FUNDA Flashcards
NURSING THEORIES
1. Nature of nursing model (14 basic needs) dole in assisting sick/healthy individuals to gain independence in meeting the 14 basic needs
2. Defines nursing as service. Her theory is Patient Centered approaches to nursing model identifying the 21 nursing probs
3. Nursing as an interaction process of pt and nurse leading to GOAL ATTAINMENT
- Virginia Henderson
- Faye Abdellah
- Imogene King
NURSING THEORIES
1. each personal as a behavioral system composed of of 7 subsystem
2. Transcultural nursing model
3. 4 conservation principles
- Dorothy Johnson
- Madelain Leininger
- Myra Levine
NURSING THEORIES
- Concerning to response to stress (intrapersonal stressors, interpersonal stressors, extra-personal stressors)
- Self care and self care deficit nursing theory
- Psychodynamic (interpersonal RELATIONS) model
- Betty Neuman
- Dorothea Orem
- Hildegard Peplau
NURSING THEORIES
- Science of Unitary Human being (whole is greater than sum of its parts)
- Adaptation Model (integration)
- Core, Care, Cure Model
- Martha Rogers
- Sister Callista Roy
- Lydia Hall
NURSING THEORIES
- Dynamic Nurse-Patient Relationship Model (assistance to meet an immediate need of pt
- Human Caring Theory (caring as unifying focus of practice)
- Human becoming theory
- Ida Jean Orlando
- Jean Watson
- RoseMarie Parse
- accdg to __ nursing is the protection, promotion, optimization, alleviation of suffering, etc
- accdg to __ Health is state of complete physical, mental, social wellbeing ad not merely the absence of dse
- accdg to __ health is the ability to maintain homeostasis
- ANA
- WHO
- WALTER CANNON
4 scopes of N. Practice
- Promoting health and wellness
- Preventing illness
- Restoring health
- Caring for dying
7 expanded CAREER roles of Nurses
- Nurse midwife
- Nurse entrepreneur
- Nurse practitioner
- Nurse administrator
- Nurse educator
- Clinical nurse specialist
- Certified Nurse Anesthetist
PATRICIA BENNER’s STAGE OF NURSING EXPERTISE
1. W 2-3 yrs expi, focuses on client’s needs and wants
2. Demonstrates acceptable performance, focuses on theory and real life situations
3. Focuses on rules and regulations
4. No longer requires to maxims, uses instinct
5. 3-5 yrs expi, prioritize ABC, uses maxims, focus on long term goal and perceive situations a a whole rather than its parts
- Competent
- Adv Beginner
- Novice
- Expert
- Proficient
Type of Records
1. Traditional record, each person makes notations in separate sections
2. All data abt their prob
- SOMR/ Source Oriented Medical Record
- POMR/ Problem Oriented Medical Record
Provides concise method of recording data
KARDEX
Types of Fever
1. Alternates at regular intervals
2. Fluctuations more than 2 C for over 24h
3. Interpersed w periods of 1-2 days normal temp
4. Always remains above normal
5. Temp rises to fever rapidly ff normal tep then returns to normal within few hrs
- Intermittent
- Remittent
- Relapsing
- Constant
- Fever spike/ stair case
Most accurate site of assessing temp
Rectal
Normal CO
5L/min
Pulse sites:
1. used when radial is not accessible
2. Used during cardiac arrest in adults
3. used sa infants and < 3yo
4. Determine leg circulation
- Temporal
- Carotid
- Apical
- Femoral
Pulse sites:
1. Determine lower leg circulation
2. Determine foot circulation
3. used in cardiac arrest and shock
4. Use din cardiac arrest in infants
- Popliteal
- Posterior Tibia and Dorsalis Pedis
- Femoral
- Brachial
term to discrepancy between apical and radial pulse
Pulse deficit
Scale in Pulse assessment
- 0
- 1+
- 2+
- 3+
- Absent
- Weak
- Normal
- Bounding
Fire extinguisher class
1. Combustible cooking
2. Metals
3. Electrical
4. Flammable/ combustible liquids/ gas
5. Ordinary
- Class K
- D
- C
- B
- A
More Fall scale (MFS) high risk score and no rx score
> 50: high rx
0-24: no rx
Kelan ginagawa MFS
q shift
Percussions sounds
1. Solid organs like bone and muscle
2. Soft tissue like liver heart
3. Normal
4. air in lungs
5. air and fluids in stomach
- Flat
- Dull
- Resonance
- Hyperresonance
- Tympany
diff of bell and diaphragm in stet
DiapHragm- HigH pitch
Pattern of abdominal auscultation and how many mins pakikinig per quadrant
RLQ to RUQ to LUQ to LLQ
At least 5 mins
Normal number of bowel sounds per min
5-20 bowel sound/ min
<5 bowel sound/min means __
>20 bowel sound/min means __
hypoactive/ consti
Hyperactive/ diarrhea
Assessment Position
1. Respiratory assessment
2. Abd assessment
- Upright
- Dorsal recumbent
TYPES OF ENDOSCOPY
1. Resp
2. Upper GI
3. Lower GI
- Bronchoscopy and Laryngoscopy
- Esophagogastroduodenoscopy
- Colonoscopy
respiratory and Upper GI endoscopy (UPPER ENDOSCOPY) Prep “canva”
- Consent
- Atropine sulfate
- NPO post midnight 6-8h
- Valium (sedate)
- Anes spray- lidocaine
respiratory and Upper GI endoscopy (UPPER ENDOSCOPY) post procedure
Post procedure:
1. Gag reflex- tongue depressor
2. Compli ass
Compli of upper endoscopy
- Bleeding- freq swallowing or spit blood
- Perforation- severe abdominal pain and board like
Lower endoscopy- COLONOSCOPY prep “linis bituka goal”
- 1-3 days fiber
- NPO post midnight
- Laxative night before procedure
- Cleansing enema
- Left sims position (during procedure)
Lower endoscopy- COLONOSCOPY post procedure
Assess compli: Same with upper bleeding and perforation
Barium studies
1. Contraindicated kanino
2. conjoined w __ (series of x-ray) and for barium enema
3. conjoined w __ and for barium swallow
- Preg
- Colonoscopy
- Fluoroscopy
Choose if barium swallow or barium enema
1. For upper GI series
2. For lower GI series
3. Same w colonoscopy ang prep
4. NPO post midnight and assess barium allergy
5. Fowlers position during
- BS
- BE
- BE
- BS
- BS
After barium studies considerations
Goal to excrete barium (intestinal obstruction)
1. OFI
2. FIBER
3. LAXATIVE
4. INFORM STOOL IS WHITE
5. STOOL WITHIN 24-48h
BSE
Start sa: TAIL OF SPENCE
Most common are of tumor: UPPER OUTER QUADRANT
TSE
age:
Sino Mas lower sa side ng testicle:
age: 13
Sino Mas lower sa side ng testicle: LEFT
Postural drainage by virtue of gravity, how many mins
5
CPT
time:
Post procedure:
time: BEFORE MEALS, 2 H AFTER MEALS, AFTER NEBULIZATION
Post procedure: MOUTHCARE (suction)
SUCTIONING anong gloves
Oropharyngeal:
Naso:
Tracheal:
Oropharyngeal: ETO LANG CLEAN GLOVES
Naso: sterile
Tracheal: sterile
SUCTIONING POSITION
unconscious:
Conscious:
Apply suction during:
Hyperoxygenate:
Duration:
Interval:
Total suction time:
unconscious: S LYING
Conscious: FOWLERS
WITHDRAWAL
100% for 1 min
Duration: 5-10, max na ung 15 sec
Interval: 20-30 sec (suction in between suction)
Total suction time: 5 min
Tracheal length of insertion
Same w naso, just pull 1-2 cm
2TYPES OF SUCTION MACHINE ilang mmhg
1. Portable:
2. Wall-mounted:
10-15
100-120
Most accurate 02 device that has valve
Venturi (24-60%, 3-10 flow rate)
02 device na highest flow 30-60 and highest Fi02 na 100
02 device na lowest w 2-6% and 25-40 lang
High flow nasal cannula
nasal cannula
02 device na 2nd to the highest w 10-15 L/min and 80-90 Fi02
02 device na 2nd to the lowest w 6-10L/min and 35-50 Fi02
Non rebreather
Simple facemask
THORACENTESIS prep
Lidocainape allergy
PT
Xray
Consent
CTT
nabasag:
Disconnect:
Do not KINK, immerse sa NSS/water
Tape 3 sides w Dry gauze/ PETROLATUM gauze
3 parts of Tracheostomy and fxn
How to lock & unlock
Outer cannula
Inner cannula: ito ung nireremove pag naga suction na
Obturator: guide
Lock: cLOCKwise
unlock: coUNter cLOCKwise
Trach inner cannula is cleaned tuwing__ with__rinsed w__and dry w__
How abt trach ties kelan pinapalitan
Every shift
Hydrogen peroxide half strength
Water/NSS and brush/pipe cleaner
MESH gauze❌cotton gauze
Change WHEN NECESSARY
Trach ties is tied at?
Side of neck
Types of NGT
1. Single lumen-
2. Double lumen-
3. NasINTESRINAL tube-
Position:
While inserting instruct pt to:
Insertion length:
LEVIN
SALEM SUMP
MILLER-ABBOTT
semi/highfowlers while FLEX neck
swallow/sip thru straw
NEX
To ensure NGT PLACEMENT
Aspiration ng gastric content dat 1-4 pneumonia
Confirm: xray
FEEDING
position-
Residuals-
Hold _inch above Insertion
if percutaneous endoscopic gastrotomy ilan inch-
Flush with-
SEMI F
check ibalik <400 proceed pakain, >400 HOLD
12 inches
6 inch
Water/NSS 30-60 ml
Ileostomy location
Empty colostomy bag when
Foods that reduces odor
RLQ
1/3-1/2 full
PaBuYoCOT (parsley, buttermilk, yogurt, cranberry juice, Orange juice, Tomato juice)—mga acidic
RECTAL CATH
W Waterbased lubricant ilang inch submerge dito
Insert
Inch hawakan if low flow enema? Highflow enema?
1-2 inch
3-4 inch
12 inch, 18 inch above
Urinary Cath
Single lumen-
Double lumen-
Triple lumen-
Male
position-
inch insertion-
Anchor-
FEMale
position-
inch insertion-
Anchor-
Single lumen-STRAIGHT CATH
Double lumen- FOLEY
Triple lumen-CYSTOCLYSIS OR CBI
Male
position-SUPINE
inch insertion- 6-9
Anchor- UPPER thigh/lower abdomen
FEMale
position- DORSAL RECUMBENT
inch insertion- 2-3
Anchor- INNER THIGH