FUNDAMENTALS OF NURSING ESSENTIAL CONCEPTS NURSING THEORIES NIGHTINGALE ENVIRONMENTAL ROGERS- UNITARY INTERACTION HENDERSON- ASSIST TO INDEPENDENCE( 14 FUNDAMENTAL

L NEEDS) OREM- SELF CARE DEFICIT KING GOAL ATTAINMENT ROY- ADAPTATION PATERSON / ZDERAD- HUMANISTIC NEEDS LEININGER- TRANSCULTURAL JOHNSON- BEHAVIORAL LEVINE- CONSERVATION PEPLAU- PSYCHODYNAMIC ORLANDO-NURSING PROCESS NEWMAN- HEALTHCARE SYSTEMS MODEL LEVELS OF PREVENTION PRIMARY- HEALTH PROMOTION AND MAINTENANCE(TOTAL PREVENTION OF CONDITION) SECONDARY CURATIVE AND EARLY DETECTION(ERALY RECOGNITION OF CONDITION AND MEASURES TAKEN TO SPEED RECOVERY TERTIARY-REHABILITATION(MINIMIZE EFFECTS OF THE CONDITION AND PREVENT LONG TERM COMPLICATIONS) it is a systematic method that directs the nurse and client as they together determine the need for nursing care, plan and implement the care, and evaluate the result it is a G O S H approach (goal-oriented, organize, systematic, and humanistic care) for efficient and effective provision of nursing care. THE NURSING PROCESS ASSESSMENT- SYSTEMATIC COLLECTION OF DATA TO DETERMINE PATIENTS STATUS AND TO IDENTIFY ANY ACTUAL OR POTENTIAL HEALTH PROBLEMS ANALYSIS/NURSING DIAGNOSIS- IDENTIFICATION OF ACTUAL OR POTENTIAL HEALTH PROBLEMS AMENABLE TO RESOLUTIONS BY NURSING ACTIONS PLANNING- DEVELOPMENT OF GOALS AND A PLAN OF CARE DESIGNED TO ASSIST THE PATIENT IN RESOLVING THE NURSING DIAGNOSIS ( ORGANIZE,ANALYSE,SYNTHESIZE AND PRIORITIZE) (IDENTIFY PROBLEM,PNT.CHARAC. AND ETIOLOGIES) IMPLEMENTATION- ACTUALIZATION OF THE PLAN OF CARE THROUGH NURSING INTERVENTIONS ( COORDINATION,DELEGATION-CAPABILITIES ,LIMITATIONS AND SUPERVISION EVALUATION-DETERMINATION OF PATIENTS RESPONSES TO THE INTERVENTIONS AND EXTENT TO WHICH GOALS HAVE BEEN ACHIEVED(FEEDBACK) Subjective data (symptoms)- described by person experiencing it (e.g. pain, dizziness, vertigo etc.) Objective data (signs)- can be observed (by the use of senses) and measured (e.g. BP 130/90, abdominal rigidity upon palpation, exopthalmus, pallor, redness etc.) ASSESSMENT

OBSERVATION- VISION,SMELL,HEARING,TOUCH INTERVIEWING OPENING , BODY AND CLOSING PERSONAL SPACE VARIABLES-TIME SPACE SEATING ARRANGEMENT,DISTANCE AND CULTURE EXAMINING PHYSICAL EXAMINATION(CEPHALOCAUDAL (HEAD TO TOE) INITIAL ASSESSMENT-SPECIFIED TIME AFTER ADMISSION FOCUS OR ONGOING ASSESSMENT-ONGOING PROCESS INTEGRATED WITH NURSING CARE EMERGENCY ASSESSMENT-DURING ANY PHYSIOLOGIC OR PSYCHOLOGIC CRISIS OF THE CLIENT TIME-LAPSED- SEVERAL MONTHS AFTER INITIAL ASSESSMENT *GOALS SHOULD BE SYSTEMATIC MEASURABLE ATTAINABLE REASONABLE TIME-FRAMED VALUE STANDARDS MORALS STANDARDS OF RIGHT AND WRONG INTUITIONISM NOTION AUTONOMY INDEPENDENCE NON-MALEFICENCE DO NO HARM BENEFICENCE DOING GOOD JUSTICE FAIRNESS FIDELITY FAITHFULLNESS AND COMMITMENT VERACITY TRUTHFULNESS ADVOCACY- INFORMED SUPPORT / ENHANCE AUTOMOMY COMPR. SITUATIONS NO-REFERENCE , INAPPROPRIATE TERMS OR WORDS, JUDEGMENTAL STATEMENTS, ----MONITORING AND DOCUMENTATION TELEPHONE ORDERS- REPEAT ORDER TO THE AP AND LET HIM SIGN WITHIN 24 HOURS STRATEGIES FOR SEXUAL HARASSMENT CONFRONT REPORT INCLUDE WITNESS DOCUMENT SEEK SUPPORT INFORMED CONSENT AGGREED UPON FACTS KNOWN TREATMENT EXPLANATION RISK UNDERSTOOD CONSENT CONSIDERATIONS OB , STD,REHAB ,BLOOD DON. ( MINOR CAN GIVE) ER, LIFE THREATENING(IMPLIED) MENTALLY ILL(INCAPABLE) MODELS FOR DELIVERY OF NURSING CASE METHOD-TOTAL CARE-CONSISTENCY

FUNCTIONAL METHOD-TASK ORIENTED- CENTRALIZED DIRECTION AND CONTROL TEAM NURSING-TEAM COORDINATED CARE-INDIV. ROLES EFFICIENCY PRIMARY NURSING-COMPREHENSIVE,INDVIDUALISTIC, CONSISTENT TECHNICAL KNOWLEDGE AND MNGT.SKILLS CASE MNGT. COMPREHENSIVE CONTINOUS CARE MANAGED CARE- COST CONTAINMENT DIFFERENTIATED-COMPETENCY-DELINEATION Universal Precautions Strict Isolation-highly transmissible diseases by direct contact and airborne routes of transmission Private room,gowns, mask , gloves, handwashing,double bagged techniques for soiled articles Diptheria(pharyngeal),Herpes Zoster, Varicella , Pneumonia( S.Aureus , Strep,group A) Respiratory Isolation-droplet transmission(3 feet) Private rom,patient w/ same organism,mask,handwashing,labelled plastic bags for soiled articles H. influenza, measles, mumps, N. Meningitidis Tuberculosis/ AFB isolation-suspected / active TB Private room with negative pressureventilation so that air room is vented outside, mask, handwashing, bronchoscopy and dental examination postponed until 2 weeks of antibiotic therapy Tuberculosis Contact Isolation infectious disseases or multiple resistant microorganisms that are spread by direct contact or close contact Private room , mask gown , gloves diptheria( cutaneous), Herpes simplex, MRSA , Pediculosis , Scabies , Syphilis Enteric Precautions infectious diseases transmitted through direct or indirect contact with infected feces. Handwashing , gloves , gowns worn only when handling contaminated objects with feces Aseptic meningitis, AGE , Hepa A , Typhoid fever, diarrhea (CDT ) Drainage / Secretions precautions patients with wound drainage or infected wounds Gloves, gowns indicated if clothing is likely to be contaminated Burns Universal Blood and Body fluids precautions blood borne , body fluids pathogens ( blood , semen , vaginal secretions , CSF , synovial fluid , pleural fluid , peritoneal fluid , pericardial fluid , amniotic fluid and tissues. Gloves , mask, protective eyegears, gown , contaminated needles not recapped and sharps in puncture resistant containers Aids , Hepatitis B and C , STDs Patient is protected from pathogens and nosocomial infections by instituting reversed transmission precautions Burns and open wounds, patients with artificial airway , immunocompromised patients leukemia , AIDS , steroid therapy , radiation or cancer chemotherapy , medication effect of leukopenia or agranulocytosis

GAS ALARM-RESISTANCE-EXHAUSTION COPING AND STRESS MANAGEMENT ANXIETYMILD SLIGHT AROUSAL AND INCREASED PERCEPTION MODERATE-INC. TENSION AND SELECTIVE INATT. SEVERE DEC. PERCEPTION AND FOCUSSED ENERGY PANIC OVERPOWERING AND LOSS OF CONTROL POSITIONING FOR SPECIAL CONDITIONS ABDOMINAL ANEURYSM SURGERY-FOWLERS ASTHMA ORTHOPNEIC POSITION AUTNOMIC DYSREFLEXIA-HIGH FOWLERS POST BRONCHOSCOPY-SEMI FOWLERS CARDIAC CATHETERIZATION-KEEP INSETION SITE EXTENDED FOR 4-6 HOURS TO PREVENT ARTERIAL OCCLUSION CAST ELEVATE EXTREMITY CATARACT SEMI FOWLERS CEREBRAL ANEURYSM SEMI - FOWLERS CLEFT LIP SUPINE CLEFT PALATE PRONE CHF HIGH FOWLERS CRANIOTOMY SUPRATENTORIAL SEMI FOWLERS ;INFRATENTORIAL FLAT ICP LEVATE HEAD DUMPING SYNDROME SUPINE AFTER MEALS EPISTAXIS LEAN FORWARD FLAIL CHEST AFFECTED SIDE FEMORO-POPLITEAL BYPASS GRAFT AFFECTED EXTREMITY EXTENDED GLAUCOMA(POST OP) AFFECTED SIDE HEMORROIDECTOMY SIDE LYING HIATAL HERNIA- UPRIGHT HIP SURGERY LEGS IN ABDUCTION LAMINECTOMY BACK AS STRAIGHT AS POSSIBLE LIVER BIOPSY RIGHT SIDE LYING LOBECTOMY SEMI FOWLERS POST LP FLAT MASTECTOMY ELEVATE EXTREMITY ON PILLOW MYELOGRAM WATER BASED DYE ELEVATE THE HEAD --- OIL BASED DYE - FLAT POSTURAL DRAINAGE LUNG SEGMENT UPPERMOST POSITION PROLAPSED CORD KNEE-CHEST PULMONARY EDEMA FOWLERS PYLORIC STENOSIS RIGHT SIDE LYING RADIUM IMPLANT FLAT ON BED RETINAL DETACHMENT AFFECTED SIDE TOWARDS THE BED SEIZURE SIDE-LYING SHOCK MODIFIED TRENDELENBURG SCI IMMOBILIZE TONSILLECTOMY SIDELYING / PRONE THYROIDECTOME SEMI FOWLERS THROMBOPHLEBITIS ELEVATE LEG TPN TRENDELENBURG DURING INSERTION THORACENTESIS FOWLERS(DURING) AFTER POSITION OF COMFORT THERAPEUTIC DIET FOR SPECIFIC CONDITIONS AGE CLEAR LIQUID AGN LOW NA , LOW CHON

STRESS

ADDISONS HIGH NA , LOW K ANEMIA , PERNICIOUS HIGH CHON , VIT. B. ANEMIA SICKLE CELL HIGH FLUID GOUT PURINE RESTRICTED ADHD AND BIPOLAR FINGER FOODS BURN HIGH CAL. HIGH CHON CELIAC GLUTEIN FREE CHOLECYSTITIS HIGH CHON, HIGH CARB, LOW FAT CHF LOW NA , LOW CHOL. CROHNS HIGH CHON AND CHO, LOW FAT THERAPEUTIC DIET FOR SPECIFIC CONDITIONS CYSTIC FIBROSIS HIGH CAL., HIGH NA LITHIASIS----ACID ASH FOR ALK. STONES------ALK. ASH FOR ACID STONES DECUBITUS ULCERS HIGH CHON , HIGH VIT C DIARRHEA HIGH K AND NA DUMPING SYNDROME HIGH FAT, HIGH CHON,DRY HEPATIC ENCEPHALOPATHY-LOW CHON HEPATITIS HIGH CHON,HIGH CAL. HIRSPRUNGS LOW RESIDUE, HIGH CHON AND CHO

CIRRHOSIS LOW CHON MENIERES LOW NA MI AND HPN LOW CHOL.,FATS,NA HYPERTHYROIDISM- HIGH CAL. AND CHON HYPOTHYROIDISM LOW CAL. , LOW CHOL, LOW SAT. FAT NEPHROTIC SYNDROME LOW NA, HIGH CHON , HIGH CAL. HYPERPARATHYROIDISM LOW CALCIUM HYPOPARATHYROIDISM HIGH CA, LOW PHOSPHORUS OSTEOPOROSIS HIGH CALCIUM AND HIGH VIT. D PANCREATITIS LOW FAT PUD HIGH FAT, HIGH CARB. LOW CHON PKU LOW CHON / PHENYLALANINE PIH HIGH CHON RENAL FAILURE (ACUTE) LOW CHON,HIGH CARB LOW NA (OLIGURIC PHASE) HIGH CHON , HIGH CAL AND RESTRICTED FLUID (DIURETIC PHASE RENAL FAILURE (Chronic) LOW CHON , LOW NA , LOW K