Autonomic dysreflexia – High fowler’s
Post-bronchoscopy – Semi-fowler’s
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
________________________________________________________
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 stepping-stone 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 Humanistic-Altruistic
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.
MAINTAINING ASEPSIS
 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
DETERMINATION REFERENCE RANGE
Bleeding Time 1.5-9.5 min
________________________________________________________
 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, PRE-OP.
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
 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
HEMATOLOGY
CLINICAL SIGNIFICANCE
Prolonged in thromcytopenia,
 defective platelet function and aspirin
therapy.
Factor VIII Assay 60% - 140 % Deficient in Classical Hemophilia
PTT (Activated) 25-45 sec Prolonged deficiency of fibrinogen
PTT (normal 2.5x control) factors II, V, VIII, IX, X , XI and XII and
60-70 sec in heparin therapy
PT 9-14 sec Prolonged by deficiency of Factos I, II,
V, VII and X, fat malabsorption, severe
liver disease, Coumarin anticoagulant
therapy
INR 1.0 Used to standardize the prothrombin
time and anticoagulation therapy.
Erythrocyte count M: 4.6-6.2 x 1012/L Increased in severe diarrhea and
F: 4.2-5.4 x 1012/L dehydration, polycythemia, acute
poisoning, pulmonary fibrosis
Decreased in all anemias, in leukemia
and after hemorrhage when blood
volume has been restored
ESR Westergren Method <15-200 mm/h Increased in tissue destruction,
ESR Zeta Centrifuge Method <0.40-0.60 whether inflammatory or
degenerative, during menstruation
and pregnancy and in acute febrile
illness
Hematocrit M: 42-52% Increased in erythrocytosis of any
F: 35-47% cause and in dehydration or
hemoconcentration associated with
shock.
Decreased in severe anemias, anemia
of pregnancy, acute massive blood
loss.
Hemoglobin M: 13-18 g/dL Increased in polycythemia, COPD,
F: 12-16 g/dL failure of oxygenation because of CHF
and normally in people living at high
altitudes
Decreased in various anemias,
pregnancy, severe or prolonged
hemorrhage, with excessive fluid
intake
WBC/Leukocytes 5 000-10 000/cu mm Increased in various infections

Neutrophils 45%-73% Neutrophils increased with acute

Eosinophils 0%-4% infections, trauma or surgery,
Basophils 0%-1% leukemia, malignant disease, necrosis;
Lymphocytes 20%-40% Decreased with viral infections, bone
Monocytes 2%-8% maroow suppression, primary bone
marrow disease
Eosinophils increase in allergies,
parasitic disease, collagen disease,
subacute infections, decreased with
stress, use of some medications
(ACTH, epinephrine, thyroxine)
Basophils increased with acute
leukemia and following surgery or
trauma, decreased with allergic
reactions, stress, parasitic disease, use
of corticosteroids.
Lymphocytes increased with
infectious mononucleosis, viral and
some bacterial infections, hepatitis,
decreased in aplastic anemia, SLE,
immunodeficiency including AIDS
Monocytes increased with viral
infections, parasitic disease, collagen
and haemolytic disorders, decreased
with use of corticosteroids, RA, HIV
infection
Platelet count 150 000-450 000/cu mm Decreased in thrombocytopenic
purpura, acute leukemia, aplastic
anemia and during cancer
chemotherapy

________________________________________________________
SERUM, PLASMA AND WHOLE BLOOD CHEMISTRIES

DETERMINATION REFERENCE RANGE INCREASED DECREASED

Conventional Units SI Units
Acid, total M: 2-12 U/L M: 2-12 U/L Carcinoma of prostate
phosphatase F: 0.3-9.2 U/L F: 0.3-9.2 U/L Advanced Paget’s
Disease
Hyperparathyroidism
Gaucher’s Disease
Alkaline phosphatase Adults: 50-120 U/L 50-10 U/L Conditions reflecting
increased osteoblastic
activity if the bone
Rickets
Hyperparathyroidism
Hepatic Disease
Bone disease
Ammonia (plasma) 15-45 ug/dL (varies 11-32 umol/L Severe liver disease
with method) Hepatic
decompensation
Amylase 60-a60 Somogyi 111-296 U/L Acute pancreatitis Chronic pancreatitis
U/dL Mumps Pancreatic fibrosis
Duodenal ulcer and atrophy
Carcinoma of head of Cirrhosis of liver
pancreas Pregnancy (2nd and
Prolonged elevation 3rd trimester)
with pseudocyst of
pancreas
Increased by
medications that
constrict pancreatic
duct sphincters
(morphine, codeine,
cholinergics)

AST (Aspartate M: 10-40 U/L M: 0.34-0.68 µkat/L Myocardial infarction

aminotrnasferase) F: 15-30 U/L F: 0.25-.0.51 µkat/L Skeletal muscle disease
formerly SGOT Liver disease
ALT(Alanine M: 10-40 U/ml M: 0.17-0.6 µkat/L Same conditions as AST
aminotransferase) F: 8-35 U/ml F: 0.14-0.60 µkat/L (SGOT) but increase is
formerly SGPT more marked in liver
disease than AST
Bilirubin Total: 0.3-1.0 mg/dL 5-17 µmol/L Hemolytic
Direct: 0.1-0.4 mg/dL anemia(indirect)
Indirect: 0.1-0.4 1.7-3.7 µmol/L Biliary obstruction and
mg/dL disease
3.4-11.2 µmol/L Hepatocellular
damage(hepatitis)
Pernicious anemia
Hemoltic disease of
newborn

BLOOD GASES

Oxygen, arterial 85-95 mm Hg 10.64-12.64 kPa Polycythemia Anemia

(whole blood) Cardiac or
Partial pressure (PaO- pulmonary disease
2)

Saturation (SaO2) 95%-99% Volume fraction: Cardiac

0.95-0.99 decompensation
Chronic obstructive
lung disease
Carbon dioxide, 35-45 m Hg 4.66-5.99 kPa Respiratory acidosis Respiratory alkalosis
arterial (whole blood) Metabolic alkalosis Metabolic acidosis
Partial pressure
(PaCO2)
pH (whole blood, 7.35-7.45 7.35-7.45 Vomiting Uremia
arterial) Hyperventilation Diabetic acidosis

________________________________________________________

NURSING PROCESS
 Nursing processp provides continuity of care and
patient participation in health care
 Care plans should never be unchangeable and
revised prn
 NANDA – responsible for formulating taxonomies or
classifications
 Nursing order should include the date, the specific
nursing action, time / length of time and signature
 Provide safety from falls – keep bed in lowest level
and locking wheels
 The point at which the brachial pulse can no longer
be palpated provides an estimate of the maximum
pressure required to measure systolic blood
pressure.
 Last Korotkoff sound heard on auscultation with a
stethoscope is the diastolic pressure
 The primary reason for bedrest is to decrease
metabolic activity, which reduces the cells need for
oxygen.secondary is to conserve energy and
decrease cardiac output
 The normal APTT is 16 – 25 seconds and PT is 12 – 15
seconds, these levels must remain within two to two
½ the normal levels
 Negligence – failure to act as an ordinary prudent
person would.
 Malpractice – professional misconduct, improper
discharge of professional duties or failure to meet
standards of care
 Three elements necessary to establish nursing
malpractice – nursing error , injury and proximal
cause
 A DNR order means that basic and advanced life
support measures won’t be initiated if respiratory or
cardiac arrest occurs. It does not mean that ordinary
treatment measures or nursing care is stopped
COMMUNICATION SKILLS
Nursing theory – one that generates knowledge in
nursing
 Conceptual model – group of general ideas that
serves as framework upon which nursing theories
can be developed and tested.
 In 1960, Nursing schools adopted theories from the
biological and psychosocial sciences to serve as
conceptual frameworks
 Four concepts – person, environment – health and
nursing(actions)
 Martha Rogers – life process model – evolving
creature interacting with the environment in an
open, adaptive manner-achieve maximum health in
his environment
 Dorothea Orem – persons need to achieve self care.
Goal of nursing is to help patient develop self- care
activities to maintain maximum wellness
 High level wellness - OLOF
 Maslow – a need as a satisfaction whose absence can
cause illness
 Safest way to identify patient is checking
identification band on his wrist
 Diagnosis and Tx of human responses to actual or
potential health problems
 Profession – requires specialized knowledge with
long and intensive academic preparation
 Student nurses do not provide services, they are
solely on the unit to learn
 Patient safety is a major concern in all situations
________________________________________________________
 The goal of listening- identify problems and needs
and a supportive act.
 Delegating responsibility shows respect for the staff
members abilities to solve problems on their own
 The nurse managers function is to guide , direct and
coordinate patient care, not to provide it.
 Primary nursing – comprehensive form of nursing in
which one nurse is responsible for comprehensive
care of a given patient
 Evaluation of staff members must be based on
performance criteria as established by professional
standards and the job description.
 Poor performance stems from poor morale
 Trust is the foundation of positive nurse patient
relationship
 Therapeutic communication – two way , deliberative
interaction between the patient and nurse in which
they establish mutually acceptable, achievable goals
---fundamental component at all phases of the
nursing process
 Problem orientedmedical record- information is
recorded as prob.,observations and plan
 Narrative chart – decriptive storylike record
 A positive change in the patient’s behavior is the best
way to identify learning
 Teacher should always try to involve the learner
 Asking questions shows that the patient is interested
in learning
 Maintaining independence, a need common to
patients of all age-groups, fosters the elderly
person’s feelings of self worth
NURSING ASSESSMENT
 Too much Yin causes digestive disorders and
nervousness and too much yang causes dehydration ,
fever and irritability.
 Correct sequence in abdl. Assessment is RLQ, RUQ,
LUQ and LLQ
 Guaiac – hemoccult test
 Rectal examination – sims , genupectoral and dorsal
recumbent
 Romberg test – test for sensory or cerebellar ataxia
 Narrowed pulse pressure less than 30 – hypovolemia
 Oral temp.-36.1- 37.8’C (axillary 1‘deg.lower) (rectal
-1’higher)
 BP cuff small – false high readings
 Rectal temp – 3 to 5 mins. And axillary 10 mins.
 Rinne hearing tests compare sound conduction
through air and bone.air conduction greater than
bone conduction normal hearing or sensorineural
hearing loss. Vice versa conductive hearing loss
 Weber’s – determine if patient hears better in one
ear or to differentiate sensorineural hearing loss
from conductive hearing loss
 Level of consciousness is the most important
element in assessing the patient’s mental status
 Lethargic patient sleep’s on and off but will respond
to verbal or tactile stimuli. Stupor – needs constant
stimulation
 Brain highly sensitive to inadequate oxygenation
( mental changes – hypoxia – first sign)
 Body’s response to elevated temperature –
tachycardia and peripheral vasodilation(inc.
metabolism) - hypotension
 Crisis – turning point in the course of a disease
usually indicated by a rapid decrease in temperature
 Lysis – gradual improvement in condition
INFORMED CONSENT
 Capacity and competence
 Includes explanation of
  Benefits, expected results,alternatives and risk  Biot’s – shallow breaths interrupted by apnea
 Voluntary THERAPEUTIC EXERCISES
 Information understood  Passive ROM-retention of rom and maintenance of
 Cannot sign if under alcohol or premedicated circulation
MANAGED CARE  Assistive- increases motion , maintains muscle tone
 Work allocation  Active – maintains mobility of the joint and
 Patient needs and conditions maintains muscle strength
 Abilities of staff  Resistive – increases muscle power
 Continuity of care  Isometrics- maintenance of strength and prevents
 Knowledge of staff and qualifications\ muscular atrophy
 Right task- function , activity , DANGERS OF IMMOBILITY
decision…….information , supervision , follow-up  Decubitus ulcer-osteomyelitis
 Don’t delegate assessment,teaching  Osteoporosis-pathological fractures and renal calculi
evaluation,planning  Increased cardiac workload- tachycardia
 Contractures- deformities
SCOPE  Thrombus formation-pulmonary embolism
 RN  Orthostatic hypotension-weakness,faintness and
 Planning and health teaching dizziness
 Licensure requirements  Respiratory stasis – hypostatic pneumonia
 Assessment and evaluation  Constipation – fecal impaction
 Need for knowledge and skill  Urinary stasis-urinary retention
 LPN/LVN-  Negative nitrogen balance-weight loss/debilitation
 Stable patients
 Standard unchanging procedures NUTRITION
 Simple monitoring and implementation  PREMATURE INFANTS-less than37wks/2,500g-100-
 Sequenced/predictable outcomes 200 cal/kg/day and higher na,ca and chon
 State practice act inclusion  FULL TERM-120 cal/kg/day
 UAP-direct patient care activity and standard  Pregnancy + 300cal/day
operating unchanging procedures  Lactation+ 500cal/day
RESTRAINTS
 Liable for false imprisonment
 Last resort
 Informed consent(proxy)
 Alternative measures first
 Benefits> risks
 Length of time and circumstances specified
 Ensure safety – circulation checks,skin care, rom and
remove q2h
RESTRAINTS IS USED FOR:
 The purpose of discipline
 Comfort and convenience of provider
 Required to treat medical symptoms
 Ensure used to control behavior
 Prevent breach in safe and effective delivery of
medical therapy.
 Ensure safety of other patients
 Medium of limit setting and provision of external
controls
COMPLAINTS
 Compromise / collaborative agreement
 Listen attentively
 Explain scopes and limitations
 Ask and relay expected solutions and terms
 Non-defensive
HEALTH TEACHING
 C-consider support systems / compliance
 H- olds motivation and insight
 A- allow feedback
 N-needs met and assured
 G- goals and priorities set w/ pnt.
 E- empathetic and ensures collaboration
BREATHING PATTERNS
 Cheyne stokes – periodic breathing characterized by
rhytmic waxing and waning
 Dyspnea - labored painful breathing
 Hyperventilation – abnormally rapid deep prolonged
breathing
 Kussmauls – air hunger , marked increase in depth
and rate
 Tachypnea – fast shallow breathing
 Paradoxical – flail chest , deflates during inhalation

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