Nursing Notes-Nursing Board Exam Questions

RN Heals 2

noreply@blogger.com (grey26) — Mon, 14 Nov 2011 04:43:38 PST

- Applicants shall apply directly to the recipient DOH hospitals or through the CHDs. The registry of nurse applicants from the Department of Labor and Employment (DOLE) shall also be a source of candidates to the project.

- Only nurses and midwives with official and validated Professional Regulations Commissions (PRC) license are eligible to apply. Verification shall be done via the internet at www.prc.gov.ph

- Preference shall be given to nurses and midwives residing in the localities where the recipient DOH hospitals or health facilities are sited.

-Nurse and midwife volunteers, trainees, or those exposed in the recipient hospitals and other health facilities shall be given priority.
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Nurses and midwives must be physically and mentally fit. A medical certificate from a government hospital is required.

DOH launches RN HEALS project to deploy nurses to poor communities

noreply@blogger.com (grey26) — Fri, 21 Jan 2011 01:37:39 PST

Department of Health (DOH)
Press Release
January 12, 2011
DOH LAUNCHES ‘RN HEALS’ PROJECT TO DEPLOY NURSES TO POOR COMMUNITIES
“The Department of Health (DOH) today announced that applications can be filed starting next week, January 17, for its project where unemployed nurses will be deployed to poor communities in the country.
“The project, billed RN HEALS, seeks to make essential health services available to all Filipinos by training and deploying 10,000 unemployed nurses in communities to be identified by the DOH in collaboration with the Department of Social Welfare & Development (DSWD),” Health Secretary Enrique Ona said.
RN HEALS, an acronym for Registered Nurses for Health Enhancement And Local Service, is expected to address the shortage of skilled and experienced nurses in 1,221 rural and unserved or underserved communities for one year.
They will undergo learning and development in accordance with the roles and functions required by the project. A certificate of competency and employment will be given by the DOH, DSWD, and the Professional Regulation Commission to those who have satisfactorily completed their requirements.
While on deployment, the nurses will be given an allowance of P8,000 a month by the DOH while the local government unit (LGU) where they are assigned shall supervise them, ensure their safety and security, and provide modest board and lodging. Likewise, LGUs are encouraged to provide additional allowances and benefits worth at least P2,000 for these nurses.
PhilHealth and the Government Service Insurance System will provide group insurance to the nurses while private corporations are encouraged to chip in through their available resources.
The recruitment and selection of these nurses shall be under the Department of Labor and Employment (DOLE) through its Regional Offices.
Registered nurses who are physically and mentally fit, and willing to serve in their municipalities may apply online at the DOLE website (www.nars.dole.gov.ph) from January 17 to February 4 this year. Preference will be given to residents of the municipalities covered by the Health Facilities Enhancement Program of DOH and Pantawid Pamilyang Pilipino Program or the Conditional Cash Transfer of the DSWD.
The list of successful applicants with their area of assignments shall be posted online at the DOLE website from February 7-10. An orientation shall be held on February 11-12 in their provincial centers of assignment by the regional DOH, DSWD, Professional Regulation Commission – Board of Nursing and the Philippine Nurses Association prior to deployment.
“Eventually, these nurses will be part of the pool of competent nurses for later employment or absorption in health facilities, thus addressing the inadequate supply of skilled nurses and increasing the nurses’ employment rate,” the health chief concluded.”

To APPLY ONLINE http://www.nars.dole.gov.ph/apply.aspx

Fire hits hospital in QC; 106 newborns evacuated : Inquirer headlines

noreply@blogger.com (grey26) — Thu, 09 Dec 2010 02:49:15 PST

By Nancy C. Carvajal
Philippine Daily Inquirer
First Posted 22:56:00 12/08/2010

WHEN A fire broke out shortly after dawn yesterday on the second floor of East Avenue Medical Center (EAMC) in Quezon City, the smoke drifted to the third floor where the nursery was located.
A nurse on duty immediately took stock of the situation and ordered everyone to start evacuating the ward’s patients which included 106 newborn babies placed in cribs.
Powered by a rush of adrenaline, the nursery staff gathered up the infants and took them down to the ground floor in batches.
As a precaution, the supervisor on duty stayed behind to make sure that none of the babies would be left in the nursery. She only joined the others when she was certain that all of the patients under her care had been safely evacuated.
“We were focused on getting the infants out of harm’s way and we did not even notice how heavy it was to carry three or four babies in a crib from the third floor down to the ground floor. We experienced an adrenaline rush,” one of the nurses told the Inquirer as she and her coworkers waited for the go-signal from hospital management to return the babies to the nursery.
Records showed that the fire broke out at 4:30 a.m. in a conference room at the hospital mezzanine located on the second floor.
Located directly above it was the nursery.
Marife Co, one of the nurses on duty, said that aside from the babies, they also had to wake up the mothers who were sleeping next to the nursery.
One patient told the Inquirer that when she got up from bed, the ward had started to fill with smoke but the nurses were there to guide them to safety.
We just followed the nurses who woke us up,” she said.
City fire marshal Bobby Baruelo said the fire was put out at 5:10 a.m. with the cause still under investigation.
Dr. Emmanuel Bueno, EAMC chief of staff, said no one was hurt during the fire but they had to transfer three patients from the emergency room.
He added that all patients had been accounted for and that hospital operations returned to normal at around 6 a.m.

POEA News Advisory: Job scammers target medical workers

noreply@blogger.com (grey26) — Thu, 09 Dec 2010 02:47:42 PST

The Philippine Overseas Employment Administration (POEA) released a news advisory dated December 7, 2010, about job scammers targeting medical workers.
POEA
News Advisory
December 7, 2010
Job scammers target medical workers
Medical students, graduates, and practitioners seem to be the favorite targets of employment scammers, the Philippine Overseas Employment Administration revealed yesterday.
Administrator Jennifer Jardin-Manalili said her office has received various reports regarding the illegal recruitment of medical professionals and skilled workers.
The Philippine Embassy in Berne has verified that a certain “Semino Private Hospital”, which claims to have a student program and offers internship jobs in Switzerland does not exist. Some applicants reported that Semino recruits medical students through e-mail and offers substantial allowances to lure its victims.
According to the Philippine Embassy, Semino Private hospital is not in the list of hospitals of the Canton of Vaud and is not even heard of in the area according to Swiss officials.
Semino Private Hospital has a mock website, seminohospital.com that is hosted in Nigeria, the report said. In its website, Semino claims that it shares the same address with Clinique Cecil, a prestigious hospital at Avenue Ruchonnet 53, CH -1003 Lausanne, Switzerland. The hospital also has no listed telephone number in Switzerland.
In Israel, Labor Attache Merriam C. Cuasay reported that unscrupulous recruiters are offering nursing jobs for “Jordan Valley Medical Center”.
The jobs were found to be fictitious as no such hospital exists. Israel has job openings for home-based caregivers but not for nurses.
The Consul General in Agana has also alerted the POEA of a fake hospital in Guam, the “Guam General Hospital” which has a website www.guamgeneralhospital.com that is soliciting applications for employment as nurses.
Another website, www.westernpacifichospital.com was recently discovered and has the same content as that of www.guamgeneralhospital.com.
This online scam is now being investigated by the U.S. Federal Bureau of Investigation.
The POEA stressed that there is only one hospital in Guam, the Guam Memorial Hospital (GMH).

Professional adjustment for nursing reviewer

noreply@blogger.com (grey26) — Fri, 03 Dec 2010 21:45:48 PST

Professional adjustment for nursing reviewer

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PROFESSION
 An occupation or calling requiring advance training
 Experience in some specific or specialized body of knowledge
 Provides service to society in that special field
 The term profession is honoric and should be carried with pride and honor
NURSING
 An occupation requiring a unique body of knowledge and skills and which serves society
PROFESSIONAL NURSE
 Completed a basic nursing education program
 Licensed in his/her country or state to practice professional nursing
NURSING PRACTICE
 Primary responsibility promotion of health and prevention of illness
 Collaborate with other health care providers
o Curative
o Preventive
o Rehabilitative aspects of care
o Restoration of health
o Alleviation of suffering
o Towards a peaceful death
 Provide nursing care through the utilization of the nursing process
o Therapeutic use of self
o Executing health care techniques and procedures
o Essential primary health care
o Comfort measures
o Health teachings
o Administration of written prescription for treatment
o Therapies
o Oral
o Topical
o Parenteral medications
o Internal examination during labour in the absence of antenatal bleeding and delivery
o Suturing of perineal laceration
 Establish linkages with community resources
 Coordination with the health team
 Provide health education to individuals, families and communities
 Teach, guide and supervise students in nursing education programs
 The nurse is required to maintain competence by continual learning through continuing professional education

QUALIFICATIONS AND ABILITIES OF A PROFESSIONAL NURSE
 Professional Preparation
o Have a license to practice
o Bachelor of science degree in nursing
o Be physically and mentally fit
 Personal Qualities and Professional Proficiencies
o Interest and willingness to work and learn
o Warm personality and concern for people
o Resourcefulness and creativity, well balanced emotional condition
o Capacity and ability to work cooperatively with others
o Skill in decision making
DEFINITION OF LICENSE
 A legal document given by the government that permits a person to offer to the public his or her skills and knowledge in a particular jurisdiction
CONTRACT
 Meeting of minds between two persons whereby one binds himself, with respect to other, to give something or to render some service
 A promise or a set of promise which the law recognizes as a duty and when that duty is not performed the law provides a remedy
NURSING ETHICS
 Ethics came from the Greek word ETHOS moral duty
 Standard to examine and understand moral life
 Guides of human conduct provided by ethical systems
 How people make judgement in regard to right or wrong
 Critical reflection about morality and rational analysis about it
 JOHNSTON- examination of all ethical and bio-ethical issues from the prospective of nursing theory and nursing ethics
 VERCOE- the fields of nursing ethics be focused on the needs and experiences of practicing nurses, the exploration of its meaning and that of ethical practice in terms of the perception of these nurses

Morals
 Specific ways of behaviour or of accomplishing ethical principles
 Greek work MORALIS
 Social consensus about moral conduct for human beings and society
 Morality is what you believe is right and good
Health Care ethics
 Division of ethics that relates to human health
 Realm of human values, morals, customs, personal beliefs and faith
Bioethics
 Specific domain of ethics that focuses on moral issues in the field of health care
 Result of life and death dilemmas faced by health care practitioners
 Systematic study of human behaviour in the field of life science and health care in the light of moral values and principles
TELEOLOGICAL APPROACH
 Greek word TELOS or goal or end
 The right thing to do is the good thing to do
 Act utilitarianism- good resides in the promotion of happiness or the greatest net increase of pleasure over pain
 If the act helps people, then it is a good act
 If the act hurts people then it is a bad act

FLETCHER’S GUIDELINES FOR MAKING ETHICAL DECISIONS
1. Consideration for people as human beings
2. Consideration of consequences
3. Proportionate good to come from the choices
4. Propriety of actual needs over ideal or potential needs
5. A desire to enlarge choices and reduce chance
6. A courageous acceptance of the consequence of the decision
DEONTOLOGICAL APPROACH OR DUTY ORIENTED THEORY
 Basic rightness or wrongness of an act depends on the intrinsic nature rather than upon the situation or its consequences
 Greek word DEON meaning DUTY
 Immanuel Kant- rational human being with freedom and social worth
 A person is morally good and admirable if his actions are done from a sense of duty and reason
W.D ROSS- PRIMA FACIE DUTIES- WHAT ONE SHOULD DO WHEN OTHER RELEVANT FACTORS IN A SITUATION ARE NOT CONSIDERED
 Duties of fidelity- telling the truth, keeping promises
 Duties of reparation- righting the wrong we have done to others
 Duties of gratitude- recognizing the service others have done for us
 Duties of justice- preventing distribution of pleasure or happiness that is not in keeping with the merit of people involved
 Duties of beneficence-helping to better the condition of other beings
 Duties of self improvement- bearing ourselves with respect to virtue or intelligence
 Duties of nonmaleficence- avoiding or preventing injury to others
VIRTUE ETHICS APPROACH
 ARETIC, Greek word ARETE, heart of the person performing the act
 Traits and virtues of a good person, courage, temperance, wisdom, and justice
DIVINE COMMAND ETHICS
 Supreme or divine that sets down rules to provide guidance to moral decisions
UNIVERSAL PRINCIPLES OF BIOMEDICAL ETHICS
 To determine right or wrong in regard to value issues
 Autonomy-
o Greek word AUTOS meaning self and nomos meaning governance
o Self determination
o Freedom to choose and implement one’s decision
o Informed consent
o Allowing the patient to refuse treatment if he decides so
o The person making the decision must be deemed competent, intellectual capacity, legal age
 Veracity
o Health care providers are bound to tell the truth
 Beneficence
o Promotes the doing acts of kindness and mercy that directly benefit the patient
 PATIENT’s BILL OF RIGHTS
o Considerate and respectful care
o Relevant, current and understandable information
o Make decisions regarding his care plan
o Have advance directive (living will)
o Every consideration of his privacy
o Confidentiality of communications and records
o Review his records concerning his medical care
o Be informed of business relationship among the hospital educational institution
o Consent or decline to participate experimental research affecting his care
o Reasonable continuity of care when appropriate and be informed of other care options
o Be informed of hospital polices and practices
 NONMALEFICENCE-
o To do no harm
o Not assisting in or performing abortion
o Not to assist people to commit suicide
o Be involved in mercy killing
 JUSTICE
o The right to demand to be treated justly, fairly and equally
 NURSES’ BILL OF RIGHTS
o Registered nurses promote and restore health
o Prevent illness
o Protect the people entrusted to their care
o Alleviate suffering
o Provide services that maintain respect for human dignity
 LVING WILLS OR ADVANCE DIRECTIVE
o Accept or refuse any treatment, service or procedure used to diagnose or treat physical or mental condition
o Decision to provide or withhold life-sustaining measures
o This living will is signed by the patient
o Witnessed by two other persons who is not designated as the person’s health care representative
o Directive has force of law
 MORAL PRINCIPLES
o The golden rule
 Do unto others what you would like others do unto you
o The two fold effect
 May have bad and good effect
 Must be morally good
 Good effect must be willed and the bad effect merely allowed
 Good effect must not come from an evil action
 Good effect must be greater than the bad effect
o The Principle of Totality
 The whole is greater than any of its parts
o Epikia
 Exception to the general rule
o One who acts through an agent is himself responsible
 Ex. Nurse recommends patient to another clinic for abortion but does not want to perform
o No one is obliged to betray himself/herself
 No one can force any person to answer a question if such will incriminate him/her
o The end does not justify the means
 Giving sleeping tablets to someone who has chronic illness
o Defects of nature may be corrected
 Corrected by plastic surgery
o If one is willing to cooperate in the act, no injustice is done to him/her
 With patient’s consent
o A little more or less does not change the substance of an act
 Stealing
o The greatest good for the greatest number
 Have more good effects for more people than a smaller group
o No one is held to the impossible
 Do not promise impossible things
o The morality of cooperation
 Formal cooperation is an evil act and never allowed
o Principle relating to the origin and destruction of life
 Thou shall not kill
GOOD SAMARITAN LAW
• A nurse who renders first aid or treatment at the scene of an emergency and who does so within the standard of care, acting in good faith, is relieved of the consequences
CODE OF GOOD GOVERNANCE
• Service to others
o Commitment to a life of sacrifice and genuine selflessness in carrying out their professional duties
• Integrity and Objectivity
o Perform their responsibilities with the highest sense of integrity
• Professional Competence
o Knowledge, technical skills, attitudes and experience
• Solidarity and teamwork
o Maintain and support one professional organization
• Social and Civic Responsibility
o Shall always carry out their professional duties with due consideration of the broader interest of the public
• Global Competitiveness
o Shall remain open to challenges of a more dynamic and interconnected world
• Equality of All professions
o Shall treat their colleagues with respect and strive to be fair in their dealings with one another
AMENDED CODE OF ETHICS FOR NURSES
• Section 3 Republic Act No. 877 known as the Philippine Nursing Law and Section 6 of P.D No. 223 the amended Code of Ethics of Nurses
• Article I
o Preamble- health is a fundamental right of every individual
• Article II
o Values, customs and spiritual beliefs held by individual shall be represented
o Consider the individuality and totality of patients when they administer care
• Article III
o Human life is inviolable
o Quality and excellence in the care of patients are the goals of the nursing practice
o Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability
• Article IV
o The registered nurse is in solidarity with other members of the healthcare team in working for the patient’s best interest
• Article V
o Preservation of life, respect for human rights and promotion of healthy environment
o Promotion in local, national, and international efforts to meet health and social needs of the people
• Article VI
o Maintenance of loyalty to the nursing profession and preservation of its integrity are ideal
• Article VII
o The certification of registration of the registered nurse shall either be revoked or suspended for violation of any provisions of this code.
DEFINITION AND MEANING OF LAW
• The sum total of rules and regulations by which society is governed
• Man mad regulates social conduct in a formal and binding way
• Rule of conduct pronounced by controlling authority and which may be enforced
o Authority or right to declare that the rule exists
o Rule is pronounced or expressed
o Source can be defined
o A right to enforce the same must be provided
• Controlling authority in our system is the government
• Fundaments law of the government is the constitution
• Principal sources of pronouncements
o Constitution
o Statutes or legislations
o Executive branch
o Case decision/judicial opinions
o Presidential decrees
o Letters of instructions
RESONSIBILITY AND ACCOUNTABILITY FOR THE PRACTICE OF PROFESSIONAL NURSING
• Professional Negligence
o Commission or omission of an act, pursuant to a duty
 Existence of a duty on the part of the person charged to use due care under circumstances
 Failure to meet the standard of due care
 The foresee ability of harm resulting from failure to meet the standard
 The fact that the breach of this standard resulted in an injury to the plaintiff
• Article 19 of the civil code
o One shall act with justice, give every man his due, observe honest and good faith
• Article 20
o Those who in the performance of their obligations through negligence causes any injury to another, are liable for damages
• Common acts of negligence
o Burns resulting from hot water bags, heat lamps, vaporizers, sitz bath
o Objects left inside the patient’s body; sponges suction tips, loose dentures lodged in the patient’s trachea
o Falls of the elderly; confused, unconscious, sedated patients
o Falls of children whose bed rails were not pulled up and locked
o Failure to observe and take appropriate action
o Failure to report observations to attending physicians
o Failure to exercise the degree of diligence which the circumstances of the particular case demands
o Mistaken identity- drug given to the wrong patient
o Wrong medicine, wrong concentration, wrong route, wrong dose
o Defects in the equipment
o Errors due to family assistance
o Administration of medicine without a doctors prescritption
THE DOCTRINE OF RES IPSA LOQUITUR
• Injury was of such nature that it would not normally occur unless there was negligent act
• Injury was caused by an agency within control of the defendant
• Plaintiff himself did not engage in any manner that would tend to bring about the injury
MALPRACTICE
• The idea of improper or unskilful care of a patient by a nurse
• Stepping beyond one’s authority with serious consequences
• Carelessness of professional personnel
• LESNIK- negligent act committed in the course of professional performance
DOCTRINE OF FORCE MAJEURE
• Irresistible force; unforeseen or inevitable
• No person shall be responsible for those events which cannot be foreseen
• Floods fire, earthquakes
DOCTRINE OF RESPONDEAT SUPERIOR
• Let the master answer for the acts of the subordinate
• The liability is expanded to include the master as well as the employee
INCOMPETENCE
• Lack of ability, legal qualifications or fitness to discharge the required duty
CONSENT TO MEDICAL AND SURGICAL PROCEDURES
• Consent
o Free and rational act that presupposes knowledge of teh thing to which consent is being given by a person who is legally capable to give consent
o Signed by the patient or authorized representative/legal guardian
o An authorization by a patient or a person authorized by law to give the consent on the patient’s behalf
o Nurse secures the consent of the patient upon admission
• Informed Consent
o Established principle law that every human being of adult years and sound mind has the right to determine what shall be done with his own body
o May choose whether to be treated or not
• Proof of Consent
o A written consent should be signed to show that the procedure is the one consented to and that the person understands the nature of the procedure
TORTS
• A legal wrong, committed against a person or property
• Assault and Battery
o Imminent threat of harmful or offensive bodily contact
o Unjustifiable to tough another person or to threaten to do so
• Battery
o An intentional, unconsented touching of another person
• False Imprisonment of Illegal Detention
o Unjustifiable detention of a person without a legal warrant within boundaries
• Invasion of Right to Privacy and breach of confidentiality
o Right to privacy is the right to be left alone
o Right to be free from unwarranted publicity
o Exposure to public view
o Divulge information from patient’s chart to improper sources or unauthorized person
• Defamation
o Character assassination
o Slander-oral defamation
o Libel-written words
o There must be a third person who hears or read the comment before it can be considered defamation

CRIMES, MISDEMEANORS, AND FELONIES

CRIME
• An act committed or omitted in violation of the law
• Two elements
o Criminal act
o Evil/criminal intent
• Conspiracy to commit a crime
o Two or more persons agree to commit a felony
 Principals- who take a direct plan/part
 Accomplices- cooperate in the execution
 Accessories- having knowledge of the commission of the crime
• Criminal Actions
o Acts or offenses against public welfare
• Criminal negligence
o Reckless imprudence- person does an act or fails to do it voluntarily but without malice
o Simple imprudence- did not use precaution and the damage was not immediate or the impending danger was not evident or manifest
• Criminal Intent
o States of mind of a person at the time the criminal act is committed that he/she knows that an act is not lawful and still decide to do it anyway

WILLS
• A legal declaration of a person’s intentions upon death
• Testamentary document takes effect after the death of its maker
• Decedent- person whose property is transmitted through the succession whether or not he left a will
• If he left a will he is called a testator
• Woman is testatrix
• Heir- called to succession either by the provision of a will or by operation of law
• A person who dies leaving a will is said t have died testate
• One who dies without will is said to have died intestate
• Validation of the will in a court is known as probate
• A will which is written, dated and signed by the testator is called holographic will
• An oral will is called nuncupative will or nuncupation- made during the person’s last illness, that it be done in the place in which he died, one or more witnesses to the will
• Testator must have the expressed intention of making a will
• Must be right of age
• Under 18 cannot make a will
• Required to have sound mind
• Think clearly ability at the time of its execution
NURSES OBLIGATIONS IN THE EXECUTION OF A WILL
• The nurse should note the soundness of the patient’s mind
• There was freedom from fraud or undue influence
• Make a notation on the patient’s chart of the apparent mental and physical condition of the patient at the time of making the will

Professional adjustment for nursing reviewer

Bioethics in Nursing Reviewer

noreply@blogger.com (grey26) — Fri, 03 Dec 2010 21:25:12 PST

Bioethics in Nursing Reviewer Notes

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Bioethics
• Is ethics as applied to human life or health
• Ex: Abortion or euthanasia

Moral Principles
• Are statements about broad, general, philosophical concepts, such as autonomy and justice. They provide the foundation for moral rules which are specific prescriptions for actions
• Ex: people should not lie

Autonomy
• The right to make one’s own decisions

Nonmaleficence
• Duty to “do no harm”

Beneficence
• Means “doing good”
• Nurses are obliged to do good, to implement actions that benefit clients and their support persons

Justice
• Referred to as fairness

Fidelity
• To be faithful to agreements and promises

Veracity
• Telling the truth

Responsibility
• Refers to specific accountability or liability associated with the performance of duties of a role

Philippine Nursing Act of 1992 – defines the scope of nursing practice

• Nurses are held responsible and accountable for the quality of performance of their duties.
• Nurses employed in any agencies are directly responsible to their immediate supervisors.
• PDN are held to a standard of conduct that is expected of reasonably prudent nurses.

Nurses’ Bill of Rights
• Nurses have the right of practice in any manner that fulfills their obligations to society and to those who receive nursing care.
• Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice.
• Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses and its imperative statements.
• Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
• Nurses have the right to fair compensation for their work, consistent with their knowledge, experience, and professional responsibilities.
• Nurses have the right to a work environment that is safe for themselves and their patients.
• Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all practice settings.

Unprofessional Conduct
• Incompetence or gross negligence
• Conviction for practicing without a license
• Classification of client’s records
• Legally obtaining, using, or possessing controlled substances
• Having personal relationship with a client

Categories of Confidential Information
• Vital statistics
• Infections and communicable diseases
• Child or elder abuse
• Violent incidents

Definition of a Law
• Is the sum total of rules and regulations by which a society is governed

Functions of the Law in Nursing
• Provides a framework for establishing which nursing actions in the care of the clients are legal
• Differentiates the nurses’ responsibilities from those of other health professional
• Helps establish the boundaries of independent nursing action
• Assists in maintaining a standard of nursing practice by making nurses accountable under the law

Types of Law
1. Public Law
• The body of law that deals with relationships between individuals and the government and government agencies
• An important segment of public law is criminal law which deals with actions against the safety
2. Private Law/Civil Law
• Body of law that deals with relationships among private individuals
a. Contract law –involves the enforcement of agreements and private individuals or the payment of compensation for failure to fulfill the agreements
b. Tort law – defines and enforces duties and rights among private individuals that are not based on contractual agreements

Sources of Law
1. Constitutional Law – supreme law
 Establishes general organization of the government
 Grants certain powers to the government
 Places limitations to what the government may do
 Creates legal rights and responsibilities
 Foundation for a system of justice
2. Legislation (Statutory Law)
 Law enacted by any legislative body
3. Administrative Law – when a state legislature passes a statute, an administrative agency is given the authority to create rules and regulations to enforce the statutory laws.
4. Common Law – law evolving from court decisions.

Tort Law
- Deals with rights and obligations of the person involved in an act; related to injury or harm committed to a person; invasion of privacy; damage to a person’s property, business, reputation
- Forms: Intentional and Unintentional

Characteristics of Law
• It comes from an authority: the right to declare that the rule exists
• Rule is pronounced and source is identified
• Right to enforce the same is provided

The controlling authority
• Government: embodiment of such control is the constitution
• Constitution is the fundamental law of the land
• Constitution contains principles on which the government is founded; regulates the sovereign powers; directs to which the powers are entrusted; specifies manner by which the powers are exercised

Pronouncement of the Law
• Declared in writing: to enforce control
• Sources of Pronouncements:
1. Constitution
2. Statues or legislations
3. Regulations
4. Judicial decisions
5. Presidential decrees
6. LOI

Rules of Conduct
• Provided by the law making body
• Issued in writing
• Provisions on consequences for violations

Will
• Legal declaration of a person’s intentions upon death
• Testamentary document because it takes effect after the death of its maker

Decedent
• A person whose property is transmitted through succession whether or not he left a will
o Testator – person who left a will
o Testatrix – woman who makes a will

Heir
• A person called to succession either by the provision of a will or by operation of law

Testate
• A person who dies leaving a will

Intestate
• A person dies without leaving a will

Probate
• Validation of a will in court

Administrator
• One who administer the provision of the will

Holographic Will
• A will which is written, dated and signed by the testator

Nuncupative / Nuncupation Will
• Oral will

Six Elements that must be present for a case of nursing malpractice to be proven
1. Duty
o The nurse must have a relationship with the client that involves providing care and following an acceptable standard of care
2. Breach of duty
o There must be a standard of care that is expected in the specific situation, but that the nurse did not observe
3. Foreseeability
o A link must exist between the nurse’s act and the injury suffered
4. Causation
o It must be proved that the harm occurred as a direct result of the nurse’s failure to follow the standard of care and the nurse could have known that failure to follow the standard of care could result in such harm
5. Harm or injury
o The client or plaintiff must demonstrate some type of harm or injury as a result of the breach of duty owed the client
6. Damages
o If malpractice caused the injury, the nurse is held liable for damages that may be compensated. The goal of awarding damages is to assist the injured party to his or her original position so far as financially as possible.

Nursing Research Reviewer

noreply@blogger.com (grey26) — Fri, 24 Sep 2010 18:13:19 PDT

Nursingnotes.info nursing-research-review

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Slide 1: Visit http://www.nursingnotes.info/ for more RESEARCH – (Kerlinger) systematic, empirical, controlled & critical investigation of a hypothetical proposition related to natural phenomenon. PHENOMENON – anything that affects human life - disease, signs & symptoms, procedures, MD, RNs HYPOTHESIS – educated guess, scientific guess, tentative statement of a supposed answer. - not known yet if true of false, right or wrong RESEARCH - must be conducted to affirm or deny a hypothesis. 4 major Characteristics of a Scientific Research 1. Systematic – follow step by step process. Fr identification of problem to conclusion. 2. Empirical – proper objective. To collect data, facts & evidence to support hypothesis. 3. Controlled – proper planning/ direction. Research design. 4. Critical investigation – fact finding investigation. (synonym) PURPOSE OF ASIENTIFIC NURSING RESEARCH D – descriptive purpose. Gain richer familiarity regarding a phenomena. Observation. 100% known to RN. E – exploratory purpose. 50% still unknown to RN. E – experimental purpose. Perform manipulation. Perform intervention. What to find out cause & effect. D – developmental purposes. Fro improvement of system of care. F Nightingale – birthplace. Italy Training ground: Germany Greatest contribution: environmental theory & training of RNs in Crimean War School: St. Thomas School of Nursing Patient –nursing focus on research 10 MAJOR STEPS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Identification or formulation of research problem Review of related literature conceptualization of conceptual/ theoretical framework Formulation/ Adapting hypothesis Choosing the appropriate design Choosing sample from pop Conducting final study or pilot study Collection of data base Analysis & interpretation of data base Disseminating the conclusion & recommendation. Problem: in res – requires a solution Sources (CLIENT) of good problem C – concepts L – literatures I – issues E – essays N – nursing problems T – theories Char of good problem (GRIFINS) G – general applicability – result should be helpful or applicable to all. a.) basic/ Pre – for personal knowledge b.) Applied – focus is solving problems of others Re – researchable – collectable & abundant data F – feasible or measurable
Slide 2: a.) b.) c.) d.) e.) f.) time money/ cost participants instruments experience proper ethics of good researcher I – important N – novelty – original to avoid plagiarism. S – significant ETHICS OF A PROPER RESEARCHER: (SCIENTIFIC) S – scientific objective always (good faith) C – consent I – integrity E – equitable (appropriate acknowledgments) liable for N – noble – Respect 3 basic rights of research sample T – truthfulness I – importance of topic to nursing profession C – courage to look for data. Legal owner of chart: Hospital Legal owner of data in the chart: Patient Plagiarism – illegal replication: no consent & acknowledge 3 rights of sample/ pt 1.) Right not to be harmed 2.) Right to self determination – get consent & right to withdraw consent 3.) Right to privacy a.) anonymity – privacy of identity of informant b.) confidentiality – name given but privacy of info/ data Harm that can happen to sample/pt 1.) right from physical , mental & moral harm 2.) Right to self determination Negligence 1.) Commission – unacceptable in standard of practice 2.) Owrission – didn’t do anything. No intervention done. Mental Harm: 1.) Assault – threatened. Mental fear 2.) Assault & Battery – with mental fear & physical harm 3.) Battery – with physical harm. Moral harm – Slander – Oral defamation – Libel Restraint – dependent with doctors order - physical – vest or jacket - chemical – valium A study in the difference in the financial income of Filipinos working in NYC & QC (comparative & basic) Variables – anything that is subject t change on manipulation. 1.) Independent variable – target population IV – stimulus intervention 2.) Dependent variable – response DV – response measured Independent variable (stimulus) Target Population (Organism) Dependent Variable (Response)
Slide 3: Place of work Filipino RNs Reviewers Financial income early review Jan Pavolovian Theory (SOR) Stimulus Organism Response Intervening variables comes between independent & dependent ex. Organismic variable internal factors age, sex, gender, color. Extraneous variable – ext influences can be changed Allure, citizenship, educational status Dichotomus variable – 2 choices/ results Ex. Male or Female Polychotmus – multiple choices/ multi variables Preferred food – Japanese, Chinese, Filipino, American Research 1.) Identity Problem 2.) Purpose – objective (SMART) 3.) Define terms 4.) Revision of terms S – smart M – measurable A – attainable R – realistic T – time bound (limit) Conceptual definition – dictionary meaning Operational definition – based on use of research char of problem Toxic – conceptual – waste products Operational – very busy day for RNs Review of related literature Purpose: for proper formulation of conceptual & theoretical framework. Theory – relationship bet concepts Conceptual framework. Illustration showing relationship between variables Paradigm- diagrammatic presentation / illustration of conceptual framework. Source of review literature 1. Conceptual Sources – authors & conceptualists ( DOH book, Lippincott, Mosbys) - for general use, can be sold. 2. Research sources – researchers cant be sold. Types of Hypothesis: 1. NULL hypothesis (-) no relationship, no difference bet 1 variable to another ex. There’s no diff regarding prof Opportunities in US & RP 2. Alterative, simple or operational hypothesis – (+) show a relationship bet 1 variable to another ex. Filipino RNs has more prof opportunities un US 3. complex hypothesis – shows a relationship bet 2 or more variables to another. Ex. Filipino RNs who worked for 5 yrs & passing all CG tests have opportunities to acquire starting salaries, insurance. 4. Directional Hypothesis – specifies the direction of relationship bet variables
Slide 4: Ex. Filipino RNs working in USA have more prof opportunities than those in Phil 5. Non directional Hypothesis – no specific direction There is a big difference between all Filipino RNs working in the USA 5 Choosing appropriate design: - skeletal framework of research Research Design: According to application or motive According to approach According to data Method used applicable to quantitative research: survey Case study – focus 1 patient only or 1 family Research Design Application motive Basic / pure Applied Approach Data Quantitative (majority answer) Survey Non experimental 1.) Observe sample subject, Research has 2.) Massive participation 3.) Describe & record 4.) Natural setting – where pop exists Experimental: 1.) Active manipulation – treatment or intervention done 2.) Active participation to sample pop 3.) Controlled setting – lab research units Types of non experimental res design. 1. Historical research design – happened in the past - collect written, published, circulated or archived - pt’s chart ex. Health practices during Crimean War 2. Expost Facto (after facts) (Retrospective) - Antecedent facts happened Study a group of people who have naturally experienced a particular phenomena related to a problem & has something to do with present study - Interview only, no manipulation! Subject is related to present problem. 3. Prospective – focus; future time to look for a data existing subject with future happening Focus: weekend review in pentagon Result: of board exam this coming June Present future 4. Descriptive – no intervention but merely observe & collect data. Ex. Study on absentism in St Lukes Study on environmental pollution in Quezon Types: a.) comparative study – similarity & difference of variables ex. Environmental pollution between variables Qualitative facts (single pt) Case study
Slide 5: b.) Correlatonal – relationship between variables ex. Environmental pollution & increased TB cases c.) Evaluative – effects/ results ex. Effects of environmental pollution d.) Survey type – data collection based on majority result Types or survey research 1.) groups – small group 2.) Face to face method - can get response/ feed back right away b.) Mailed survey method Problem; data collection 3.) Time orientation Cross sectional & longitudinal – extend period of time. 2 or more # of groups – 1 core group/ long term study unidentical groups - purpose: dev’t/ study - purpose: comparison - initial & fallow up survey - short term study # of time Steps in experimental type of research design 1. controlled stage – discipline/ direction a controlled group – will not be subjective experimental – group will be manipulated 2. Randominization – choose your sample by chance 3. Manipulation - intervention 4. Measurements of effect – determine the result Quasi experimental- when you lack in steps in experimental Pop – group where you get your sample Types of sampling 1.) Probability – choose sample by chance Types of probability Incidental sampling – these present in coffee shop a.) Simple random sampling – equal chance/ opportunity to be chosen - done if identical or equal footing b.) Stratified random sampling – create subdivided population (divide into 4 levels in school) or substrata before doing randominization c.) Cluster random sampling – create sub areas MNL hospitals – UST – 3rd floor d.) Systematic random sampling – sampling frame 3,000 HIV patients in Phil – write list of names appearing in pop uses multiple number in choosing. 2. Non probability sampling – not by chance - with pre-selected group, with braised group, favoritism a.) Accidental or convenience sampling. Criteria – immediate availability/ accessibility of sample. b.) Purposive/ judgmental sampling. - based on personal knowledge/ info ex. Research on prostitution I know location of prostitution – Ermita Prostitution also in Pasay & Makati I will not choose Pasay & Makati only Ermita because I have personal info c.) Snowball sampling – based on last referral d.) Quota sampling – setting a certain criteria, with favoritism will choose only who he likes. Collection of Data Base: - time & budget consuming – 70 –80% time Methods of collection of data
Slide 6: 1.) Questionnaire – source of collection f data - pen & paper type of data 3 Major type of Q a.) Dichotomasis – (2) – answerable by T/F, Y/N, right or wrong b.) Checklist style – rating scale 1,2,3,4,5 poor, fair, average. . . c.) Multiple choice – a) man b) dog c) cat d) all of the above 2.) Records – easiest – get pre existing data – journals, essays, documents, newspapers 3.) Interviewer – use oral communication 1.) Structured – with checklist formal 2.) Non structured – anything goes answer open ended questions. The sample will expand on topic researcher will illicit answers their ACTIVE LISTENING. 4.) observation – ocular approach a.) Participant – journey b.) Non-participant – passive observer but uses tools to determine results of data. 2 main problems in colleting data 1. Hawthorne’s effect – problem in experimental design inaccurate due to consciously being observed (PAASCU accreditation – management keeps school clean before PAASCUA comes to school. 2. Halo Effect – special relationship inaccurate due bias - solution of researcher to avoid halo effect do double blind res method Double blind research – no bias or prejudice on treatment blind folded - gives accuracy due not conscious & biased Analysis & Later pultation of data phase - research is forming a body of knowledge for the purpose providing an answer 2 Methods in presenting your analysis 1.) Qxuantitative – using numerical or graphical presentation of answer ex. 50% of q 500 Filipinos becomes 75% richer - or use pie chart, bar graph, line graph 2.) Quantitive – narrative approach using words (text) & facts ex. Majority of all graduating students prefer to nursing course than PT LEADERSHIP Dissemination of Finding/ Core/ Recommendations Importance of core – conc is final result of study How can conc affect others – recommendation Methods of dissemination of Findings/ Result a.) Book b.) Symposia – oral c.) Publication LEADER will influence LEADERSHIP S T Y L E P R 4 group Called Followers O C2 E S S 1 5 goal/ objective– patient – recipient of care
Slide 7: RNs implementor, assistant to dentist, Not leader Principles for effective leadership 1. Unity of command – all will receive orders, command from nurse manager/ supervisor 2. Unity of direction – whole group leader &newborns will have goal – towards patient. 3. Subordination of personnel to the general interest - save patient 1st before self (ex fire in pt room) R – remove/ rescue patients A – alert fire alarm C – confine fire in / area E – extinguish fire R – run 4. Esprit de corps – team spirit fault of one is fault of all credit of 1 is credit of all 5. Chain of command - hierarchy Patient reacted to meds given, allergy. Inform MD he will give anti-histamine. Incident report – for purpose of risk management - Report of sudden occurrence - Go to Head nurse Pt has appendicitis. Pain in RLQ who is primarily responsible for patient – Head nurse. HN can delegate to staff nurse pt died. Head Nurse is liable Command responsibility – Respondia Superior Theories of effective leader. 1. Great man theory – to be a good leader, leader must be born. Leaders cant be developed. Some are born a follower. 2. Trait theory – behavior/ characteristic P – personality I – intelligence A – ability Personality – + attitude/ trait/ knows to adjust to pt – adaptability a.) acceptability – can cope, adjust to needs of pt b.) independent c.) creative/ assertive d.) advocate Char of nurse if you are defender of patient against harm/ negligence – advocate Intelligence – proper judgment Proper decision Fluency of speech Ability – influence others – most effective way to influence pt – HI optimum level of is attain OLF Command of others Respect others Participate Cooperate 3. Charismatic theory – charm, charisma, inspirational quality 4. situational theory – a person can be a good leader in 1 situation & a follower in another situation. Case to case Adv – can get best person to the job Disadvantage – there’s no continuity of leadership
Slide 8: Styles of leadership: 1. Autocratic – authoritarian, dictatorial, bureaucratic traditional or “Hard leader” - Unilateral style of nursing - Leader is only 1 performing without input from other staff. - Not getting opinion, recommendations Char – unilateral from style of staff leadership – leader does decision making without. A – apathy – not sensitive B – boisterous speech C – consistent Demanding – E – egoistic F – ferocious Putting self in shoes of pet recognize & sensitive to pt. – empathy Not good style in leadership but good in emergency cases. Or during acute crisis. 2. Laizzes Faire/ Frierein/ Loose - excess freedom / or liberates to members - authority neglect control malpractice discipline patients will suffer 3. Democratic / Participative - gets input from members (decision making) - Mutual participation - Members makes mistake – member will get notice/ hearing before discipline = due process Quality/ Skills/ Abilities of good nursing leader: A – authority B – behavior C – Communication skills D – decision making E – ethics F – face conflict A – ability – basis of a leader to unsure / demand task, obligation & resp to his subordinates. 2 types 1. Centralized – top to bottom for proper management of whole hospital - to problems of whole institution 2. Declaralized – bottom (delegation) - to manage directly pts or concerns B. Behavior of good nurse leader: S – specific body of knowledge & skills to do safe care to patient. RN should be competent with scientific rationale P – patient cettered/ client focus A – accountability – liable for result of actions C – confidentiality E – ethics General rule: RN: can be charged with : Invasion of privacy, breach of confidentiality Exemption to gen rule (RN cant be charged with breach of confidentiality ) P – patients consent I – inform/ report to other members of HC team for precautionary measure C – common dse (report) – DOH/ WHO C – crimes – within 48h – report child abuse RA 3573 – Law on notifiable disease
Slide 9: Within 24h report disease like – polio & measles 1 week – HIV/ tetanus/ severs acute diarrhea Priority for child – rape – sexual abuse, domestic abuse, all kinds of abuse a.) report to barangay official b.) report to police c.) provide safe environment – focus on pt 1st – reporting can be done within 48h d.) call med legal Rule!! (in order) 1. S – safety 2. R – report 3. R – referral – DSWD, NGO C – communication skills - transfer of ideas / info with understanding Without understanding barrier/ backlog Sender – message – (idea/ info which sender would like to transmit Encoding – verbal or non verbal method Receiver – recipient of communication Decoding – manner of interpretation after receiving messages Feedback – response of receiving after interpreting messages D –decision making E – ethics Principle: 1. Autonomy – independent judgment & decision making who should decide for care of patient. a.) doc b.) attending pt c.) pt d.) relatives Pt refuses to remove lucky bracelet before surgery Bt due- Jehovah’s witness a.) respect decision of pt – respect cultural diversity b.) refer to doc – let doc explain risks involve c.) let pt sign a waver Doctrine of assumption or risk - pt given risks & signed waver - pt will assume all the risks/ danger Pills IUD - string should be checked during & after mens Diaphragm – removed after 6h Toxic shock syndrome Vasectomy – after 2 negative sperm count, 1st is probable 2nd is confirmatory BTL – can do coitus anytime. When pain & bleeding ceases. Principles in leadership Veracity – truth don’t give false reassurance - all med prognosis, dx, sex of baby – given by MD! Beneficence – doing good to pt Non malefience – do no harm 3 type of harm 1. Physical – negligence by commission – performed wrong action negligence by omission – neglect of care 2. Mental – assault – mental threat/ fear battery – physical harm 3. Moral – slander – verbal libel – written, published pictures
Slide 10: Tolality – let pt feel like a whole being even if a part is removed. - offer wigs, bandana – CA pt prosthesis, casts, w/c – amputation Double effect – if made to choose between 2 evils, choose the one that will have les bad effect. More good effect Justice of care – priority coz @ pt has unique needs. Basic char or nursing process A – acceptance universable B – based on pts needs C – client focus D – dynamic – update nursing process depending on clients needs E – equitable care F – familiarity G – goal oriented toward solving problem Inviolability of life – respect of life (promote H & prevent disease) - no abortion! Conflict – clash of ideas resulting to crisis Methods to solve conflict. A – avoidance – putting in one corner – dedma – not good method S – smoothing – appealing to conscience/ kindness U – unilateral – force fear, threats correction N – negotiation – best method – both parties will mutually decide & participate to solve problem. Nsg management Mgt – MAN+ TASK = GOAL (pts) Theories: 1. Human relations theory – must focus on proper relationship If needs provided to member (rest day, leave) Achievement of organization 2. Frederick Taylors scientific mgt theory 4 t’s Tao – get rt person/ tao Training Tool Tx 3. Douglas McGregor mgt theory Theory Y Positive worker - efficient diligent trustworthy reliable love their job = minimal supervision only Theory X Negative worker - inefficient negligent non trustworthy don’t love job for the money only = increase cases of negligence affecting pts. = use cozf I d power to discipline workers 4. Max Weber’s burocaratic (autocratic) theory - whoever is on top would perform mgt functions - centralized - not good style of management 5. Elton Mayo’s behavioral theory - overtime pay, rest day, day off - provide physical needs of worker like rest & recreation - HAWTHORNE’S EFFECT – if worker knows that they are being observed, workers will have better output. 6. Henry Fayol’s principles of mgt a.) Unity of command – one person given instructions to workers b.) Unity of direction – whole team should have one goal, objective, direction towards pt. c.) Subordination – personal general interest – pt 1st before self d.) Esprit de corp – team spirit – all (-) & (+) output credited to the group
Slide 11: e.) Chain of command – heiarchy of command Get appropriate orders from MD f.) Channels of communication – MD orders SN SN g.) Respondent supervisor – command responsibility - let master answer for negligence conduct of subordinate - liable: both HN liable for damages – due resp supervisor SN – negligence - jail h.) Security of tenure – i.) Re-numeration of workers – compensation - probationary – 6 months - regular employee Private – RA 4901 – 40% work 8h a day 5 days a week Gov’t – RA 7375 – magna carta for public HWorker 15k Overtime = + 25% Night shift differential = +10% Special non working holiday + 30% Legal Holiday= X2 +100% Occupational Hazard – work related disease Private – SSS – employees compensation Gov’t – GSIS National health Insurance Act – PhilHealth - Provide for unemployed/ employed - Aesthetic, cosmetic, dental not included Maternity leave – 60 days NSD 78 days C/S 1st 4 pregnancies to legit spouse 4. Abortions 5th pregnant - & delivered – not entitled to maternity leave Paternity leave 7 days Stage/ Steps in nursing management process P – planning O – organizing S – staffing D – directing/ delegating Co – coordinating Co – controlling/ eval Planning stage – conceptualizing/ product of mind/ looking at future/ looking prospectively Types: Vision – what org likes to achieve in future Ex. Health for all by 2000 Heath in the hands of the people by 2020 Mission – focus in present - reason why org was established ex. DOH – to five quality health Philosophy – values. Besides org (members) Goal – gen statement of mission Objective – specific statement of mission Goal- nursing form St. Lukes should provide quality care to pt Objective – nursing from St Lukes should have IV training (specific)
Slide 12: Policies – set of rules/ regulation of org 3 types of plan 1.) Short term – for every day ordinary activity ex. NCP 2.) Contingency plan – for emergency or acute crisis, stand by plan 3.) Long term plan – duration of care is linger for chronic pts. Ex. CVA pts Budgeting – performed in planning stage - proper allocation of resources - Money, manpower, machine 1.) Operati0nal budget – cheapest – everyday ordinary activities (gloves, gown, goggles – OR, LR, DR,ER) 2.) Personal/ labor budget – used to compensate & re-numerate labor – most important 3.) Capital budget – long term use equipment - MRI equipment, beds Budget – asks “How” Organizing stage – answers the question ‘WHO” Nurse Mgr RN Subordinate Nsg personnel – nurse aid RN will do: (for stable & unstable pt) A – assessment T – health teaching – when best time start discharge E – explain proc to pt health teaching – start during admission of pt P – preparation – computation of dosage A – adm – give meds or treatment T – treatment – oral, IV, ID E – evaluation – nursing care plan J – judgment – PRN meds – nursing will decide when to five Subordinates can perform: (comfort measures only not VS) R – routine tasks – standard procedure, monitor I & O ambulating, bathing bed making - stable pts – predictable outcomes S – stable pts S – supervision of RN Styles/ method delivery care 1. Primary nursing – private duty nurse – from admission to d/c! D – direct plan of care to pt A – active participation/ consent of pt. M – mgt of care – from basic to complex PD will do 24h – from admission t o discharge tip = answer is primary nurse 2. Functional – most useful type D – duty task – 1 RN all patients O – one task H – highly recommended RNS budget 3. Case Method – ICU critical case resp for: T – total care (from basic care to most complex) O – one RN: 1 patient In extreme cases 1:2 pts Staffing stage – “how many” - nurse manager will determine correct # of patients/ RN
Slide 13: Staffing pattern – Phil – 40h/ wk/ 5d Traditional – 8h/40h/5d 10h shift – 10h/ 4d Monday – Thursday On call – emergency schedule Baylor plan – M – F (traditional) Sat-Sun (skeletal force) Directing/ Delegation stage – job/ task is done by another pt for you. Gen rule: RN can delegate any task to another RN Except: disciplinary task (this is done by higher person) : confidential task (charting) : technical task (expertice should be done by same expert) : official medical task Coordinating/ collaboration stage 1. canned food – highest purine content (uric) 2. Anchovies – next highest purine content 1. Interpersonal/ intra departmental – collaboration bet 1 nurse to another nurse - under 1 ward - ex. Endorsement 2. Interdepartmental – collaboration between two or more hosp for benefit of pt. Why RN needs to collaborate to others in HC team? - pt is entitled to continuous care. Evaluation stage – determine whether, plan goal, objective where met or achieved Types” 1. Nurse rounds – 2 x rounds/ day - short term plan Psyche ward – contraindicated nurse rounds in psych ward 2. Checklist – Nurse mgr – evaluates/ rates member 3. Gam H chart – used to evaluate nurses , multiple plan at same time 4. Peer evaluation – co workers – poorest type of eval – cause might be effected by halo effect due to special relationship. Performance Appraisal – pt or client evaluates most reliable coz --------- or care evaluates.

Maternal and Child Nursing Reviewer Notes

noreply@blogger.com (grey26) — Fri, 24 Sep 2010 18:00:16 PDT

Nursingnotes.info maternal-and-child-nursing

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Slide 1: The Royal Pentagon Review Specialist, Inc. Maternity Nursing Visit http://www.nursingnotes.info/ for more I. Human Sexuality a. Concepts 1. A person’s sexuality encompasses the complex behaviors, attitudes and emotions and preferences that is related to sexual self and eroticism 2. Sex is basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human sexuality 15 – 44 y.o. – age of reproductivity CBQ b. Definitions related to sexuality Gender Identity – sense of feminity and masculinity – developed @age 3 or 2 -4 y.o. Role Identity – attitudes, behaviours and attitudes that differentiate roles Sex – biologic male or female status. sometimes referred to as specific sexual behavior such as sexual intercourse Sexuality - behavior of being a girl or boy and is identity subject to a lifelong dynamic change II. Sexual Anatomy and Physiology a. Female Reproductive System 1. External – Vulva/ Pudenda a. Mons pubis/ veneris – mountain of venus, a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as a cushion or protection to the symphysis pubis Stages of Pubic Hair Development (Tool Used: Tanner’s Scale/ Sexual Maturity Rating) Stage 1 – Pre adolescence • no pubic hair, fine body hair Stage 2 – Occurs bet. 11 – 12 y.o • sparse, long, slightly pigmented and curly that develop along labia Stage 3 – Occurs bet. 12 – 13 y.o. • hairs become darker and curlier develops along pubis symphysis Stage 4 – 13 – 14 y.o. • hair ssumes normal appearance of an adult but is not so thick and does not appear to the inner aspect of the upper thigh Stage 5 – Sexual Maturity • assumes the normal appearance of an adult, appears at the inner aspect of thigh b. Labia Majora – large lips latin, longitudinal fold from perenium to pubis symphysis c. Labia Minora – aka Nymphae, soft and thin longitudinal fold created between labia majora Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 2: The Royal Pentagon Review Specialist, Inc. Maternity Nursing Clitoris – “key”, pea – shaped erectile tissue composed of sensitive nerve endings; sight of sexual arousal in females • Fourchet – tapers posteriorly of the labia majora. Site for episotomy - sensitive to manipulation, torn during pregnancy d. Vestibule – almond shaped area that contains the hymen, vaginal orifice and batholene’s gland • Urinary Meatus – small opening of urethra/ opening for urination • Skene’s Gland – aka Paraurethral Gland, 2 small mucus secreting glands for lubrication • Hymen – membranous tissue that covers the vaginal orifice • Vaginal Orifice – external opening of the vagina • Bartholene’s Gland – paravaginal gland, secretes alkaline substance, neutralizes acidity of the vagina o Doderleins Bacillus – responsible for vaginal acidity o Parumculae Mystiformes – healing of a hymen e. Perenium – muscular structure in between lower vagina and anus 2. Internal a. Vagina – female organ for ovulation, passageway of menstruation, ¾ inches 8 – 10 cm long containing rugae o Rugae – permits considerable stretching withouit tearing during delivery CBQ b. Uterus – hollow muscular organ, varies in size, weight and shape, organ of menstruation Size : 1 x 2 x 3 Shape : pear shaped, pregnant - ovoid Weight : Uterine involution CBQ Non pregnant : 50 – 60 g Preganant : 1000 g th 4 stage of Labor : 1000 g 2nd week after of Delivery : 500 g 3rd weeks after delivery : 300 g 5 – 6 Weeks after delivery: 50 – 60 g Three Parts of Uterus • Fundus – upper cylindrical layer • Corpus/ Body – upper triangular layer • Cervix – lower cylindrical layer Isthmus – lower uterine segment during pregnancy Muscular Composition: 3 main Muscles making possible expansion in all direction a. Endometrium  muscle layer for menses o Lines the non-pregnant uterus o Volumes the non pregnant uterus o Decidua – slouching off of endometrium during menstruation o Endometriosis  Ectopic Endometrium Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006 •
Slide 3: The Royal Pentagon Review Specialist, Inc.     Maternity Nursing Common site is ovaries Proliferation of abnormal growth of lining of outer part Persistent dysmenorrhea, low back pain Dx Exam: biopsy,laparoscopy  Tx: Lupron (luprolide)  inhibits FSH & LH  Tx: Danazol (Danacrine) DOC 1. Inhibits ovulation 2. stop menstruation b. Myometrium o Power of labor o Smooth muscles is considered to be LIVING LIGATURE (muscles of delivery, capable of closing) of the body o Largest portion of the uterus c. Peremetrium o Protects the entire uterus c. Ovaries • 2 female sex gland • almond shape • Fxn: Ovulation,production of 2 hormones( estrogen and progesterone) d. Fallopian Tube • 2 – 3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus • 4 significant segments o Infundibulum – most distal part, trumpet shape, has fimbrae o Ampulla – outer 3rd or 2nd half, site of fertilization, common site for ectopic preg. o Isthmus – site for sterilization, site for BTL o Interstitial – most dangerous site for ectopic pregnancy b. Male Reproductive System 1. External • Penis • The male organ of copulation and urination • Contains of a body or shaft consisting of 3 cylindrical layers and erectile tissues o 2 corpora cavernosa o 1 corpus spongiosum • At the tip is the most sensitive area comparable to clitoris = glans penis • Scrotum • Pouch hanging below the pendulous penis, with medial septum deviding into 2 sacs each containing testes • Requires 2 degrees celcius for continuous spermatogenesis • Cooling mechanism of testes 2. Internal Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 4: The Royal Pentagon Review Specialist, Inc. The Process of Spermatogenesis Testes (900 coiled seminiferous tubules) ↓ epididymis (site of maturation of sperm 6 m) ↓ Vas Deferens (conduit pathway of sperm) ↓ Seminal Vesicle (secreted: fructose form of glucose, nutritative value Prostaglandin: causes reverse contraction of uterus) ↓ Ejaculatory Duct (conduit of semesn) ↓ Prostate Gland (release alkaline substances) ↓ Cowpers Gland (release alkaline substance) ↓ Urethra Hypothalamus GNRH ↓ APG ↓ FSH – maturation of sperm LH – testosterone production Leydig Cells – releases testosterone Male & female Homologues Male Female Penile Glans Clitoris Penile Shaft Clitoral shaft Testes Ovaries Prostate Skene’s gland Cowper’s Glands Bartholin’s Gland Scrotum Labia Majora III. Basic Knowledge on Genetics and Obstetrics Maternity Nursing 1. DNA – Deoxyribonucleic Acid – carries genetic code 2. Chromosomes – threadlike structure of hereditary material known as the DNA 3. Normal amount of ejaculated sperm – 3 – 5 cc/ 1 teaspoon Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 5: The Royal Pentagon Review Specialist, Inc. Maternity Nursing 4. Ovum is capable of being fertilized within 24 – 36 hours after ovulation. 5. Sperm 48 – 72 days viability 6. Reproductive cells divide by the process of MEIOSIS (haploid number) • Spermatogenesis – process of maturation of sperm • Oogenesis – process of maturation of ovum o 30 weeks AOG – 6 million immature ovum o @ birth – 1 million immature oocytes o @ puberty – 300 – 400 immature oocytes o @ 13 y/o – 300 – 400 mature oocytes o @ 23 y/o – 180 – 280 mature ovum o @ 33 y/o – 60 – 160 mature ovum o @ 36 y/o – 24 – 124 mature ovum o @46 y/o – 4 mature ovum • Gametogenesis – process of formation of two haploid into diploid 7. Age of reproductivity – 15 – 44 y/o childbearing age – 20 – 35 y/o High risk  <18 & >35 y.o. With Risk  18 – 20; 30 – 35 8. Menstruation • Menstrual Cycle – beginning of menstruation to the beginning of the next menstruation • Average menstrual cycle – 28 days • Average menstrual period – 5 days • Normal blood loss – 50 cc/ ¼ cup accompanied by FIBRINOLYSIS – prevents clot formation • Related terminologies o Menarche – 1st menstruation o Dysmenorrhea – painful menstruation o Metrorrhagia – bleeding in between menstruation o Menorrhagia – Excessive bleeding during menstruation o Amenorrhea – absence of menstruation o Menopause – cessation of menstruation (Average Age- 51 y.o.)  Tofu – has isoflavone – estrogen of plant that mimics the estrogen with a woman 9. Functions of Estrogen and Progestin • ESTROGEN – hormone of woman o Primary function  Responsible for the development of secondary characteristics in females  inhibit production of FSH o Other function  Hypertrophy of the myometrium  Spinnbarkeit and Ferning Pattern (Billings Method)  Ductile structure of the breast  Osteoblastic bone activity (causes increased in height)  Early closure of the epiphysis of the bone  Sodium retention  Increased sexual desire  Responsible for vaginal lubrication Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 6: The Royal Pentagon Review Specialist, Inc. Maternity Nursing • PROGESTERONE – Hormone of the mother o Primary function – prepares the endometrium for implantation making it thick and tortous o Secondary Function – inhibit uterine contractibility o Others  Inhibit LH (hormone of ovulation) production  ↓ GI motility  ↑ Permeability of kidneys to lactose and dextrose causing + 1 sugar in urine  Mammary gland development  ↑ BBT  Mood swings 10. Menstrual Cycle 4 phases of menstrual cycle 1. Proliferative 2. Secretory 3. Ischemic 4. Menses 1. On the initial phase of menstruation, the estrogen level is ↓, this level stimulates the hypothalamus to release GnRH/ FSHRF • 2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH FSH Function o Stimulate ovaries to release estrogen o Facilitate the growth of primary follicle to become GRAAFIAN FOLLICE  structure that secretes large amount of estrogen that contain mature ovum Proliferative Phase (↑estrogen) Follicular Phase – responsible for the variation and irregularity of mense Postmenstrual Period – after menstruation Preovulatory Phase – happen before menstruation 13th day of menstruation, estrogen level is PEAK while progesterone is ↓, these stimulates the hypothalamus to release GnRH/ LHRF GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH • Functions of LH o Stimulates the release of progesterone o Hormone for ovulation 14th day estrogen level is ↑ while progesterone level is ↑ • S/S o Rupture of the graafian follicle - OVULATION o Mittelschsmerz – slight abdominal pain lower right quadrant 15th day, after ovulation day, graafian follicle starts to degenerate, estrogen level ↓, progesterone ↑, causing degeneration of the graafian follicle becoming yellowinsh known as CORPUS LUTEUM – secretes large amount of progesterone PLM College of Nursing Batch 2006 3. 4. 5. 6. 7. Jomar Anthony D. Maxion, BSN, RN
Slide 7: The Royal Pentagon Review Specialist, Inc. Maternity Nursing 8. Secretory Phase Lutheal Phase (↑progesterone) Postovulatory phase Premenstrual Phase 9. 24th day – Corpus Albicans (whitish) corpus luteum degenerates and becomes white 10. 28th day – if no sperm united the ovum, the uterine begins to slough off to have the next menstruation Note: • if there is no fertilization, corpus luteum continues functioning • Ovarian Cycle – from primary follicle – corpus albicans • Stages: o 1 – 5 days – menses o 6 – 14 – proliferative o 15 – 26 – secretory o 27 – 28 – ischemic 11. Stages of Human Sexual Response Initial Response: VASOCONGESTION – constriction of blood vessels MYOTONIA – increased muscle tension • Excitement Phase • ↑ muscle tension, moderate VS • erotic stimuli causing ↑ sexual tension, may last from minutes to hours • Plateu Phase • ↑ and sustained tension near orgasm • may last 30 sec – 30 minutes • Orgasm • Involuntary release of sexual tension accompanied by physiologic and psychologic release, • immeasurable peak of experience 2 – 3 seconds • Resolution • Return to normal state • VS return to normal REFRACTORY PERIOD – only period present in male, wherein he cannot restimulated for about 10 – 15 minutes IV. Wonders of Fertilization a. Fertilization 1. Phonones – song of sperm 2. Capacitation – ability of sperm to release proteolytic enzyme and penetrate the ovum b. Stages of Fetal Growth and Development 1. Pre Embryonic Stage Zygote  fertilized ovum (3 – 4 days travel, 4 days floating)> from fertilization Morula  mulberry-liked ball containing 16 – 50 cells PLM College of Nursing Batch 2006 I. II. Jomar Anthony D. Maxion, BSN, RN
Slide 8: The Royal Pentagon Review Specialist, Inc. Maternity Nursing III. IV. I. II. Blastocyst  enlarging cell forming a cavity that later becomes the embryo covered by thropoblast which later becomes the placenta and membrane Implantation  7 – 10 days after fertilization • Thropoblast – covering of blastocyst that become placenta • S/Sx of Implantation  Slight pain, Slight Vaginal Spotting • 3 Processes o Apposition o Adhesion o Invasion 2. Embryonic Stage Zygote – fertilization to 14 days Embryo – 15th – 2 mos/ 8 weeks Fetus – 2 mos to birth c. Decidua – thickened endometrium, latin word for “falling off” 1. Basalis – located directly under the fetus where placenta developed 2. Caspularis – encapsulates the fetus 3. Vera – remaining portion of and endometrium d. Chorionic Villi – 10 – 11 weeks 1. Chorionic Villi Sampling (CVS) – removal of tissue from the fetal postion of the developing placenta • For genetic screening • Fetal limb defects, missing digits of toes e. Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis (24 weeks/ 6 months) f. Synsitiotrophoblast – syncitial layer – responsible for hormone production 1. Amnion – inner most layer 2. Chorion Umbilical cord (Funis) – whitish gray (50 – 60 cm) • Short  abruptio placenta, uterine inversion • Long  cord prolapse, cord coil • 3 vessels (AVA) – Artery Vein Artery • Wharton’s Jelly – protects the umbilical cord Amniotic fluid  bag of water  clear color, musty/mousy odor • With crystallized forming pattern, slightly alkaline • 500- 1000 cc Normal o Oligohydramnios – kidney malformation o Hydramnios – GIT , TEF/ TEA • Functions o Cushion the fetus against sudden blow or trauma o Maintains temperature o Facilitate muscuskeletal development o Prevents cord compression o Helps in development process Diagnostic Test for Amniotic Fluid  Amniocentesis • Purpose: obtain sample of amniotic fluid by inserting a needle hrough the abdomen into the amniotic sac Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 9: The Royal Pentagon Review Specialist, Inc. • Maternity Nursing • • • • • • • • • • • • • • Fluid is tested for: • Genetic screening • Determination of fetal maturity primarily by evaluating factors indicative of lung maturity Done with empty bladder Complication > Most common side effect : INFECTION > Late : pre term labor > Early : spontaneous abortion Indication for Amniocentesis: > Early in Pregnancy Advance Maternal Age > Later in Pregnancy Diabetic Mothers ↑ - down syndrome ↓ - neural tube defect, spina befida L/S ratio : 2:1 (Lecitin/ Spingomyelin) Definitive test = Phosphatiglycerol: PG +  best Answer Greenish – Meconium Stains (Fetal Distress) Yellowish – jaundice, hyperbilirubinemia Cloudy – Infection Most Important Consideration  Needle insertion site Amnioscopy – direct examination through intact fetal membrane via ultrasound Fern Test – a test determining if bag of water has rupture or not Nitrazine Paper Test – differentiate amniotic fluid and urine Blue geen  + rupture of bag of H2O 2. Chorion – outermost layer a. Placenta – AKA Secundines  chorionic Villi and basalis • • • • • Pancake in latin 500 grams in weight 15 – 28 cotyledons 15 – 20 cm in diameter and 2 – 3 cm in depth Functions o Respiratory  02 – CO2 exchange via simple diffusion o GIT  glucose transport via facilitated diffusion o Excretory  via 2 arteries, carries unoxygenated blood then detoxify by maternal liver o Circulatory  fetoplacental circulation by SELECTIVE OSMOSIS o Endocrine  HCG – primary maintain corpus luteum/ secondary basis of pregnancy test  Human Placental Lactogen – aka Somatomammothrophin • Responsible for the development of mammary gland • Diabetogenic Effect – insulin antagonist  Relaxin – softening of maternal joints and bones PLM College of Nursing Batch 2006 Jomar Anthony D. Maxion, BSN, RN
Slide 10: The Royal Pentagon Review Specialist, Inc. o Maternity Nursing Serves as protective barrier against some microorganism  Can pass: HIV CMV Rubella  PINOCYTOSIS – transport of virus Pregnancy – 266 – 288 days/ 37 – 42 weeks FETAL STAGE: Fetal Growth and Development First Trimester : Period of organogenesis, most critical period First Month FHT, CNS Develops, GIT and Respi Tract remains as single tube Differentiation of Primary Germ Layer • Endoderm o Thyroid – responsible for basal metabolism o Thymus – immunity o Liver o GIT o Linings of Upper GI Tract • Mesoderm o Heart o Musculoskeletal o Reproductive Organ o Kidney • Ectoderm o Brain o CNS o Skin o 5 senses o Hair, nails o Anus o Mouth Second Month • Life span of corpus luteum ends • All vital organs are formed • Placenta is developed • Sex organ is developed • Meconium is present Third Month • Placenta is complete • Kidneys are functional • Fetus begins to swallow amniotic fluid • Buds of milk appear • Sex is distinguishable • FHT audible via dopples @ 10 – 12 weeks Terratogens – any drug or irradiation, the exposure to which may cause damage to the fetus • DRUGS Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 11: The Royal Pentagon Review Specialist, Inc. Maternity Nursing o Streptomycin – anti – TB – (quinine) damage to the 8th cranial nerve  poor learning and deafness/ ototoxic Tetracycline – stoning the tooth enamel, inhibits long bone growth Vitamin K – hemolysis, destruction of RBC, jaundice, hyperbilirubenemia Iodides – enlargement of thyroid and goiter Thalidomides – anti-emetics  Amelia or Pocomelia  absence of distal part of extremities o Steroids – cleft lip or palate and even abortion o Lithium – congenital maformation ALCOHOL – LBW, fetal alcohol syndrome ( characterized by microcephaly) SMOKING – LBW CAFFEINE – LBW COCCAINE – LBW, abruptio placenta TORCH – group of infections that can cross the placenta or ascend through the birth canal and adversely effect fetal growth o Toxoplasmosis – cat lovers o Others - Hepa AB, HIV, Syphillis o Rubella – CHD,  Rubella Titer – N @ 1:10 or ↓ = immunity to rubella = notify doctor  Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos. o Cytomegalo virus o Herpes Simplex virus o o o o • • • • • Second Trimester : continuous growth and development (focus  lengh of fetus) Fourth Month • Lanugo begins to appear • Buds of permanent teeth appear • FHT audible via Fetuscope @ 18 – 20 weeks Fifth Month • Quickening : 1st fetal movement Primi: 18 – 20, Nulli - 16 - 18 • Lanugo covers the body • FHT audible via stethoscope or w/out instrument • Actively swallow amniotic fluid • Fetus : 19 – 25 cm Sixth Month • Skin is red and wrinkled • Vernix caseosa covers the skin • Eyelids open • Exhibits startle reflex rd 3 Trimester : period of most rapid growth and development Focus: weight Seventh Month • Surfactant development • Male: the testes begins to descent into the scrotal sac • Female : clitoris is prominent and labia majora are small doesn’t cover the minora Eight Month • Active moro reflex Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 12: The Royal Pentagon Review Specialist, Inc. Lanugo begins to disappear • Sub q fats deposits, steady weight gain, nails to fingers Ninth Month • Lanugos and vernix caseosa is evident in body fold • Birth position assumed • Amniotic fluid somewhat decrease • Sole of the foot has few creases Tenth Month • Bone ossification in the fetal skull • Vernix caseosa is evident in body PHYSIOLOGIC ADAPTATION TO PREGNANCY • Maternity Nursing Systemic Changes 1. Cardiovascular System • ↑ blood volume 30 – 50% • 1500 cc; additional 500 cc for multiple pregnancy • ↑ plasma volume • ↑ cardiac workload – easy fatigability/ slight ventricular hypertrophy • Epistaxis due to hyperemia of nasal membrane • Palpitation due to SNS stimulation • Physiologic Anemia/ pseudoanemia in pregnacy o Normal Value Hct : 32 – 42% Hgb: 10.5 – 14 g/dl o Criteria 1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl 2nd Trimester : Hct > 32% Hgb > 10.5 g/dl o Pathologic Anemia  Iron Defficiency Anemia is the most common hematologic disorder. It affects 20% of pregnant women  Assesment reveals: • Pallor • Slowed capillary refill = Normal = 2 – 3 sec • Concave fingernails (late sign of progressive anemia) – clubbing = chronic tissue hypoxia • constipation  Nursing care • Nutritional instruction o Source of iron  Kangkong  Liver = best source due to FERRIDIN Content  Red and lean meat  Green Leafy Vegetables • Parenteral Iron (Imferon) o Z tract IM o incorrect causes hematoma Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 13: The Royal Pentagon Review Specialist, Inc. o o Maternity Nursing  • • Alert • • • best given 1 hour before meals (causes GI irritation) Maybe given 2 hours after meal (results to poor absorption)  Given with orange juice to ↑ absorption Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day) Monitor for hemorrhage Iron from red meat is better absorbed iron from other sources Iron is better absorbed when taken with foods high in Vitamin C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs • • • • • Edema o Impeded venous return due to the gravid uterus o Nursing Intervention  Elevate legs above the hips level Varicosities o Wear support stockings o Elevate legs Vulvar Varicosities o D/t pressure of gravid uterus o Side –lying with pillow under the hips o Modified knee – chest position Thrombophlebitis o Presence of thrombus in inflamed blood vessels o + Homan’s Sign – pain on the calf upon dorsiflexion o Medical Management  Anticoagulant/ HEPARIN • Does not cross the placental barrier • Monitor APTT • Antidote: PROTAMINE SULFATE • No aspirin Milk Leg/ Plagmasia Alba Dolens o Shiny white legs due to stretching of skin & hyperfibrinogenemia o Nursing intervention  Check dorsalis pedis pulse (compare both)  Never massage  Assess for Homan’s sign only once 2. Respiratory System • Shortness of Breath d/t gravid uterus • Nursing intervention: Side-lying – lateral expansion of the lungs 3. Gastrointestinal System • Nausea and vomiting • Morning Sickness Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 14: The Royal Pentagon Review Specialist, Inc. Maternity Nursing o Due to ↑ HCG levels o Crackers 30 min before arising o AM – Carb diet 30 mins o PM – small frequent meal • Constipation o Due to PROGESTERONE = ↑ fluid reabsorption due to ↓ GIT motility o Nursing intervention • ↑ Fluid • ↑ Fiber • Exercise • Flatulence o Due to increased progesterone o Avoid gas forming foods • Heartburn (pyrosis) o Reflux of stomach content into esophagus o Nursing Intervention • Small frequent meals • Sips of milk • Avoid fatty and spicy foods • Proper body mechanics o Waist Above – Acid o Waist Below – Base • Hemorrhoids o Due to gravid uterus o Hot sitz bath for comfort • Ptyalism o ↑ salivation o Mouthwashes to relieve 4. Urinary System • Normal = + 1 sugar due to Progesterone via BENEDICT’S TEST • First Trimester - Frequency • Second Trimester - normal • Third Trimester - Frequency 5. Muscoloskeletal • Calcium sources o Milk - ↑ Ca ↑ P – 1 pint/ day or 3 – 4 servings/ day o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli • Lordosis o Pride of Pregnacy • Waddling Gait o Awkward gait while walking due to relaxin o Prone to accidental falls  Wear low healed shoes • Leg Cramps o Ca – P Imbalance during pregnancy o Lumbo-sacral nerves by pressure of gravid uterus during labor Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 15: The Royal Pentagon Review Specialist, Inc. o o o Over sex Dorsiflex the foot affected 3-4 servings/ 4 cups/day sa milk, sardines, dilis Maternity Nursing A. Local Chnages • • • Vagina o Chadwick’s Sign – bluish discoloration o Leukorrhea – whitish gray, moderate in amount, mousy odor Cervix o Goodel’s Sign – change in consistency of uterus o Operculum – mucus plug to seal bacteria/ progesterone Uterus o Hegar’s Sign – change in consistency Vagina Cervix Uterus Chadwick’s Goodel’s Hegar’s Problems related to the changes of Vaginal Environment a. Vaginitis - AVOCADO • Trichomonas Vaginalis o Flagellated protoxzoan, Loves alakaline environment • Signs and Symptoms o Greenish, cream, colored, frothy, irritably itchy, foul smelling vaginal discharge o Vaginal edema • Management o Drug of choice: METRONIDAZOLE (Flagyl)  Antiprotozoan  Carcinogenic  Not given in 1st trimester • vaginal douche as substitue o 1 qt Water = 1 tbsp white vinegar o Treat partner as well to prevent reinfection o No alcohol – due to antabuse effect b. Moniliasis - CHEESE • Candida Albicans • Transvaginal transfer in fetus – Oral Trush • Signs and Symptoms o White Cheeselike patches that adheres to the walls of the vagina • Management o Antifungals  Mycostatin  Contrimazole – Canisten  Gentian Violet 1. Abdominal Changes Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 16: The Royal Pentagon Review Specialist, Inc. • Maternity Nursing Striae Gravidarum o Due to destruction of the subcutaneous tissue by the enlarge uterus 2. Skin Changes • Melasma/ Chloasma o White light brown pigmentation related to ↑ melanocytes • Linea Nigra o Brown pinkish line from symphysis pubis to umbilicus 3. Breast Changes • Due to hormonal changes • Change in color and size of nipple and areola • Precolostrum – 6 weeks • Colustrum – 3rd trimester • Supine with pillow under the back 4. Ovaries – rest period, no ovulation 5. Signs and Symptoms of Pregnancy Presumptive Probable S/sx felt and observed by the Signs observed by mother but does not confirm the members of the the diagnosis of pregnancy health care team First Breast changes Goodel’s sign trimester Urinary changes Chadwick’s sign Fatigue Hegar’s sign Amenorrhea Elevated BBT Morning sickness Positive HCG Enlarge uterus Second Chloasma Ballotement Trimester Linea Nigra Enlarge Abdomen Increase Skin Pigmentation Braxton Hicks Striae gravidarum Contraction Quickening CBQ Cancer of the Breast  quadrant B Mamography 35 and above  1/ year Ballotement  bouncing of the fetus  may be present in uterine myoma Transvaginal Ultrasound – empty bladder Abdoiminal ulrasound – full bladder Placenta Grading System • Grade 0 – immature • Grade 1 – slightly mature • Grade 2 – moderately mature • Grade 3 – fully mature • What is deposited?  calcium Positive Undeniable signs confirmed by the use of instrument Ultrasound Evidence etal Heart Tone etal movement etal outline etal parts palpable Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 17: The Royal Pentagon Review Specialist, Inc. VI. Psychological Adaptation to Pregnancy – Reva Rubin First Trimester • No tangible s/sx • Feeling of surprise • Ambivalence • Denial of pregnancy  maladaptation • Developmental Task: Accept biological facts of pregnancy • Health Teaching: Body changes of pregnancy and Nutrition Second Trimester • Tangible s/sx • Mother identifies fetus as separate entity due to quickening • Fantasy • Developmental Task: Accept growing fetus as a baby to nurture • Health Teaching: Growth and development of fetus Maternity Nursing Third Trimester • Mother has personally identifies with the appearance of the baby • Developmental Task: Prepare child birth and parenting the child • Health Teaching: responsible parenthood, prepare baby’s layette, Lamaze Class • Address Mother’s fear  let she hear the FHT VII. Pre – Natal Visit Basic Consideration 1. Frequency of Visit • 1 – 7th mos.  once a month • 8 – 9th mos.  twice per month • 10th month  every week 2. Personal Data • Home Based Mother’s Record/ HBMR  determines high risk pregnancy • Pseudocyesis  false pregnancy  appearance of presumptive & probable signs • Comade Syndrome  psycosomatic disorder, father experience what the mother goes through 3. Diagnosis of Pregnancy • Urine Exam HCG  40 – 100th day; peak 60 – 70th day • ELISA  beta subunits of HCG is detected as early as 7 – 10th day • RIA  beta subunits of HCG is detected as early as 8th day • Home Pregnancy Kit 4. Baseline Data • Roll – Over Test  test of pre-eclampsia by the use of BP • Weight monitoring Normal Weight Gain Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 18: The Royal Pentagon Review Specialist, Inc. 1st Trimester = 1.5 – 3 lbs  1 lb/ mo 2nd Trimester = 10 – 12 lbs  4 lbs/mo 3rd Trimester = 10 – 12 lbs  4 lbs/mo Minimum allowable weight gain  20 – 25 lbs Optimal weight gain  25 – 35 lbs 5. Obstetrical Data Maternity Nursing a. Gravida  no. of pregnancy b. Para  no. of viable pregnancy Viability  the ability of the fetus to live outside the uterus at the earliest possible gestational age 1 abortion 1 pregnancy 3rd mos. G2P0 G2 T0 P0 A1 L0 c. Important Estimates 1. Nagele’s Rule • Use to determine expected date of delivery • Jan – Mar  +9 months +7 days • Apr – Dec  -3 months +7 days + 1 year 2. McDonald’s Rule • Determines age of gestation in weeks • Fundic Height x 7/8 = AOG in weeks 3. Bartholomew’s Rule • Determines age of gestations o 3 mos – above pubis symphysis o 5 mos – level of umbilicus o 9 mos – below xiphoid process o 10 mos – level of 8th mos 4. Haases Rule • Determines the length of fetus in cm. • 1st half  square each month • 2nd half  month x 5 d. Tetanus Immunization • TT1 – anytime or early during pregnancy • TT2 – 1 month after TT1  3 years protection • TT3 – 6 months after TT2 – 5 years of protection • TT4 – 1 year after TT3  10 years of protection • TT5 – 1 year after TT4  lifetime protection 1 39TH Week, 1 miscarriage, 1 still birth, 1 2nd mo. preg G4P2 G4 T1 P1 A1 L1 Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 19: The Royal Pentagon Review Specialist, Inc. 5. Physical Examinations a. Danger Signs of Pregnancy Chills & Fever Cerebral Disturbances Abdominal Pain  epigastric pain  auro of impending convulsion Boardlike Abdomen  Abruptio placenta Blurred Vission  pre eclampsia Bleeding  abortion/ ectopic pregnancy – 1st trimester  H Mole/ Incompetent Cervix – 2nd trimester  Placental Anomalies – 3rd Trimester BP ↑ Swelling Scotoma – spots in the eye Sudden gush of fluid – PROM – premature rupture of membrane Maternity Nursing 6. Pelvic Examination  Pelvic examination or IE – empty bladder, precaution  1st visit – Chadwicks, Goodle’s sign, etc.  Position : dorsal recumbent, lithotomy  Pap smear – done 1st visit  Cytological exam – determine presence of cancer cells.  Result : o Class I – normal o Class II A – cytology without evidence of malignancy B – suggestive of inflammation o Class III – cytology suggestive of malignancy o Class IV – cytology suggestive og malignancy o Class V – conclusive for malignancy  Most common cancer report organ : cervical cancer  Most common site for pap smear – external OS of cervix (squamocolumnar tissue)  Common site of cervical cancer. maternal – speculum (open)  Stages of cervical cancer o 0 – carcinoma in situ o 1 – Ca strictly confined to cervix o 2 – from cervix extends to the vagina o 3 – pelvic metastasis o 4 – affectation to bladder & rectum 7. Leopolds Maneuver  Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of descent an estimate of the size, and no. of fetuses  Procedure 1. 1st maneuver o place patient in supine position with knees slightly flexed. Put towel under head and right hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape, movement and firmness of the part o determine the presenting parts: 2. 2nd maneuver Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 20: The Royal Pentagon Review Specialist, Inc. o Maternity Nursing with both hands moving down, identify the back of the fetus where the ball of the stethoscope is placed to determine FHT. o PR of mother : uterine soufflé – MHR o fundic soufflé – FHR 3. 3rd maneuver o using the right hand, grasp the symphysis pubis part using the thumb and fingers. o Assess whether the presenting part is engaged in the pelvis. o Alert! If the head is engaged it will not be movable 4. 4th maneuver o the examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. o When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head 8is flexed and vertex presenting.  Attitude – relationship of fetus to one another.  Full Flexion – when the chin touches the chest 8. Assessment of Fetal Well-being a. Daily fetal Movement Counting (DFMC)  Done starting 27th week  Consideration  fetal sleep wake pattern  maternal food intake  drug-nicotine use  environmental stimuli  maternal dose  Cardiff count to 10 method – one method currently available o begin at the same time each day (usually in the morning after breakfast ) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) o expected findings – 10 movements in 1hrs or less o warning signs – 10-12 movements in 1hr or less  more than 1hr to reach 10 movements  less than 10 movements in 12hrs  longer time to reach 10 FMs than on previous days.  movements are becoming weaker, less vigorous  movement alarm signal <3 FMs in 12hrs o warning signs should be reported to healthcare provider immediately; often require further testing. Eg. Non stress test (NST), biophysical profile (BPP) b. Nonstress Test o to determine the response of the fetal heart rate to the stress to activity. o Indications – pregnancies at risk for o placental insufficiency o Postmaturity • pregnancy induced hypertension (PIH), diabetes • warning signs noted during DFMC • maternal history of smoking, inadequate nutrition Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 21: The Royal Pentagon Review Specialist, Inc. o Maternity Nursing o o o o Procedure : • Done within 30mins wherein the mother is in semifowlers position; external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors • tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) • ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected • monitor until at least 2 FMs are detected in 20mins. if no FM after 40mins provide women with a light snack or gently stimulate fetus through abdomen If no FM after 1hr further testing may be indicated, such as a CST Result : • Noncreative Nonstress Not Good • Reactive Response is Real Good Interpretation of results • Reactive result – real good  baseline FHR between traction beteen 120 and 160 beats per min.  at least two accelerations of the FHR of at least 15 beats per min., lasting at least 15secs in a 10 to 20 min period as a result of FM  good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (↓ FHR) and sympathetic (↑ FHR) nervous system; noted as an uneven line on the rhythm strip  result indicates a healthy fetus with an intact nervous system o Nonreactive result – not good  stated criteria for a reative result are not met  could be indicative of a compromised fetus requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST) 9. Health Teachings o do nutritional assessment o daily food intake o determine habit o if ↓ folic acid – lead to spina bifida/open neural tube defect o HIGH RISK MOTHERS • pregnant teenagers – poor compliance to health regimen • extremes in wt – underwt – eg. Elite models overwt – eg. DM/HPN • low social economic status. Refer to OSWD • vegetarian mothers because ↓ intake of vit B12 (Cyanocobalamin) – formation of folic acid (cell DNA & RNA formation) • types :  strict vegetarian – prone to develop anemia  lacto vegetarian – milk  lacto-ovo vegetarian – milk & egg Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 22: The Royal Pentagon Review Specialist, Inc. Maternity Nursing a. Recommended Nutrient Requirement that Increases During Pregnancy Nutrients Requirements Food sources Calories Essential to supply energy for 300 calories/day above the Caloric ↑ should reflect prepregnancy daily requirement • foods of high nutrient value • ↑ metabolic rate to maintain ideal body weight such as protein, complex • Utilization of nutrients and meet energy requirement of carbohydrates (whole grains, • Protein sparing so it can be activity level vegetables, fruits) used for : • begin ↑ in 2nd Trimester • variety of foods representing o growth of fetus • use wt-gain pattern as an food sources for the nutrients o development of indication of adequacy of required during pregnancy structures requires calories intake • no more than 30% fat for pregnancy • failure to meet caloric including placenta, requirements can lead to Na – 3gms/day – eat in amniotic fluid, tissue ketosis as fat & protein are moderation growth used for energy, ketosis has CHON x 4K Cal been associated with fetal CHO x 4K Cal damage. Fats x 9K Cal Non pregnant: 2200 calories Pregnant: 2500 calories 2200+500 @ lactation=2700 cal Protein Essential for • fetal tissue growth • maternal tissue growth including uterus and breasts. • Development of essential pregnancy structures • Formation of RBC and plasma proteins Inadequate protein intake has been associated with onset of pregnancy induced hypertension (PIH) Calcium-Phosphorous Essential for • Growth and development of fetal skeleton and tooth buds • Maintenance of mineralization of maternal bones and teeth • Current research is demonstrating an association between adequate calcium intake 60mg/day or an ↑ of 10% above daily requirements for age group Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein to meet the pregnancy requirement Protein ↑ should reflect • Lean meat, poultry, fish • Eggs, cheese, milk • Dried beans, lentils, nuts • Whole grains Vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids Calcium ↑ of • 1200mg/day representing an ↑ of 50% above pre pregnancy daily requirement • 1600mg/day is recommended for adolescent • 10mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous Calcium ↑ should reflect • Dairy products, milk, yogurt, ice cream, cheese, egg yolk • Whole grain, tofu • Green leafy vegetables • Canned salmon & sardines with bones • Ca fortified foods such as orange juice • Vitamin D sources fortified Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 23: The Royal Pentagon Review Specialist, Inc. and the prevention of pregnancy induced hypertension Iron Essential for • Expansion of blood volume & RBC formation • Establishment of fetal iron stores for first few months of life Non Pregnat:15mg/day Pregnant : 30mg/day - representing a doubling of the prepregnant daily requirement • Begin supplementation at 30mg/day in second trimester, since diet alone is unable to meet pregnancy requirement • 60 – 120mg/day along with copper and zinc supplementation for women who have low Hgb values prior to pregnancy or who have iron deficiency anemia • 70mg/day of vitamin C which enhances iron absortion o Inadequate iron intake results in maternal effects anemia, depletion of iron stores, ↓ energy and appetite, cardiac stress especially during labor & birth o fetal effects ↓ availability of oxygen thereby affecting fetal growth • iron deficiency anemia is the most common nutritional disorder of pregnancy Maternity Nursing milk, margarine, egg yolk, butter, liver, seafood Iron ↑ should reflect • liver, red meat, fish, poultry, eggs • enriched, whole grain cereals & breads • dark green leafy vegetables, legumes • nuts, dries fruits • vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, tomatoes, green peppers, broccoli or cabbage, potatoes • iron form food sources is more readily absorbed when served with foods high in vit C Zinc Essential for • the formation of enzymes • maybe be important in the prevention of congenital malformation of the fetus Folic acids, folacin, folate Essential for • Formation of RBC & prevention of anemia • DNA synthesis & cell 15 g/day representing an ↑ of 3mg/day over prepregnant daily requirement Zinc ↑ should reflect • liver, meats • shell fish • ↑ grains, legumes, nuts ↑ should reflect • Liver. Kidney, lean beek, veal • Dark, green leafy vegetables, broccoli, asparagus, 400mcg/day representing an ↑ of more than 2x the daily prepregnant requirement Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 24: The Royal Pentagon Review Specialist, Inc. formation; may play a role in the prevention of neural tube defects (spina bifida), abortion, abruption placenta Additional requirements Minerals • Iodine • Magnesium • selenium 300mcg/day supplement for women with low folate levels or dietary deficiency Maternity Nursing artichokes, legumes • Whole grains, preanuts 175mcg/day 320mg/day 65mcg/day ↑ requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy Vitamins E Thiamine Riboflavin Pyridoxine (B6) B12 Niacin 10mg/day 1.5mg/day 1.6mg/day 2.2mg/day 2.2mcg/day 17mg/day b. Sexual Activity • Principles of sex in Pregnancy o Should be done in moderation o Should be done in a private place o That the mother should be placed in a comfortable position o It must be avoided 6 weeks prior to EDD o Avoid blowing of air during cunnilingus • Contraindication in sex: o vaginal spotting – 1st tri o incompetent cervix – 2nd tri o placenta previa, abruption placenta – 3rd tri o pre-term labor R: prostaglandin – oxytocin – contraction o PROM – infection • Changes in sexual appetite during pregnancy: o 1st tri - ↓ o 2nd tri - ↑ o 3rd tri - ↓ c. Exercise • strengthen muscle to be used during the delivery process • Walking – best form of exercise • Squatting – strengthen perineum & ↑circulation to the perineum (raise the buttocks before head to prevent postural hypotension) • Tailor sitting – same purpose with squatting • Kegel exercise – strengthen pubococcygeal muscle • Abdominal exercise – muscle of the abdomen ( done as if blowing a candle) Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 25: The Royal Pentagon Review Specialist, Inc. Maternity Nursing • Shoulder circling exercise – strengthen muscle of the chest • Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good posture (arching back for 3 sec) • Principles of exercise o must be done in moderation o must be individualized d. Childbirth Preparation • Overall goal: To prepare patents physically & psychologically while promoting wellness behavior that can be used by parents & family thus, helping them achieved a satisfying & enjoying childbirth experiences. • Psychological o Bradley Method – Dr. Robert Bradley – discoverer  advocated active participation of husband during labor & delivery to serve as coach, based on “imitation of nature” Features: • darkened room • quiet & calm environment • relaxation technique • close eyes o Grantly Dick Read Method  fear can lead to tension while tension can lead to pain. (break cycle by removing the fear-by abdominal breathing exercises & relaxation technique) Psychosexual o Kitzinger Method – Dr. Shiella Kitzinger  pregnancy, labor & birth & the care of the newborn is an important turning point in a woman’s life cycle. “flowing with contractions rather than struggle with contractions” Psychoprophylaxis o Lamaze – Dr. Ferdinand Lamaze  Prevention of pain thru mind & requires discipline, conditioning & concentration with the husband’s help.  Features: • conscious relaxation • cleansing breathe – inhaling thru nose & exhaling thru mouth • effleurage – gentle circular massage • over abdomen to relieve pain • imaging Different methods of delivery o birthing chain – semi-fowlers – mother o bathing bed – dorsal recumbent o squatting – position relieve on back pain & maintain good posture o Leboyer’s method  features : • darkly lighted room  • • • Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 26: The Royal Pentagon Review Specialist, Inc. • quiet & calm environment • room temp. • soft music Birth under water Maternity Nursing o IX. INTRAPARTAL NOTES A. Admitting the laboring Mother • Personal data • Baseline data • Obstetrical data • Physical exams • Pelvic exams B. Basic knowledge in intrapartum • Theories of the Onset of Labor o Uterine Stretch Theory – any hollow organ once stretched to its maximum potential will always contract & expel its content o Oxytocin Theory – released by PPG, contraction effect o Prostaglandin Theory – stimulation by Arachidonic acid, causes contraction of uterus o Aging Placenta – 42wks (lifespan) by 36wks placenta begins to degenerate causes contraction o Progesterone deprivation theory - ↓ level of progesterone will facilitate contraction of the uterus • The 4 Ps of Labor o Passenger – fetus  fetal head • is the largest presenting part • ¼ of its length • Bones – 6 bones (sphenoid, temporal, ethmoid) Frontal, occipital & 2 parietal bones • Sutures/intermembranous spaces – allows molding • Molding – the overlapping of the sutures of the skull to permit passage of the head to the pelvis o Sagittal bones – connect to parietal bones o Cororontal bones – connect to parietal & frontal bones o Lambdoidal bones – connect to parietal & occipital bones • Fontanels o 6 fontanels only 2 palpable  anterior fontanel/Bregma • diamond in shape • 3cm x 4cm size • close 12-18 mos post delivery • ↑ 5cm – hydrocephalus  posterior fontanel/lambda • triangular in shape • 1 x 1cm size • close 2-3mos post delivery Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 27: The Royal Pentagon Review Specialist, Inc. • Maternity Nursing Measurements of fetal head : o transverse diameter  Bi-parietal - largest transverse diameter- 9.25cm  Bi-temporal - 8cm  Bi-mastoid - smallest transverse diameter - 7cm o AP diameter  Suboccipitobregmatic – complete flexion  Occipitofrontal – partial flexion - 12cm  Occipitotemporal – largest AP diameter; hyperextended (13.5cm)  Submentobrgmatic - face presentation; poor flexio o Passageway – vagina & pelvis  Pelvis • 4 main pelvic types o gynecoid – round, wide, deeper, most suitable for pregnancy o android – heart shape “male pelvis” – anterior pointed post part – shallow o Anthropoid – oval “ape-like pelvis“ AP wider transverse narrow o Platypelloid – flat transverse oval AP narrow transverse – wider – c/s for delivery • Problem : o mother who encounter accident o ↓ 4’9” o ↓ 18y/o – R: pelvis not achieve its full pelvic growth  Bones of pelvis • 4bones o 2 hips (2 innominate bones)  3parts of 2 innominate bones • Ileum – lateral/side of hips o Iliac crest – flaring superior border that forms prominence of hips; common site for bone marrow aspiration • Ischium – inferior portion o Ischial tuberosities of the area where we o Sit; basis in getting external measurement of pelvis • Pubis – anterior portion o Symphysis pubis – junction in between o sacrum – posterior portion  Sacral prominence – basis internal measurement of pelvis o 1 coccyx - 4 small bones that compresses during vaginal delivery • universal precaution in measurement of pelvis is to empty bladder first • Important Measurements o Diagonal Conjugate Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 28: The Royal Pentagon Review Specialist, Inc. Maternity Nursing o o o o measure between Sacral promontory & inferior margin of the symphysis pubis  Measurement 11.5-12.5 cm  Basis in getting the true conjugate. True Conjugate/Conjugate Vera  Measure between the anterior surface of the sacral promontory & superior margin of the symphysis pubis.  Measurement: 11.0 cm  Diagonal conjugate: 1.5 cm = true conjugate. Obstetrical Conjugate  smallest AP diameter of the pelvis measuring 10cm or more. Tuberoischii Diameter  transverse diameter of the pelvic outlet.  Approx by a fist- 8cm & above.  • Power  the forces acting to expel the fetus & placenta • involuntary contractions • voluntary bearing down efforts • characteristics: wave like • timing: frequency, duration, intensity  myometrium – power of labor o Psyche/person  psychological stress exist when the mother is fighting the labor experience. • cultural interpretation preparation • past experience • support system Pre-eminent signs of labor o Preeminent Signs  lightening • settling of the presenting part into the pelvis brim (shooting pain radiating to the legs, urinary frequency) • primi- early 2 weeks prior to EDD • engagement – settling of presenting part into pelvic inlet (not signs of labor)  Braxton Hicks Contractions – painless irregular contractions  Increase Activity of the Mother – Nesting • Instinct (mgt: save energy) • epinephrine production (hormone that ↑ the activity of the mother)  Ripening of the cervix –butter softness  Decrease in weight – 1.5-3 lbs.  Bloody show • pinkish vaginal discharge (blood + leucorrhea + operculum = pink in color)  Rupture of membranes • check FHT • IE check for cord prolapse PLM College of Nursing Batch 2006 Jomar Anthony D. Maxion, BSN, RN
Slide 29: The Royal Pentagon Review Specialist, Inc. Maternity Nursing • after several hrs – check temp. Premature Rupture of Membranes (PROM)  contraction drop in intensity even though very painful  contraction drop in frequency  uterus tense &/or contracting between contractions  abdominal palpitations  Nursing Care: • administer analgesics (morphine) • attempt manual rotation for ROP or LOP • bear down with contractions • adequate hydration • sedation as ordered • cesarean delivery may be required, especially if fetal distress is noted o Cord Prolapse  a complication when the umbilical cord falls or is washed through the cervix into the vagina.  Danger Signs: • PROM • Presenting part has not yet engaged • Fetal distress • Protruding cord from vagina – cerebral palsy – ↑ 5 mins., irreversible brain damage mgt: CS  Nursing Care • Positioning – knee chest or trendelenberg, place wet sterile gauze R: to make it slippery • Observe for fetal distress • Provide emotional support • Prepare for cesarean section o • Difference Between True and False Contraction True False • No in intensity • • Pain confined in the abdomen • • Pain is relieved by walking • • No cervical changes • There is an in intensity Pain begins @ the lower back to abdomen Pain is intensified by walking Cervical effacement (thinning of the cervix, measured thru %) & dilatation (widening of the cervix, measurement thru cm) *best/major sign of true labor • • Duration of Labor o Primipara – 14 hrs but not more than 120 hrs o Multipara – 8 hrs but not more than 14 hrs Nursing Interventions in Each Stage of Labor o First Stage: onset of contractions to full dilatation & effacement of the cervix o stage of effacement & dilatation PLM College of Nursing Batch 2006 Jomar Anthony D. Maxion, BSN, RN
Slide 30: The Royal Pentagon Review Specialist, Inc.  Maternity Nursing o Latent Phase: • Assessment: o Dilatations 0-3 cm o Frequency 5-10 mins o Duration 20-40 mins o Intensity mild o Mother is excited, apprehensive but can communicate • Nursing Care: o Encourage walking : shortens 1st stage of labor o Encourage to void q 2-3 hrs : full bladder inhibits uterine contraction o breathing (chest breathing technique)  Active Phase: • Assessment: o Dilatations 4-8 cm o Frequency q 3-5 mins lasting for 30-60 secs o Duration 30-60 secs o Intensity moderate • Nursing Care: o M – edications – have meds ready o A – ssessment include: v/s, cervical dilatation & effacement, fetal monitor, etc o D – ry lips – oral care (ointment), dry linens o Breathing – abdominal breathing  Transitional Phase: • Assessment: o Dilatations 8-10cm o Frequency q 2-3 mins contractions o Duration 45-90 sec o Intensity strong o Mood of mother suddenly change accompanied by hyperesthesia (hypersensitivity of mother to touch) of the skin • Management o sacral pressure, cold compress • Nursing care: o T – tires o I – inform of progress (to relieve emotional support) o R – restless support her breathing technique o E – encourage & praise o D – discomfort Pelvic Exams  Effacement & Dilatation • Station – relationship of the presenting part to the ischial spine o 5 - -1 = the presenting part is above the ischial spine o Engagement 10 = the presenting part is in line with the ischial spine PLM College of Nursing Batch 2006 Jomar Anthony D. Maxion, BSN, RN
Slide 31: The Royal Pentagon Review Specialist, Inc. Maternity Nursing • o (-) fetus is floating o (+) below the ischial spine Presentation o the relationship of the long axis of the fetus to the long axis of the mother. o spine relationship of the spine of the mother & the spine of the fetus o Two Types  Longitudinal Lie (Parallel)/ Vertical • Cephalic – when the fetus is completely flexed o Vertex o Face o Brow o Chin • Breech o Complete breech – thigh rest on abdomen while legs rest on thigh o Incomplete breech  Frank – thigh resting on abdomen while legs extend to the head  Footling  Kneeling  Transverse Lie (Perpendicular)/Horizontal lie • Position – relationship of the fetal presenting part to specific quadrant of the mother’s pelvis. o ROA/LOA  left occipito anterior  most common & favorable position o ROT/LOT – left occipito transverse o ROP/LOP – left occipito posterior o L/R- side of maternal pelvis o Middle – presenting part o ROP/ROT – most common malposition o ROP/LOP – most painful mgt: pelvis squatting o Breech – sacro place the stethoscope above the umbilicus o Chin – mentum o Shoulder – acromnio dorso Monitoring the contractions & fetal heart tone  PLM College of Nursing Batch 2006  Jomar Anthony D. Maxion, BSN, RN
Slide 32: The Royal Pentagon Review Specialist, Inc. • Maternity Nursing • • • • • • • • • • • spread the finger lightly over the fundus to monitor the contraction Increment/Cresendro - beginning of contraction until it increases Apex/Acne – height of contraction Decrement/Decresendro – from height of contraction until it decreases Duration – beginning of contraction to the end of the same contraction Interval – from end of contraction to the beginning of the next contraction Frequency – from the beginning of 1 contraction to the beginning of next contraction Intensity – strength of contraction if contract – blood vessel constricts; the fetus will get the oxygen on the placenta reserve which is capable of giving oxygen to the fetus up to 1min. Duration of placenta to the fetus should not exceed 1min. Significance During active phase, if ↑ to 1min should notify the AMD ↑ BP; ↓ FHT : best time to get BO & FHT just after a contraction NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR  Bath is necessary  Monitor VS especially BP o Same BP = rest o Elevated = notify the physician  NPO o Prevent aspiration  chemical pneuminitis  Enema (per hospital policy) o Purpose  Cleanse the bowel  Prevent infection o 12 – 18 inches normal length of tube o 18 inches optimal length o Lateral sims position o If there is contraction  clump the tube o If there is resistance  slowly remove o Before and after administration: check FHT (120 – 160) and contractions  Encourage mother to void  Perennial preparation (rule of 7)  Rest on left side lying position o Prevent supine vena cava syndrome or supine hypotension  If membrane doesn’t rupture  amniotomy  FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen  For Pain o Systemic analgesic  DEMEROL (Meperidine HCl) • Narcotic and antispasmonic • Don’t give during latent phase • Given @ 6-8 cm dilated • WOF : Respiratory depression Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 33: The Royal Pentagon Review Specialist, Inc. Narcan (Naloxone, nalorfan, nalline) o Antidote for toxicity o Injected on the baby Epidural Anesthesia • WOF : Hypotension • Prehydrate the client to prevent hypotension • In case of Hypotension o Elevate leg o Fast Drip IV • Maternity Nursing  SECOND STAGE OF LABOR (FETAL STAGE)  Complete dilatation and effacement to birth  Crowning occurs  PRIMI – transfer to DR @ 10 cm dilatation  MULTI – transfer to DR @ 7 – 8 cm dilatation  Position in lithotomy both legs at the same time  BULGING OF PERENIUM  surest sign of delivery initiation  PANT & BLOW Breathing, fetal pushing should be done on an open glottis  Respiratory alkalosis o Due to incorrect breathing o Hyperventilation o S/sx  ↑ RR  Lightheadedness  Tingling sensation  Carpopedal spasm  Circumoral numbness Episiotomy  Prevent laceration  Widen the vaginal canal  Shortens the 2nd stage of labor  2 types o MEDIAN  Less bleeding  Less pain  Easy repair  Possible urethroanal fistula  major disadvantage o MEDIOLATERAL  More bleeding  More pain  Hard to repair and slow healing  Ironing the Perenium  prevent laceration Mechanism of Labor (ED FIRE ERE)  Engagement  Descent  Flexion Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 34: The Royal Pentagon Review Specialist, Inc. Maternity Nursing     Internal Rotation Extension External Rotation Expulsion PELVIS  3 Parts o Inlet – AP diameter narrow, transverse wider o Cavity – between inner and outer o Outlet – AP diameter wider, transverse narrow  LINEA TERMINALES Nursing Care  MODIFIED RIGEN’S MANEUVER o Done by supporting the perenium with a towel during delivery o Facilitates complete flexion o Avoids laceration  First intervention: Support the head and suction secretion  Do not milk the cord, wait for pulsation to stop before cutting o Milking may cause too much blood going to the baby that may cause cardiac overload  When there is still birth, let the mother see the baby to accept the finality of death THIRD STAGE OF LABOR (PLACENTAL STAGE)  3 – 10 minutes after child birth  1st sign  Fundus rises  CALKIN’S SIGN  Signs of Placental Separation o Fundus becomes globular and rises  calkin’s sign o Lengthening of the cord o Sudden gush of blood  BRANT – ANDREW’S MANEUVER o slowly pulling the cord and wind at the clamp o rapidly  may cause uterine inversion Types Placental Delivery  SHULTZ (Shiny) o From center to the edges o Presenting fetal side  DUNCAN (Dirty) o Form edges to center o Presenting the maternal side Nursing Considerations during placental delivery  Check placental completeness o Should be 500 g  Check Fundus – Massage if Boggy  BP Check  Methergine, methylergonovine mallate (IM) Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 35: The Royal Pentagon Review Specialist, Inc.     Oxytocin (IV) if methergine is not present Check perenium for lacerations Assist in episioraphy Vaginoplasty/ Vaginal Landscape – Virgin again Maternity Nursing FOURT STAGE OF LABOR (Recovery Stage)  First 1 – 2 hours after delivery of placenta  Maternal observation – body system stabilize o 1st hour – q15 min 2nd hour - q 30 min  Placement of fundus o In between umbilicus and pubis symphysis o Check bladder, assist in voiding, May lead to uterine atony  hemorrhage  Lochia  Perineum o Check REEDA  R edness  E dema  E cchymosis  D ischarge  A pproximation o Fully saturated – 30 – 40 cc o Weighing – 1 cc = 1 gram Common Board Question Nursing Consideration during Recovery  Flat on bed to prevent dizziness  If with Chills  give blanket due to dehydration  Give nourishment (progression of meal) o Clear liquids – gatorade, ginger juice, gelatins o Full liquid – milk, ice cream o Soft diet o Regular diet  Check VS/ Pain  Pychic State  Bonding – interaction between mother and newborn o Strict – 24 hours with mother o Partial – morning with mother, night nursery COMPLICATIONS OF LABOR Dystocia  Difficult labor related to mechanical factor  Primary cause is Uterine Inertia Uterine Inertia  Sluggishness of contraction  Types o Primary/ Hypertonic  Intense contraction resulting to ineffective pushing Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 36: The Royal Pentagon Review Specialist, Inc.  Management : Sedation Secondary/ Hypotonic  Slow, irregular contraction resulting to ineffective pushing  Management : Oxytocin Augmentation Prolonged Labor  > 20 H for primi  > 14 H for multi  proper pushing should be encourage if inappropriate: o may cause fetal distress o caput succedaneum o cephalhematoma o maternal exhaustion  monitor contractions and FHT o Maternity Nursing Precipitate Labor  labor less than 3 hours  causes excessive laceration leading to profuse bleeding  hypovolemic shock  s/sx of hypovolemic shock HYPO TACHY TACHY o HYPOtension o TACHYpnea o TACHYcardia o Cold clammy skin o Management  Modified trendelenburg  Fast Drip IV Inversion of Uterus  Situation in which uterus is turn inside out due to: o Short cord o Hurrying of placental delivery o Ineffective fundal push  Cause profuse bleeding  hypovolemic  Hysterectomy Uterine Rupture  Rupture of uterus  Caused by o Previous classical CS o Very large baby o Improper use of oxytocin  S/sx o Sudden pain o Profuse bleeding  Prepare fore TAHBSO Physiologic Retraction Ring  boundary between upper and lower uterine segment Bandl’sPathologic Ring  suprapubic depression sign of uterine rupture Amniotic Fluid/ Placental Embolism Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 37: The Royal Pentagon Review Specialist, Inc. Maternity Nursing  Anaphylactic syndrome of pregnancy  Situation in which placental fragment and amniotic fluid enters maternal circulation  S/Sx o Dyspnea o Chest Pain o Frothy Sputum o End Stage – DIC  Prepare for CPR, Suction and emergency etc Trial Labor  Fetal head measurement = measurement of pelvis  6 hours labor allowance given to mother  monitor FHT and contractions Preterm Labor  labor after 20 weeks and before 37 weeks  Triad signs o Premature conditions every 10 minuets o Effacement of 60 – 80% o Dilatation of 2 – 3 cm  Home Management o CBR o Avoid Sex o Empty bladder o Drink 3 – 4 Glasses of H2O  Full bladder inhibit contraction  Hospital Management o If Cervix Close (Criteria: cervix is closed if it is 2 – 3 cm dilated only)  2 – 3 cm dilated, pregnancy can be saved  Tocolytic Therapy • Yutupar (Ritodine HCl) o Side effect maternal BP < 90/60 o Check Impt. Presence of crackles • Brethine (terbutaline) Bricanyl o DOC o Side effect: sustained tachycardia o Antidote: propanolol/ inderal • Mg SO4 o If cervix is dilated ( > 4cm)  Give steroid dexamethasone • Promote surfactant maturation • Immediately cut the cord after delivery to prevent jaundice/ hyperbilirubinemia POSTPARTAL PERIOD Puerperium – 5th stage of labor, 1st 6 weeks post partum Characterize by involution Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 38: The Royal Pentagon Review Specialist, Inc. Involution - return to the normal stage of reproductive organ after pregnancy Return to Normal Healing Physiologic Changes Systemic Changes  Cardiovascular System o ↑plasma volume o sudden ↓ in blood volume o elevated WBC’s up to 30, 000 mm3 o hyperfibrinogenemia o orthostatic hypertension can be possible o early ambulation prevents thrombos formation  steps in ambulation • Flat • Semifowlers • Fowlers with dangling • Walk with assist Maternity Nursing  Genital Tract o Fundus  goes down 1 finger breadth a day  10th day – non palpable behind the symphysis pubis  Subinvolution • delayed healing of uterus containing quarters or clots of blood • may lead to puerperal sepsis • Management : D&C o After Pains  After birth pains  Multiparous breastfeeding – most common to develop  Position = prone  Cold compress  Mefenamic acid o Lochia  Components • Blood • Deciduas • WBC • Microorg  3 types • Rubra – 1 – 3 days, musty, moderate amount • Serosa – 4 – 10th day, pink or brown • Alba – 10 – 21th day, crème white, ↓ amount  Urinary Tract o Urinary Frequency – due to urinary retention with overflow o Dysuria  Damage to trigone of the bladder Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 39: The Royal Pentagon Review Specialist, Inc.      Urine collection for culture and sensitivity Stimulate navel to urinate Palpate bladder Running water listening Pull pubic hair - stimulate cremasteric reflex Maternity Nursing  Colon o Constipation  Due to NPO  Bearing down may cause pain  Perenium o Pain relieved by sim’s position o Cold compress 1st 24 hours if there is pain at episioraphy followed by warm EMOTIONAL SUPPORT 1. Taking phase • 1st 3 days • dependent phase • passive, can’t make decision • tells about childbirth experience • focus on: Hygiene 2. Taking Hold • 4 – 7th day • dependent to independent phase • active, decides actively • focus: care of newborn • health teaching : Family planning 3. Letting Go • Interdependent phase • Redefines goals, new roles as parents • May extend till the child grows Post Partum Blues • 4th – 5th days • overwhelming feeling of depression, inability of sleep and lack of appetite • 50 – 80% incidence rate • cause by sudden hormaonal change – progesterone suddenly decreases • allow crying: therapeutic • may lead to postpartum psychosis/ depression Postpartal Complications Hemorrhage  bleeding within 24 hours postpartum Early Pospartal Hemorrhage Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 40: The Royal Pentagon Review Specialist, Inc. 1. Uterine Atony  boggy fundus  profuse bleeding  interventions o massage the uterus o cold compress o modified trendelenburg o fast drip IV o breastfeeding – to release oxytocin 2. Laceration  well contracted uterus with profuse bleeding  assess perenium for laceration  degrees of laceration o 1st degree – vaginal skin and mucus membrane o 2nd degree – 1st degree + muscles o 3rd degree – 2nd degree + external sphincter of rectum o 4th degree – 3rd degree + mucus membrane of rectum Maternity Nursing 3. Hematoma  bluish discoloration of subQ tissues of vagina or perenium  candidates o delivery of very large babies o pudendal block o excessive manipulation due to excessive IE  intervention o cold compress 10 – 20 min then allow 30 minutes rest period for 24 h 4. DIC – disseminated intravascular coagulation  Consumption of pregnancy (otherterm)  Failure to coagulate  Bleeding in the eyes, ears, nose  Oozing blood  Seen in cases with o Abruptio placenta o Still birth / IUFD  Management o Blood transfusion of cryoprecipitate or fresh frozen plasma o hysterectomy Late Postpartum Hemorrhage Retained placental fragments  manual extraction of fragments is done  uterine massage  D&C except for cases of o Placenta Acreta – umusual attachment of the placenta to the myometrium o Placenta Increta – deeper attachment of placemat to the myometrium Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 41: The Royal Pentagon Review Specialist, Inc. Maternity Nursing o Placenta Percreta – invasion of placenta to the perimetrium  Candidates of these disorders are • Grand multiparous • Post CS All these requires hysterectomy  Infection  Sources o Endogenous – from normal flora of the body o Exogenous – from the health care team  Most common – Anaerobic Streptococci  Management o Supportive care o ↑ Fluid intake o TSB if there is fever/ cold compress + paracetamol may also be given o Analgesics  Given on time to achieve maximum effect o Culture and sensitivity Perenial Infection  Same s/ sx with infection  2 – 3 stitches are dislodges  with purulent drainage  Tx – resuturing Endometritis  Inflammation of the endometrium  Gen s/sx of infection + abdominal tenderness  Management o High fowler’s – facilitates drainage & localize infection o Administer oxytocin FAMILY PLANNING METHOD Guiding Principles 1. determine your own beliefs first 2. never advise a permanent method of family planning 3. informed concent 4. the method is an individual decision Natural Method – accepted by the church Billing’s/ Cervical Mucus/ Spinnbarkeit • clear watery & stretchable • 13th day – longest due to estrogen Basal Body Temp – in the morning before arising/ 13th – 14th day due to peak of progesterone LAM – Lactational Amenorrhea Method  prolactin – inhibits ovulation  breastfeeding – 4 – 6 months no menstrual cycle Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 42: The Royal Pentagon Review Specialist, Inc.  bottle fed – 2 – 3 months Sympthothermal – combination of Billings and BBT – most effective method Social Methods Coitus Interuptus  withdrawal  least effective method Coitus Reservatus  sex w/o ejaculation Coitus interfemora  between femor Calendar Method  14 days before menstrual cycle – ovulation day (regular)  - 4, + 4 days – unsafe period Origoknause Formula ( irregular menstrual cycle)  get the longest and shortest cycle  subtract 18 to shortest  11 to the longest  the difference is the unsafe period Maternity Nursing PILLS  combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland roduction of FSH and LH which are essential for he maturation and rupture of a follicle.  Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH which is responsible for ovulation.  contains estrogen that inhibits FSH and progesterone that inhibit LH  99.9% effective  21 day feel on the 5th day of mense start taking  28 day – 1st day of mense  if forgotten, take 2 tablets the following day  adverse effect : breakthrough bleeding  if mother wants to get pregnant o wait 3 monts o another 3 months if unsuucessful before consulting gyne  contraindications o chain smoking o Hypertension o DM o Extreme obesity o Thrombophlebitis  Side effects (ressembles Hypertension)/ Immediate Discontinuation o Abdominal paon o Chest pain o Headache o Eye problem o Severe leg cramp  Alerts on oral contraceptives : Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 43: The Royal Pentagon Review Specialist, Inc. o Maternity Nursing In case a Mother who is taking an oral contraceptive for almost a long time and plans to have a baby, she would wait for at least 3mos before attempting to conceive to provide time for estrogen and progesterone levels to return to normal. If after 6months the mother did not get pregnant, consult AMD. o If a new oral contraceptive is prescribed, the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses. o Discontinue oral contraceptive if there is signs of severe headache as this are an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage. o If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days, stop the pill and wait for the next mens.  Adverse reaction : breakthrough bleeding DMPA – Depoprovera  Contains progesterone  Depomedroxy progesterone Acetate  IM q 3 months – never massage the site  may decrease effectiveness NORPLANT  6 match stick like capsules/ rod  contain progesterone  sub Q planted  good for 5 years Mechanical Device IUD  prevent implantation  alters mobility of sperm and ovum  99.7% effective  best inserted after delivery and during menstruation  Common complication – EXCESSIVE MENSTRUAL FLOW  Common problem – EXPULSION OF THE DEVICE  No protection against STD  Side effects include o Uterine infection o Uterine perforation o Ectopic pregnacy  Major indication for the use is PARITY  HT: monthly check up and regular pap smear CONDOM  Made up of latex  Put in erected penis or lubricated vagina  Prevents sperm to enter the uterus  FEMALE CONDOM – higher protection than that of male Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 44: The Royal Pentagon Review Specialist, Inc. Maternity Nursing DIAPRAGHM  Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the uterus  Reusable  HT : Proper hygiene o Check for holes o Must be refitted in case of weight gain of 15 lbs - - board question o Kept in place for about 6-8 Hours – Board question  Contraindicated to o Frequent UTI CERVICAL CAP  More durable than the diaphram  Could stay on place for more than 24 hours  No need to apply spermicides  Contraindicated to – abnormal papsmear CHEMICAL SPERMICIDES  FOAMS – most effective  Jellies  Creams  These may cause toxic shock syndrome SURGICAL METHOD  Bilateral tubal Ligation o @ isthmus o 20% probability of reversal  Vasectomy o Vas deferens is cut o More than 30 x or 0 sperm count or 2 x negative sperm count before it could be consider safe sex HIGH RISK PREGNANCY HEMORRHAGIC DISORDERS General management  CBR  Avoid sex  Prepare ultrasound – determine the sac integrity  Assess bleeding and approximation  Assess hypovolemia  Save discharge for histopathology o Determine whether the product of labor has been expelled Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 45: The Royal Pentagon Review Specialist, Inc. Maternity Nursing First Trimester Bleeding Abortion – termination of labor before age of viability  SPONTANEOUS o AKA miscarriage o Causes 1. Chromosomal aberrations due to advanced maternal age 2. Blighted ovum 3. germ plasm defect o Natures way of expelling defective babies o Classifications : 1. Threatened • pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be saved. 2. Inevitable • moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open. o Types : 1. Complete • all products of conception are expelled. • Mgt : emotional support 2. Incomplete • placenta and membranes retained. • Mgt : D&C  HABITUAL o 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. o Management (suture of cervix) 1. McDonald procedure • Temporary circlage • Side effect – infection • May have NSD 2. Shirodkar • CS delivery  MISSED o fetus dies; product of conception remain in uterus 4 weeks or longer o signs of pregnancy cease 1. (-) pregnancy test 2. Dark brown 3. Scanty bleeding o Mgt : induction of labor/ vacuum extraction  INDUCED o Therapeutic abortion  principle of 2 fold effect 1. Done when mother has class 4 heart disease Ectopic Pregnancy • occurs when gestation is location outside the uterine cavity • Common site : Ampulla or Tubal Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 46: The Royal Pentagon Review Specialist, Inc. • Dangerous site: Interstitial Unruptured • Missed period • Abdominal pain within 3- 5wks of missed period (maybe generalized of one sided) • Scant, dark brown vaginal bleeding • Vague discomfort Maternity Nursing Ruptured • sudden, sharp severe unilateral pain, knife like • shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm & phrenic nerve) • (+) Cullen’s sign – bluish tinged umbilicus • syncope/fainting • • Nursing Care : o vital signs o administer IV fluids o monitor for vaginal bleeding o monitor I&O o prepare for culdocentesis to determine o hemoperitoneum Mgt : non-surgical Methotrexate SECOND TRIMESTER BLEEDING Hydatidiform Mole / “bunch of grapes” • Gestational Trophoblastic Disease – progressive degeneration of Chorionic Villi • gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed from the swelling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus very rapidly. • Cause : Unknown • Assessment : o Early signs  vesicles passed thru the vagina  Hyperemesis gravidarum due to ↑ HCG  Fundal height  Vaginal bleeding (scant or profuse) o Early in pregnancy  high levels of HCG  Pre ecclampsia at about 12wks  Vesicles look like a “snowstorm” on sonogram  Anemia  Abdominal cramping o Serious late complications  Hyperthyroidism  Pulmonary embolus • Nursing care : o prepare for D&C o do not give oxytocin drugs due to proneness to embolism o Health Teaching: Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 47: The Royal Pentagon Review Specialist, Inc. Maternity Nursing    return for pelvic exams as scheduled for one year to monitor HCG and assess for enlarged uterus and rising titer could be indicative of choriocarcinoma Avoid pregnancy for at least one year Methotrexate therapy Incompetent Cervix Management: • McDonald procedure o temporary circlage of incompetent cervix. o Delivery : NSVD o SE: infection o Health teaching  observe for signs of infection  signs of labor • Shhirodkar procedure o permanent procedure. o Delivery : caesarian section required. THIRD TRIMESTER BLEEDING “PLACENTAL ANOMALIES” Placenta Previa • it occurs when the placenta is improperly implanted in the lower uterine segment, sometime covering the cervical os. • Assessment o Outstanding sign : frank, bright red, painless bleeding o enlargement (usually has not occurred) o fetal distress o abnormal presentation • Nursing care : o Initial mgt : NPO candidate for CS o Bedrest o prepare to induce labor if cervix is ripe o administer IV o No IE, No Sex, No enema – complication : Sudden fetal blood loss o prepare Mother for double set –up –DR is converted to OR Abruptio Placenta • it is the premature separation of the placenta from the implantation site. • It usually occurs after the twentieth week of pregnancy • Cause: o Cocaine user o Severe PIH o Accident • Assessment: o Outstanding sign : dark red & painful bleeding o concealed hemorrhage (retroplacental) o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 48: The Royal Pentagon Review Specialist, Inc. rigid boardlike abdomen severe abdominal pain dropping coagulation factor (a potential for DIC) o sx : bleeding to any part of the body. Mgt : for hysterectomy General Nursing care : o infuse IV, prepare to administer blood • type and crossmatch o monitor FHR o insert Foley catheter o measure bllod loss; count pads o report s/s of DIC o monitor v/s for shock o strict I&O o o o Maternity Nursing • Placental Succenturiata – 1 or 2 lobes connected to the placenta by a blood vessel Placenta Bipartita – placenta divided into 2 lobes HYPERTENSIVE DISORDER Pregnancy Induced Hypertension o HPN after 24wks resolved 6wks postpartum which cause pregnancy. o Types : o Gestational HPN  HPN without edema & proteinuria.  Mgt : monitor BP o Pre-eclampsia – triad o sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or idiopathic but multifactoral  primis d/t 1st exposure to chorionic villi  multiple pregnancies due to ↑ exposure to chorionic villi  Mothers of low socio-economic status due to ↓ protein intake  Teenagers d/t low compliance to protein intake o HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count Transitional Hypertension – HPN between 20-24wks Chronic or Pre-existing Hypertension o HPN before the 20th wk not resolved 6wks postpartum o 3 types of pre-eclampsia o Sign of pre-eclampsia : o > 30mmHg systolic o > 15mmHg diastolic o Roll over test  10-15min side lying  Then supine  Then take BP o mild pre-ecclampsia Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 49: The Royal Pentagon Review Specialist, Inc. Maternity Nursing o o 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear wedding ring due to developing edema  Signs present • cerebral & visual disturbances, epigastric pain to liver edema and oliguria usually indicates an impending convulsion • Before convulsion : if you see sign of epigastric pain, 1º mgt is to place tongue depressor and put the side rales up • During convulsion : observe the Mother for safety • After convulsion – turn to side to facilitate drainage Severe pre-ecclampsia  160/110, +3 or +4, proteinuria, visual disturbances  Nursing care  P – promote bedrest  Prevent convulsions by nursing measures • to ↑ O2 demand & facilitate Na excretion • Management: quiet & calm environment, minimal handling, avoid moving the bed • Heat Acetic Acid – determine protein in the urine • Prepare the following at bedside o tongue depressor, Suction machine & O2 tank  E – ensure high protein intake (1g/kg/day) • Na in moderation  A – antihypertensive drug with hydraluzine  C – CNS depressant with Mg Sulfate for anti-convulsion • Mgt : evaluate for hypermagnesiumenimia  E – evaluate physical parameters for Magnesium Sulfate toxicity : • B – BP ↓ • U – Urine output ↓ • R – RR ↓ • P – Patellar reflex is absent • Antidote : Ca gluconate Eclampsia – with seizure  ↑ BUN – sign of glumerular damage  Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 50: The Royal Pentagon Review Specialist, Inc. Maternity Nursing Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 51: The Royal Pentagon Review Specialist, Inc. Maternity Nursing Diabetes Mellitus o cause by absent & lack of Insulin o Action of Insulin is to facilitate transfer of glucose into the cell o Dx test : 50gm 1hr Glucose Tolerance Test o ↑ 130 – hyperglycemia o ↓ 70 – hypoglycemia o 80-120 – euglycemia o if > 130mg/dl, the Mother needs to undergo a 3hr GTT o Maternal Effects : o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus yung glucose ng nanay. o Hyperglycemia during the 2nd & 3rd trimester  HPL effect Mgt : give insulin. OHA are teratogenic.  1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly  Frequent infections eg. Moniliasis  Polyhydramnios  Dystocia o Fetal Effects : o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd trimester thru facilitated diffusion o Macrosomia/LGA .4000gms o IUGR due to prolonged DM o Preterm birth promote still birth o Newborn Effects : o Hyperinsulinism and Hypoglycemia  40mg/dl  Normal : 45-55mg/dl  Borderline : 40mg/dl  Sx : ↑ pitched shrill cry, tremors, jitteriness  Dx test : heel stick test to check glucose levels o Hypocalcemia  < 7mg/dl  Calcemic tetany  Tx : Ca gluconate Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 52: The Royal Pentagon Review Specialist, Inc. Maternity Nursing Heart Disease o Classification : o I – no limitation o II – Slight limitation, ordinary activity causes fatigue  good prognosis can deliver vaginally  Mgt : sleep of 10hrs/day, rest 30mins after meals o III – moderate limitation, less than ordinary activity causes discomfort  poor prognosis. Good for vaginal delivery  Mgt : early hospitalization by 7-8mos o IV – marked limitation of physical activity for even at rest there is fatigue  poor prognosis. Good for vaginal delivery only with regional anesthesia.  Low forceps delivery when unable to push & to shorten the stage of labor  Mgt : • therapeutic abortion, high semi- fowlers position, left side lying, no valsalva maneuver - may trigger cardiac arrest, heparin therapy required, antibiotic therapy for prevention of sub acute bacterial endocarditis INTRAPARTAL COMPLICATIONS Cesarean Delivery • Indications a. multiple gestation b. diabetes c. active herpes II d. severe toxemia e. placental previa f. abruption placenta g. prolapse of the cord h. cephalo pelvic disproportion and primary indication i. breech presentation j. transverse lie • procedure : o classical – vertical incision o low segment – “bikini”, for aesthetic purposes. Can have vaginal birth after c/s Genotype – genetic make-up Phenotype – Physical appearance Karyotype – pictorial analysis of individual chromosome for detecting chromosomal abnormalities Autosomal Dominant • huntington’s chorea • retinoblastoma • achondroplasia • polydactyl Autosomal Recessive • sickle cell Jomar Anthony D. Maxion, BSN, RN PLM College of Nursing Batch 2006
Slide 53: The Royal Pentagon Review Specialist, Inc. • Cystic fibrosis • Celiac • PKU • Galactosemia X- Linked Recessive • Hemophilia • Duchenne’s muscular dystrophy • Color blindness X – Linked Dominant • Rickette’s

Nursing Quotes

noreply@blogger.com (grey26) — Fri, 24 Sep 2010 17:42:47 PDT

Nursing Quotations

We'd all be worse without a nurse

Always than your nurse Sometimes the only one between you and a hearse

Whether a person is a male or, female a nurse is a nurse

A nurse will always give us hope an angel with a stethoscope

PRC Manila open an extension office for Nurses July 2010 M-Z

noreply@blogger.com (grey26) — Wed, 15 Sep 2010 00:09:05 PDT

PRC

Initial registration of New Nurses July 2010 M-Z
PRC Manila to open an extension office for July 2010 Nursing Board Exam Passers

September 15 MATUNDAN, RAINALEX M. – MONDERIN, MARIA PAMELA V.

September 16 MONDILLA, JEROME P. – NOVENO, INGRID STEPHANIE V.

September 17 NOVERO, CHARLOTTE P. – PADUA, REMEDIOS A.

September 22 PADUA, RICHARD M. – PE, EZCA JAMES P.

September 23 PEARSON, IVY LORENNE F.- PUNO, MARY ROSE ANN C.

September 24 PUNONGBAYAN, RENEE G. – REBUSTES, KORINAH A.

September 27 RECOTO DY, TIFFANY JANELLE T. – RODRIGUEZ, RONALDO P.

September 28 RODRIN, CATHERINE CATUNGAL – SAMONTE, CHRISTINE JANE A.

September 29 SAMONTE, KATRINA L. – SEBASTIAN, JOVER B.

September 30 SEBASTIAN, KATRIN MAY INOBAYA – SUMAIL, SETTIE SULFAICAL U.

October 1 SUMAJIT, KRISTINE MARIE R. – TINDUGAN, CHARLY-MAE F.

October 4 TINDUGAN, JOEL JOHN C. – VALENCIA, ERIKA IVY I.

October 5 VALENCIA, GAY V. – VILLAS, JOMANA GERONIMO

October 6 VILLAS, MERLYN KRISTEL Z. – ZUNO, RALF RAYMUND P

LATE REGISTRANTS WILL BE ALLOWED TO FILE ONLY IN PRC Manila office AS FOLLOWS:

November 8 A to C
November 9 D to M
November 10 N TO Z

Nursing Schools Performance July 2010

noreply@blogger.com (grey26) — Wed, 15 Sep 2010 00:01:11 PDT

PRC

Nursing Board Exam Schools Performance July 2010
Top Performing Schools

Initial Registration PRC license for new nurses schedule

noreply@blogger.com (grey26) — Wed, 15 Sep 2010 00:02:44 PDT

PRC

Initial Registration PRC license for new nurses schedule Metro manila and Pampanga - Updated Version
PRC Initial Registration Schedule for July 2010 Nursing Board Exam Passers (Metro Manila and Pampanga) [2nd...

H.E.A.R.T. Foundation Bls Ecg Acls Pals Training Schedule 2010

noreply@blogger.com (grey26) — Wed, 15 Sep 2010 00:05:43 PDT

Heart

H.E.A.R.T. Foundation Bls Ecg Acls Pals Training Schedule 2010 - Nursing Training, Basic Life Support

Heart Bls-ecg-Acls-pals Training Sched 2010

Nurses Need to be Aware of Patient Rights

noreply@blogger.com (grey26) — Tue, 14 Sep 2010 23:01:36 PDT

Nurse takes great care to offer patients the best care possible. They help meet their basic needs at all levels that the needs of individual patients. Nursing assistants often have to make decisions for patients under their care. However, it is very important for all nurses and nursing assistants to be aware of the rights of all patients. Nursing assistants must be familiar with these rights and respect them.

All patients have the right to refuse treatment. This can be difficult for nursing assistants as they really want to be a benefit to the patient as possible. However, if they want help, can not be forced. You should tell your manager and document information on the patients chart

Patients have the right to receive all the information at the time, and throughout his residence structure. Nursing can be added as questions that patients who are not qualified to answer. In contrast with the patient, telling them they can answer your question, and the document of information on paper. Most patients and their families information will directly pay the doctor or nurse.

If a patient is not satisfied with the care they receive, they have the right to inquire about the complaint procedures and file a complaint. If a patient voice a complaint with you, give them the information to file a formal complaint. Policies and procedures for doing so varies clinics.
Patients have the right to participate in the religion of their choice. They are allowed to receive visitors to the church as well as private visitors, and does not interfere with medical advice. The nurse must learn to work on the needs of patients in these visits.

Providing quality care for people is a very rewarding challenge for nurses. Note that each patient has its own personality, desires and needs. They want to continue to be respected, even when they are in a medical center. This allows them to keep a routine and a sense of normalcy. The more attention to a patient, the better you know how to take better care of them.

It is difficult to balance the medical needs of a patient with their own personal desires. However, it is possible to provide both by respecting the patient's rights. This will ensure that they understand and denied requests are done purely in the best interest of their well being. Nursing Assistants are often considered an ally by patients. They help reduce any issues between the patient and Nursing staff as well as the patient and physician.

Nursing Schools in the Philippines

noreply@blogger.com (grey26) — Sun, 12 Sep 2010 01:05:07 PDT

Here are the List of Schools of Nursing in the Philippines

* Ateneo de Davao University
* Ateneo de Naga University
* Angeles University Foundation
* Ateneo de Zamboanga University
* Aquinas University
* Araullo University -Cabanatuan
* Arellano University College of Nursing
* Asia Pacific College of Advance Studies
* Asian College of Technology
* Ago Medical and Educational Center – Legazpi City, Albay
* Ago Foundation College – Naga City
* Aquinas University – Legazpi City, Albay

* Baliuag University, College of Nursing
* Benguet State University
* Baguio Central University
* Bataan Peninsula State University
* Brokenshire College
* Bukidnon State University
* Bicol University Legazpi City, Albay
* Bicol College Legazpi City, Albay

* Capitol Medical Center Colleges
* Cebu Normal University
* Central Philippine University
* Centro Escolar University
* Cebu Doctors’ University
* Christ the King College
* Cor Jesu College
* Cebu Institute of Technology
* Cebu Sacred Heart College, Cebu City

* De La Salle Health Sciences Institute
* De La Salle Lipa
* Davao Medical School Foundation
* Davao Doctors College
* Dominican College
* Dr. Carlos S. Lanting College

* Far Eastern University Institute of Nursing
* Father Saturnino Urious University, Butuan City

* Global City Innovative College
* Dr. Gloria D. Lacson College -San Leonardo, Nueva Ecija
* Good Samaritan Colleges -Cabanatuan City
I
* Ifugao State College (ISCAF)
* Iloilo Doctors College
* Immaculate Conception College Albay
* Immaculate Conception College -Cabanatuan City

* Jose C. Feliciano College

* Kester Grant College

* La Fortuna College -Cabanatuan City
* Lorma Colleges
* Liceo de Cagayan University
* Lourdes College
* La Salle University – Osamis City
* Lyceum of the Philippines University – Manila
* Lyceum of Batangas
* Lyceum Institute of Technology – Laguna
* Lyceum – St. Cabrini College of Allied Medicine – Batangas

* Manila Central University
* Manila Doctors College
* Manila Adventist Medical Center and Colleges
* Mariano Marcos State University
* Mati Doctors College
* Mindanao Medical Foundation College
* Misamis University
* Mountain View College

* New Era University
* Notre Dame University
* Notre Dame of Dadiangas University
* Notre Dame of Marbel University
* Notre Dame of Kidapawan College
* North Valley College
* North Eastern College, Santiago City, Isabela
* Nueva Ecija Doctors College, Cabanatuan City
* Nueva Ecija University of Science and Technology, Cabanatuan City

* Our Lady of Fatima University
* Our Lady Of the Pillar Colleges, Cauayan City, Isabela
* Olivarez College

* Pines City Colleges
* Pamantasang Lungsod ng Maynila College of Nursing
* Philippine Rehabilitation Institute Foundation Inc.
* Polytechnic College of Davao del Sur
* Province of Negros Occidental-Northern Negros State College of Science and Technology School of Nursing

* Doña Remedios Trinidad Romualdez Medical Foundation,Tacloban City
* Remedios Trinidad Romualdez Memorial Schools, Inc. – Makati Medical Center

* San Juan De Dios Educational Foundation, Inc.
* STI College San Pablo – College of Nursing
* St. Luke’s College of Nursing
* Systems Plus College Foundation
* Saint Louis University, Baguio City
* Saint Mary’s University
* San Pedro College
* Saint Mary’s College of Tagum
* St. Paul University Iloilo
* Silliman University
* Southern Philippines Adventist College
* Southville International School and Colleges
* Southwestern University, Cebu City
* St. Joseph College – Cavite City
* St. Ferdinand College, Ilagan, Isabela

* Tarlac State University
* Thomas Del Rosario College
* Tomas Claudio Memorial College
* Tanchuling College – Legazpi City, Albay

* University of Cebu – College of Nursing (formerly Chong Hua Hospital – School of Nursing)
* University of Cebu – Lapu-lapu and Mandaue Campus
* Universidad de Sta Isabel
* University of the East Ramon Magsaysay Memorial Medical Center
* University of Santo Tomas – College of Nursing
* University of Baguio
* University of the Cordilleras
* University of Iloilo
* University of La Salette – College of Nursing
* University of Mindanao
* University of Mindanao Digos Branch
* University of Immaculate Conception
* University of the Philippines, Manila
* University of San Carlos
* University of San Agustin
* University of Southern Philippines Foundation – College of Nursing, Cebu City
* University of Southeastern Mindanao
* Universidad de Zamboanga
* University of San Jose-Recoletos
* University of Saint La Salle
* University of the Visayas – Gullas Medical Center

* West Visayas State University
* Wesleyan University -Philippines -Cabanatuan City

* Xavier University-Ateneo de Cagayan

Fundamentals of Nursing Reviewer

noreply@blogger.com (grey26) — Mon, 13 Sep 2010 00:50:02 PDT

Fundamentals of Nursing
Slide 1: Vocation/education/financial Breast and axillae ↓ Blood to kidney Home and Family Thorax and lungs ↑ Renin Social, leisure, spiritual and cultural Cardiovascular system FUNDAMENTALS OF NURSING Sexualalarm reaction, the stage of resistance and the stage of exhaustion. The three stages of adaptation to stress: the Nervous system Activities of daily living Cotisone Abdomen and gastrointestinal system Health Habits Anus and rectum Protein catablism Psychological Genitourinary system Gluconeogenesis Reproductive system Stage of Resistance Musculoskeletal system Adaptation Shock Phase Stage of Exhaustion ↓↓ Rest Death NURSING NOTES http://www.nursingnotes.info/ DATA COLLECTION – is the process of gathering info about a client’s health status. DATABASE – is all info about the client; includes nursing health history, physical assessment, doctor’s history and physical exam, results of lab and diagnostic tests, and material contributed by other health personel. CLIENT DATA – past history and current problems. TYPES OF DATA: 1. SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or verified only by the affected person. Examples: itching, pain, worry, sensations, feelings, values, attitudes, perception of personal status and life situation. 2. OBJECTIVE DATA – signs or overt (obvious) data. It is detectable by the observer, can be measured or tested against accepted standard. They can be seen, heard and felt, or smelled, can be obtained by observation or physical exam. SOURCES OF DATA: 1. PRIMARY DATA – from the CLIENT, it is the best source of data unless too ill, young, confused to communicate clearly. 2. SECONDARY DATA – are SUPPORT PEOPLE(family members, friends, caregivers), CLIENT RECORD, HEALTH CARE PROFESSIONALS(doctors, nurses, physiotherapist, social workers), LITERATURE (standards/norms,cultural and health practices, spiritual beliefs) DATA COLLECTION METHODS 1. OBSERVATION – is a conscious, deliberate skill that is developed through effort and with an organized approach. 2. INTERVIEW – is planned communication or a conversation with a purpose. TWO APPROACHES: a. DIRECTIVE INTERVIEW. The nurse establishes the purpose and controls the interview. The client responds to questions but may limited opportunity to ask questions or discuss concerns b. NONDIRECTIVE INTERVIEW – rapport-building interview. The nurse allows the client to control the purpose, subject matter, and pacing. RAPPORT- is the understanding b/w 2 or more people. TYPES OF INTERVIEW: a. CLOSED QUESTION – (directive interview) restrictive and answered by YES/NO, questions begin by WHEN, WHERE, WHO, WHAT, DO or IS. 1
Slide 2: b. OPEN-ENDED QUESTIONS – (indirective interview) invite clients to discover, explore, elaborate, clarify, or illustrate their thoughts and feelings. It may begin with WHAT/HOW. c. NEUTRAL QUESTION – (open ended and indirective) is a question a client can answer without direction or pressure from the nurse ( regarding feelings and point of views) d. LEADING QUESTIONS – (closed and directive) directs the client’s answer. It gives the client less opportunity to decide whether the answer is true or not. (Ex. You’re stressed about the surgery tomorrow, aren’t you?) 1. A. Nursing As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health. It’s recovery, or to a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge. Help the client gain independence as rapidly as possible. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE Theorist FLORENCE NIGHTINGALE Description THEORETICAL FRAMEWORK of NURSING PRACTICE • • • • Developed the first theory of nursing. Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. Introduced the Interpersonal Model. She defined nursing as a therapeutic, interpersonal process which strives to develop a nurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate. Defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people; developed list 21 nursing problem areas HILDEGARD PEPLAU FAYE ABDELLAH • • IDA JEAN ORLANDO Developed the three elements – client behavior, nurse reaction and nurse action – compose the nursing situation. She observed that the nurse provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. MYRA LEVINE • Described the Four Conservation Principles. 1. 2. 3. 4. 1. 2. 3. conservation of energy conservation of structured integrity conservation of personal integrity conservation of social integrity Developed the Behavioral System Model. Patient’s behavior as a system that is a whole with interacting parts how the client adapts to illness goal of nursing is to reduce so that the client can move more easily through recovery. DOROTHY JOHNSON • MARTHA ROGERS Conceptualized the Science of Unitary Human Beings. She asserted that human beings are more than different from the sum of their parts; the distinctive properties of the whole are significantly different from those of its parts. Emphasizes the client’s self care needs; nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention Presented the Adaptation Model. She viewed each person as a unified bio-psychosocial system in constant interaction with a changing environment. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. DOROTHEA OREM IMOGENE KING BETTY NEUMAN SISTER CALLISTA ROY LYDIA HALL Introduced the notion that nursing centers around three components: person(core), 2
Slide 3: pathologic state and treatment(cure) and body(care). JEAN WATSON Conceptualized the Human Caring Model. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony, which generates self-knowledge, selfcontrol, self-care and self-healing. Introduced the Theory of Human Becoming. She emphasized free choice of personal meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange with the environment and contranscending in many dimensions as possibilities unfold. Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition ROSEMARIE RIZZO PARSE MADELEINE LENINGER 2. a. b. ROLES AND FUNCTION OF A NURSE Caregiver – the caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. Caregiving encompasses the physical, psychosocial, developmental, cultural and spiritual levels. Communicator – communication is an integral to all nursing roles. Nurses communicate with the client, support persons, other health professionals, and people in the community. In the role of communicator, nurses identify client problems and then communicate these verbally or in writing to other members of the health team. The quality of a nurse’s communication is an important factor in nursing care. Teacher – as a teacher, the nurse helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health. The nurse assesses the client’s learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies and measures learning. Client advocate – a client advocate acts to protect the client. In this role the nurse may represent the client’s needs and wishes to other health professionals, such as relaying the client’s wishes for information to the physician. They also assist clients in exercising their rights and help them speak up for themselves. Counselor – counseling is a process of helping a client to recognize and cope with stressful psychologic or social problems, to developed improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual, and psychologic support. Change agent – the nurse acts as a change agent when assisting others, that is, clients, to make modifications in their own behavior. Nurses also often act to make changes in a system such as clinical care, if it is not helping a client return to health. Leader – a leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels; individual client, family, groups of clients, colleagues, or the community. Effective leadership is a learned process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence others. Manager – the nurse manages the nursing care of individuals, families, and communities. The nurse-manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance. Case manager – nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes. Research consumer – nurses often use research to improve client care. In a clinical area nurses need to: c. d. e. f. g. h. i. j. • Have some awareness of the process and language of research • Be sensitive to issues related to protecting the rights of human subjects • Participate in identification of significant researchable problems • Be a discriminating consumer of research findings B. Concepts of Health and Illness I. a. i. ii. iii. Health – As defined by the World Health Organization (WHO): state of complete physical, mental and social well-being, not merely the absence of disease or infirmity. Characteristics A concern for the individual as a total system A view of health that identifies internal and external environment An acknowledgment of the importance of an individual’s role in life A dynamic state in which the individual adapts to changes in internal and external environment to maintain a state of well being b. Models of Health and Illness i. ii. iii. Health-Illness Continuum (Neuman) – Degree of client wellness that exist at any point in time, ranging from an optimal wellness condition, with available energy at its maximum, to death which represents total energy depletion. High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment. Agent – Host – environment Model (Leavell) – The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment  Agent – any internal or external factor that disease or illness.  Host – the person or persons who may be susceptible to a 3
Slide 4:  iv. particular illness or disease Environment – consists of all factors outside of the host Health – Belief Model – Addresses the relationship between a person’s belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies. Four Components  The individual is perception of susceptibility to an illness  The individual’s perception of the seriousness of the illness  The perceived threat of a disease  The perceived benefits of taking the necessary preventive measures v. Evolutionary – Based Model – Illness and death serves as a evolutionary function. Evolutionary viability reflects the extent to which individual’s function to promote survival and well-being. The model interrelates the following elements:  Life events  Life style determinants  Evolutionary viability within the social context  Control perceptions  Viability emotions  Health outcomes Health Promotion Model – A “complimentary counterpart models of health protection”. Directed at increasing a client’s level of well being. Explain the reason for client’s participation health-promotion behaviors. The model focuses on three functions:  It identifies factors (demographic and socially) enhance or decrease the participation in health promotion  It organizes cues into pattern to explain likelihood of a client’s participation healthpromotion behaviors  It explains the reasons that individuals engage in health activities vi. II. a. Illness – State in which a person’s physical, emotional, intellectual, social developmental or spiritual functioning is diminished or impaired. It is a condition characterized by a deviation from a normal, healthy state. 3 Stages of Illness i. ii. iii. b. i. ii. iii. iv. v. c. i. ii. iii. iv. v. C. a. b. a. b. c. d. e. Stage of Denial – Refusal to acknowledge illness; anxiety, fear, irritability and aggressiveness. Stage of Acceptance – Turns to professional help for assistance Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through of resolving loss or impairment of function Rehabilitation A dynamic, health oriented process that assists individual who is ill or disabled to achieve his greatest possible level of physical, mental, spiritual, social and economical functioning. Abilities not disabilities, are emphasized. Begins during initial contact with the patient Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of function as short a time as possible Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process. Focuses of Rehabilitation Coping pattern Functional ability – focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene, dressing/grooming, toileting and mobility Mobility Integrity of skin Control of bowel and bladder function Concepts of Stress I. Stress (Theory by Hans Selye) Non specific response of the body to nay demand made upon it Any situation in which a non specific demand requires an individual to respond or take action II. Characteristics of Stress Stress is not nervous energy. Emotional reactions are common stressors Stress is not always the result of damage to the body Stress does not always result in feelings of distress (harmful or unpleasant stress) Stress is a necessary part of life and is essential for normal growth and development Stress involves the entire body acting as a whole and is an integrated manner 4
Slide 5: f. Stress response is natural, productive and adaptive III. Stressors – Factor or agent producing stress, maybe: physiological, psychological, social, environmental, developmental, spiritual or cultural and represent an unmet needs a. Classification of Stressors i. ii. b. Internal Stressors – originate from within the body. E.g. fever, pregnancy, menopause, emotion such as guilt External Stressors – originate outside a person. E.g. change in family or social role, peer pressure, marked change in environmental temperature Factors influencing response to stressors i. ii. iii. iv. D. E. F. Physiological functioning Personality Behavioral characteristics Nature of the stressor: integrity, scope, duration, number, and nature of other stressors Homeostasis – Process of maintaining uniformity, stability and constancy with in the living organisms. (from Greek word homotos – like, and stasis – position) Adaptation – Body’s adjustment to different circumstances and conditions. Process by the physiological or psychological dimensions change in response to stress; attempt to maintain optimal functioning Adaptation to Stress-Physiological Response (Hans Selye) I. Local Adaptation Syndrome (LAS) – Response of a body tissue, organ or part to the stress of trauma, illness or other physiological change a. Characteristics i. ii. iii. iv. b. The response is localized, it does not involve entire body systems The response is adaptive, meaning that a stressor is necessary to stimulate it The response is short term. It does not persist indefinitely The response is restorative, meaning that the LAS assists in restoring homeostasis to the body region or part Two Localized Responses i. Reflex Pain Response – is a localized response of the central nervous system to pain. It is an adaptive response and protects tissue from further damage. The response involves a sensory receptor, a sensory nerve from the spinal cord, and an effector muscle. An example would be the unconscious, reflex removal of the hand from a hot surface. Inflammatory Response – is stimulated by trauma or infection. This response localizes the inflammation, thus revenging its spread and promotes healing. The inflammatory response may produce localized pain, swelling, heat, redness and changes in functioning. ii. c. Three Phases of Inflammatory Response i. ii. iii. II. First Phase – Narrowing of blood vessels occurs at the injury to control bleeding. Then histamine is released at the injury, increasing the number of white blood cells to combat infection. Second Phase – It is characterized by release of exudates from the wound Third Phase – The last phase is repair of tissue by regeneration or scar formation. Regeneration replaces damaged cells with identical or similar cells. General Adaptation Syndrome (GAS) or Stress Syndrome – characterized by a chain or pattern of physiologic events. a. 3 Stages i. ii. iii. Alarm Reaction – initial reaction of the body which alerts the body’s defenses. SELYE divided this stage into 2 parts:  The SHOCK PHASE  The COUNTERSHOCK PHASE Stage of Resistance – occurs when the body’s adaptation takes place; the body attempts to adjust with the stressor and to limit the stressor to the smallest area of the body that can deal with it. Stage of Exhaustion – the adaptation that the body made during the second stage cannot be maintained; the ways used to cope with the stressors have been exhausted 5
Slide 6: b. c. d. e. f. g. h. i. j. STRESSORS stimulate the sympathetic nervous system, which in turn stimulates the hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH). During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE & NOREPINEPHRINE in response to sympathetic stimulation. Significant body responses to epinephrine include the following: i. ii. iii. iv. v. G. Increased myocardial contractility, which increases cardiac output & blood flow to active muscles Bronchial dilation, which allows increased oxygen intake Increased blood clotting Increased cellular metabolism Increased fat mobilization to make energy available & to synthesize other compounds needed by the body. Physiologic Indicators of Stress a.Pupils dilate to increase visual perception when serious threats to the body arise. b. Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism. c.The heart rate & cardiac output increase to transport nutrients and by-products of metabolism more efficiently. d. Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine. e.Sodium & water retention increase due to release of mineralocorticoids, which results in increased blood volume. f. The rate & depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation. g. h. Urinary output may increase or decreases. The mouth may be dry. i. Peristalsis of the intestines decreases, resulting in possible constipation and flatus. j. For serious threats, mental alertness improves. k. Muscle tension increases to prepare for rapid motor activity or defense. l. Blood sugar increases because of release of glucocorticoids & gluconeogenesis. H. a. b. c. d. Psychologic Indicators – psychologic manifestations of stress include anxiety, fear, anger, depression & unconscious ego defense mechanisms. Anxiety – a common reaction to stress. It is a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. It can be experienced, subcutaneous or unconscious level. Can be manifested on 4 LEVELS: Fear – an emotion or feeling of apprehension aroused by impending or seeming danger, or other perceived threat. The object of fear may or may not be based in reality. Anger – an emotional state consisting of a subjective feeling of animosity or strong displeasure. People may feel guilty when they feel anger because they have been taught that to feel angry is wrong. Depression – common reaction to events that seem overwhelming or negative. It is an extreme feeling of sadness, despair, dejection, lack of worth or emptiness. Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or numbness Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions, loss of sexual desire, crying, sleep disturbance and social withdrawal. Physical signs include: Loss of appetite, weight loss, constipation, headache and dizziness I. Cognitive Indicators – are thinking responses that include problem-solving, structuring, 6
Slide 7: self-control or self-discipline, suppression and fantasy a. b. c. d. e. Problem solving – involves thinking through the threatening situation, using a specific steps to arrive at a solution Structuring – arrangement or manipulation of a situation so that threatening events do not occur. Self-Control (discipline) – assuming a manner of facial expression that convey a sense of being in control or in change. Suppression – consciously and willfully putting a thought or feeling out of mind Fantasy – (daydreaming) – likened to make believe. Unfulfilled wishes & desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality. 2. COPING STRATEGIES (COPING MECHANISMS) Coping – dealing with problems & situations or contending with them successfully. Coping Strategy – innate or acquired way of responding to a changing environment or specific problem or situation. According to Folkman and Lazarus, coping is “the cognitive & behavioral effort to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person”. A. Coping Strategies: 2 Types I. II. Problem-focused coping – efforts to improve a situation by making changes or taking some action Emotion-focused coping – does not improve the situation, but the person often feels better. Coping strategies are also viewed as: a. b. Long-term coping strategies – can be constructive & realistic Short-term coping strategies – can reduce stress to a tolerable limit temporarily but are in the end od ineffective ways to deal with reality. Coping can be adaptive or maladaptive: B. C. Adaptive Coping – helps the person to deal effectively with stressful events & minimizes distress associated with them. Maladaptive Coping – can result in unnecessary distress for the person & others associated with the person or stressful event. *Effective coping results in adaptation; ineffective coping results in maladaptation. The effectiveness of an individual’s coping is influenced by a number of factors: The number, duration & intensity of the stressors Past experiences of the individual Support systems available to the individual Personal qualities of the person *If the duration of the stressors is extended beyond the coping powers of the individual, that person becomes exhausted and may develop increased susceptibility to health problems. *Reaction to long term stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden & produces responses such as chronic fatigue, sleeping difficulties & high BP. *Prolonged stress can also result in mental illness. • • • • D. Relaxation Techniques – used to quiet the mind, release tension & counteract the fight or flight responses of General Adaptation Syndrome (GAS). I. Breathing Exercises II. Massage III. Progressive Relaxation IV. Imagery V. Biofeedback VI. Yoga VII. Meditation VIII. Therapeutic Touch IX. Music Therapy X. Humor & Laughter 3. PSYCHOLOGICAL RESPONSE Exposure to a stressor results in psychological and physiological and physiological adaptive responses. As people are exposed a stressors, their ability to meet their basic needs is threatened. This threat whether actual or perceived, produces frustration, anxiety and tension. Psychological adaptive behaviors assist the person’s ability to cope with stressors. These behaviors are directed at stress management and are acquired through learning and experience as a person identifies acceptable and successful behaviors. Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves: 7
Slide 8: A. Task – Oriented Behaviors – Involve using cognitive abilities to reduce stress, solve problems, resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of a stressor. Three General Types I. Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a need II. Withdrawal Behavior – Is removing the self physically or emotionally from the stressor III. Compromise Behavior – Is changing the usual method of operating, substituting goals or omitting the satisfaction of needs to meet other needs or to avoid stress. B. Defense Mechanisms – Unconscious behaviors that offer psychological protection from a stressful event. They are used by everyone and help protect against feelings of worthlessness and anxiety. Frequently activated by short-term stressors and usually do not result in psychiatric disorders. 4. A. Formulating the Nursing Diagnosis TYPES OF NURSING DIAGNOSES I. Actual a. b. II. a. b. c. Clients demonstrates defining characteristics of a problem Nurse intervenes to resolve or help client cope with the problem High-risk A problem is likely to develop based on assessment of risk factors Nurse intervenes to reduce risk factors or increase protective factors Example: encourage smoking cessation III. Wellness a. Client is presently healthy but wishes to achieve a higher level of function b. Nurse intervenes to promote growth or maintenance of the healthy response B. Collaborative Problems I. II. Definition: a potential problem the nurse manages using both independent and interdependent interventions Example: potential complication of head injury: loss of consciousness, epidural or subdural hematoma, seizures III. Usually occurs when a disease is present or a treatment is prescribed IV. Clients with similar disease or treatment will have the same potential for complications, which must be managed collaboratively; however, their responses to the condition will vary, so a broad range of nursing diagnoses will apply. a. Example: a client with asthma will always be at risk for lowered oxygen saturation; however, the client’s response to this condition will be unique based on his/her developmental level, past experiences and family configuration b. Refer to Table for examples of collaborative problems Example: Disease/Situation Complication Related to Potential complication of Hemorrhage Related to childbirth Etiology 1.Uterine atony 2. Retained placental fragment 3. Bladder distention Low serum potassium Potential complication of diuretic therapy Dysrhythmia Related to 5. A. Collaboration of Data: Objective & Subjective METHODS USED for ASSESSMENT I. Review of clinical record a. b. II. Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification. Interview a. b. c. The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support. The goals of an interview are to develop a rapport with the client and to collect data An interview has 3 major stages i. Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time. 8
Slide 9: ii. iii. d.           Body: during this phase, the client responds to open and closed-ended questions asked by the nurse. Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process. Types of questions i. Closed questions used in directive interview Re____ short factual answers; e.g. “Do you have pain?” Answers usually reveal limited amounts of information Useful with clients who are highly stressed and/or have difficulty communicating ii. Open-ended questions used in nondirective interview Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’ Specify the broad area to be discussed and invite longer answers Useful at the start of an interview or to change the subject iii. Leading questions Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?” Suggests what answer is expected Can result in client giving inaccurate data to please the nurse Can limit client choice of topic for discussion III. Nursing History a. Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response) b. Subjective data i. ii. iii. iv. c. i. ii. iii. iv. May be called “covert data” Not measurable or observable Obtained from client (primary source), significant others, or health professionals (secondary sources). For example, the client states, “I have a headache” Objective data May be called “overt data” Can be detected by someone other than the client Includes measurable and observable client behavior For example, a blood pressure reading of 190/110 mmHg. IV. Physical assessment a. Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion b. • A body system format for physical assessment is found below: V. • Psychosocial assessment a. b. Helpful framework for organizing data A suggested format for psychosocial assessment is found below: c. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection VI. Consultation a. The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records) 9
Slide 10: b. c. VII. a. b. Consultation with individuals who can contribute to the client’s database is helpful in achieving the most complete and accurate information about a client Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the client’s status prior to admission Review of literature A professional nurse engages in continued education to maintain knowledge of current information related to health care Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database 6. A. I. II. III. IV. DOCUMENTING and REPORTING Guidelines for Good Documentation and Reporting Fact – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells Accuracy – information must be accurate so that health team members have confidence in it Completeness – the information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand Currentness – ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following: a. b. c. d. e. f. V. VI. Vital signs Administration of medications and treatments Preparation of diagnostic tests or surgery Change in status Admission, transfer, discharge or death of a client Treatment fro a sudden change in status Organization – the nurse communicate in a logical format or order Confidentiality – a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed B. Documentation – anything written or printed that is relied on as a record of proof fro authorized persons. Purposes of Records: I. Communication II. Planning Client Care III. Auditing Health Agencies IV. Research V. Education VI. Reimbursement VII. Legal Documentation VIII. Health Care Analysis C. Documentation Systems I. Source – Oriented Record a. b. c. d. e. II. a. b. The traditional client record Each person or department makes notations in a separate section or sections of the client’s chart It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes NARRATIVE CHARTING is a traditional part of the source-oriented record Problem – Oriented Medical Record (POMR) Established by Lawrence Weed The data are arranged according to the problems the client has rather than the source of the information. The four (4) basic components: i. ii. iii. iv. Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved Plan of Care – care plans are generated by the person who lists the problems. Physician’s write physician’s orders or medical care plans; nurses write nursing orders or nursing care plans Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data Example: SOAP Format Or SOAPIE and SOAPIER S – Subjective data 10
Slide 11: O – Objective data A – Assessment P – Plan I – Intervention E – Evaluation R- Revision Advantages of POMR:   It encourages collaboration Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem.    Disadvantages of POMR: Caregivers differ in their ability to use the required charting format Takes constant vigilance to maintain an up-to-date problem list Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated. III. PIE (Problems, Interventions, and Evaluation) a. Groups information in to three (3) categories b. This system consists of a client care assessment floe sheet & progress notes c. FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns d. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes IV. Focus Charting a. Intended to make the client & client concerns & strengths the focus of care b. Three (3) columns fro recording are usually used: date & time, focus & progress notes V. Charting by Exception a. b. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded Incorporates three (3) key elements: i. ii. iii. Flow sheets Standards of nursing care Bedside access to chart forms VI. Computerized Documentation a. Developed as a way to manage the huge volume of information required in contemporary health care b. Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress. VII. a. b. D. Case Management Emphasizes quality, cost-effective care delivered within an established length of stay Uses a multidisciplinary approach to planning & documenting client care, using critical pathways. Nursing Care Plan (NCP) Two Types: I. II. E. Traditional Care Plan – written fro each client; it has 3 columns: nursing diagnoses, expected outcomes & nursing interventions. Standardized Care Plan – based on an institution’s standards of practice; thereby helping to provide a high quality of nursing care KARDEX widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms. Information may be organized into sections: I. Pertinent information about the client II. List of medications III. List of IVF IV. List of daily treatments & procedures V. List of Diagnostic procedures VI. Allergies VII. Specific data on how the client’s physical needs are to be met VIII. A problem list, stated goals & list of nursing approaches to meet the goals F. Nursing Discharge / Referral Summaries – completed when the client is being discharged & transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it include some or all of the following: I. Description of client’s physical, mental & emotional state II. Resolved health problems III. Unresolved continuing health problems IV. Treatments that can be continued (e.g. wound care, oxygen therapy) V. Current medications VI. Restrictions that relate to activity, diet & bathing VII. Functional/self-care abilities VIII. Comfort level IX. Support networks 11
Slide 12: X. Client education provided in relation to disease process XI. Discharge destination XII. Referral Services (e.g. social worker, home health nurse) 7. A. Purposes The nurse uses physical assessment for the following reasons: PHYSICAL EXAMINATION I. To gather baseline data about the client’s health II. To supplement, confirm or refute data obtained in the nursing history III. To confirm and identify nursing diagnoses IV. To make clinical judgments about a client’s changing health status and management B. Preparation of Examination I. II. Environment – A physical examination requires privacy. An examination room that is well equipped for all necessary procedures is preferable Equipment – Hand washing is done before equipment preparation and the examination. Hand washing reduces the transmission of microorganisms III. Client a. Psychological Preparation – clients are easily embarrassed when forced to answer sensitive questions about bodily functions or when body parts are exposed and examined. The possibility that the examination will find something abnormal also creates anxiety so reduction of this anxiety may be the nurse’s highest priority before the examination b. c. Physical Preparation – the client’s physical comfort is vital to the success of the examination. Before starting, the nurse asks if the client needs to use the toilet. Positioning – during the examination, the nurse asks the clients to assume proper positions so that body parts are accessible and clients stay comfortable. Client’s abilities to assume positions will depend on their physical strength and degree of wellness. C. Order of Examination I. General Survey – includes observation of general appearance and behavior, vital signs, height and weight measurement II. Review of systems III. Head to toe examination D. Skills in Physical Examination I. Inspection – to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles: a. b. c. d. e. II. Make sure good lighting is available Position and expose body parts so that all surface can be viewed Inspect each areas fro size, shape, color, symmetry, position and abnormalities If possible, compare each area inspected with the same area of the opposite side of the body Use additional light (for example, a penlight) to inspect body cavities Palpation – the hands can make delicate and sensitive measurements of specific physical signs, so palpation is used to examine all accessible parts of the body. The nurse uses different parts of the hand to detect characteristics such as texture, temperature and the perception of movement. III. Percussion – examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue IV. Auscultation – is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope. a. b. Bowel sounds Breath sounds i. ii. iii. E. Vesicular Bronchovesicular Bronchial Examples of Adventitious Breath Sounds I. Crackles (previously called rales) II. Rhonchi III. Wheeze IV. Friction rub Therapeutic Communication Techniques 1. 2. 3. 4. 5. 6. 7. Using silence Providing general leads Being specific & tentative Using open-ended questions Using touch Restating to paraphrasing Seeking clarification 12
Slide 13: 8. Perception checking or seeking consensual validation 9. Offering self 10. Giving information 11. Acknowledging 12. Clarifying time or sequence 13. Presenting reality 14. Focusing 15. Reflecting 16. Summarizing & planning B. Barriers to Communication 1. Stereotyping 2. Agreeing & disagreeing 3. Being defensive 4. Challenging 5. Probing 6. Testing 7. Rejecting 8. Changing topics & subjects 9. Unwarranted reassurance 10. Passing judgment 11. Giving common advice Phases of the Helping Relationship 12. Pre-interaction Phase 13. Introductory Phase a. Opening the relationship b. Clarifying the problem c. Structuring & formulating the contract 14. Working Phase a. Exploring & understanding thoughts or feelings b. Facilitating & taking action 15. Termination Phase 8. A. Chain of Infection PRINCIPLES of ASEPSIS and INFECTION CONTROL I. II. The chain of infection refers to those elements that must be present to cause an infection from a microorganism Basic to the principle of infection is to interrupt this chain so that an infection from a microorganism does not occur in clients III. Infectious agent; microorganisms capable of causing infections are referred to as an infectious agent or pathogen. IV. Modes of transmission: the microorganism must have a means of transmission to get from one location to another, called direct and indirect V. Susceptible host describes a host (human or animal) not possessing enough resistance against a particular pathogen to prevent disease or infection from occurring when exposed to the pathogen; in humans this may occur if the person’s resistance is low because of poor nutrition, lack of exercise of a coexisting illness that weakens the host. VI. Portal of entry: the means of a pathogen entering a host: the means of entry can be the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract). VII. Reservoir: the environment in which the microorganism lives to ensure survival; it can be a person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support organism that are pathogenic to humans are inanimate objects food and water, and other humans. Portal of exit: the means in which the pathogen escapes from the reservoir and can cause disease; there is usually a common escape route for each type of microorganism; on humans, common escape routes are the gastrointestinal, respiratory and the genitourinary tract. VIII. Modes of Transmission 1. 2. 3. B. Direct contact: describes the way in which microorganisms are transferred from person to person through biting, touching, kissing, or sexual intercourse; droplet spread is also a form of direct contact but can occur only if the source and the host are within 3 feet from each other; transmission by droplet can occur when a person coughs, sneezes, spits, or talks. Indirect contact: can occur through fomites (inanimate objects or materials) or through vectors (animal or insect, flying or crawling); the fomites or vectors act as vehicle for transmission Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the air for long periods and dust particles containing infectious agents can become airborne infecting a susceptible host generally through the respiratory tract Course of Infection 13
Slide 14: I. Incubation: the time between initial contact with an infectious agent until the first signs of symptoms - - > the incubation period varies from different pathogens; microorganisms are growing and multiplying during this stage Prodromal Stage: the time period from the onset of nonspecific symptoms to the appearance of specific symptoms related to the causative pathogen - - > symptoms range from being fatigued to having a low-grade fever with malaise; during this phase it is still possible to transmit the pathogen to another host II. III. Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to as the acute stage; during this stage, it may be possible to transmit the infectious agent to another, depending on the virulence of the infectious agent IV. Convalescence: time period that the host takes to return to the pre-illness stage; also called the recovery period; - - >the host defense mechanisms have responded to the infectious agent and the signs and symptoms of the disease disappear; the host, however, is more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label related to this process would be Risk for Infection C. Inflammation – The protective response of the tissues of the body to injury or infection; the physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic Body’s response I. II. The “inflammatory response” begins with vasoconstriction that is followed by a brief increase in vascular permeability; the blood vessels dilate allowing plasma to escape into the injured tissue WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack and ingest the invaders (phagocytosis); this process is responsible for the signs of inflammation blood in the area, swelling occurs from fluid accumulation; the pain occurs from pressure or injury to the local nerves. III. Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result of the heat from the increased D. Immune Response I. II. The immune response involves specific reactions in the body to antigens or foreign material This specific response is the body’s attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the Tlymphocytes and B-lymphocytes III. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity a. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen b. c. d. Once theantigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen After the antigen is gone, the lymphokines disappear Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again. IV. Humoral response: the ability of the body to develop a specific antibody to a specific antigen (antigen-antibody response) a. B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections b. Active immunity is produced when the immune system is activated either naturally or artificially. i. ii. iii. Natural immunity involves acquisition of immunity through developing the disease Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity) Passive immunity does not require a host to develop antibodies, rather it is transferred to the individual, passive immunity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen. E. Nosocomial Infection I. II. Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system Iatrogenic infection: these nosocomial infections are directly related to the client’s treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning III. Exogenous Infection: are a result of the healthcare facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection IV. Endogenous Infection: can occur from clients themselves or as a reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish. F. Factors Increasing Susceptibility to Infection I. Age: young infants & older adults are at greater risk of infection because of reduced defense mechanisms a. Young infants have reduced defenses related to immature immune systems 14
Slide 15: b. In elderly people, physiological changes occur in the body that make them more susceptible to infectious disease; some of these changes are: i. ii. iii. iv. II. Altered immune function (specifically, decreased phagocytosis by the neutrophils and by the macrophages) Decreased bladder muscle tone resulting in urinary retention Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate normal secretions Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric emptying. Heredity: some people have a genetic predisposition or susceptibility to some infectious diseases III. Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene practices, can influence a person’s susceptibility to infectious diseases IV. Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases; nutritional practices that do not supply the body with the basic components necessary to synthesized proteins affect the way the body’s immune system can respond to pathogens Stress: stressors, both physical and emotional, affect the body’s ability to protect against invading pathogens; stressors affect the body by elevating blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes energy stores, thus increasing the risk of infection V. VI. Rest, exercise and personal health habits: altered rest and exercise patterns decrease the body’s protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the body’s response to pathogens VII. Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal defense mechanisms in the body, making the client more susceptible to infection; the immune system functions throughout the body and depends on the following: a. b. c. d. Intact skin and mucous membranes Adequate blood cell production and differentiation A functional lymphatic system and spleen An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune disease, the body has a problem with recognizing it’s own tissue and cells; people with autoimmune disease are at increased risk of infection related to their immune system deficiencies. VIII. Environmental: an environment that exposes individuals to an increased number of toxins or pathogens also increases the risk of infection; pathogens grow well in warm moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an environment that increases exposure to toxic substances also increases risk IX. Immunization history: inadequately immunized people have an increased risk of infection specifically for those diseases for which vaccines have been developed. X. G. Medications and medical therapies: examples of therapies and medications that increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery Diagnostic Tests Used to Screen for Infection I. II. Signs and symptoms related to infections are associated with the area infected; for instance, symptoms of a local infection on the skin or mucous membranes are localized swelling, redness, pain and warmth Symptoms related to systemic infections include fever, increased pulse & respirations, lethargy, anorexia, and enlarged lymph nodes III. Certain diagnostic tests are ordered to confirm the presence of an infection. 9. A. Specific Theory THEORIES OF PAIN I. II. Proposes that body’s neurons & pathways for pain transmission are specific, similar to other senses like taste Free nerve endings in the skin act as pain receptors, accept input & transmit impulses along highly specific nerve fibers III. Does not account for differences in pain perception or psychologic variables among individuals. B. Pattern Theory I. II. Identifies 2 major types of pain fibers; rapidly & slowly conducting Stimulation of these fibers forms a pattern; impulses ascend to the brain to be interpreted as painful III. Does not account for differences in pain perception or psychologic variables among individuals. C. Gate Control Theory I. II. Pain impulses can be modulated by a transmission blocking action within the CNS. Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or scratching an area) and may inhibit smaller diameter fibers to prevent transmission of the impulse (“close the gate”). 15
Slide 16: D. Current Developments in Pain Theory – Indicate that pain mechanisms & responses are far more complex than believed to be in the past. I. Pain may modulated at different points in the nervous system. a. b. c. II. First-order neurons at the tissue level Second-order neurons in the spinal cord that process nociceptor information Third-order tracts & pathways in the spinal cord & brain that relay/process this information The role of the pain experience in the development of new nociceptors and/or reducing the threshold of current nociceptor is also being investigate 10. TYPES OF PAIN A. Acute Pain I. Usually temporary, sudden in onset, localized, lasts for 6 months; results from tissue injury associated with trauma, surgery, or inflammation. Types of Acute Pain a. b. c. II. Somatic: arises from nerve receptors in the skin or close to body’s surface; may be sharp & well-localized or dull & diffuse; often accompanied by nausea & vomiting Visceral: arises from body’s organs; dull & poorly localized because of minimal noriceptors; accompanied by nausea & vomiting, hypotension & restlessness Referred pain: pain that is perceived in an area distant from the site of stimuli (e.g. pain in a shoulder following abdominal laparoscopic procedure). Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous System and is characterized by the following symptoms: a. b. c. d. e. f. g. B. I. Tachycardia Rapid, shallow respirations Increased BP Sweating Pallor Dilated pupils Fear & Anxiety Chronic Pain Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often unresponsive to medical treatment. Types of Chronic Pain a. b. Neuropathic: painfuil condition that results from damage to peripheral nerves caused by infection or disease; posttherapeutic neuralgia (shingles) is an example Phantom: pain syndrome that occurs following surgical or traumatic amputation of a limb. i. ii. iii. iv. v. vi. c. II. The client is aware that the body part is missing Pain may result of stimulation of severed nerves at the site of amputation Sensation may be experienced as an itching, pressure, or as stabbing or burning in nature It can be triggered by stressors (fatigue, illness, emotions, weather) This experience is limited for most clients because the brain adapts to amputated limb; however, some clients experience abnormal sensation or pain over longer periods This type of pain requires treatment just as any other type of pain does. Psychogenic: pain that is experienced in the absence of a diagnosed physiologic cause or event; the client’s emotional needs may prompt pain sensation. Depression is a common associated symptom for the client experiencing chronic pain; feelings of despair & hopelessness along with fatigue are expected findings. 11. PAIN ASSESSMENT A. TOOLS/INTRUMENTS USED I. A VERBAL REPORT using an intensity scale is a fast, easy & reliable method allowing the client to state pain intensity & in turn, promotes consisted communication among the nurse, client & other healthcare professionals about the client’s pain status; the 2 most common scales used are “0 to 5” or “0 to 10”. With 0 specifying no pain & the highest number specifying the worst pain A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers at both ends of the scale, such as “no pain” at one end and “worst pain” at the other, clients are asked to point or mark along the line to convey the degree of pain being experienced II. III. A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a numerical scale with the word modifiers, usually the numbers “0 to 10” are added to the scale. 16
Slide 17: IV. FACES PAIN SCALE children, clients who do not speak English & clients with communication impairments may have difficulty using a numerical pain intensity scale; the FACES pain scale may be used for children as young as 3 years old; this scale provides facial expressions (happy face reflects no pain, crying face represents worst pain) V. PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to assess pain for a non-communicating client, facial & vocal expression may be the initial manifestations of pain; expressions may include rapid eye blinking, biting of the lip, moaning, crying, screaming, either closed or clenched eyes, or stiff unmoving body position B. A B C D E method of pain assessment I. This acronym was developed for cancer pain; however, it is very appropriate for clients with any type of pain, regardless of the underlying disease. II. A = Ask about pain III. B = Believe the client & family reports pain IV. C = Choose pain control options appropriate for the client V. D = Deliver interventions in a timely, logical &coordinated fashion VI. E = Empower clients & families C. P Q R S T assessment for pain reception I. This method is especially helpful when approaching a new pain problem II. P = What precipitated the pain? III. Q = What are the quality & quantity of the pain? IV. R = What is the region of the pain? V. S = What is the severity of the pain? VI. T = What is the timing of the pain? D. Pain History I. Location – when clients report “pain all over”, this generally refers to total pain or existential distress (unless there is an underlying physiologic reason for pain all over the body, such as myalgias); assess the client’s emotional state for depression, fear, anxiety or hopelessness. Intensity – It is important to quantify pain using a standard pain intensity scale. When clients cannot conceptualize pain using a number, simple word categorizes can be useful (e.g. no pain, mild, moderate, severe). II. III. Quality a. Nociceptive pain are usually related to damage to bones, soft tissues, or internal organs; nociceptive pain includes somatic & visceral pains. i. ii. Somatic pain is aching, throbbing pain; example arthritis Visceral pain is squeezing, cramping pain; example: pain associated with ulcerative colitis IV. Pattern – pain may be always present for a client; this is often termed baseline pain. Additional pain may occur intermittently that is of rapid onset & greater intensity than the baseline pain; known as breakthrough pain. People at end-of-life often have both types of pain. Cultural beliefs regarding the meaning of pain should be examined ADMINISTRATION OF MEDICATIONS 12. DRUG NOMENCLATURE and FORMS A. Names I. II. Chemical Name – provides an exact description of the drug’s composition. An example of chemical name acetylsalicylic known common as Aspirin Generic Name – is given by the manufacturer who first develops the drug before it receives official approval. Protected by law, the generic name is given before a drug receives official publications. III. Official Name – is the name under which drug is listed in official publication IV. Trade, Brand or Propriety Name – is the name under which a manufacturer markets. B. Classification – Nurses categorized medications with similar characteristics by their class. Drug classification indicates the effects on a body system, the symptoms relieved or the desired effect. Each class contains drugs prescribed for similar types of health problems. The physical and chemical composition of drugs within a class is not necessarily the same. A drug may also belong to more than one class. For example, aspirin is an analgesic and antipyretic and an anti-inflammatory drug. Forms – Drugs are available in a variety of forms preparations. The form of the drug determines its route o administration. For example, a capsule is taken orally and a solution may be given intravenously. The composition drug is designed to enhance its absorption and metabolism within the body. Many drugs are available in several forms such as tablets, capsules, elixirs and suppositories. When administering a medication, the nurse must be certain to give the metabolism in the proper form. Principles in Administering Medications C. D. I. Observe the 7 RIGHTS of Drug Administration: a. b. c. d. e. Right Drug Right Dose Right Time Right Route Right Patient 17
Slide 18: f. g. II. Right Recording Right Approach Practice asepsis III. Nurses who administer medications are responsible for their own actions. Question any order that you can consider incorrect. IV. Be knowledgeable about medications that you administer V. Keep narcotics & barbiturates in locked place VI. Use only medications that are in clearly labeled containers VII. VIII. Return liquid that are cloudy or have changed in color to the pharmacy Before administering a medication, identify the client correctly IX. Do not leave the medication at the bedside X. XI. XII. XIII. A. If the client vomits after taking an oral medication, report this to the nurse in charge and/or physician Preoperative medications are usually discontinued during the post operative period unless ordered to be continued When a medication is omitted for any reason, record the fact together with the reason When a medication error is made, report immediately to the nurse in charge and/or physician 13. BASIC HUMAN NEEDS Abraham Maslow – developed the five (5) levels of human needs: I. Physiologic Needs – needs such as air, food, water, shelter, rest, sleep, activity and temperature maintenance are crucial for survival II. Safety and Security Needs – the need for safety has both physical and physiologic aspects III. Love and Belonging Needs – the third level of needs includes giving and receiving affection, attaining a place in a group and maintaining the feeling of belonging IV. Self-Esteem Needs – the individual needs both self-esteem and esteem from others V. Self-Actualization – when the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one’s maximum potential and realize one’s abilities and qualities B. Maslow’s Characteristics of a Self-Actualized Person Is realistic, sees life clearly and is objective about his or her observations I. Judges people correctly II. Has superior perception, is more decisive III. Has a clear notion of right or wrong IV. Is usually accurate in predicting future events V. Understands art, music, politics and philosophy VI. Possesses humility, listens to others carefully VII. Is dedicated to some work, task, duty or vocation VIII. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes IX. Is open to new ideas X. Is self-confident and has self-respect XI. Has low degree of self-conflict; personality is integrated XII. Respect self, does not need fame, possesses a feeling of self-control XIII. Is highly independent, desires privacy XIV. Can appear remote or detached XV. is friendly, loving and governed more by inner directives than by society XVI. Can make decisions contrary to popular opinion XVII. Is problem centered rather than self-centered XVIII. Accepts the world for what it is 14. MEETING OXYGENATION NEEDS A. B. Oxygenation – a basic human need & is required to sustain life. Cardiovascular Physiology – the function of the cardiac system is to 18
Slide 19: deliver oxygen, nutrients, & other substances to the tissues and to remove the waste products of cellular metabolism C. Structure and Function – the heart pumps blood through the pulmonary circulation by way of the right ventricle and to the systemic circulation by way of the left ventricle I. II. Myocardial Pump – the “pumping action” of the heart is essential to maintain oxygen delivery Myocardial Blood Flow – to maintain adequate blood flow to the pulmonary and systemic circulations, myocardial blood flow must sufficiently supply oxygen and nutrients to the myocardium itself itself. It is the branch of the systemic circulation that supplies oxygen and nutrients and removal of waste from the myocardium III. Coronary Artery Circulation – blood flow to the atria and ventricles does not supply oxygen and nutrients to the myocardium IV. Systemic Circulation – the arteries and veins of the systemic circulation deliver nutrients and oxygen and remove wastes from the tissues. Oxygenated blood flows from the left ventricle by way of of the aorta and into the large systemic arteries V. Regulation of Blood Flow – the amount of blood ejected from the left ventricle each minute is the cardiac output. The circulating volume of blood changes according to the oxygen and metabolic needs of the body. For example, during exercise, pregnancy and fever, the cardiac output increases but during sleep, the cardiac output decreases. D. Steps in the Process of Oxygenation I. Ventilation – process by which gases are moved into and out of the lungs. Adequate ventilation requires coordination of the muscular and elastic properties of the lung and thorax and intact innervation. The major inspiratory muscle is the “diaphragm” which is innervated by the “phrenic nerve”. Perfusion – the primary function of pulmonary circulation is to move blood to and from the alveolar-capillary membrane so that gas exchange can occur II. III. Exchange of Respiratory Gases – respiratory gases are exchanged in the alveoli of the lungs and the capillaries of the body tissues a. b. c. Diffusion – movement of molecules from an area of higher concentration to an area of lower concentration Oxygen Transport – delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs & tissues (perfusion), adequacy of diffusion & capacity of the blood to carry oxygen. Carbon Dioxide Transport – carbon dioxide diffuses into RBCs and I rapidly hydrated into carbonic acid because of the presence of carbonic hydrase 15. MEETING NUTRITIONAL NEEDS A. Principles of Nutrition I. II. Digestion – process by which food substances are changed into forms that can be absorbed through cell membranes Absorption – the taking in of substance by cells or membranes III. Metabolism – sum of all physical and chemical processes by which a living organism is formed and maintained and by which energy is made available IV. Storage – some nutrients are stored when not used to provide energy; e.g. carbohydrates are stored either as glycogen or as fat V. Elimination – process of discarding unnecessary substances through evaporation, excretion B. Nutrients I. Carbohydrates – the primary sources are plant foods Types of Carbohydrates a. b. II. Simple (sugars) such as glucose, galactose, and fructose Complex such as starches (which are polysaccharides) and fibers (supplies bulk or roughage to the diet) Proteins – organic substances made up of amino acids III. Lipids – organic substances that are insoluble in water but soluble in alcohol and ether. a. Fatty acids – the basic structural units of all lipids and are either saturated (all the carbon atoms are filled with hydrogen) or unsaturated (could accommodate more hydrogen than it presently contains) b. Food sources of lipids are animal products (milk, egg yolks and meat) and plants and plant products (seeds, nuts, oils) IV. Vitamins – organic compounds not manufactured in the body and needed in small quantities to catalyze metabolic processes a. Water-soluble vitamins include C and B-complex vitamins b. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts in the body V. Minerals – compounds that work with other nutrients in maintaining structure and function of the body a. b. Macronutrients – calcium, phosphate, sodium, potassium, chloride, magnesium and sulfur Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese and fluoride The best sources are vegetables, legumes, milk and some meats VI. Water – the body’s most basic nutrient need; it serves as a medium for metabolic reactions within cells and a transporter fro nutrients, waste products and other substances 16. MEETING URINARY ELIMINATION NEEDS A. Normal Urinary Function I. II. Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to ensure continued normal kidney function Urine normally consists of 96% water 19
Slide 20: III. Solutes found in urine include: a. Organic solutes: urea, ammonia, uric acid and creatinine b. Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus B. Common Assessment Findings I. Urgency – strong desire to void my be caused by inflammations or infections in the bladder or urethra II. Dysuria – painful or difficult voiding III. Frequency – voiding that occurs more than usual when compared with the person’s regular pattern or the generally accepted norm of voiding once every 3 to 6 hours IV. Hesitancy – undue delay and difficulty in initiating voiding V. Polyuria – a large volume of urine or output voided at any given time VI. Oliguria – a small volume of urine or output between 100 to 500 mL/24 hr VII. Nocturia – excessive urination at night interrupting sleep VIII. Hematuria – RBCs in the urine  17. URINARY CATHETERIZATION Is the introduction of a catheter through the urethra into the bladder for the purpose of withdrawing urine. A. Purposes I. To relieve urinary retention II. To obtain a sterile urine specimen from a woman III. To measure the amount of residual urine in the bladder IV. To obtain a urine specimen when a specimen cannot secure satisfactory by other means V. To empty bladder before and during surgery and before certain diagnostic examinations ***Several BASIC FACTS about the lower urinary tract system should be borne in mind when considering catheterization. B.  Necessary Equipment for Catheterization Catheters are graded on the French scale according to the size of the lumen. For the female adult, No. 14 and No. 16 French catheters are usually used. Small catheters are generally not necessary and the size of the lumen is also so small that it increases the length of time necessary for emptying the bladder. Larger catheter distends the urethra and tends to increase the discomfort of the procedure. For male adult, No.18 and No. 20 French catheters usually used, but if this appears to be too large, smaller catheter should be used. No. 8 and No. 10 French catheters are commonly used for children. C. Preparation of the Patient I. II. Adequate exploration Position – dorsal recumbent for the female and supine for the male using a firm mattress or treatment table, Sim’s or lateral position can be an alternate for the female patient III. Provision for privacy D. Retention or Indwelling Catheter (Foley) – A catheter to remain in place for the following purposes: I. The gradual decompression of an over distended bladder II. For intermittent bladder drainage III. For continuous bladder drainage An indwelling catheter has a balloon which is inflated after the catheter is inserted into the bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter is retained in the bladder. E. Procedure for Insertion I. II. Inflate the balloon with the prefilled syringe before inserting the catheter to check for balloon patency. Aspirate the fluid back into the syringe when it is determined that the balloon is patent. Hold the catheter with one hand and inflate the balloon according to the manufacturer’s instructions, as soon as the catheter is in the bladder and urine has begun to drain from the bladder. Usually 5 ml to 10 ml of sterile water is used balloon is probably located in the urethra and is causing discomfort owing to distention of the urethra III. If the patient complains of pain after the balloon is inflated, allow it to empty and replace the catheter with another one. The IV. Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in the bladder V. Connect the catheter to the drainage tubing and drainage bag if not already connected VI. Tape the catheter along the interior aspect of the thigh fro a female patient. Be sure there is no tension on the catheter when it is taped to the patient VII. F. I. II. Hang the drainage bag on the frame of the bed below the level of the bladder Caring for the Patient with an Indwelling Catheter Be sure to wash hands before and after caring for a patient with an indwelling catheter Clean the perineal area thoroughly, especially around the meatus, twice a day and after each bowel movement. This helps prevent organisms for entering the bladder III. Use soap or detergent and water to clean the perineal area and rinse the area well IV. Make sure that the patient maintains a generous fluid intake. This helps prevent infection and irrigates the catheter naturally by increasing urinary output V. Encourage the patient to be up and about as ordered VI. Record the patient’s intake and output VII. Note the volume and character of urine and record observations carefully 20
Slide 21: VIII. Teach the patient the importance of personal hygiene, especially the importance of careful cleaning after having bowel movement and thorough washing of hands frequently odor to the urine, an elevated temperature and chills IX. Report any signs of infection promptly. These include a burning sensation and irritation at the meatus, cloudy urine, a strong X. G. Plan to change indwelling catheters only as necessary. The usual length of time between catheter changes varies and can be anywhere from 5 days to 2 weeks. The less often a catheter is changed, the less the likelihood than an infection will develop Removing the Indwelling Catheter and Aftercare of the Patient I. II. Be sure the balloon is deflated before attempting to remove the catheter. This may be done by inserting a syringe into the balloon valve or by cutting the balloon valve Have the patient take several deep breaths to help him relax while gently removing the catheter. Wrap the catheter in a towel or disposable, waterproof drape III. Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removed IV. See to it that the patient’s fluid intake is generous and record the patient’s intake and output. Instruct the patient to void into the bedpan or urinal V. Observe the urine carefully for any signs of abnormality VI. Record and report any usual signs such as discomfort, a burning sensation when voiding, bleeding and changes in vital signs, especially the patient’s temperature. Be alert to any signs of infection and report them promptly 18. MEETING BOWEL ELIMINATION NEEDS A. Factors that influence Bowel Elimination I. Age II. Diet III. Position IV. Pregnancy V. Fluid Intake VI. Activity VII. Psychological VIII. Personal Habits IX. Pain X. Medications XI. Surgery/Anesthesia B. Characteristics of Normal Stool I. Color – varies from light to dark brown foods & medications may affect color II. Odor – aromatic, affected by ingested food and person’s bacterial flora III. Consistency – formed, soft, semi-solid; moist IV. Frequency – varies with diet (about 100 to 400 g/day) V. Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates) C. Common Bowel Elimination Problems I. Constipation – abnormal frequency of defecation and abnormal hardening of stools II. Impaction – accumulated mass of dry feces that cannot be expelled III. Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence IV. Incontinence – involuntary elimination of feces V. Flatulence – expulsion of gas from the rectum VI. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation. 19. TYPES OF ENEMAS A. Cleansing Enemas: Stimulate peristalsis through irrigation of colon and rectum and by distention I. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 1000 ml of water II. Tap water: Give caution o infants or to adults with altered cardiac and renal reserve III. Saline: For normal saline enemas, use smaller volume of solution IV. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require further preparation B. C. D. Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass Carminative Enema: Provides relief from gaseous distention Astringent Enema: Contracts tissue to control bleeding Key Points: Administering Enema I. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too cold, or solutions that are instilled too quickly, can cause cramping and damage to rectal tissues II. Allow solution to run through the tubing so that air is removed III. Place client on left side in Sim’s position IV. Lubricate the tip of the tubing with water-soluble lubricant 21
Slide 22: V. Gently insert tubing into client’s rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for children), past the external and internal sphincters VI. Raise the water container no more than 12 to 18 inches above the client VII. Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The client will also be able to tolerate and retain a greater volume of solution VIII. After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutes IX. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes. 20. NASOGASTRIC and INTESTINAL TUBES A. Nasogastric Tubes I. Levin Tube – single lumen a.Suctioning gastric contents b. Administering tube feedings II. Salem Sump Tube – double lumen (smaller blue lumen vents the tube & prevents suction on the gastric mucosa, maintains intermittent suction regardless of suction source) a. b. Suctioning gastric contents Maintaining gastric decompression Key Points: a. b. c. d. e. f. • • • Prior to insertion, position the client in High-Fowler’s position if possible. Use a water-soluble lubricant to facilitate insertion Measure the tube from the tip of the client’s nose to the earlobe and from the nose to the xiphoid process to determine the approximate amount of tube to insert to reach the stomach Flex the client’s head slightly forward; this will decrease the chance of entry into the trachea Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow occurs, progress the tube past the area of the trachea and into the esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares g. Measure ph of aspirate fluid Validating placement of tube. Aspirate gastric contents via a syringe to the end of the tube Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A characteristic sound of air entering the stomach from the tube should be heard h. Characteristics of nasogastric drainage: •Normally is greenish-yellowish, with strands of mucous •Coffee-ground drainage – old blood that has been broken down in the stomach •Bright red blood – bleeding from the esophagus, the stomach or swallowed from the lungs •Foul-smelling (fecal odor) – occurs with reverse peristalsis in bowel obstruction; increase in amount of drainage with obstruction B. Intestinal Tubes – provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight and allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstruction where decompression will occur I. Types of Intestinal Tubes a. Cantor and Harris Tubes i. ii. iii. b. i. ii. iii. iv. II. a. b. c. d. e. Approximately 6-10 feet long Single lumen Mercury placed in rubber bag prior to tube insertion Miller-Abbot Tubes Approximately 10 feet long Double lumen One lumen utilized for aspiration of intestinal contents Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stomach Nursing Implications Maintain client on strict NPO Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray After the tube has been placed in the stomach, position client on the right side to facilitae passage through the pyloric valve Advance the tube 2 to 4 inches at regular intervals as indicated by the physician Encourage activity, to facilitate movement of the tube through the intestine 22
Slide 23: f. g. h. i. j. Evaluate the type of gastric secretions being aspirated Do not tape or secure the tube until it has reached the desired position Tubes may attached to suction and left in place for several days Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirst Removal of the tube depends on the relief of the intestinal obstruction i. ii. May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth May be allowed to progress through the intestines and expelled via the rectum. 21. LOSS AND GRIEF A. Loss – absence of an object, person, body part, emotion, idea or function that was valued I. Actual loss is identified and verified by others II. Perceived Loss cannot be verified by others III. Maturational Loss occurs in normal development IV. Situational Loss occurs without expectations V. Ultimate Loss (Death) results in a lost for a dying person as well as for those left behind, can be viewed as a time of growth for all who experienced it B. Grieving Process (Theories of Grief, Dying and Mourning) I. 3 Phases of Grief a. b. c. II. Protest: lack of acceptance, concerning the loss, characterized by anger, ambivalence and crying Despair: denial and acceptance occurs simultaneously causing disorganized behavior, characterized by crying and sadness Detachment: loss is realized; characterized by hopelessness, accurately defining the relationship with the lost individual and energy to move forward in life. Kubler-5 Stages of Grieving a. b. c. d. e. Denial – characterized by shock and disbelief, serves as a buffer to mobilize defense mechanism Anger: resistance of the loss occurs, anger is typically directed toward others Bargaining = deals are sought with God or other higher power in an effort to postpone the loss Depression: loss is realized; may talk openly or withdraw. Acceptance: recognition of the loss occurs, disinterest may occur; future thinking may occur. III. Worden’s 4 Tasks of Mourning a. Accept the reality of the loss, the loss is accepted b. Experience the pain of grief, healthy behaviors are accomplished to assist in the grieving process. c. Adjust to the environment without the deceased, task are accomplished to reorient the environment, i.e. removing the clothes of the deceased from the closet. d. C. Emotionally relocate the deceased and move forward with life, correctly align the past, the present & look towards the future Anticipatory Grief – expression of the symptoms of grief prior to the actual loss, grief period following the lost may be shortened and the intensity lessened because of the previous of grief; for example, a child told that a family move is expected may grieve about losing friends prior to actually living Complications of Bereavement D. I. II. E. Chronic Grief – symptoms of grief occur beyond the expected time frame and the severity of symptoms is greater; depression may result. Delayed Grief – when symptoms of grief are not expressed and are suppressed, a delayed reaction of grief occurs, the nurse should discuss the normal process of grieving with the client and give permission to express these symptoms Symptoms of Normal Grief I. Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and disorganization, preoccupation with the lost object or person, anxiety, depression. II. Thought patterns include fear, guilt, denial, ambivalence, anger III. Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of breath, tachycardia IV. Behaviors include crying, difficulty carrying out activities of daily living and insomia F. Nursing Health Promotion (to facilitate mourning) 1. 2. 3. Help client accept that the loss is real by providing sensitive, factual information concerning the loss Encourage the expression of feelings to support people; this build relationships and enhances the grief process Support efforts to live without the diseased person or in the face of disability; this promotes a client’s sense of control as well as a healthy vision of the future 23
Slide 24: 4. 5. 6. 7. 8. Encourage establishment with new relationships to facilitate healing. Allow time to grief, the work of grief may take longer for some; observe for a healthy progression of symptoms. Interpret “normal” behavior by teaching thoughts, feelings, and behaviors that can be expected in the grief process Provide continuing support in the form of the presence for therapeutic communication and resource information. Be alert for signs of ineffective coping such as inability to carry out activities of daily living, signs of depression, or lack of expression of grief. NURSING NOTES http://www.nursingnotes.info/ 24

Psychiatric Nursing - Language and thought disturbances

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 20:14:39 PDT

Psychiatric Nursing - Language and thought disturbances

• Clang association: Repetition of words or phrases that are similar in sound but in no other way.

• Echolalia: Repetition of words or phrases heard from another person

• Mutism: Absence of verbal speech

• Neologism: A new word devised that has a special meaning to the client

• Word salad: Form of speech in which words or phrases are connected meaninglessly

• Thought broadcasting: believe that others can hear their thoughts

• Thought withdrawal: believe others are taking their thoughts

Psychiatric Nursing - Schizophrenia reviewer

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 20:10:29 PDT

Types of schizophrenia

• Paranoid schizophrenia

Suspiciousness
Hostility
Delusions
Auditory hallucinations
Anxiety and anger
Violence

• Disorganized schizophrenia

Extreme social withdrawal
Disorganized speech or behavior
Flat or inappropriate affect
Silliness unrelated to speech
Stereotyped behaviors
Grimacing mannerisms
Inability to perform activities of daily living

• Catatonic schizophrenia

Significant psychomotor disturbances
Immobility
Stupor
Waxy flexibility
Excessive purposeless motor activity
Echolalia
Automatic obedience
Stereotyped or repetitive behavior

• Residual schizophrenia

Diagnosed as schizophrenic in the past
Time limited between attacks but may last for many years
The client exhibits considerable social isolation and withdrawal and impaired role functioning

• Undifferentiated schizophrenia

Undifferentiated schizophrenia does not meet the criteria for paranoid, disorganized, or catatonic schizophrenia
Delusions and hallucinations
Disorganized speech
Disorganized or catatonic behavior
Flat affect
Social withdrawal

Interventions Psychiatric Nursing - Schizophrenia

• Assess the client’s physical needs
• Set limits on the client’s behaviors when it interferes with others and becomes disruptive
• Maintain a safe environment
• Initiate one-on-one interaction and progress to small groups as tolerated
o Although, reintegrating the client into the milieu as soon as possible is essential
• Spend time with the client even if client is unable to respond
• Monitor for altered thought processes
• Maintain ego boundaries and avoid touching the client
o Touching others without warning or invitation
o Intruding in others’ living spaces
o Talking to or caressing inanimate objects
o Undressing, masturbating, or urinating in public
• Limit the time of interaction with the client
o Initially, the client may only tolerate 5-10 minutes of contact at one time.
• Avoid an overly-warm approach; a neutral approach is less threatening
• Do not make promises to the client that cannot be kept
• Establish daily routines
• Assist the client to improve grooming and to accept responsibility for self-care
• Sit with the client in silence if necessary
• Provide short, brief and frequent contact with the client
• Tell the client when you are leaving
• Tell the client when you do not understand
• Do not “go along” with the clients delusions or hallucinations
• Provide simple concrete activities such as puzzles or word games
• Reorient the client as necessary
• Help the client establish what is real and unreal
• Stay with the client if he is frightened
• Speak to the client in a simple direct and concise manner
• Reassure the client that the environment is safe
• Remove the client from group situations if the client’s behavior is too bizarre, disturbing, or dangerous to others
o Reassure others that the client’s inappropriate behaviors or comments are not his fault (without violating confidentiality).
• Set realistic goals
• Initially do not offer choices to the client, and gradually assist the client in making own decisions
• Use canned or packaged food, especially with the paranoid schizophrenic client
• Provide a radio or tape player at night for insomnia
• Explain to the client everything that is being done
• Set limits on the client behavior if the client is unable to do so
• Decrease excessive stimuli in the environment
• Monitor for suicide risk
• Assist the client to use alternative means to express feelings through must or art therapy or writing.

Nursing Sample Questions Thyroidectomy

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 19:54:23 PDT

Nursing Sample Questionnaire Thyroidectomy

Situation - The body has regulatory mechanism to maintain the needed electrolytes. However there are conditions/surgical interventions that could compromise life. You have to understand how management of these conditions are done.

1. You are caring for Leda who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid cancer. Prior to total thyroidectomy, you should instruct Leda to:

a. Perform range and motion exercises on the head and neck
b. Apply gentle pressure against the incision when swallowing
c. Cough and deep breath every 2 hours
d. Support head with the hands when changing position

2. As Leda's nurse, you plan to set up an emergency equipment at her beside following thyroidectomy. You should include:

a An airway and rebreathing tube
b. A tracheostomy set and oxygen
c. A crush cart .with bed board
d. Two ampules of sodium bicarbonate

3. Which of the following nursing interventions is appropriate after a total thyroidectomy?

a. Place pillows under your patient's shoulders
b. Raise the knee-gatch to 30 degrees
c. Keep your patient in a high-fowler's position
d. Support the patient's head and neck with pillows and sandbags

4. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develops postoperative?

a. Cardiac arrest
b. Dyspnea
c. Respiratory failure
d. Tetany

5. After surgery Leda develops peripheral numbness, tingling and muscle twitching and spasm. What would you anticipate to administer?

a. Magnesium sulfate
b. Calcium gluconate
c. Potassium iodine
d. Potassium chloride

Nursing Sample Answers Thyroidectomy

1. C
2. B
3. C
4. D
5. B

Emergency Nursing Sample Questions And Answers

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 19:59:40 PDT

Emergency Nursing Sample Exam Questionnaire.

Situation - In a disaster there must be a chain of command in place that defines the roles of each member of the response team. Within the health care group there are pre-assigned roles based on education, experience and training on disaster.

1. As a nurse to which of the following groups are you best prepared to join?

a. Treatment group
b. Triage group
c. Morgue management
d. Transport group

2. There are important principles that should guide the triage team in disaster management that you have to know if you were to volunteer as part of the triage team. The following principles should be observed in disaster triage, EXCEPT:

a. any disaster plan should have resource available to triage at each facility and at the disaster site if possible
b. make the most efficient use of available resources
c. training on disaster is not important to the response in the event of a real disaster because each disaster is unique in itself
d. do the greatest good for the greatest number of casualties

3. Which of the following categories of conditions should be considered first priority in a disaster?

a. Intracranial pressure and mental status
b. Lower gastrointestinal problems
c. Respiratory infection
d. Trauma

4. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT?

a. perfusion
b. locomotion
c. respiration
d. mentation

5. The most important component of neurologic assessment is:

a. pupil reactivity
b. vital sign assessment
c. cranial nerve assessment
d. level of consciousness/responsiveness

Situation - Because of the serious consequences of severe burns management requires a multi disciplinary approach. You have important responsibilities as a nurse.

6. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst into flames. The most effective way to extinguish the flames with as little further damage as possible is to:

a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames

7. Once the flames are extinguished, it is most important to:

a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess the Sergio's breathing

8. Sergio is brought to the Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness bums on his trunk, right upper extremities ad right lower extremities. His wife asks what that means. Your most accurate response would be:

a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

9. During the first 24 hours after thermal injury, you should assess Sergio for

a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and hypernatremia

10. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago, begins to exhibit extreme restlessness. You recognize that this most likely indicates that Teddy is developing:

a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure

Emergency Nursing Sample Exam Answers.

1. B
2. C
3. D
4. B
5. D
6. A
7. D
8. D
9. B
10. D

Nursing Questions Cancer

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 19:54:57 PDT

Nursing Sample Questionnaire Exam Cancer

Situation - Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer.

1. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer.

a. Barium enema
b. Carcinoembryonig antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy

2. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?

a. carcinoembryonic antigen
b. proctosigmoidbscopy
c. stool hematologic test
d. abdominal computed tomography (CT) test

3. The following are risk factors for colorectal cancer, EXCEPT:

a. inflammatory bowels
b. high fat, high fiver diet
c. smoking
d. genetic factors-familial adenomatous polyposis

4. Symptoms associated with cancer of the colon include:

a. constipation, ascites and mucus in the stool
b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped, stools
d. anorexia, hematemesis, and increased peristalsis

5. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to:

a. promote rest of the bowel by minimizing peristalsis
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. soften the stool by retaining water in the colon

Situation - Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able to understand the consequences of the disease and the treatment.

6. You are caring for Conrad who has a brain tumor and increased intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?

a. Administer bowel! Softener
b. Position Conrad with his head turned toward the side of the tumor
c. Provide sensory stimulation
d. Encourage coughing and deep breathing

7. Keeping Conrad's head and neck in alignment results in:

a. increased intrathoracic pressure
b. increased venous outflow
c. decreased venous outflow
d. increased intra abdominal pressure

8. Which of the following activities may increase intracranial pressure (ICP)?

a. Raising the head of the bed
b. Manual hyperventilation
c. Use of osmotic Diuretics
d. Valsava's maneuver

9. After you assessed Conrad, you suspected increased ICP! Your most appropriate respiratory goal is to:

a. maintain partial pressure of arterial 02 (PaO2) above 80 mmHg
b. lower arterial pH
c. prevent respiratory alkalosis
d. promote CO2 elimination

10. Conrad underwent craniotomy. As his nurse; you know that drainage on a craniotomy dressing must be measured and marked. Which findings should you report immediately to the surgeon?

a. Foul-smelling drainage
b. yellowish drainage
c. Greenish drainage
d. Bloody drainage

Situation - You are going to participate in a Cancer Consciousness Week. You are assigned to take charge of the women to make them aware of cervical cancer. You reviewed its manifestations and management.

11. The following are risk factors for cervical Cancer EXCEPT:

a. immunisuppressive therapy
b. sex at an early age, multiple partners, exposure to socially transmitted diseases, male partner's sexual habits
c. viral agents like the Human Papilloma Virus
d. smoking

12. Late signs and symptoms of cervical cancer include the following EXCEPT:

a. urinary/bowel changes
b. pain in pelvis, leg of flank
c. uterine bleeding
d. lymph edema of lower extremities

13. When a panhysterectomy is performed due to cancer of the cervix, which of the following organs are moved?

a. the uterus, cervix, and one ovary
b. the uterus, cervix, and two-thirds of the vagina
c. the uterus, cervix, tubes and ovaries
d. the uterus and cervix

14. The primary modalities of treatment for Stage 1 and IIA cervical cancer include the following:

a. surgery, radiation therapy and hormone therapy
b. surgery
c. radiation therapy
d. surgery and radiation therapy

15. A common complication of hysterectomy is:

a. thrombophlebitis of the pelvic and thigh vessels
b. diarrhea due to over stimulating
c. atelectasis
d. wound dehiscence

Nursing Answers Cancer
1. B
2. B
3. B
4. C
5. B
6. A
7. B
8. B
9. D
10. A
11. A
12. B
13. C
14. D
15. A

Nursing Questions Burns

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 19:38:33 PDT

Nursing Questionnaire Exam Burns

Situation - Because severe burn can affect the person's totality it is important that you apply interventions focusing on the various dimensions of man. You also have to understand the rationale of the treatment.

1. What type of debribement involves proteolytic enzymes?

a. Interventional
b. Mechanical
c. Surgical
d Chemical

2. Which topical antimicrobial is most frequently used in burn wound care?

a. Neosporin
b. Silver nitrate
c. Silver sulfadiazine
d. Sulfamylon

3. Hypertrophic burns scars are caused by:

a. exaggerated contraction
b. random layering of collagen
c. wound ischemia
d. delayed epithelialization

4. The major disadvantage of whirlpool cleansing of burn wounds is:

a. patient hypothermia
b. cross contamination of wound
c. patient discomfort
d. excessive manpower requirement

5. Oral analgecis are most frequently used to control burn injury pain:

a. upon patient request
b. during the emergent phase
c. after hospital discharge
d. during the cute phase

Situation - Because of the serious consequences of severe burns management requires a multi disciplinary approach. You have important responsibilities as a nurse.

6. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst into flames. The most effective way to extinguish the flames with as little further damage as possible is to:

a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames

7. Once the flames are extinguished, it is most important to:

a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess the Sergio's breathing

8. Sergio is brought to the Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness bums on his trunk, right upper extremities ad right lower extremities. His wife asks what that means. Your most accurate response would be:

a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

9. During the first 24 hours after thermal injury, you should assess Sergio for

a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and hypernatremia

10. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago, begins to exhibit extreme restlessness. You recognize that this most likely indicates that Teddy is developing:

a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure

Nursing Answers Burns
1. D
2. B
3. A
4. A
5. C
6. A
7. D
8. D
9. B
10.D

Nursing Triage System

noreply@blogger.com (grey26) — Tue, 07 Sep 2010 19:23:18 PDT

Triage is a method of prioritizing care according to the type of illness or injury and the urgency of the patients condition. It is used to ensure that each patient receives care appropriate to his need and in timely manner.
It is important to us in medical team especially nursing to know the triage system. In case of emergency , means we can quickly identify and treating those patient with more serious condition.

There are 5 system established guidelines for triage .

Level I is Resuscitation, this include patient who need immediate nursing and medical attention, such as pulmonary arrest , major trauma, severe respiratory distress and seizures.

Level II is called Emergent , these patient need immediate nursing assessment and rapid treatment. Patient who may be assessed as level II include those with head injuries, chest pain, stroke, asthma, and sexual assault injuries.

Level III, Urgent . These patients need quick attention, but can wait as long as 30 minutes for assessment and treatment. Such patient might report signs of infection, mild respiratory distresss or moderate pain.

Level IV Less Urgent, Patients in this triage can wait up to 1 hour for assessment and treatment, those with an earache, chronic back pain, upper respiratory symptoms, and mild headache.

Level V NonUrgent, These patients can wait up to 2 hours or possibly longer for assessment and treatment, those wit sore throat, menstrual cramps, and other minor symptoms are typically assigned to level V.

Pathognomonic Signs Nursing List

noreply@blogger.com (grey26) — Thu, 02 Sep 2010 05:22:25 PDT

Pathognomonic Signs are terms often used in medical fields, describe the characteristic of a particular disease to make a Diagnosis. Marking a sign or symptom -pathognomonic- represents a significant intensification of a diagnostic signs or symptoms. Here are some Pathognomonic signs and symptoms of different diseases.

Cushings syndrome – moon like face appearance and buffalo hump.
Graves Disease –exopthalmus.
Intussusception – sausage shaped mass
Hyperpituitarism - carotemia
Parkinson’s Disease. - Pill Rolling Tremors
Myocardial Infarction -Levine’s Sign
Pulmonary Tuberculosis – low-grade afternoon fever.
Pneumonia – a rusty sputum.
Asthma – there are wheezing heard over expiration.
Emphysema – barrel chest.
Typhoid fever – rose spots in abdomen.
Diptheria – pseudo membrane formation
Kawasaki disease – strawberry tongue.
Pernicious anemia – a red beefy tongue.
Cholera – rice watery stool.
Malaria – stepladder like fever with chills.
Down syndrome – protruding tongue.
Patent Ductus Arteriosus – machine like murmur
Measles – koplik’s spots.
Systemic lupus erythematosus – butterfly rashes.
Liver cirrhosis – spider like varices.
Appendicitis – rebound tenderness.
Dengue fever – petechiae or (+) positive Herman’s sign.
Leprosy – lion face.
Bulimia nervosa – chipmunk face.
Meningitis – Kernig’s sign (leg pain), Brudzinski sign (neck pain).
Tetany – Hypocalcemia , positive Trousseau’s sign, Chvostek sign or facial spasm.
Liver cirrhosis – spider like varices.15. Leprosy – lioning face.
Bulimia nervosa – chipmunk face.
Pancreatitis – Cullen’s sign or positive ecchymosis of umbilicus, positive Grey turners spots.
Pyloric stenosis – olive like mas
Tetanus – risus sardonicus.
Addisons Disease – bronze like skin pigmentation.

Steps in Applying for PRC Nursing Board Exam

noreply@blogger.com (grey26) — Thu, 02 Sep 2010 04:32:06 PDT

Steps In Applying For Nursing Board Exam/ Nursing Licensure Exam For First Time and Repeaters

CHECKLIST OF REQUIREMENTS (ORIGINAL and PHOTOCOPY) for Applying for PRC Nursing Licensure Exam

NSO Birth Certificate
NSO Marriage Contract (female married applicant)
Transcript of Records with degree/course, exact date of graduation , Special Order (S.O)/exemption/ accreditation/deregulation status, SCANNED PICTURE and remarks “FOR BOARD EXAMINATION PURPOSES ONLY”
Summary of Related Learning Experience (with total number of hours)
Record of O.R-D.R Cases
CHED Recognition or permit to operate for graduates of new schools/programs

OTHER REQUIREMENTS For Applying for PRC Nursing Board Exam

Examination Fee Php : 900.00 (complete)/ 450.00 (conditioned)
4 pcs passport pictures in white background with complete name tag
1 piece window mailing envelope with metered postage stamp
Current Community Tax Certificate (cedula)

Steps In Applying For Nursing Board Exam

STEP 1: Secure Nurses’ Application Form (NAF) at the Information Desk or download Here
STEP 2: Fill-up Application Form and proceed to Processing Counters (windows 5,6,7,8) or other designated counters.

For : OTHER DEGREE HOLDER/2ND COURSER - proceed to the Rating Division for interview by the Board of Nursing; Regional Filing Center - submit and return at appointed schedule

REPEATER/CONDITIONED - proceed to Records Section/Unit for rating/result verification

REPEATER WITH CHANGE OF CIVIL STATUS - proceed to the Asst. Secretariat’s office for change status approval

FOREIGN SOUNDING SURNAME/BORN ABROAD/FOREIGN PARENT/S : proceed to Legal
Division/Unit for approval of citizenship

STEP 3: Pay examination fee at the Cashier’s Counters (windows 1,2,3,4) or other designated counters.
STEP 4: Accomplish all PRC Forms. Copy Application Number on the Notice of Admission.
STEP 5: Proceed to the Customer Service Center/ PRC Coop Store for the metered stamps and window
mailing envelope.
STEP 6: Proceed to the Issuance Counters (windows 9,10,11,12) or other designated counters.
STEP 7: Return to PRC 2-3 days before the exam date for verification of school/building/room assignment.

Source. prc.gov.ph