Fundamentals of Nursing (4)
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TYPES OF ISOLATION Strict Isolation – highly transmissible diseases by direct contact and airborne routes of transmission Private rooms, gowns, mask, gloves handwashing, double bagged techniques for soiled articles Ex. Diphtheria(pharyngeal), Herpes Zoster, Varicella, Pneumonia (S. Aureus, Strep group A) Respiratory Isolation – droplet transmission (3 feet) Private room, patient w/ same organism, handwashing, labeled plastic bags for soiled articles Ex. H. influenza, measles, mumps, N. meningitidis Tuberculosis/ AFB isolation – suspected/active TB Private room with negative pressure ventilation, mask, handwashing, bronchoscopy and dental examination postponed until 2 weeks of antibiotic therapy Contact isolation – infectious diseases or multiple resistant microorganisms that are spread by direct contact or close contact. Private room, mask, gown, gloves Ex. Diphtheria (cutaneous), Herpes simplex, MRSA, Pediculosis, Scabies, Syphilis Enteric precautions – infectious diseases transmitted through direct or indirect contact with infected feces Handwashing, gloves, gowns worn only when handling contaminated objects with feces Ex. Aseptic meningitis, AGE, Hepa A, Typhoid fever, diarrhea Drainage/Secretions precautions – patient with wound drainage or infected wounds Gloves, gowns indicated if clothing is likely to be contaminated Ex. Burns Universal Blood and Bloody Fluids Precautions – blood- borne, body fluids (blood, semen, vaginal secretions, CSF, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid) Gloves, mask, protective eyegears, gown, contaminated needles not recapped and sharps in puncture resistant containers Ex. AIDS, Hepatitis B and C, STD’s
Reversed Isolation – patient is protected from pathogens and nosocomial infections by instituting reversed transmission precautions Burns and open wounds, patients with artificial airway, immunocompromised patients – leukemia, AIDS, steroid therapy, radiation or cancer chemotherapy, medication effect of leucopenia or agranuloctosis POSITIONING FOR SPECIAL CONDITIONS Abdominal aneurysm surgery – Fowler’s Asthma – Orthopneic position Autonomic dysreflexia – High fowler’s Post-bronchoscopy – Semi-fowler’s Cardiac catheterization – Keep insertion site extended for 4-6 hours to prevent arterial occlusion Cast – Elevate extremity Cataract – Semi-fowler’s Cerebral Aneurysm – Semi-Fowler’s Cleft Lip – Supine Cleft Palate – Prone Congestive Heart Failure – High-Fowler’s Craniotomy – Supratentorial:Semi-Fowler’s; Infratentorial: Flat Increased ICP – Elevate Head Dumping Syndrome – Supine after meals Epistaxis – Lean forward Flail Chest – Affected Side Femoro-Popliteal Bypass Graft – Affected extremity extended Glaucoma(post-op) – Affected side Hemorrhoidectomy – Side-lying Hiatal Hernia – Upright Hip Surgery – Legs in Abduction Laminectomy – Back as straight as possible Liver Biopsy – Right side-lying Lobectomy – Semi-Fowler’s Mastectomy – Elevate extremity on pillow Myelogram – Water-based dye:Elevate the head; Oil-based dye: Flat Prolapsed cord – Knee-chest position Pulmonay edema – Fowler’s Pyloric stenosis – Right side-lying Radium implant – Flat on bed Retinal detachment – Affected side towards the bed Seizure – Side-lying Shock except Cardiogenic shock – Modified Trendelenburg Cardiogenic Shock – Semi-Fowler’s Spinal Cord Injury – Immobilize Tonsillectomy – Side-lying/Prone Throidectomy – Semi-Fowler’s Thrombophlebitis – Elevate Leg Total Parenteral Nutrition – Trendelenburg – During insertion Thoracentesis – Fowler’s (During procedure) Position of comfort (After procedure) THERAPEUTIC DIET FOR SPECIFIC CONDITIONS AGE- Clear liquids AGN – Low Na, Low CHON Addisons’s Disease – High Na, Low K Anemia, Pernicious – High CHON, Vit B Anemia, Sickle Cell – High Fluid Gout – Purine Restricted ADHD and Bipolar Disorder – Finger foods
Burn – High calorie, High CHON Celiac Disease – Glutein-free Cholecystitis – High CHON, High CHO, Low Fat Congestive Heart Failure – Low Na, Low Cholesterol Crohn’s Disease – High CHON and CHO, Low Fat Cystic Fibrosis – High Calorie, High Na Urolithiasis – Acid ash for alkaline stones; Alkaline ash for acid stones Decubitus ulcers – High CHON, High Vitamin C Diarrhea – High K, High Na Dumping syndrome – High Fat, High Protein, Low CHO Hepatic Encephalopathy – Low CHON Hepatitis – High CHON, High calorie Hirschprung’s Disease – Low Residue, High CHON and CHO Cirrhosis – Low CHON Meniere’s Disease – Low Na Myocardial Infarction&Hypertension – Low Cholesterol, Fats & Na Hyperthyroidism – High calorie and CHON Hypothyroidism – Low Calorie, Low Cholesterol, Low Saturated Fat Nephrotic syndrome – Low Na, High CHON, High Calorie Hyperparathyroidism – Low Calcium Hypoparathyroidism – High Calcium, Low Phosphorus Osteoporosis – High Calcium, High Vitamin D Pancreatitis – Low Fat PUD – High fat, High CHO, Low CHON PKU – Low CHON/Phenylalanine PIH – Hign CHON Renal Failure (Acute) – Low CHON, High CHO (Oliguric Phase) – Low Na (Diuretic Phase) – High CHON, High Calorie, and restricted fluid Renal Failure (Chronic) – Low CHON, Low Na, Low K
THREE LEVELS OF PREVENTION
I. PRIMARY PREVENTION ➢ Applied to generally healthy individuals/groups ➢ Generalized health promotion (mother’s class) ➢ Specific protection against disease (immunization) ➢ Precedes (before) disease or dysfunction E.g. 1. HEALTH EDUCATION about a. prevention of accidents b. standards of nutrition c. growth & development d. exercise e. stress management f. protection against occupational hazards 2. Immunization (active) 3. Risk assessment of specific disease 4. Family planning services & marriage counseling 5. Environmental sanitation & provision of adequate housing, recreation
II. SECONDARY PREVENTION ➢ Emphasizes on early detection of disease/diagnosis (case finding) ➢ Prompt intervention / treatment (passive--immunoglobulin) ➢ health maintenance for individuals experiencing health problems ➢ includes prevention of complication & disabilities (turn side-to-side, increase fluid intake) E.g. 1. SCREENING 2. Encouraging regular checkups 3. Teaching BSE & TSE 4. Nursing assessment & CARE provided (home, hospital, agency) III. TERTIARY PREVENTION ➢ Begins after illness ➢ When a defect/disability is fixed, stabilized or irreversible ➢ Support for the client to achieve a. successful adaptation to known risk b. optimal reconstitution c. re-establishment of high level wellness ➢ Focus: to rehabilitate & restore client to optimum level of functioning w/in the constraints of disability E.g. a. Referring a client w/ colostomy to a support group b. Teaching clients w/ DM to administer insulin c. Physical therapy to post amputation client
OVERVIEW OF NURSING THEORIES
1. FLORENCE NIGHTINGALE, 1850’s – Mother of Modern Nursing THEORY:Environmental Theory NURSING: Provision of optimal conditions to enhance the person’s reparative process and prevent the reparative process of being interrupted. Nursing is religious calling for women.
2. VIRGINIA HENDERSON, 1966 THEORY: Definition of Nursing PERSON: A whole, complete and independent being who has 14 fundamental needs. 1. to breathe 2. eat and drink 3. eliminate 4. move and maintain posture 5. sleep and rest 6. dress and undress 7. maintain body temperature 8. keep clean 9. avoid danger 10. communicate 11. worship 12. work 13. play 14. learn NURSING: The unique function of the nurse is to assist clients, sick or well, in performing those activities contributing to health, its recovery, or peaceful death – activities clients would perform
unaided if they have the necessary strength, will or knowledge. GOAL – to gain independence as soon as possible ➢ This definition was a major steppingstone in the emergence of nursing as a discipline separate from medicine. ➢ Nurse has complimentary and supplementary roles ➢ He/she can be a partner, a helper, or a substitute for the client. 3. MARTHA ROGERS,1970 THEORY: Unitary Human Beings as an Energy Field NURSING: A humanistic science dedicated to compassionate concern with maintaining and promoting health, preventing illness, and caring for and rehabilitating the sick and disabled. Seeks to promote symphonic interaction between the environment and the person. 4. DOROTHEA OREM, 1980 THEORY: SELF-CARE DEFICIT THEORY 1. Self-care Theory 2. Self-care Deficit Theory 3. Nursing System Theory NURSING: A helping or assisting service to persons who are wholly or partly dependent when they (to include others) are no longer able to give or supervise their care. Nursing is a deliberate action. 5. SISTER CALLISTA ROY, 1976 THEORY: Adaptation Model NURSING: A theoretical system of knowledge that prescribes a process of analysis and action related to the care of the ill or potentially ill person. Nursing is a science and a practice discipline. 6. IMOGENE KING, 1971 THEORY: Goal Attainment Theory NURSING: A helping profession that assists individuals and groups in society to attain, maintain and restore health. If this is not possible, nurses help individuals die with dignity. Nurses interact with clients to communicate information needed to establish mutual goals and to explore and agree on means to achieve goals (Transaction). 7. BETTY NEUMAN, 1972 THEORY: Health Care Systems Model NURSING: A unique profession in that it is concerned with all the variables affecting an individual’s response to stressors, which are intra-, inter-, and extrapersonal in nature. The concern of nursing is to prevent stress invasion, or, following stress invasion, to protect the client’s basic structure and obtain or maintain a maximum level of wellness. The nurse helps the client through primary, secondary, and tertiary prevention modes, to adjust to environmental stressors and maintain client system stability. 8. DOROTHY JOHNSON, 1968 THEORY: Behavioral System Model NURSING: An external regulatory force that acts to preserve the organization and integration of the client’s behavior at an optimal level under those conditions in which the behavior constitutes a threat to physical or social health or in which illness is found.
9. HILDEGARD PEPLAU, 1952 THEORY: Psychodynamic Nursing Theory and Interpersonal Relations Theory NURSING: A maturing force that is realized as the personality develops through educational, therapeutic and interpersonal processes. It involves four phases (Orientation, Identification, Exploitation, Resolution) The nurse acts as a resource person, a counselor, and a surrogate. Psychodynamic nursing is defined as understanding one’s own behavior to help others identify felt difficulties and applying principles of human relations to problems arising during the experience. 10. MADELEINE LEININGER, 1978 THEORY: Transcultural Care Theory or Culture Care Diversity and Universality Theory NURSING: She found it senseless to define “nursing” as a distinct concept. ➢ However, these are some of her concepts with regards to culture care. ➢ “There can be no cure without caring, but there may be caring without curing.” ➢ Caring is the essence of nursing. ➢ Nursing care that is not congruent with beliefs, values of a patient’s culture will lead to noncompliance and stress. ➢ Through the three types of nursing care decisions and actions (Cultural Care Preservation, Cultural Care Accommodation and Cultural Care Restructuring), it is possible to provide culture congruent care that is beneficial, satisfying and meaningful to people. 11. JEAN WATSON, 1979 THEORY: Philosophy and Science of Nursing NURSING: The purpose of caring is to assist the person in gaining control and becoming knowledgeable, and in the process promote health changes. The science of caring is complementary to science of curing. There are Ten (10) Carative Factors 1. Formation of a HumanisticAltruistic Value System 2. Faith-Hope 3. Cultivation of Sensitivity to Self and Others 4. Establishing a Helping-Trust Relationship 5. Expression of Feelings, Both Positive and Negative 6. Research and Systematic Problem-Solving 7. Promotion of Interpersonal Teaching-Learning 8. Provision for a Supportive, Protective, and/or Corrective Mental, Physical, Sociocultural and Spiritual Environment 9. Gratification of Human Needs (low and high order needs) – survival, functional, integrative and growth-seeking needs. 10. Allowance for Existential Phenomenological Force 12. FAYE ABDELLAH, 1960 THEORY: Typology of Nursing Problems NURSING: Promotion of wholeness for all whether well or ill. Must use a problem-solving approach.
Lists 21 Nursing Problems that fall into one of the three categories. 1. Physical, emotional, social needs 2. Interpersonal needs 3. Common elements of client care. 13. ERNESTINE WIEDENBACH, 1964 THEORY: Helping Art of Clinical Nursing NURSING: An art based on goal-directed care. Nursing consists of identifying a “need for help” which is desired by the individual, ministering to the need, and validating that the need was met. 14. Joyce Travelbee, 1966 THEORY: Human to Human Relationship Model NURSING: Nursing is accomplished through human-to-human relationships. She defined Empathy as the ability to share in the patient’s experience, and thus be able to predict the behavior of the patient. She defined Sympathy as going beyond empathy and occurring when the nurse desires to alleviate the cause of patient’s suffering and is “involved but incapacitated”. Her works are applicable to psychiatric nursing and greatly influenced hospice movement. 15. LYDIA HALL, 1960’S THEORY: Theory of Care, Core and Cure NURSING: Nursing is helping clients move in the direction of self-awareness. Nursing care is given exclusively by nurses educated in the behavioral sciences who take the responsibility and opportunity to coordinate and deliver the total care of their patients. This includes nursing, teaching, and advocacy in fostering healing. 16. IDA ORLANDO, 1961 THEORY: Dynamic Nurse-Patient Relationship or Deliberative Process of Nursing NURSING: Nurse’s reaction to patient behavior forms the basis for nurse actions. It can be Automatic or Deliberative. Orlando emphasized patient participation in planning care by allowing the patient to give feedback. 17. MYRA LEVINE, 1969 THEORY: Four Conservation Principles of Nursing NURSING: Nursing is a human interaction designed to promote “wholeness” through adaptation. Nursing care is seen as both supportive and therapeutic. The supportive aspect is designed to maintain a state of wholeness in the face of a client’s failing health. The therapeutic aspect is designed to promote adaptation that contributes to health or restoration of health of clients. KEY CONCEPTS 1. Conservation of Energy 2. Conservation of Structural Integrity 3. Conservation of Personal Integrity 4. Conservation of Social Integrity 18. ROSEMARY RIZZO PARSE, 1981 THEORY: Theory of Human Becoming NURSING: Focuses on man as “living unity”. Goal is to guide individuals and families uncover the meaning and relate it to their present situation. Parse sees nursing as a human
science rather than one founded on the natural sciences. 19. MARGARET NEWMAN, 1979 THEORY: Energy Field Theory – “Health as Expanding Consciousness” NURSING: A partner in the process of expanding consciousness. The nursing process is one of pattern recognition. 20. PATERSON AND ZDERAD, 1976 THEORY: Humanistic Nursing NURSING: The nurturing response of one person (the nurse) to another in need (the client), by performing actions to increase the possibility that the client will make responsible choices.
organisms mode of transmission determines isolation precautions barrier used to break the chain of infection between mode of transmission and susceptible host sterile items can be only stored for 1 -2 months handwashing not less than 30 seconds autoclave – kills all micorbes including spores –penetrate thick linen patient in isolation – need sensory stimulation soaps and detergents – remove bacteria – lower surface tension of water and act as emulsifying agents antiseptic – inhibit growth bactericides and disinfectants – detsroy pathogens exudate – clear protein rich fluid good nutrition - crucial in the healing of pressure ulcers
THERAPIES AND TREATMENTS
phlebitis – warmth and burning sensation Z – track - prevent skin staining and irritation mid – deltoid - can accommodate only 1 ml. of medication insulin injection- validate dose accuracy insulin injection – G25 , 5/8 “ needle G20 – IM oil based 22G 1 ½”– im meds. G26 – intradermal length of tubing should make no influence in how the infusion flows
COMFORT AND SAFETY MEASURES lotions containing lanolin – preferred for backrub sleep deprivation causes behavior and personality changes. adequate sleep maintains coordination and perception and decreases restlessness REM –deep sleep, depressed muscle tone and possibly irregular heart and respiratory rates NON-REM SLEEP is a deep restful sleep without dreaming DELTA STAGE OR SLOW WAVE SLEEP – non-REM stage III and IV –quiet sleep napping in the afternoon – not conducive to nightime sleeping pain is whatever the patient says it is , exists whenever she says it does
preventing pain is always easier than relieving it bedrail only a reminder not to leave bed
SPECIAL NEEDS Aging decreased elasticity of blood vessels, increased peripheral resistance and decreased blood flow Azheimer’s Disease – loss of short term memory sensory deprivation- involuntary loss of physical awareness caused by detachment from external sensory stimuli – isolation speak directly in front and enunciate well- hearing impaired “devoid of feelings” – acceptance in the grieving process nurse can help ensure a peaceful death by providing dignified support high protein diet – acidic urine ; vegetarian diet – alkaline urine TPN CONSIDERATIONS: GENERAL COND;LOSS OF 7% OF USUAL BODY WEIGHT OVER 2 MONTHS, LACK OF ORAL NUTRITION FOR 5 DAYS, PREOP. PREPARATION OF SEVERELY MALNOURISHED PATIENTS, CA in the GIT and IBD Soft diet – no fried foods , organ or red meats, whole grain breads and seasoning Bland – no gastric irritants and seasonings, fruit juice OK Venturi mask – precise o2 concentration. Humidification of O2 – distilled H2O Vomiting of fluids for 3 days – loss of fluids DETERMINATION
Lungs and kidneys - body’s homeostatic regulators Hypertonic solution enema-120 ml left in place for 7 – 10 minutes Cleansing enema – 1000 ml. MOBILITY INCREASED ADRENALIN PRODUCTION IN IMMOBILE PATIENTS – DECREASED PERISTALSIS Anorexia – depleted protein stores Anatomic alignment prevents strain on body parts, amintains balance and promotes physiologic functioning Drawsheet is the best device to use when moving a patient up in bed Virchow’s triad- collectively predispose a ptient to thrombophlebitis , impaired venous return to the heart , blood hypercoagubility and injury to to blood vessel wall. Valsalva maneuver – forced expiratory effort against a closed glottis Oxygen improves respiratory function only if he has symptoms of hypoxia Cold skin and impalpable pulse in the leg – refer ASAP (embolus) Pulse rate – most reliable indicator of activity tolerance Complication of immobility – foot drop
Prolonged in thromcytopenia, defective platelet function and aspirin therapy.
Factor VIII Assay
60% - 140 %
Deficient in Classical Hemophilia
(normal 2.5x control)
Prolonged deficiency of fibrinogen factors II, V, VIII, IX, X , XI and XII and in heparin therapy
60-70 sec PT
Prolonged by deficiency of Factos I, II, V, VII and X, fat malabsorption, severe liver disease, Coumarin anticoagulant therapy
Used to standardize the prothrombin time and anticoagulation therapy.
M: 4.6-6.2 x 1012/L
Increased in severe diarrhea and dehydration, polycythemia, acute poisoning, pulmonary fibrosis
F: 4.2-5.4 x 1012/L
Decreased in all anemias, in leukemia and after hemorrhage when blood
volume has been restored ESR Westergren Method