Fundamentals Of Nursing - Toprank PDF

lOMoARcPSD|34461803 Fundamentals OF Nursing - Toprank Nursing (Southville International School and Colleges ) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by L...

lOMoARcPSD|34461803 Fundamentals OF Nursing - Toprank Nursing (Southville International School and Colleges ) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 FUNDAMENTALS OF NURSING History of nursing in the Philippines A. Doña Hilaria de Aguinaldo Nursing - Filipino red cross Art: therapeutic use of self B. Trinidad Tecson SITS - Mother of Filipino red cross STAYS SELF SILENCE Hospital and schools of nursing REFLECT 1. Iloilo mission hospital school of PATIENT TELLS NURSE (FORM nursing (Iloilo city, 1906) CENTRAL OF CATHARSIS) PHILIPPINE UNIVERSITY 2. Philippine general hospital school AVOID: of nursing (manila, 1907) UP 1. Why MANILA 2. That's why 3. St. Paul's school of nursing 3. It's okay (manila, 1907) 4. Advice: only give options Colleges of nursing in the Philippines 1. University of Santo Tomas college of Requires dexterity and skills nursing (1946) - Manual (hands on) 2. Manila Central university college of - Communication nursing (1947) - Cognitive Science Nursing leaders in the Philippines - Requires a 1. Anastacia giron tupas: pna specific/specialized body of 2. Cesaria tan: first to receive master's knowledge degree abroad Caring 3. Rosa militar: pioneer of school - Committed to promoting health nursing education individual, family, community, 4. Loreto tupaz: f.n. of Iloilo, asked the and national health goals in board exam to be held outside the manner manila - Committed to personalized 5. Dean julita Sotejo: f.n. of the services for all persons Philippines without regards to color, creed, or social or economic Mother of modern nursing: UK status - Not included sa food tray of First true nursing law: act 2808-1919→ an Islam patient: created BON → 1920 BON manila - Haram (forbidden)- land animals RA 877-1953 - Halal (allowed)- sea animals - First Philippine nursing law Before 1935: ACT / P.D. After 1935: REPUBLIC ACT Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 A. Period of intuitive nursing Oral antiviral COVID drug Prehistoric times among - EUA (Emergency use authorization) primitive tribes: - Paxlovid: nirmatrelvir 300 mg + GCS→ PAIN: Ritonavir 100 mg (aids; prevents 1. Sternal rub degradation of nirmatrelvir in liver) 2. Nailbed pressure - 3 tabs: 2 nirma (cos nirma is only 3. Trapezius squeeze available in 150 mg) + 1 tab Ritonavir Out of compassion for others A function that belongs to - Take it within 5 days after a positive women result Illness caused evil spirits - Delta: flu like symptoms, majority through the use of magic or have lossmof sense of self voodoo - Omicron: soar throat, only 19% have Medicine man or "shaman" lossmof sense of smell Trephining: drilling a whole in - Paxlovid SE: hypertension, paxlovid the head so evil spirits can mouth (bitter taste in mouth) exit - 2x a day for 5 days, 12 hrs apart "Herbman" TAKE IT ON TIME "Mabuting hilot" good midwives Roles of a professional nurse - Mothering actions of the nurse Ig G: transplacental Ig → passive with - Teacher: ebiurage compliance with immunity prescribed therapy, promote healthy Ig M: first ig produced by the fetus lifestyle (exercise) Ig A: colostrum (1-10 days milk) - Counselor: interpersonal skills, give Ig D: serum (unknown) an option, family planning Ig E: increased allergic reaction, increased - Change agent: initiate changes or asthma, allergic rhinitis assist clients to make modifications - Client advocate: promotes what is DEngue duo: best for the client 1. NS1: Positive 3 days after fever - Manager: head nurse, needs BSN 2. IgG, IgM: positive IgM on fifth day of fever Levels of management: top level management → Extracorporeal membrane oxygenation director, chief nurse - Femoral artery Middle → supervisor - On heparin Low → team leader, head - Good for patients with lung collapse nurse cos it ensures gas exchange Research→ to enhance or improve the quality of bedside care Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 EXPANDED ROLES OF A NURSE B. Nurse Practitioner A. Clinical specialties - Either as certificate program or a - Master's degree in specialty master’s program, certified by the - Clinical expertise appropriate specialty organization - Provides expert care to - Skilled at making nursing individuals managerment, performing PE, - Participates in educating counselling, teaching and treating health care professionals and minor and self limiting illness ancillary - Clinical consultant and C. Nurse midwife participates in research kpa - Completion of a program in midwifery, provides prenatal and Nursing specialty certification program - postnatal care and delivers babies to BON woman with incomplicated - 10% RNs trained by DOH for free pregnancies - Required to serve any PH hospitals D. Nurse anesthetist for 2 years - Completion of the course of study in an anesthesia school and carries out Ladder of clinical proficiency pre-operative status of clients 1. Novice E. Nurse educator - (0-1yrs) new nurse, rule - With advanced degree, who teaches governed behavior in clinical or education settings, 2. Advanced Beginner teaches theoretical knowledge, - (1-2 yrs) decision making is clinical skills, and conduct research based on theory F. Nurse entrepreneur 3. Competent - Advanced degree and manages - (2-3 yrs) decision making is health-related behaviors based on client needs G. Nurse administrator 4. Proficient - Functions at various levels of - (3-5 yrs) decision making is management in health settings based on prioritization (ABCs) 5. Expert Crackles = bubbling - (>5 yrs) decision making is Fine = fluid (cardio:CHF) intuitive/instinctive Coarse = phlegm (pulmo) Pleural friction rub = grating NCSBN TSE - Nurse Council for State Board of - After warm shower Nursing - May feel like bag of worms Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 QUALIFICATIONS FOR DIALYSIS 1. Increased BUN (20) and VALVE LOCATION: APTM 2245 CREATININE (1.3) aortic: 2nd ics 2. Fluid retention = edema Pulmonic: 2nd ics 3. Increased K >6 mEq/L Tricuspid: 4th ics Mitral: 5th ics ROLE OF POTASSIUM IN DIABETES ○ Common in RHD, DT, - Hypokalemia Streptococcus (GAHBS) - Complication of insulin ○ Use JONES CRITERIA therapy - Best snack to bring when traveling: RAISINS RHEUMATIC HEART DISEASE Inject insulin for burn patients JONES CRITERIA - Because cell is damaged/lysis K Joint involvement escapes cells which causes O - heart (myocarditis) hyperkalemia Nodules (subcutaneous) - Insulin controls intracellular Erythema marginatum movement of potassium Sgolenhams chorea Cruciferous foods - Cabbage, broccoli, cauliflower, Varicella zoster (chicken pox) lettuce, bockhoy (PH) - Pockmark (deep lesion in eyebrow - Kale, brussels sprout (US) and chin - Can go to posterior horn of spinal Herbal meds cord (sensory signal) - Gingko biloba (for memory) - If reactivated -> HERPES ZOSTER - Ginseng (libido) (shingles) - Unilateral involvement (if on CD4 T-cell count R side, only R lesion) - auscultate the lungs anticholinergics monitor for temp because lake water is adrenergic stagnant and dirty AtSO4 Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 ECT (electroconvulsive therapy) 2. Radiation: heat loss w contact -D.R: norepinephrine (peripheral cold stress - the body will vasoconstrictor: drug of last resort compensate by increasing BMR for shock) 3. Convection: heat loss via air current epinephrine (central vasoconstrictor) 4. Evaporation: heat loss via water bonamine: motion sickness vapor Scopalamine: devil’s breath, used 5. hyperhidrosis: excessive sweating for human trafficking 6. Bromhidrosis: foul smelling sweat Antipsychotic: causes dry mouth and photosensitivity Frequent use of deodorant - contributes to alzheimer’s MEDS FOR PNS: cholinergic #1 universal need of newborn prostigmine / neostigmine: DOC for - thermoregulation myasthenia gravis B-blockers: contraindicated for BMR uses O2 which leads to hypoxemia asthma Cardioselective Betablockers ○ nebivolol: safe for asthma TYPES OF FEVER ○ B1: heart B2: lungs 1. Intermittent: within 24hrs temp fluctuates from N to fever ACETYLCHOLINE 2. Remittent: within 24 hrs fever fluctuates - primary neurotransmitter of PNS but fever never goes down to normal 3. Constant: continuously high fever of TENSILON 40-41C for more than 5 days - diagnosis - lobar pneumonia - Fast acting drug (8 to 10 mins) but short - Bacterial meningitis duration (30 mins) - UTI - ANTIDOTE: atropine sulfate - Kawasaki: prob is vasculitis - strawberry tongue Myasthenia gravis crisis: 4. Relapsing: every 2-3 days temperature Cholinergic crisis: overmedication fluctuates from normal to fever Myasthenic crisis: undermedication - dengue - Boirelia fever/lyme Bee sting - Inject EPINEPHRINE PEN ASPIRIN - not used to patients w viral infections bc of blood level below 4 REYE’S SYNDROME: liver and brain - indicates SHOCK damage - N: 4.5-5.5L DECLINE OF FEVER PROCESS INVOLVED IN HEAT LOSS 1. Crisis: sudden 1. Conduction: heat loss w contact 2. Lysis: gradual Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 - Infants: toxic A drop of 1C within 15 mins is abnormal - Adults: renal failure: acute renal failure INTRA RENAL FAILURE Nursing intervention for clients w fever - Acute renal failure 1. Increase fluid intake - Pre-renal: cardiac 2. Full diet: bc of increased BMR - Intra-renal: within the kidney 3. Oral care: sordes - dead cells - Post-renal: bladder, prostate 4. TSB: 28-30C and should be tap water, - MINAMATA DISEASE patting motion - heavy metal poisoning - Contraindicated to infants Iced bath: - Because they are mouth 1. Neuroleptic malignant syndrome breathers - antipsychotic - Seizure - Might swallow mercy 1. Malignant hyperthermia - hereditary Best indicator of cardiac output - Gas/ general anesthesia: - URINE sevoflourane, halothane - Muscle spasm: friction thereby b. Rectal increasing heat - accurate - ANTIDOTE: muscle relaxant - Insert 0.5-1.5 inches into the DANTROLENE SODIUM patient’s rectum/ use water based lubricant METHODS OF TEMP TAKING a. Oral CONTRAINDICATIONS - most accessible and convenient A. Hemorrhoids stages: - Placed under the tongue beside the 1. Anal canal frenulum 2. Protrudes spontaneously 3. Protrudes, manual reduction Contraindications: 4. Cant be reduced - coughing B. Diarrhea - N/V - acid = heat C. Increased ICP - H2 blockers: stop secretion - Monro Kellie Doctrine - PPIs: stop HCL acid - 3 things are constant: cranial vault- - Antacid: neutralize short skull acting Al- constipation, Mg- - Brain volume diarrhea - CSF - Cytoprotective agents: - Intracerebral blood sucralfate - Brain stem - O2 therapy - Midbrain: pupils, arousal - Decrease LOC - Pons: - < 5yrs old = febrile seizure - Pneumotacsic center: - Mercury prevents Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 overdistention of 0 absent/ no pulse lungs - Apneustic center: PULSE SITES: deep inhalation - Medulla oblongata: RR, HR, Coughing, vomitting, swallowing - Hiccups in CVA patients indicates brain stem compression D. Cardiac disease - M. I - bradycardia c. Axillary Contraindications: 1. Lesion 2. CVA: get temp on unaffected side 3. Amputation PULSE Factors affecting pulse rate: - as you age your pulse decreases - Inotropic - Force/strength of contraction - Chronotropic - Heart rate Digitalis - hold if 60bpm Temporal pulse Dopamine drip - located lateral to the eyes - close if patient is death - Easy to palpate in infants next to - missing neurotransmitter for brachial PARKINSON’S DISEASE - DOC: LEVODOPA Carotid pulse - Because DOPAMINE - located under the mandible cant cross the BBB - used in CPR in adults - Not infants because have short AMPLITUDE/VOLUME OF THE PULSE necks +4 strong and bounding +3 full pulse Point of Maximal Impulse (PMI) +2 normal and easy to palpate - Located sternal border midclavicular +1 weak and thready line, 5th intercostal space Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 - Most routinely checked/assessed in - Canal of Guyon newborn - Median nerve Brachial pulse - the nerve that passes - 1 ½ inches above the antecubital through the carpal tunnel space - Only supplies the thumb, - BP monitoring index, middle, and half of ring - CPR in infants finger - Carpal tunnel Radial pulse syndrome - located in line with thumb - Before ABG is done Femoral pulse - Allen’s Test - After Cardiac catheterization check - To check for collateral for bleeding circulation (ability of ulnar artery in Popliteal pulse compensating the - for circulation to the leg blood supply into the hand) Dorsalis pedis pulse - for circulation to the foot Ulnar pulse - An absent pulse indicates CLOT - collateral circulation checked after cardiac catheterization - Allen’s chart not asking for bleeding but in - To check for the general visual acuity of - CLOT children - anticoagulants: prevent - Images are used further clot - Snellen’s chart - Heparin: - Visual acuity of adults PROTAMINE - Letters are used SULFATE: PTT - 20/40 reading - Warfarin: Vitamin K: - Patient can PT and INR read 20ft what - thrombolytics: dissolve clot a normal - Streptokinase person can - Urokinase read 40ft - TPAs (Tissue away Plasminogen - 30/60 Activators) - Patient can read at 30ft what a normal BLOOD PRESSURE person can read at 60ft Factors affecting: away Age: higher age = higher BP Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 Gender: ○ males - increase in BP after puberty and before the age of 65 ○ females - increase in BP after age of 60 years old due to decreased estrogen due to menopause Estrogen - vasodilator Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 Retake BP - Sterile closed drainage system - 1 to 2 mins Types of cathether - Deflate: 2-3mmHg at a time/ per ○ Indwelling - long term second too fast -> low systolic, high use 72 hours diastolic ○ Straight - short term - Width of BP cuff use relieve urinary - Has to be 40% of the arm retention circumference of the patient 2nd stage of - cover 80% of the area from labor = the shoulder to the elbow encourage - narrow: false high fetal descent - wide: false low ○ Coude - small lumen - too lose: false high cath - Arm above the heart: false BPH: low hesitancy, urgency, Laboratory and Diagnostic Examinations frequency (triage Urine Specimen collection symptoms) 1. Clean catch, midstream urine ○ 3 way catheter - specimen cystoclysis - Best for culture and CBI - sensitivity continuous - Container should be sterile bladder 2. 24 H Urine collection irrigation - done w patients for creatinine Cold clearance sterile - PIH water - Shilling’s Test: Pernicious to Anemia cause - VMA VASO - Diagnostic test for CONS Pheochromocytoma TRICTI - 3 days before the test ON avoid Prostatectomy - Caffeine TURP - Citrus fruits First 24 hours - Cheese drain should - Oranges be PINK - Always discard first voided IF urine RED - increas 3. Catheterized urine specimen e rate - aseptic technique of Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 infusio n Total drainage - total infused = PT’s urine Downloaded by Leigh Balane ([email protected])  lOMoARcPSD|34461803 Catheterization causes CAUTI - closed system drainage (sterile) - Liberal amount of fluid intake Downloaded by Leigh Balane ([email protected])