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mutilation Anti Social - habitual break of law, no guilt Dependent - demand for attention,low confidence Schizoid – withdrawn, “baduy”, introvert, aloof Schizotypal - low social skills, odd, eccentric Histrionic – “KSP”, attention seeker, extrovertAvoidant – fear of criticism, fear of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