ALL FOR NURSING

Standard Precautions: Tier 1 Perform hand hygiene before and after care and when soiled; most important way to prevent infection Use personal protective equipment (PPE) if touching, spilling, or splashing of blood or body fluids is likely; use gloves, gowns, mask, goggles, shields, aprons, head and foot protection Discard disposable items in fluid-impermeable bag and contaminated Do not recap used needles; dispose in sharps container  Hold linen away from body; place in impermeable bag in a covered hamper; do not let hampers overflow Place lab specimens in a leak-proof transport bag without contaminating the outside; label with biohazard sticker and patient information Institute procedure for accidental exposure: Wash area, report to supervisor, receive emergency care, seek referral for follow-up Receive hepatitis B vaccine Assign patient to private room if hygiene practices are unacceptable Avoid eating, drinking, touching eyes, apply...

Physical Assessment Handouts View more documents from Mark Fredderick Abejo .

Nursing Process Handouts View more documents from Mark Fredderick Abejo

Vital Signs  Ø   Temperature (NV 36 – 37.5 C) ü   Elderly people are at risk of hypothermia ü   Hard work or strenuous exercise can increase body temperature ü   Oral: most accessible 2-3 mins. * 15 minutes interval after ingestion of hot or cold drinks ü   Rectal: most accurate 2-3 mins. ü   Axillary: most safest 6-9 mins. Ø   Pulse (NV 60-100 bpm)    ü   Wave of blood created by contraction of the left ventricle of the heart    ü   Radial: best site for adult    ü   Brachial: best site for children    ü   Apical: best site for 3 years old below Ø   Respiration (NV 12/16-20) Normal Breath Sound Vesicular Soft, low pitch Lung periphery Broncho-vesicular Medium pitch Larger airway blowing Bronchial Loud, high pitch Trachea Abnormal Breath Sound Crackles Dependent lobes ...

ASSESSMENT PHASE Data Collection Organize Data Validate Data Document Data Subjective Data   also referred to as symptoms or covert data Objective Data also referred to as signs or overt data, are detectable by an observer Primary source is the client Secondary source is family or anyone else that is not the client Methods of Data Collection Observing To observe is to gather data by using the sense. Interviewing Is a planned communication or a conversation with purpose Examining Is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. DIAGNOSIS PHASE Analyze Data Identify Health Problem Formulate Diagnostic Statements Diagnostic Statements Problem (P) : statement of the client’s response. Etiology (E) : factors contributing Signs and Symptoms (S) : defining characteristics manifested by the...

Nursing Theories and History from Mark Fredderick Abejo

Fundamentals of Nursing Review Bullets View more documents from Mark Fredderick Abejo DOWNLOAD PROCEDURE: LIKE us on Facebook via our FACEBOOK PAGE widget FOLLOW us on Twitter via our TWITTER ACCOUNT widget SHARE this blog on your own Facebook and Twitter account  via SHARE IT widget ANSWER our SURVEY POOL widget NOTE: Widgets can be found on the right side portion of this BLOG CLICK  view on slideshare   button on the left lower corner of this presentation.  CREATE / SIGN UP your own account to  www.slideshare.com. LOG IN using your own account SEARCH  Mark Fredderick Abejo   to view all uploaded documents. DOWNLOAD the document you like.

Hygiene from Mark Fredderick Abejo

Nasogastric Tube (NGT) Ø   Gavage (feeding) / Lavage (suctioning) Ø   Select the nostril that has greater airflow. Ø   Assist the client to a high fowler’s position Ø   NEX technique (nose-ear-xiphoid) Ø   Checking the patency: ü   Aspirate stomach contents and check the pH, which should be acidic ü   Introduce 10-30 ml of air into the NGT and auscultate at the epigastric area, gurgling sound is heard ü   The most accurate method of assessing the placement of NGT is X-ray study Ø   Before feeding assess residual feeding contents. To assess absorption of the last feeding, if 50 ml or more, verify if the feeding will be given. Ø   Height of feeding is 12 inches above the point of insertion. Ø   Ask the client to remain in position for at least 30 min Ø   Common Problems of Tube Feedings ·          Vomiting ·       ...

Urinary Catheterization Ø  Use appropriate size of catheter Male: Fr 16-18 Female: Fr 12-14 Ø  Place the client in appropriate position: Male: Supine, legs abducted and extended Female: Dorsal recumbent Ø  Locate the urinary meatus properly: Male: at the tip of the glans penis Female: between the clitoris and vaginal orifice Ø  Lubricate catheter with water soluble lubricant before insertion Male: 6 – 7 inches Female: 1 – 2 inches Ø  Length of catheter insertion: Male: 6 – 9 inches Female: 3 -4 inches Ø  Anchor catheter properly: Male: laterally or upward over the lower abdomen / upper thigh Female: inner aspect of the thigh Nursing Interventions to Induce Voiding/Urination v  Provide privacy v  Assist the patient in the anatomical position of voiding v  Serve clean, warm and dry bedpan (female) or urinal (male) v  Allow the client to listen to the sound of running ...