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342 Cards in this Set
- Front
- Back
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Erikson- Stage 1
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Trust vs. Mistrust
- trust caregiver when out of sight- not upset - consistency |
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Erikson- Stage 2
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Autonomy vs. Shame/Doubt
- RISKS - sense of identity - "separate" from the world - "copy-cats" |
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Erikson- Stage 3
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Initiative vs. Guilt
- developes conscious - limits on behavior - pre-school DO NOT SHAME THEM |
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Erikson- Stage 4
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INdustry vs. Inferiority
- (School - Age) - love praise/ accomplishment - competition with peers |
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Erikson- Stage 5
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Identity vs. Role Confusion
- Adolescents - trying new things/identities - harmful substances |
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Erikson- Stage 6
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Intimacy vs. Isolation
- young adults - develope capacity to love |
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Erikson- Stage 7
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Generativity vs. Self-Absorption/Stagnation
- what can I give back? - society as a whole |
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Erikson- Stage 8
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Integrity vs. Despair
- losses increase - look back upon life |
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Freud- Oral
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birth-18 months
derive pleasure from sucking |
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Freud- Anal
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12 months-3 years
urine/stool obsessed digress in hospital |
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Freud- Phallic or Oedipal
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3-6
become more aware of genitals masturbation |
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Freud- LAtency
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School Age
no emphasis on sex boys/girls are gross |
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Freud- Genital
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PUBERTY
interested in sex again |
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Hyponatremia
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below 135 mEq/L
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Hypernatremia
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above 145 mEq/L
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Hypokalemia
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below 3.5 mEq/L
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Hyperkalemia
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above 5 mEq/L
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Hypocalcemia
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below 8.9 mg/dl
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Hypercalcemia
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above 10.1 mg/dl
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Hypomagnesemia
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below 1.5 mEq/L
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Hypermagnesemia
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above 2.5 mEq/L
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Primary Care
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health promotion, education and protection
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Secondary Care
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acute care
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Tertiary Care
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rehab, restorative
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Health
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level of wellnedd of a person's biologic, physchological and socialogical status
JUST A LEVEL of Health |
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HEalth Belief Model
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PERCEIVED susceptibility
belief drives our behaviors |
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Health promotion model
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activites that improve wellness and prevent disease
health is in our control |
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Holistic health
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good mental, physical and spiritual health in order to be truly healthy
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Basic Human Needs Model
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MASLOW
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MASLOW
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Physiological
Safety Psych |
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Stages of Health Behavior Change
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Precontemplation
COntemplation preparation action maintenance |
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Precontemplation
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before the decide to make a change
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COntemplation
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thinking about change
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Preparation
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coming up with a plan
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Action
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carry the plan out
MOTIVATION needs |
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Maintenance
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most difficult
provide support |
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3 levels of prevention
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primary
secondary tertiary |
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Primary Prevention
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used to delay the occurance of a particular illness or disease
immunizations |
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Secondary Prevention
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early detection
screenings |
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Teriarty Prevention
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once the disease has occurred, limits severity
REHABiliitation |
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HIPAA
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chart is protected
minimum info is shared |
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Problem oiriented medical records
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places empahsis on patients problem
date is organized by diagnosis SOAP, PIE, FOCUS |
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SOAP
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Subjective
Objective Assessment Plan SOAPIE- Intervention , evaluation |
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PIE
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PRoblem
Intervention Evaluation |
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FOCUS
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Data= subj./obj.
Action= intervention Response= patient's response |
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SBAR
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Situation
Backround Assessment Recommendation |
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Nursing Diagnosis
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to distinguish or know responses to actual or potential life processes; interventions that are appropriate for the patient
NANDA |
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Related to...
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etiological factors
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DIagnosis
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essense of wht is going on with the client
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Nursing Process
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AADPIE
Assessment Analysis Diagnosis PLanning Implementation Evaluation |
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Actual Nursing DIagnosis
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problems that exsist, signs and symtoms, ACTUAL response to a problem
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Risk Diagnosis
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potential problem
doesn't exsist YET |
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Wellness Diagnosis
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indicates slients deire to achieve a higher level of wellnes
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Education
METHOD |
Medications
Environment Treatments Health knowledge of disease Outpaitent/ inpatient referrals Diet |
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MASLOW
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Physical
Safety Psych |
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Insensible Fluid Losses
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through skin and lungs
evaporation |
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Electrolytes outside cell
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Na
Cl Ca HCO3 |
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Electrolytes inside the cell
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K
P Mg |
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When body can't compensate for shifts in fluid?
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Dehydration
Hypovolemia Hypervolemia |
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Dehydration
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fluid is drawn into extracellular space ( dilute Na)
concentration of electrolytes increases kidneys retain water |
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Signs and Symptoms: Dehydration
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DRY MUCOUS MEMBRANES
poor skin tugor incr. urince spec. gravity weight los fever( no perspiration) increased RR BP low |
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Dehydration
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Hypotonic Solutions- D5W- SLOWLY--> Cerebral edema if given too fast
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Hypovolemia
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loss of fluid AND solutes ( hemorrhage)
Tachycardic- compensate for lack of circulating volume BP drops ( orthostatic hypo) less than 30 ml/hr of urine restless( not enough o2 in circulation) shock |
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SHOCK
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Bp down, Urine Down, HR INCREASE
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Hypovolemia Treatment
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ISOTONIC= same level of each lost
NS or LR Dopamine ( raise BP) = vasopressors LOWER HOB |
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FLuid CHallenge
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LOTS of fluid...FAST
- shock, hypovolemia -porportions arent't echnically OFF |
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Hypervolemia
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excess water and Na in extracellular space
rapid pulse, increased BP, distended veins, edema ( dependent areas), weight gain, crackles in the lungs--> Pulmonary Edema |
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Hypervolemia Tx
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restrict Na and fluid
STOP IV diuretics MOrphine ( air hunger is present-lowers RR) RAISE HOB |
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Na
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135-145 mEq/L
Extracellular transmits impulses |
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Hyponatremia
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excess h20, increased Na loss or deficient Na intake
headache nausea lethargy |
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Hyponatremia Tx
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Hypovolemic- IV NS and high sodium foods
Hypervolemic- restrict fluids, replace NA |
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Tx of Hyponatremia
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GIVE IV SLOWWWLY!!! Can cause fluid overload--> irreversible brain damage
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Hypernatremia ( rare)
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>145--thirst prevents this from happening
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Causes of Hypernatremia?
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MODEL ( Medications, osmotic diuretics, diabestes inspipidus, excessive fluid loss, low water intake)
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Signs and Hymptoms of Hypernatremia
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SALT
skin flushed agitation low grade fever thirst |
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Hypernatremia Tx
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treat the cause:
hypovolemia or dehydration= -Oral/IV replacement ( D5W) LImited Na Loss= - Thiazide Diuretics ( na dump) Hypertonic IV therapy ( to treat hyponatremia)= - slow rate of IV Increased Na intake= - diet change |
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Na
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big time responsibility for fluid balance and nerve impulse control
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Potassium
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3.5-5 mEq/L
within the cell neuromuscular transmission skeletal and cardiac muscle contraction and conductivity |
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Hypokalemia Causes
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< 3.5
diuresis vomiting, diarrhea NG suctioning poor intake low Mg levels--renin--aldosterone = K secretion |
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S&S Hypokalemia
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muscle paralysis ( repiratory/cardiac)
decreased DTR decreased pulse polyuria- dumping K |
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Tx of Hypokalemia
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IV potassium replacement if severe:
GIVE THROUGH CENTRAL LINE--SLOWLY--CARDIAC ARREST IF TOO FAST!!!!! NEVER GIVE POTASSIUM IV PUSH!!! |
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Hyperkalemia
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>5mEq
-use of salt substitutes -Beta-blockers, chemotherpay, K-sparring ( destroy cells--leak) |
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Hyperkalemia S&S
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muscle weakness
crampls decreaed pulse and BP ( iregular and slow) decreased CO ( cardiac arrest) |
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TX of Hyperkalemia
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hemodyalysis
Kayexelate/Sorbitol EMERGENCY= 1-% ca gluconate ( treats cardiac changes) Insuilin with hypertonic dextrose |
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Hypertonic solutions ABOVE 500
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can't be used through traditional IV--- CENTRAL venous catheter
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Parenteral Nutrition
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through central venous access ( above 50 osm)
only used whn problem is with the GI tract |
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Short Peripheral Catheter
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72-96 hours dwell time
If Massectomy/lymphodissection- start in opp arm ( will need a doc order to start on same arm) Tingling sensation? STOP |
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Midline Catheter
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1-4 weeks
inside elbow insertion- basilic need education! |
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Vein collapse?
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start distal and work proximal!
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PICC ( Peripheral Inserted Central Cath)
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months--years
tip n superior vena cava ( OR) central cath= extreme hypertonic chest x-ray to make sure need education to insert |
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Nontunneled Percutanous Central Cath
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through subcl. vein in upper chest or jugular in neck
3 ports of access DO NOT USE IF TRACHed Trendelembourg position when inserting fairly short dwell confirm by x-ray |
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Tunneled Central Cath
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frequent and long term infusion
superior vena cava tunneled underneath skin- out of chest wall cancer and parplegic patients |
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Implanted Port
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portal body, dense septum, cath
non-coring needle stick warning- rebound effect flushed after each use and once a month topical anesthetic |
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Dialysis Cath
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ONLY hemodyaliysis nurse
DON'T TOUCH |
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Do not take BP in arm with catheter
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infiltration
phlebitis |
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Do not draw blood from same arm
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if you have to--distal to IV bc fluids will alter test
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IV dressings
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change every 48 hours
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Adminitration sets
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change every 72 hours- just like IV
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Air embolism caution
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lie down flat--below level of heart--> clamp--old breath- disconnect/reconnect- "valsalva"--stops air from entering system
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Traction upon IV removal
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relax the area-->
relaxation, heat, edications No? must get xray bc clot or thrombosis |
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Central Cath Removal
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use antiseptic ointment so it doesn't suck in air
MEASURE TUBING and compare with documentation |
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Infilltration
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leak into extravacular tissue
edema, tight skin , coolness, tender STOP infusion, remove, cold compress, elevate |
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Phlebitits
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red, painful, vein is hard/cordlike
inflammation of the vein remove catheter, warm compress, start new cath in opp extremity |
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Thrombosis
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blood clot in vein
STOp, cold compress, remove cath, NOTIFY MD!!! |
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Echymosis/Hematoma
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bruise
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SIte Infection
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notify MD
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Air Embolism
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CLAMP IMMEDIATELY
lateral trandelembourg on left notify MD give o2 |
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Pre-Interaction Phase
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leading up to nurse and patient interacting
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Orientation Phase
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setting up goals
*talk about termination in this phase |
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Working Phase
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working to accomplish goals
re-assessing goals |
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Termination Phase
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ending the relationship
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GOals of therapuetic communication
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obtain/provide info
develope trust show caring explore feelings |
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Characteristics of Therapeutic Communication
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purposeful
well-defined boundaries client-focused non-judgemental well-planned, selected techniques |
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Principles of THerapeutic Communication
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interview at approp. time
assure privacy establish guideline for interaction provide for comfort |
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Purpose of Therapeutic Communication
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help them cope effectively
talk about complex problems allows them to "hear" themselves speak about diff. issues engage clients in problem-solving sory out priorities and actions |
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Active Listening
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SOLER
sit and face the patient open posture lean in eye contact relax |
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DNA replication
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Mitosis
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CHromosomes
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package of genes
23 pairs 2 are sex chromosomes |
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CHromosomal Analysis
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KAryotype
female= XX male= XY |
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Gene
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segment of DNA
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Allele
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each gene has 2
1 from mom 1 from dad |
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Phenotype
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physical expression of a gene
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Genotype
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what the alleles actually are
AO= Genotype Type A blood- phenotype |
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Autosomal Dominance
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only 1 allele has to have it to be expressed
Breast Cancer, Type ii diabetes |
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Penetrance
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how often or well a gene is expresses in a population
=risk of expression |
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Expressivity
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the autosomal dominant gene is expressed but to what degree?
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Autosomal recessive
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both alleles have to have it for it to be expressed
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Sex-Linked recessive pattern of inheritance
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present only on sex chromosome
X chromosome drives... |
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Carrier Testing
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does the client have the allele?
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DIagnostic Testing
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Do they have the mutation?
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Genetic Counseling
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NON-DIRECTIVE
THEIR decision |
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Nurse's Role In genetic COunseling
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Identifying risks
communication privacy/confident. information accuracy client advocacy support assess coping mechanisms |
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small intestine
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absorption( carbs protein)
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Large intestine
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primary organ of elimination
strongest peristalsis defacation begins with desending colon |
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straining bad for
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cardiac problems
glaucome increased intercranial pressure and increased BP) |
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Aging/defacation
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slows down
fiber provides for bulk |
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prolonged emotional stress
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IBS
collitis chrone's disease |
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Constipation
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symptom, not a disease
<3 bm/week hard feces= more water absorbed |
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IMpaction
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results from unrelieved constipation
oozing around that looks like diarrhea --> digital exam |
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Diarrhea
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loose, unformed stool
causes: antibiotics, NG tube feedings, foodborne pathogens, C-dipth |
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Incontinence
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inability to control passage of feces and gas to the anus
*skin breakdown potential |
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Flatulence
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inability to control feces and gas to the anus
abdominal surgery, opiates, general anesthesia |
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Hemorroids
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dilated, engorged vein in the linig of the rectum
rectal bleeding/itching |
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Ileostomy
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bypasses the large intestine- waterry/frequent stool
ascending- watery transverse- little more formed desending- normal looking |
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Loop Colostomy
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temporary in the transverse colon
emergency |
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End Colostomy
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proximal end forms stoma and distal end is removed or sewn closed
PERMAMENT |
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Double Barrel Colostomy
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bowel is surgically cute and both ends are brought through the abdomen
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Normal Bowel Color
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brown for adults
yello- small infant |
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Clay or white bowel
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no bile
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Tarry black bowel
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BLOOD- Upper Gi bleed
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Red bowel
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lower gi bleed OR hemorroids
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Mucosy bowel
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infection or collitis
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Strong odor in bowel
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blood or infection
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Frequency of Bowel
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3x/week
infant ( breat fed) 4-6/day bottle fed- 1-3/day |
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Shape of bowel
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Greasy= poor absorption
Long/Skinny= bowel obstruction or increased peristalsis |
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Cathartics and Laxatives
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short term action for bowel emptying
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Enema
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instillation of solution into rectum to produce defacation
not good to do more than 3 |
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Tap Water Enema
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Hypotonic
water toxicity never do more than 1 *older adults |
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Normal Saline Enema
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SAFEST
Isotonic |
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Hypertonic SOlution Enema
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pulls water from interstitial space -- not a large amount needed...
no for dehydrated! |
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Soapsuds Enema
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irritates the bowel-->peristalsis
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Oil Rention enema
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lubes rectum
retain for several hours= UNCOMFORTABLE softens stool |
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Carminative
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relief of gas
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Kayexalate
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Potassium
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Digital Removal
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Must have an MD order
- bleeding - stimulation of vagus nerve |
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Large Bore NG
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decompresion, gas builup, decreased peristalsis
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Small Bore NG
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med administration, feeding, lavage
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Physiologics of Pain
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prolongs the stress response
Acute: increased HR, o2 demand Chronic: decreased gastro, immune response, delays in healing |
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Acute Pain
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trauma, inflammation, ischemia, surgery
localized subsides without treatment acts as a warning signal--activates sympathetic system restless, hard to concentrate, anxiety |
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Chronic Pain
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LONG term > 3 months
healed injury but healed poorly emotional response/behavioral |
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CHronic Non-Cancer
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Neuropathic Pain
result of a nerve injury shooting pain poorly controlled diabetes |
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A Delta Fibers
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found in skin and muscles
sharp, piercing, intermittent |
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C fibers
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organs and linig of bosy cavities
thermal and chemical dull, achy |
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Dorsal Horn
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message sent to this area in the spinal cord and releases neurotransmitters---> activates more nerve cells that send message to the brain
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Thalamus
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sends message to the somatosensory cortex, limbic system, frontal cortex
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Somatic Pain
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A Delta fibers
skin and muscles sharp burning aching |
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Visceral pain
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organs, dull
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Tolerance
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adaptation in which exposure overtime results in a decrease of the drug's efficacy
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Physical Dependence
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withdrawal symptoms are manifested upon reduction or cessation of med
(womiting, perpire) wean off SLOW |
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Addiction
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primary, chronic, neuro-biologic disease that occurs when there is impaired control over drug use
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Localized PAin
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confined to the site of the origin
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Projected Pain
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along nerves or nerve pathways
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Radiating Pain
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diffused pain around the site of origin
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Referred pain
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felt in a distant area ( not along nerve pathway)
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Non-Opiod Tx
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first line for mild-moderate pain
aspirine, tylenol, NSAIDS |
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NSAID ( ibuprofen)
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GI Upset, bleeding, nephrotoxicity, CHF, drug interactions with antihypertensives
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Aspirine side effects
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bleeeding, GI discomfort
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Tylenol
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hepatotoxicity, nephrotoxicity
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Opiods
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block release of neurotransmitters
Codeine, Hydrocodone, Morphoine, Hydromorhopne, fentanyl, methadone, tramdol, meperidine |
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Codeine
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short acting weak
can cause constipation in older adults need enzyme to break down... |
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Hydrocodone
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in cmobo with acetominophen or ibuprofen
toxic because of dosage raising |
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Morphone
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gold standard
inexpensive |
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Hydromorphone
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8x stonger than morphine
diluted short acting bc so strong |
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Fentanyl
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72 hour patch
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Methadone
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long half life
assess for sedation older adult tolerance? |
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tramdol
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acute and chronic neuropathic pain
not good if on anti-depressant |
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Meperidine
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not oral
not good for older adults: numbness,twitching, confusion decreased creatinine clearance |
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Opiod Side Effects
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NV- antiemetic
COnstipation Sedation respiratory depression- narcan- iv push- wears off quickly |
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PCA
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Patient Controlled Analgesia
ONLY PATIENT CAN PUSH BUTTON |
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Adjuvent Analgesics
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used to enhance the effect of analgesics
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Antiepilieptics
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hard to control neuropathic pain
*watch electrolyte levels |
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Trycycic Antidepressants
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tx of chronic neuropathic pain
--helps with the depression cardiac and seizure patients NO |
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pathogen
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disease-producing microorganism
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communicable
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person-to-person
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pathogenicity
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ability to cause disease
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virulence
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degree of communicability
- frequency |
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Normal Flora
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competes with microorganisms to prevent infections
do NOT cause disease- prevent them! |
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Colonization
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present in tissue but not causing symptoms yet
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Reservoirs
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any place you can get an infection- animal, object, person, insect
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TOxins
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protein molecules that bacteria release in order to hurt the host at some distant site
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exotoxin
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on outside of cell- released into the surrounding environment
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endotoxin
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produced within cell wall
cells must break apart to release toxins |
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Passive Immunity
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short duration
natural or injection of antibodies |
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Active Immunity
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lasts for years
natural by infection or vaccine |
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Contact transmission
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person to person ( direct)
inanimate objects= indirect - pink eye |
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Fecal/Oral
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foodworkers don't have HepA
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Droplet transmission
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Flu
droplets don't stay susended in air |
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Airborne transmission
|
TB
leaves host and enters host BUT these are suspended in air for longer periods of time |
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Vector- borne
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insect or animal carriers
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UTI related to ecoli
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does well in low pH
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Nosocomial
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acquired in the inpatient health care setting which were not present or incubating at admission
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Endogenous
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from clients own flora
*yeast infection when giving an antibiotic |
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Exogenous
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outside the client ( hands of healthcare workers)
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sterilization
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destroys all spores and organisms
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disinfections
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only kills organisms-- doesn't kill spores
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standard precautions
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gloves, masks, gown, goggles
( splash) |
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Airborne
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negative pressure rooms
(air from hallway in) high filtration masks |
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UV lights
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TB and measles
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Droplet
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private or co-hort room
weak mask if close contact |
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COntact
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private or co-hort
gloves, gown, specific equipment |
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Noncompliance
|
someones CHOOSES not to follow drug regime
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Nonadherence
|
accidentally forgot to take their meds
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septicemia
|
SYSTEMIC INFECTION
caused by an infection in the blood |
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Infection : Physical infection
|
pain, swelling, heat, redness, puss, lymphadenopathy, GI upset, sore throat, photophobia, fever > 100.5
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Sensitivity Test
|
24-72 hours
how we treat infection no abx until cultured |
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CBC
|
Complete BLood Count
white cells elevated if infection |
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LEFT SHIFT
|
immature neutrophils
mature= segs immature= bans more bans than segs |
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ESR
|
rate at which red cells move through plasma
TITER will decrease as they become healthy |
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Hyperthermia interventions
FEVER |
eliminate underlying cause
antimicrobial, antipyretic therapy- decrease pain and fever *regular dosing External cooling, fluid administration and NO FANS! sponge with tepid water, hyperthermia blanket |
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Fever
|
fluid loss ( sweating)-- increased thirst, decreased skin tugor, dry mucous membrane---disorientation
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Shivering
|
cooled too quickly using energy to create heat--fever will spike again
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Calcium
|
bone strength, bone density, cardiac muscle contraction, transmit nerve impulses, clotting
8.9-10.1 mg |
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Ca and PTH
|
serum Ca is low--pth released--draw CA into plasma from bones increasing serum level
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CAlcitonin
|
increases and lowers by inhibiting Vtamin D activation
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Hypocalcemia S&S
|
anxiety/confusion/irritability
muscle twitching ( initial painful muscle spasms) trousseau and chvostek sign |
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Trousseu
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inflate bp cuff for 1-4 minutes...will have a palmar flexion
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Chvosteks
|
tap below and front of ear...will cause facial twitching for patient...side of mouth by nose
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Hypocalcemia Tx
|
Acute: calcium gluconate or chloride IV
Chronic: oral replacement with vitamin D |
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Ca Seizures
|
risk of seizures...
take precaution |
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Hypercalcemia causes
|
>10.1
loss of calcium INTO bone plasma prolonged immobility osteoporosis excess intake ( antacids) bone tumors |
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Hyperparathyroidism
|
pulls more Ca from bone ( excess in ECF) kidneys holding onto it
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Hypercalcemia SS
|
personality change
fractures ( serum level is high) excessive clotting |
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Hypercalcemia Management
|
weight bearing exercise
IV NS loop diuretics ambulate |
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Magnesium
|
1.5-2.5
tied in function to Ca low mg= low pth= decreased Ca |
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MEagnesium Functions
|
carb metabolism
produce ATP moves Na and K across cell membrane influences vasodilation cardiac and muscle contractility cofator in clotting cascade |
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Hypomagenesemia CAuses
|
<1.5
alcoholism hospitalized patients uncontrolled diabetes mellitis malabsorption, starvation renal disease ( dumping) |
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Hypomagenesia Symptoms
|
tetany, irritability
Chvostek's sign dysrhtymias, HTN NVAC |
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Hypomag Management
|
slow infusion of MgSo4 NO IM
dietary intake reduce environmental stimuli avoiding laxatives |
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Hypermag Causes
|
>2.5
Chronic renal failure ( not dumping) excessive intake-- ABUSE ANTACIDS--takes lots of laxatives Addison's dehydration untreated diabetic ketoacidosis |
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Hypermag Symptoms
|
>2.5
feeling of warmth BP drops sweating depression bradycardia, weak pulse respiratory weakness CARDIAC DYSRHTYMIA AND MUSCLE TETANY |
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Hypermagnesium Management
|
dialysis if renal failure
IV fluids loop diuretics Ca ( reverse cardiac affects) Diet therapy: limit nuts, beans, fish, whole grains |
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Development
|
occurs gradually and refers to changes in skill and capacity to function
|
|
|
Maturation
|
allows us to adapt and show competence in a variety of situations
|
|
|
Gesells Theory of Develpment
|
genes generate the progression of development
|
|
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Freud
|
psychoanalytic/psycosocial
|
|
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Havighurst
|
cultural pressure conditions create the need to learn social norms
|
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Gould
|
adult only 20s- away from parents
30s- existential crisis 40s- mold is set, show regret 50s- decrease in negativism |
|
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Stella Chess and alexander THomas
|
easy
difficult slow to warm |
|
|
Piaget
|
cognitive developmment
|
|
|
Sensorimotor
|
birth-2
pattern for dealing with environment ( suck, kcik,hit) *object permanence |
|
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Preoperational
|
symbol and metal images
self-centered parallel play make believe |
|
|
Concrete OPerational
|
7-11
do not understand matepahors it is what it is |
|
|
formal operational
|
teens
once you can think abstractly |
|
|
KOhlberg
|
Pre-conventional
conventional POs-conventional |
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|
Preconventional - Kohberg
|
moral reasoning based upon personal gain
|
|
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COnventional - Kohlberg
|
moral reasoning based on society's expectations
|
|
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Postconventional
|
what do actions mean to a larger set of people or soceity
|
|
|
Ethniciity
|
biological attribute
|
|
|
Emic world view
|
insiders or native prospective
|
|
|
Etic world view
|
outsider's perspective
|
|
|
Enculteration
|
as a child, you were born into it
|
|
|
Acculturation
|
adopting and adapting to a new culture
|
|
|
Assimilation
|
occurs when someone gives up their own ethnic idenityt in favor of the dominant
|
|
|
Biculturalism
|
identifies with 2 or more cultures
|
|
|
SYmptoms if DIstress at End of LIfe
|
pain, dyspnea, cheyne-stokes, lethary, restlessness
|
|
|
Kubler-Ros Theory of DEath and Dying
|
Depression
Anger Bargaining Denial Acceptance |
|
|
Hospice CAre
|
<6 months to live
non-curative |
|
|
Nuclear family
|
husband, wife, 1 or more children
|
|
|
Extended Family
|
aunts, uncles grandparents kiving with family
|
|
|
Single-Parent Famioy
|
one parent leaves the nuclear family
|
|
|
Blended-Family
|
parents bring unrelated children from previous relatiosnhip into family
|
|
|
Alternate patterns of relationships
|
multiple adult hoseholds
grandma takes care of child |
|
|
Family as COntext
|
focused really on the individual
|
|
|
Family as Client
|
how the family functions as a whole
|
|
|
Family as a system
|
family and individual fused together
|
|
|
Nable's Rule
|
first day of last period
count back 3 months and add 7 days |
|
|
Fertilization
|
fallopian tubes within 24 hours of ovum being released
|
|
|
Germinal period
|
fertilization-2 weeks
|
|
|
EMbryonic period
|
3rd-8th week
|
|
|
fetal period
|
9thweek- birth
|
|
|
gestation
|
3 trimesters
|
|
|
FIrst trimester
|
organ development
25-35 lb weight gain Folic acid important nausea |
|
|
Second trimester
|
Bundle height- measure of fetal growth
hear heart and first movement premature labor teaching |
|
|
Third trimester
|
lots of weight gain
linugo- fine hair will disappear brain and lungs grow start educating about delivery |
|
|
Teratogen
|
anything that causes structural of functional damage
|
|
|
HEalth risks of INfant
|
THermorgulation ( hard for them)
INfection |
|
|
Newborn
|
smiling spontaneousy
different cries for different needs carseats: backseat/rear-facing on back to sleep ( SIDS) co-sleeping not bed--sharing |
|
|
Infant 1 month-1 year
|
rapid physical changes
cooing, learn from environment 2-3 months: smile becomes purposeful PREVENTION IS PARAMOUNT in safety |
|
|
Cow's milk
|
avoid for first year- hard to digest
|
|
|
@ 6 months
|
start introducing food
|
|
|
@ 7 months
|
teeth appear
|
|
|
Toddler
|
12-36 months
fine motor skills develope put words together MINE redirection is most effective parallel play separation anxiety |
|
|
Pre-schooler
|
3-5 years
interacting socially with peers FEARS |
|
|
School-Age
|
6-12 years
industry vs. inferioroity aware of moral and social codes try to look and act like friends VEHICLE ACCIDENTS--cancer |
|
|
Adolescence
|
13-20 years
identity vs. role confusion ACCIDENTS |
|
|
Impairment
|
abnormality of a body structure or structures or an alteration in a body system function resulting from any cause-- disturbance at the organ level
|
|
|
Disability
|
consequence of an impairement usually described in terms of a clients altered functional ability--disturbance at the personal level
|
|
|
Handicap
|
disadvantage a person feels as a result of impairements and disability
|
|
|
STage 1 Skin Breakdown
|
erythema, dry flakes, skin intact, doesn't blanch with pressure
|
|
|
Stage 2- skin breakdown
|
skin not intact, partial thickness loss of dermis or epidermis, superficial wound, abrasion or blister0like, shallow crader ( broken bister)
|
|
|
Stage 3- Skin breakdown
|
FULL thickness loss, subq is necrotic or dmaged--extends down but not through the fassia, but still deep
|
|
|
Stage 4 - Skin breakdown
|
full thickness, tissue necrosis, dmage to muscle, bone, surrounding structures, sinus tracks, speaparete skin layers
|
|
|
Blood transfusion needle gage
|
18,19 or 20
|
|
|
Blood transfusions
|
whole blood or components ( plasma, RBC, platelets)
|
|
|
Autologous Transfusion
|
collects their own blood for 5 weeks before surgery
1-5 units |
|
|
Before entering patient room for transfusion
|
blood bag, NS, and blood tubing ( plus normal tubing)...blood tubing comes with filter and two spikes
prime tubing with NS 2 NURSES MUST VERIFY |
|
|
Starting transfusion
|
remain with client for 15 minutes
slowly finished infusing within 4 hours tell client to tell you if they feel ANYTHING |
|
|
DIfferent Types of Transfusion reactions
|
Allergic: to blood type
DIsease transmission Circulatory overload |
|
|
Transfusion Reaction
|
immediately clamp the bloodline
spike saline bag and new tubing flush with saline connect to iv hub call for help and vitals notify MD remain with patient save the blood product, tubing |
|
|
Alternative Approaches to restraints
|
re-orientation
distraction keep tubing or equipment out of line of vision overdress the wound pain? appropriate visual cues sitters explain everything familiar things next to bed toileting routines relaxation consistent caregivers |
|
|
Using restrains
|
MD order required!!!
can't be PRN |
|
|
Emergent Restraint
|
go ahead with restraint, have 1 hour for face-to-face, verbal or written order
|
|
|
Restraint order must include
|
type
behavior timeframe ONLY GOOD FOR 24 HOURS new process when writng new order |
|
|
Family COnsent of restraint
|
within 24 hours
|
|
|
Release from restraints
|
every 2 hours
|
|
|
Restraints: Circulation and Neurovascular
|
every 15-30 minutes
|
|
|
Remove Restraints
|
as soon as behavior diminishes
|
|
|
Criteria for Removal
|
improved mental status
bility to engage in a bahvior supervision available remove IV NG tube |
|
|
Documentation of Restraints
|
1 hour- Doc to give order
24 hours- order is good for 2 hour- assessment results 15 minutes- eyes on them 30- circulation and neurovascular |
|
|
Bed Bath
|
eyes, face, arms, axilla, hands, chest, legs, feet, back, perineal care
|
|
|
Eyes ( bath)
|
soak for 2-3 minutes to remove crust
|
|
|
Arms and Legs ( bath)
|
move toward belly buttong
long strokes to promote veinous return |
