Download - rationale - june 2004
RATIONALE
by: Randel C. Dalauta, RN
www.nursendoutfield.blogspot.com
Assessment (gathering)Observation Interview & Interaction
Examination & measurement
Diagnosis(breakdown and
putting together)Analysis
(breakdown)Synthesis (putting
together)Problem
identificationformulation of
nursing diagnosis
Planning(laying
out)Setting priorities
Establishing goals and objectivePlanning
intervention
Implementation(execution)
Executing the planned
interventionValidating care plan
giving/ documenting careContinuing data
collection
Evaluation(measuring and re-assessment)Comparison of clients status with expected
outcomes
IPPAInspection
- cephalocaudal: adults- proximo-distal: child
Palpation- light: 1-2 cm- deep: 4-6 cm, not beyond 10 cm
Percussion- direct: plexor- indirect: pleximeter and plexor- blunt: wider (kidney punch)
Auscultation
Progesterone- hormone of pregnancy
Estrogen- hormone of menstruation
FSH- ripening and maturation of Ovary
LH- hormone of ovulationHCG- sustain pregnancy
LEVEL DESCRIPTION TARGET STATE OF HEALTH
ACTIVITY PROVIDER
Secondary Early diagnosis/
Prompt Treatment
Early Sick - Pathogenic,
Asymptomatic /pre-
symptomatic- Carriers
Early Detection (Screening, case
finding, determining and identifying signs & symptoms)
Prompt treatment (to
prevent complication)
Phxn- infirmaries, municipal,
emergency or district hospital, city/provincial hospital ( any
facility private or gov’t. capable of
performing minor surgeries
& simple lab exams.
* ILHZ - inter
local health zone (1 central referral
hospital & RHU’s/BHS
- WHO ideal hx district w/ pop.100k-
500k
Female- growth spurt- Increase transvers
diameter of pelvis- Breast development- Growth of pubic hair- Onset of mens- Growth axilliary hair- Vaginal secretions
Male- increase weight- growth of testes- growth of hair face,
axilliary & pubic hair
- voice changes- penile growth - increase in height- spermatogenesis
Secondary Sex Characteristics in Order of Onset
Progesterone- hormone of pregnancy
Estrogen- hormone of menstruation
FSH- ripening and maturation of Ovary
LH- hormone of ovulationHCG- sustain pregnancy
Personality Disorders
Borderline - chronic fear of emptiness,self mutilation Anti Social - habitual break of law, no guilt Dependent - demand for attention,low confidence Schizoid – withdrawn, “baduy”, introvert, aloof Schizotypal - low social skills, odd, eccentric Histrionic – “KSP”, attention seeker, extrovertAvoidant – fear of criticism, fear of rejectionParanoid – mistrust is high, suspiciousPassive-Aggressive Emphatic Narcissistic – self-love, believe he’s specialObsessive compulsive- high devotion to work
PHOSPHORUSMILKCHEESEMEATNUTSLEGUMES
GREEN LEAFY VEGETABLES
WHOLE GRAIN CEREALS
Recommended Weight Gain during Pregnancy
Ist trimester – 2 to 4 lbs.
2nd trimester – 11 – 14 lbs. 3rd trimester – 8 – 11 lbs. /
0.5 lb weekly
Danger Signs of Pregnancy
S welling of face,finger,legs H eadache, continous & severe A bdominal/chest pain V aginal bleeding V omiting, persistent V isual changes E scape of vaginal fluids
Age Pschosocial Dev’t. Task Psychosexual Moral (kohlberg)
0 - 18 Infancy Trust vs Mistrust Oral (“id”) Pre-religious
18 – 3 Toddler Autonomy vs Shame&Doubt
Anal (“ego”) reality
Pre-conventional stage I
- do good because someone telling you(toddler to 7
Punishment)
3 – 6 Pre-Schooler
Initiative vs Guilt
Phallic(“super ego”)
conscience
Pre-conventional stage II
-instrumental relativist
-do good of self interest
- Good boy & girl
6 - 12 SchoolAge
Industry vs Inferiority
Latency ConventionalStage III
- Nice girl , Nice Boy- Role oriented
12 - 18 Adolescent Identity vs Role Confusion
(personality)
Genital Post conventional stage IV
-follow social norm-Moral values
18 - 45 Early Adulthood
Intimacy vs Isolation
UniversalEthical Principle
45 - 65 Middle Adulthood
Generativity vs Stagnation
65 up Late Adulthood
Ego Integrity vs Despair
VITAMINSVITAMIN SOURCES DEFICIENCY
A LIVER, EGG YOLKCARROTS
NIGHT BLINDNESS
D MILKANIMAL FATS
RICETSOSTEOMALACIA
E VEGETABLE OILS RARE
K LIVER, EGG YOLKGREEN LEAFY VEGETABLES
BLEEDING DISORDERS
C CITRUS FRUITS SCURVY
B1 LIVER, MEAT NEUROPATHYWERNICKE-KORSAKOFF
B2 LIVER, MEAT GLOSSITISCHEILOSIS
B12 LIVERMEAT
ANEMIANEUROPATHY
FOLICACID
GREEN LEAFY VEGETABLES
ANEMIA
TETANUS TOXOID VACCINE
TT1 anytime during pregnancy
TT2 1 month after TT1 3 yearsTT3 6 month after TT2 5 years
TT4 1 year after TT3 10 yearsTT5 1 year after TT4 lifetime, all
infants born to that mother will be protected
Post-Partum Phase
Taking-In = focus on “SELF”
= PASSIVE & Talkative = Dependency
( 1 – 2 days after delivery ) Taking-Hold = focus on the “NEONATE”
= ACTIVE -show interest in caring for the baby ( 3 days) Letting-Go = redefines her new role
= assuming new role (5 – 6 weeks)
TETANUS TOXOID VACCINE
TT1 anytime during pregnancy
TT2 1 month after TT1 3 yearsTT3 6 month after TT2 5 years
TT4 1 year after TT3 10 yearsTT5 1 year after TT4 lifetime, all
infants born to that mother will be protected
Age Dangers Fears DeathConcept
Others Virtue Play
0 - 18
-choking-aspiration
- stranger anxiety
No idea - thumbsuck/pacifier hope solitary
18 – 3
- Falls- Poisoning
- Separation Anxiety
No idea -Negativism – offer choices-Temper tantrums – ignore - safety-Toilet training ready when child; (1) sit (2) stand (3) walk (4) verbalize urge
well
Parallel
3 - 6 - Accidents
- Castration Anxiety
-Sleeping-Temporary-Reversible
-Masturbation = penis envy = delay surgery-Why Q – answer honestly- Bring child back to school
Motivation
Associa-
tive
6 - 12
-Accidents- CDs
-School Phobia- Teacher Rejection
- Permanent but I won’t
- Bring back child to school
Competence Associ
a-tive
12 - 18
-STDs- VehicularAccidents
- Peer Rejection
- Religious/ Philisopy
Compet
ence
Cooperative
& Comptetitive
18 - 45
Love
45 - 65
Care
65 up
Wisdom
Age Pschosocial Dev’t. Task Psychosexual Moral (kohlberg)
0 - 18 Infancy Trust vs Mistrust Oral (“id”) Pre-religious
18 – 3 Toddler Autonomy vs Shame&Doubt
Anal (“ego”) reality
Pre-conventional stage I
- do good because someone telling you(toddler to 7
Punishment)
3 – 6 Pre-Schooler
Initiative vs Guilt
Phallic(“super ego”)
conscience
Pre-conventional stage II
-instrumental relativist
-do good of self interest
- Good boy & girl
6 - 12 SchoolAge
Industry vs Inferiority
Latency ConventionalStage III
- Nice girl , Nice Boy- Role oriented
12 - 18 Adolescent Identity vs Role Confusion
(personality)
Genital Post conventional stage IV
-follow social norm-Moral values
18 - 45 Early Adulthood
Intimacy vs Isolation
UniversalEthical Principle
45 - 65 Middle Adulthood
Generativity vs Stagnation
65 up Late Adulthood
Ego Integrity vs Despair
Acute Pancreatitis
Hip Replacement
Compartment Syndrome
Pinpoint Hemorrhage
Laryngeal Diphtheria
Phases QuestionsAsk
Major Task
Pre-Orientation
Self- awareness
ORIENTATION
Phase
Questions to test the
nurse
Establish a CONTRACT & create trust
Working Phase
Personal Questions
Identification and Resolution
of problems
Terminatio
n Phase
Separation Anxiety
Referral , Assist patient review
learning
Pregnancy Induced Hypertension
Types BP Proteinuria
Edema Other S/Sx
Mild 140/90(increase of 30/15)
1+ to 2+ Slight in upper extermities
Wt gain2nd tri 2 lbs/week3rd tri 1 lb/week
Severe 160/110
3 to 4 + Pulmonary Peripheral Edema
Epigastric PainHepatic DysfunctionOliguria<500ml/24
Eclampsia
up 4+ -same- CONVULSIONCOMA
Lithotripsy
AutismABC
AutisticChild
NormalChild
Appearance
Neat , Wants
Constancy,
Dirty, Inconsistent
Behavior Retualistic, Flat affect, Repetitive
Clumpsy
Communicati
on
with difficulty to communicat
e
Talkative
Personality Disorders
Borderline - chronic fear of emptiness,self mutilation Anti Social - habitual break of law, no guilt Dependent - demand for attention,low confidence Schizoid – withdrawn, “baduy”, introvert, aloof Schizotypal - low social skills, odd, eccentric Histrionic – “KSP”, attention seeker, extrovertAvoidant – fear of criticism, fear of rejectionParanoid – mistrust is high, suspiciousPassive-Aggressive Emphatic Narcissistic – self-love, believe he’s specialObsessive compulsive- high devotion to work
Prioritization SAFETY NUTRITION CIRCULATION Social
initiation ADHD Catatonic Restraint Rape VictimSuicidal Depressed Catatonic Battered WifeManic Alcoholic Abused ChildAlzheimers Anorexia Crisis ManicDementiaDelirium
Lithium (anti-manic)Level: .5-1.5 Antedote: Mannitol(diamox)Toxicity: NAVDA – early s/sx + Tremors –
late sign
2-3 - intake of Na/day
- OFI/day (liters) - Onset of effect(weeks)
- Checking – admission-2-3x/week - discharge – 1x/mos.
Susbtance
Effect on CNS
Cardinal Sign
Withdrawal
S/Sx
StimulantsCocaine
Amphetamine
Caffeine
Alcohol /Marijuan
a
Narcotics/
OpiatesMorphineHeroineCodeineOpium
Disulfiram (Antabuse)
• given 8 -12 hrs after last alcohol intake
• AVERSION therapy• Avoid:Mouth WashOTCFood suaces made of wineFuit flavored extractsAftershave lotionsVinegarSkin products
•
Private Room
Handwashing
Gloving Gowning Mask
Strict / / / / /
Respiratory
/ / / /
TB / / /
Contact
/ / / / /
Enteric / /
Drainage
/ /
Universal
/ / / /
Leftside Rigthside
= Pulmonary S/sx= =Systemic S/Sx=
C = oughing & Dyspnea
H = ematomegaly
H = emoptysis E = dema
O = rthopnea A = scites
P = ulmonary congestion
D = istended neck viens
CHF
MANAGER LEADERAre given the position Take the initiative to
leadOrganize and staff Align people with
directionEmphasize tactics,
structure and systems
Emphasize philosophy, core value and shared
goalsFocus on the present Focus on the future
Avoid risks Takes risksMotivate people to
comply with standards
Inspire people to change
Operate WITHIN organizational rules, regulations, policies
and procedures
Operate OUTSIDE of organizational rules, regulations, policies
and procedures
The Incident ReportIdentify the client by name, hospital or id
numberGive the date, time, and place of the
incident.Describe the incident as one saw it, avoid
blame or conclusion.Incorporate the client’s account of the
accident, use direct qoutes.Identify all witnesses to the incident.Identify any equipment by number and
any meds by name and dosage.
Rule of 9
HEMOVAC
GASTRIC DUODENALSite of Ulcer Antrum of the
Stomach Proximal part of
the Duodenum
Characteristics of Pain
Gnawing Epigatric Pain
Gnawing Epigastric Pain
Time of Occurence
- An hour after Eating
- No pain @ hr of sleep
- Two hours after Eating
- Pain @ hr of sleep
Effect of Food Aggravated by Eating causes
weight loss
Relieved by Food cause weight
gain
Relief Relieved by Vomiting
Not relieved by Vomiting
Demographics - Older person- Poor
- Middle age- Rich
Blood Transfusion Use gauge 18Normal saline to be used (the only
compatible)Vital signs prior a must
(temperature)Two nurses to verify client
identificationKVO rate for first fifteen minutes
(prevent abrupt hypersentivity reaction)
Stay with the client for the first 15 minutes (usual onset of reaction)
STOP if with reactionFour hours to infuse (risk for
hyperkalemia)
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The END