces. 3 | PRELIMS CA1 4 | PRELIMS CA1  Levels of Disease Prevention - Primary No disease Prevention and Promotion Health Teaching Exercise Balanced Diet - Secondary Diagnostic and treatment - Tertiary Rehabilitation, health restoration, and palliative care Hygiene - The science of health and maintenance - Maintenance and promotion of hygiene is very important aspect of human physiological needs. - Early Morning Care (AM Care) Offer urinal / bedpan Wash face and do oral care - Morning Care Before/after breakfast Shower, back massage, nail/oral care - Hours of Sleep (PM Care) Before sleeping Same as morning care - As Needed Care (PRN) Diaphoretic client - Functional Level: 0 (completely independent). +1 (requires use of equipment and device). +2 (semi dependent) - requires help from another person for assistance, supervision, teaching (RN prepares equipment but patient do the task). +3 (Moderately dependent) - requires help from another person and equip/device (RN prepares and does the task but the patient can assist). +4 (Totally dependent) - dependent, does not participate. Categories of Bath A. Cleaning Baths 1. Complete Bath - hygienic purposes. 2. Self-help Bed Bath - patient confined to bed bath with assistance with RN. 3. Partial Bath (Abbreviated) - only that causes discomfort/odor. 4. Bag Bath - with 10-12 presoaked disposable washcloths that contain no-rinse cleaner. 5. Tub Bath 5 | PRELIMS CA1  6. Shower - warm water. Types of Data B. Therapeutic Bath 1. Subjective - To soothe irritated skin (perineum) - Symptoms - With meds - Covert - Tub bath for 20-30 minutes 2. Objective - Oral Care (Conscious) - Signs - Position: Side-lying with head turn/ - Overt sitting - Senses - Toothbrush 45 degrees angle Sources of Data 1. Primary Source: Patient Hygiene Considerations 2. Secondary Source: HCP, family, 1. Hydrogen peroxide (mouthwash) - but records diluted with NSS. 4 Types of Data 2. If no toothbrush, oral/swab/foam or gauze with 1. Initial/Comprehensive saline. 2. Problem-Focused 3. Petroleum Jelly for lips but not mouth - causes 3. Emergency burn. 4. Time-Lapsed 4. No to: Lemon-glycerin swabs - irritate and Diagnosis dry oral mucosa, calcify teeth. - Wellness Mouthwash with alcohol - dryness - Actual and irritation. - Risk 5. Oral Care (Unconscious): - Possible Position: Side-lying with head of Bed - Syndrome lowered. Formulating Diagnostic Statements Rinse using a syringe. 1. Basic Two Part = Problem Suction. related to + Etiology. - Example: Hair Care Hygiene Constipation related to - Pediculus Capitis – Hair prolonged laxative - Corporis – Body use. - Pubis – Pubic Hair 2. Basic Three Part = Problem - Management: Permethrin (Nix) related to + Etiology + Signs and Symptoms. Hygiene Considerations: - Example: Ineffective 1. Position: Supine but diagonal airway clearance 2. Heat - 40 Celsius related to excessive 3. Organized manner - Frontal, parietal, mucus production as temporal, occipital. manifested by 4. Place - washcloth in eyes. productive cough. 3. Basic One Part = For Factors Influencing Hygiene wellness diagnosis - Social practices - Example: Readiness - Personal preferences for Enhanced - Body image Parenting. - Socioeconomic status - Health beliefs and motivation Planning - Initial Nursing Process - Ongoing Assessment - Discharge - Collection - Purpose: - Organization Identify patient’s goal and appropriate - Validation nursing interventions - Documentation Direct patient care activities 6 | PRELIMS CA1  Promote continuity of care Conducive environment Focus charting requirements Medications Allow delegation of specific activities Diet - Activities: Psychological / Illness factor Establishing priorities Setting goals and expected outcomes Massage (SMART) - Back Massage Plan nursing interventions appropriate 1. Effleurage for each diagnosis 2. Petrissage 3. Tapotement Implementation 4. Kneading Types of Nursing Interventions 5. Figures of 8 1. Independent 6. Small/Big Fanning 2. Dependent 7. Hacking 3. Collaborative 8. Cupping Stop - Actual nursing problem - Contraindications Continue - Risk nursing problem Skin Injury Modify - Partially achieved objective of nursing Spine Injury problem Elderly Dependent-Independent Interdependent Respiratory Problems 1. Giving of medications as prescribed by the physician. Medications 2. Assessing skin condition of a - 10 Rights of Medications bedridden patient. 1. Medication 3. Consulting the dietitian on low uric 2. Dose acid diet for a patient 3. Time 4. Route Sleep and Rest 5. Client - Reticular Activating System 6. Client Education Responsible for sleep wake cycle 7. Client Documentation - Circadian Rhythm 8. Right to Refuse Begins 6th week of life 9. Right to Assessment Regularity by 3-6 months 10. Right to Evaluation - Types of Sleep: - Abbreviations 1. Non-Rapid Eye Movement (20-30 Stat: Immediately and only once mins) Single: Given once only at specified Stage 1: light sleep; drowsy, time relaxed, eyerolls side to side. Standing: Meds given unless Stage 2: Body processes go canceled. down; 10-15 mins; intense Pro Re Nata (PRN): As necessary or stimuli to be awakened. as the client needs it. Stage 3 and 4: deep - Time to check for Drug sleep/delta sleep; difficult to First: Read Medication Administration arouse. Record (MAR) and compare it to 2. Rapid Eye Movement (Last 5-30 drugs. minutes) Second: While preparing medication. Dream takes place. Third: Before returning the drug or - Diagnostic Studies disposing of it. 1. Electroencephalogram (EEG) - Routes: 2. Electromyogram (EMG) 1. Oral 3. Electrooculogram (EOG) - Most convenient Electrodes placed on the scalp (EEG) Least expensive and outer canthus of the eye (EOG). Safe - Promoting a Sleep Wake Pattern May stain teeth 7 | PRELIMS CA1  DIS: Taste, Irritation of gastric urinary tract, eyes, mucosa, slow absorption ears, nose) CI: vomiting, GIT suction, C. Inhalations – Unconscious, dysphagia respiratory tract Forms of Oral Drugs (inhalers, nebulizers) A. Tablets / Capsules - Crush tablets to a fine - Forms of topical drugs powder if with A. Transdermal Patch dysphagia and mix Effects: 12 Hrs to 1 week. with soft food or Site: Lower back, side and applesauce. (Never buttocks crush time-released / CI: Cuts, Burns, abrasions sustained release and SE: Redness with itching or enteric coated). burning B. Liquid - Check eye B. Ophthalmic Eye Drops level and lower Site: Lower Conjunctival Sac meniscus. (If Reservoir > Portal of exit > 5. Catheter should never be Portal of entry > Susceptible host inserted more than 4 inches - Etiologic Agent - M.O. 6. Solution should be at body - Reservoir: temperature. 1. Replication 7. If with hypotension vertigo, 2. Source – take pulse, stop, vagal 3. Reproduce response. - Portal of Exit 1. Mode of Transmission Asepsis 2. Leaves reservoir - Absence of microorganisms - Mode of Transmission Resident flora: Direct - Person-person - Collective vegetation in a given area. Indirect - droplet - 3ft - When displaced, it causes infection. Vector - rodents vehicle fomites Types of Asepsis Airborne - evaporated droplets - Medical/Clean Technique: Includes all practices intended to Breaking the chain of infection: etiologic agent confine a specific m.o. to specific area, 1. Antiseptic vs. Disinfectant limiting the number, growth and - Antiseptic: transmission of m.o. Alcohol triclosan ○ Clean– absence of MOST of Alcogel hibiclens all m.o. - Disinfectant: ○ Dirty– soiled, contaminated INANIMATE - Surgical/Sterile Technique: Hydrogen peroxide Refers to those practices that keep an Bleach (blood) area or object free of all m.o. Iodophors Destroys spores Types of infection 2. Cleaning vs. Sterilization - Nosocomial: - Cleaning: Infections acquired in the hospital Cold H20 - Nosohusial: Hot with soap Infections acquired outside the Warm hospital - Sterilization: Types of microorganism causing infection Spores 1. Bacteria Viruses 15 | PRELIMS CA1 Breaking the chain of infection: reservoir -Non dominant middle finger 1. Change Linens/dressing (pleximeter) 2. 48-72 h ideal in changing FC, NGT, IV - Dominant middle finger (plexor) Breaking the chain of infection: Portal of Entry Flatness – Muscle, Bone 1. Mode of transmission - PPE Resonance – Normal lung Personal Protective Equipment Dullness – Organs a. Gloves Hyperresonance – b. Gown - single-use technique Emphysema c. Face Mask - Prevent droplet and Tympany – Stomach with gas airborne 4. Auscultation d. Eyewear - Splashes - Listening to sounds e. Caps and shoe coverings - Direct and indirect Principles in wearing Personal Protective Skin Equipment - Edema Gown 1+ - 2mm Mask 2+ - 4mm Eyewear 3+ - 6mm Gloves 4+ - 8mm - Normal: Principles in removing Personal Protective Resilient, evenly distributed Equipment Kwashiorkor – reddish hair, coarse Gloves and dry Eyewear Gown Nails MAsk - Normal: Breaking the chain of infection: Susceptible Host Convex; 160 degrees - Types of Immunity Spoon Shaped – Anemia 1. Active – produced by the body. (koilonychia) a. Natural Flattened – 180 degrees; clubbing; from infection. >180 late clubbing (lifelong) Beau’s line – injury b. Artificial Blanch Test/Capillary Test -