2. Types of Hygienic Care TIME PROCEDURE MATERIALS PURPOSE Early morning offer urinal/bedpan, wash face & hands, & give oral care bedpan/ urinal Done in preparation for breakfast and increase appetite Morning Bath/shower, perineal care, & oral, nail & hair care bedpan/ urinal after breakfast, in preparation for diagnostic procedures Afternoon washing hands & face, oral care, & backrub bedpan/ urinal relaxation and refreshing the client Hours of Sleep(HS) Elimination needs, washing face and hands & oral care Back massage Bedpan/ urinal in preparation for sleep As needed (prn) Care as needed
3. - transfer of heat between two objects without contact - 60 % of heat in a nude person standing in a room at normal temperature RADIATION CONDUCTION HEAT TRANSFER - transfer of heat from one molecule to a molecule of lower temperature or with contact - body is immersed in cold water
4. CONVECTION EVAPORATION/ APORIZATION - dispersion of heat by air currents - body has usually a small amount of warm air adjacent to it - continuous evaporation of moisture from respiratory tract, mouth and skin. - also insensible water loss/insensible heat loss; 10% basal heat loss
5. RISK FOR SKIN INTEGRITY ON TEENAGER Increase activity of hormone testosterone Produce excess sebum Clogs the skin pores Bacteria gets the proper environment to grow and multiply Infection, swelling and inflammation
17. MANAGER LEADER Are given the position Take the initiative to lead Organize and staff Align people with direction Emphasize tactics, structure and systems Emphasize philosophy, core value and shared goals Focus on the present Focus on the future Avoid risks Takes risks Motivate 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
18. Levels of Anxiety Degree of Anxiety Characteristics Reaction Nursing Management Mild (+) * increased level of perception * well developed and effective problem solving *increase level of intelligence Psychological reaction Encourage to verbalize feelings ( Tell me more) Acknowledge feelings Moderate (++) * Narrowed perception *selective inattention *Pacing Psycho physiological reaction * relaxation technique *assist the patient *give PRN medication(anxiolytics) Severe (+++) *perception is greatly reduced *Doesn’t know what to do and say Neurologic reaction *stay with the patient all the time *give clear directions without touching *instruct the client what to do Panic (++++) *distorted reality *hyperventilating (doom/edge) Psychotic reaction * brown paper bag
20. DIET INDICATION PURPOSE LIMIT ENCOURAGE TO: Low Sodium Diet Hypertension Edema due to: - CHF, Liver cirrhosis, Nephrotic Syndrome, PIH To DECREASE sodium/ fluid load canned food, salted food, smoked meat, ham, bacon, sauce Salt Substitute: Potassium Chloride LOW CHOLESTEROL DIET Cardiovascular Disease Diabetes Mellitus To DECREASE risk for CAD FRIED FOODS, EGG YOLK, SHELL FISH, LIVER, PORK BROILED OR STEAMED FOOD, FRUITS, VEGETABLES, CHICKEN MEAT, VEGETABLE OILS
21. DIET PURPOSE LIMIT BLAND DIET promotes healing of the gastric mucosa and is chemically and mechanically nonstimulating Soft diet without spices
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24. DISEASES DETECTED BY NEWBORN SCREENING DISEASE SIGNS & SYMPTOMS INTERVENTION PKU (Phenylketonuria) - Is the inability to process phenylalanine a component in making protein in the body, high phenyl causes MR -vomiting -seizures -musty odor of the urine -mental retardation -hypertonia -hypopigmentation -hyperactive behavior - Newborn screening - Rescreen the infant by 14 days of age if the NBS was done before 48 hours of age - Restrict pheylananine intake(instead Lofenalac ) - Avoid high protein food
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26. DISEASE SIGNS & SYMPTOMS INTERVENTION Galactosemia - is the inability of the body to use (metabolize) the simple sugar galactose accumulation of galactose 1-phosphate in the body causes damage to the liver, CNS, and other body systems. - autosomal recessive - jaundice - vomiting - poor feeding - poor weight gain - lethargy - irritability - convulsions - galactosemia - strictly avoiding all milk and milk-containing products - soy formula - meat-base formula - nutramigen (a protein hydrolysate formula) - calcium supplements are recommended - read products labels and be an informed consumer
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28. Intervention: - cortisol (dexamethasone, fludrocortisones, or hydrocortisone) - chromosomes (karyotyping) - reconstructive surgery for girls with masculine external genitalia(1-3months) Boys - increasingly muscular - penis enlarges - pubic hair appears - voice deepens - appear to enter puberty as early as 2-3 years of age - puberty testes are small
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39. OLDCART METHOD O- onset of pain L- location of pain D- duration of pain C- characteristic of pain A- aggravating factors R –radiation of pain T- treatment PQRST mnemonics P- provoked ( what brought about pain) Q- quality of pain R- region or radiation of pain S- severity T- timing MNEMONICS FOR PAIN ASSESSMENT
40. ADVENTITIOUS BREATH SOUNDS NAME CAUSE LOCATION Crackles (rales) Air passing through fluid or mucus in any air passage Most commonly heard in the base of the lower lung Gurgles (ronchi) Air passing through narrowed air passage as a result of secretions, swelling and tumors Loud sounds can be heard over most lung area but predominate over the trachea and bronchi Friction rub Rubbing together of inflamed pleural surfaces Heard in most areas of greatest thoracic expansion Wheeze Air passing through constricted bronchus as a result of secretions, swelling and tumors Heard all over the lungs
