PROMOTING WELLNESS THROUGH LIFE

SPAN
GROWTH AND

DEVELOPMENT CONCEPTS
Theories of personality development

Psychosexual
Psychosocial
Cognitive
Developmental tasks
Moral
Interpersonal

Freuds psychosexual theory

Libido – inner drive
Parts of body –focus of gratification
Unsuccesful resolution - fixation
Structures of personality

Id – pleasure principle-instinct


Ego – controls action and perception –reality principle



Superego – moral behavior - conscience



0-18 m0s ;oral – mouth – trust and discriminating

18 mos. – 3 years ; anal – bowels – holding on or letting go
 Negativism and toilet training age
 3 -6 years phallic ; genitals –exploration and discovery ( inc.
sexual tension)
Gender identification and genital awareness
Oedipus and Electra complex //
Castration anxiety and penis envy

6-12 years –latency (quiet stage) sexual energy diverted to play.

Institution of superego…control of instinctual impulses
12 – young adult – genital ; reawakening of sexual drives –
relationships
Sexual maturation
Sexual identity ,ability to love and work

Psychosocial – Erickson
developmental milestones //delay
0-12mos; TRUST
1-3y AUTONOMY
3-6 INITIATIVE
6-12 INDUSTRY
12-18 IDENTITY
18-25 INTIMACY
25-60 GENERATIVITY
60 and above EGO INTEGRITY
INFANCY
CONSISTENT MATERNAL –CHILD INTERACTION –
TRUST
INNER FEELING OF SELF WORTH

 HOPE
TODDLER
ALLOW EXPLORATION
PROVIDE FOR SAFETY
NO NO – NEGATIVISM
OFFER CHOICES / REVERSE PSYCHOLOGY
TOILET TRAINING – 18 MOS.-BOWEL
DAYTIME BLADDER -2 Y

NIGHTIME BLADDER 3 Y


REWARD W/ PRAISE AND AFFECTION



INDEPENDENCE

PRE-SCHOOL
PROVIDE PLAY MATERIALS
SATISFY CURIOSITY
TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)
SIBLING RIVALRY

 WILLPOWER
SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS
CHUMS AND HOBBIES

 NEEDS TO EXCEL/ACCOMPLISH
NEED FOR PRIVACY AND PEER INTERACTION
 COMPETENCE
ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS
BODY IMAGE CHANGES

 NEED TO CONFORM BUT KEEP INDIVIDUALITY

 SELF - AWARENESS
YOUNG ADULT
 COMMITMENT AND FIDELITY
 RESPONSIBILITY

 ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS
MIDLIFE CRISIS

ADJUSTMENT AND COMPROMISE



MOST PRODUCTIVE AND CREATIVE



ALTRUISM
LATE ADULTHOOD
 SELF ACCEPTANCE

 SELF WORTH

WISDOM

PIAGET’S COGNITIVE THEORY

0-2 SENSORIMOTOR
REFLEXES
IMITATIVE REPETITIVE BEHAVIOR
SENSE OF OBJECT PERMANENCE AND SELF SEPARATE
FROM ENVT.
TRIAL AND ERROR RESULTS IN PROBLEM SOLVING
 2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC
CANNOT CONCEPTUALIZE OTHER’S VIEW
ANIMISTIC THINKING
IMAGINARY PLAYMATE – SYMBOLIC MENTAL
REPRESENTATION – CREATIVITY
2-4 PRE-CONCEPTUAL (PRE-LOGICAL)
4-7 INTUITIVE (UNDERSTANDING OF ROLES)

7-12Y CONCRETE OPERATIONAL

LOGICAL CONCRETE THOUGHT
INDUCTIVE RESAONING (SPECIFIC TO GENERAL)
CAN RELATE ,PROBLEM SOLVING ABILITY
REASONING AND SELF-REGULATION

12-ABOVE FORMAL OPERATIONAL

THOUGHT
Abstract thinking
Separation of fantasy and fact
Reality oriented
Deductive reasoning
Apply scientific method

Havighurst
Developmental Tasks
 Baby to early childhood
Right from wrong and Conscience
 Late childhood
Physical skills,wholesome attitude,social roles
Conscience morality and values
 Fundamental skills in academics
Personal independence

 Adolescence
Sexual social roles
Relationships
Independence and ideology

Early adulthood

Career
Selecting a mate
Finding Civic or social responsibility

Middle age

Achieving Civic or social responsibility
Adjusting to changes
Satisfactory career performance
Adjusting to aging parents
Adjusting to parental roles

Old age

Adjusting to changes
Establishing satisfactory living arrangements and affiliations

Kohlberg – MORAL DEVELOPMENT/

THINKING/ JUDGEMENT
 PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE
OBEDIENCE TO RULES TO AVOID PUNISHMENT

 CONVENTIONAL ( 6-12 )
MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS
AND CONFORMITY
 SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE
BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

POST –CONVENTIONAL (12 – 18 Y)

PRIOR RIGHT OR SOCIAL CONTRACT
UNIVERSAL ETHICAL PRINCIPLE
ABIDE FOR COMMON GOOD
RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND
BECOME COMMITTED TO THEM
INNER CONTROL OF BEHAVIOR UNDERSTANDING THE
EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN
BEINGS AS INDIVIDUALS

SULLIVANS
INTERPERSONAL
THEORY

INFANCY
NEED FOR SECURITY-INFANT LEARNS TO RELY ON
OTHERS TO GRATIFY NEEDS AND SATISFY WISHES,
DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND
SELF WORTH WHEN THIS OCCURS

TODDLERHOOD / EARLY CHILDHOOD

CHILD LEARNS TO COMMUNICATE NEEDS THROUGH
USE OF WORDS AND ACCEPTANCE OF DELAYED
GRATIFICATION AND INTERFERENCE OF WISH
FULFILLMENT
 PRE-SCHOOL
DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION
ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL
AND DISAPPROVAL RECEIVED
BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES
THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL
DISCOMFORT AND PAIN
SCHOOL AGE
THE PERIOD OF LEARNING TO FORM SATISFYING
RELATIONSHIPS WITH PEERS-USES
COMPETITION,COMPROMISE AND COOPERATION
THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS
OF THE SAME SEX
ADOLESCENCE
LEARNS INDEPENDENCE AND HOW TO ESTABLISH
SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE
OPPOSITE SEX
YOUNG ADULTHOOD
BECOMES ECONOMICALLY, INTELLECTUALLY AND
EMOTIONALLY SELF SUFICIENT
LATER ADULTHOOD
LEARNS TO BE INTERDEPENDENT AND ASSUMES
RESPONSIBILITY FOR OTHERS
SENESCENCE
DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR
WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW
OF HISTORY

FORMATION OF PERSONALITY

CERTAIN GOALS MUST BE ACCOMPLISHED, IF THIS

GOALS ARE NOT ACCOMPLISHED AT A CERTAIN
STAGE,….PERSONALITY WILL BE WEAKENED….
 FACTORS IN EACH STAGE PERSISTS AS A PERMANENT
PART OF PERSONALITY….

EACH STAGE HAS MAJOR TRAUMAS AND

FRUSTRATIONS THAT MUST BE OVERCOME
…….SUCCESSFUL RESOLUTION OF CONFLICTS
ASSOCIATED WITH EACH STAGE IS ESSENTIAL TO
DEVELOPMENT…..UNRESOLVED CONFLICTS REMAIN
IN THE UNCONSCIOUS AND MAY, AT TIMES, RESULT IN
MALADAPTIVE BEHAVIOR
PREVENTION AND EARLY DETECTION
OF DISEASE
GROWTH AND DEVELOPMENT
DEVELOPMENTAL TASKS---MILESTONES ----
DELAYS(FIXATIONS/LAG)

 IQ = MA / CA X 100
 JUDGEMENT , COMPREHENSION AND LISTENING

 DDST – BIRTH TO 6 YEARS

PERSONAL SOCIAL, FINE , GROSS MOTOR AND LANGUAGE SKILL
AREAS

HEALTH SCREENING
OB – GYNE / REPRODUCTIVE TESTS

UTZ-5 WKS CONFIRM PREGNANCY AND AOG
AMNIOCENTESIS – 16 WKS-DETECT GENETIC DISORDERS – 30 WEEKS – L/S RATIO ( 2-4
WKS RESULT)(EMPTY Bladder)
OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS
OBTAINED WITHIN 10 MINUTES- REACTIVE
NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR ACCELERATION OF
15BPM/MORE LASTING 15 SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE
– REACTIVE
DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION)
AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE DEFECTS – 16-18 WKS
CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-12 WKS

NEWBORN/INFANT HEALTH SCREENING

PKU – GUTHRINE BLOOD TEST-EAT CHON FOR 2 DAYS
MIN.(PHEONISTICS – DIAPER)
SICKLE CELL DISEASE –ABNORMALLY SHAPED Hg ,
ELISA AND WESTERN BLOT
CARRIER SCREENING FOR CYSTIC FIBROSIS AND
SWEAT CHLORIDE TEST

SCHOOL AGE
 HEARING AND VISION TESTS
ALLEN PICTURE CARDS
SNELLEN CHART-20/40 AT TODDLER AND 20/20 AT SCHOOL
AGE
WEBER’S-SENSORINEURAL AND CONDUCTIVE
RINNE’S- CONDUCTIVE
DENTAL EXAM – STARTS AT 2 YEARS

ADOLESCENT
PPD – INDURATION – 72 HOURS
BSE – (18-20 YRS.) POST MENSTRATION/MONTHLY
TSE – MONTHLY (18-20 YRS)
PELVIC EXAM WITH PAP SMEAR – IF SEXUALLY ACTIVE
OR 18 Y.O. ANNUALLY
ADULT/ELDERLY
HPN , DM, HEARING AND VISION
PROSTATE –ANNUALLY@40
Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO
SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS
FECAL OCCULT BLOOD TEST- > 50 = ANNUALLY
DIGITAL RECTAL EXAM - > 40 Y.O. = YEARLY
PELVIC EXAM – 18-40 Y.O. =PERFORMED Q 1 – 3 YEARS WITH PAP
TEST
MAMMOGRAM – 35-39 = BASELINE
40-49 = Q2Y
50 AND OLDER = QYEAR
 BP SCREENING(mmHg)
IMMUNITY pg 127-130
CONTRAINDICATIONS:

SEVERE FEBRILE ILLNESS
LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED
ALLERGIES
RECENTLY ACQUIRED PASSIVE IMMUNITY(BLOOD TRANSFUSION AND
IMMUNOGLOBULINS)
 if child –no evidence of immunization <7 y.o.
Give DPT,TOPV,TINE
4-6 WKS LATER MMR
1 MONTH AFTER DPT AND TOPV
REPEATED IN ANOTHER MONTH
AGAIN IN 10-16 MOS.

 CAN GIVE DPT,MMR,TOPV, AND TINE SIMULTANEOUSLY

TD- 2 DOSES 4-8 WKS APART;3RD DOSE 6-12 MOS;BOOSTER AT 10

YRS FO LIFE
RD
OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3 DOSE 2 -12 MOS
ND
AFTER 2 (OPV NOT USED IN US)
MMR-ONE DOSE – 12 MOS
VARICELLA – TWO DOSES 4-8 WEEKS APART STARTS AT 12 MOS.
ND
HEPA B – 3 DOSES;2 1-2 MOS AFTER;3RD 4-6 MS AFTER
PPV- ONE DOSE ;IF 65 AND RECEIVED > 5YEARS – ADMINISTER
INFLUENZA –ANNUALLY EACH FALL

ALLERGY CONTRAINDICATIONS
EGGS – INFLUENZA , MMR
NEOMYCIN – VARICELLA,IPV,MMR
YEAST – HEPA-B
GELATIN – VARICELLA

PREGNANCY C/I: MMR AND VARICELLA

IMMUNOSUPPRESSED; VARICELLA
WITH Ig or BT PREVIOUS 3-11 MOS – MMR AND VARICELLA

CONSIDERATIONS-IMMUNIZATION
DPT - IM – ANTERIOR OR LATERAL THIGH

 FEVER AND SWELLING 24-48 H POTENTIAL
SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC AND SCREAMING

 MMR – SC – ANTERIOR OR LATERAL THIGH

 RASH, FEVER ARTHRITIS-10DAYS-2 WKS
 TRIVALENT OPV – PO

PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS –

EVALUATED 48-72 HOURS

PHYSICAL ASSESSMENT
TEACHING OPPURTUNITY
INSPECTION –VISUALLY
 PALPATION-WARM HANDS
DORSUM OF FINGERS FOR TEMP
PERCUSSION-DIRECT,INDIRECT,BLUNT

RESONANCE-MODERATE LOW PITCHED CLEAR HOLLOW(LUNG)
HYPERRESONANCE-OVERINFLATED(EMPHYSEMA)
TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL)
DULL-SOFT MUFFLED,DENSE FLUID FILLED TISSUE(LIVER)
FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-(MUSCLE/BONE)

AUSCULTATION-
DIAPHRAGM-HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW
PITCHED(HEART MURMURS)

VITAL SIGNS
 TEMPERATURE:
ORAL – 98.6 ‘F / 37 ‘C
RECTAL – 99.6 ‘F / 37.6’C
AXILLARY – 97.6’F / 36.5’C

NORMAL VITAL SIGNS

NEWBORN=30 – 50 / MIN; 120 – 140 / MIN; 60/40 – 80/50
mmHg

1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN; 90/60 – 99/65

mmHg
5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60
mmHg

ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –140 / 90

mmHg
BREATHING PATTERNS
CHEYNE STOKES – PERIODIC BREATHING CHARACTERIZED BY RHYTMIC
WAXING AND WANING
DYSPNEA - LABORED PAINFUL BREATHING
HYPERVENTILATION – ABNORMALLY RAPID DEEP PROLONGED
BREATHING
KUSSMAULS – AIR HUNGER , MARKED INCREASE IN DEPTH AND RATE
TACHYPNEA – FAST SHALLOW BREATHING
PARADOXICAL – FLAIL CHEST , DEFLATES DURING INHALATION
BIOT’S – SHALLOW BREATHS INTERRUPTED BY APNEA

NORMAL FINDINGS
PULSE PRESSURE – 30-40 mmHg
Intracranial pressure – 10 mmHg
PULSE DEFICIT – MINIMAL(3-5 ACCEPTABLE)

 IDEAL BODY WEIGHT –

MALES -106 LBS FOR 1ST 5FT THEN ADD 6LBS/INCH
ST
FEMALE – 100LBS FOR 1 5 FT THEN ADD 5LBS/INCH
ADD OR SUBTRACT 10% DEPENDING ON BODY FRAME.
OBESE AND UNDERWEIGHT IF DEVIATION IS > 20%

SKIN
SCARS,BRUISES AND LESIONS
CHECK COLOR
EDEMA – GRADING
0-NO EDEMA
1-BARELY DETECTABLE
2-INDENTATION<5MM
3-INDENTATION 5-10MM
4-INDENTATION >10MM

PRESSURE SORE –GRADING


1-NONBLANCHABLE ERYTHEMA
2-EPIDERMIS,PARTIAL THICKNESS
3-FULL DERMIS AND SQ
4- SUPPORTING TISSUES AND BONES

TURGOR-PINCH SKIN TENTED 3 SECS NORMAL(ELDERLY-OVER STERNUM)



HAIR AND NAILS

 HIRSUTISM-EXCESS
 ALOPECIA-THINNING

SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING

ANGLE > 180 DUE TO PROLONGED DECREASED
OXYGENATION
BLANCHING =< 3 SECS-NORMAL

HEAD
SYMMETRY, SIZE AND SHAPE
CRANIAL NERVE ASSESSMENTS
OPTIC-SNELLEN
OCULOMOTOR- PERRLA
TRIGEMINAL – BITE DOWN AND STROKES WITH COTTON
FACIAL – FACIAL MOVEMENT AND TASTE
ACCOUSTIC – HEARING AND BALANCE(WATCH TICK TEST,OTOSCOPIC
EXAMS AND POSTURE TESTS)
GLOSSOPHARYGEAL-GAG AND SWALLOW
VAGUS- SWALLOWING AND SPEAKING

EYES
PTOSIS-DROOPING OF THE UPPER EYELID
ASTIGMATISM – UNEVEN CURVATURE OF CORNEA LEADING TO
REFRACTION ERRORS
NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE MOVEMENTS
STRABISMUS-ASSYMETRICAL LIGHT EFLECTION ON EACH CORNEA
RED REFLEX FROM RETINA-NORMAL
COVER UNCOVER TEST – DET.EYE ALIGNMENT
SNELLEN – FAR DISTANCE VISION/VISUAL ACUITY
IOP-TONOMETRY TESTS INDENTATION(6-12)

EARS
PINNA BACK-UP-ADULT;DOWN-BACK-CHILD
RINNE TEST – COMPARES AIR CONDUCTION WITH BONE
CONDUCTION,VIBRATING FORK PLACED ON THE MASTOID IF
SOUND NO LONGER HEARD POSITIONED IN FRONT OF EAR
CANNAL. SHOULD HEAR A SOUND= 2:1 ; AIR CONDUCTION >
THAN BONE CONDUCTION ;= POSITIVE RINNE
ASSESS CONDUCTIVE HEARING LOSS
EARS
 WEBER – SENSORINEURAL AND CONDUCTIVE HEARING LOSS
 FORK PLACED MIDDLE OF FORE HEAD,SHOULD BE HEARD
EQUALLY=WEBER NEGATIVE
 IF NOT EQUAL=SENSORINEURAL HEARING LOSS.
SOUND HEARD BETTER IN THE IMPAIRED EAR=BONE CONDUCTIVE
HEARING LOSS, IF VICE VERSA = SENSORINEURAL DISTURBANCE
NECK,MOUTH AND PHARYNX
TEETH-32
TONSILS – NO TPC , + GAG REFLEX
CERVICAL LYMPH NODES=<1CM
CAROTID – PALPATE THRILL,LISTEN BRUIT
JUGULAR VEINS – NOT DISTENDED
TRACHEA-MIDLINE

THORAX AND LUNGS

APL DIAMETER-1:2 – 5:7

1:1 = BARREL CHEST


TACTILE FREMITUS NORMAL-BRONCHOPHONY,EGOPHONY AND

WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGS
BREATH SOUNDS
VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –PERIPHERAL LUNG SURFACES
BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM BRONCHI
BRONCHIAL- LOUD COARSE - TRACHEA

ADVENTITIOUS BREATH SOUNDS


RALES-FINE SHORT,CRACKLING OR HIGH PITCHED SOUNDS-INSPIRATION
RHONCHI-CONTINOUS LOW PITCHED COARSEGURGLING HARSH SNORING BEST
HEARD ON EXHALATION
WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION
STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON INHALATION
FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ LIKE VIBRATIONS – BOTH
INHALATION AND EXHALATION

HEART SOUNDS
AORTIC AND PULMONIC VALVE AREAS- 2ND ICS, R AND L
RESPECTIVEY
RD
ERBS POINT 3 ICS
TH
TRICUSPID AREA-4 / 5TH ICS
TH
MITRAL AREA – 5 ICS , LEFT MCL
TH
PMI-5 ICS MCL –(INFANTS-LATERAL TO LEFT NIPPLE-4TH ICS)
S1LUBB-CLOSURE OFAV VALVES
S2DUBB-CLOSURE OF SEMILUNAR VALVES
MURMURS , GALLOP-ABNORMAL HEART SOUNDS

PERIPHERAL VASCULAR SYSTEM

ASSESS PAIN,PALLOR,PARALYSIS,PARESTHESIASAND
PULSES.
ASSESS HOMAN’S SIGN
PULSE DEFICIT

BREASTS
START – UPPER OUTER CLOCKWISE
ASSESS FOR SIZE,SHAPE,SYMMETRY AND NODES

ABDOMEN
DORSAL RECUMBENT
INSPECT,AUSCULTATE,PERCUSS AND PALPATE
BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20
SECOND INTERVALS( 5-25/MIN NORMAL)
IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS. MORE.
SEQUENCE IS CLOCKWISE FROM RLQ
HYPOACTIVE < 3
HYPERACTIVE =CONTINOUS,LOUD,FREQUENT
TINKLING SOUND – BOWEL OBSTRUCTION

ABDOMEN
REBOUND TENDERNESS- INFLAMMATION OF
PERITONEUM
KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLE


KIDNEY PUNCH TEST



MUSCULOSKELETAL SYSTEM
MUSCLE TONE AND STRENGTH

0=COMPLETE PARALYSIS
1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE
2=25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT
3=50% - NORMAL MOVEMENT AGAINST GRAVITY
4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE
5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE

JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS ARE ABNORMAL

FASCICULATION ABNORMAL CONTRACTIONS AND SHORTENING OF
MUSCLE FIBERS
TREMOR-INVOLUNTARY TREMBLING
TEST FOR ROM AND ASSESS FOR
ATROPHY/HYPERTROPHY/CONTRACTURES
 NEUROLOGIC TESTS
MENTAL STATUS-

LANGUAGE-CEREBRAL CORTEX-APHASIA
ORIENTATION(TIME,PLACE,PERSON)(CONFUSION)
MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY
ATTENTION SPAN AND CALCULATION
JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL VIEWS
PERCEPTION – SENSORY ANALYSIS AND INTEGRATION

 CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT

TOUCHING,ALTERNATING MOVEMENTS,GAIT
 CRANIAL NERVE FUNCTIONS
SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSE-
RHOMBERG’S TEST)
NEUROLOGIC TESTS
 DEEP TENDON REFLEX
 0-NO REFLEX
+1 – MINIMAL ACTIVITY(HYPOACTIVE)
+2 – NORMAL RESPONSE
+3 – MORE ACTIVE THAN NORMAL
+4 – MAXIMUM ACTIVITY ( HYPERACTIVE)

PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN

ADULT SIGNIFIES CNS PATHOLOGY
LEVEL OF CONSCIOUSNESS
GLASGOW COMA SCALE=15 POINTS, 7 COMA

EYE OPENING

SPONTANEOUS=4
TO VERBAL COMMAND=3
TO PAIN=2
NO RESPONSE=1

MOTOR RESPONSE

TO VERBAL COMMAND=6
TO PAINFUL STIMULI/LOCALIZES PAIN=5
FLEXES AND WITHDRAWS=4
DECORTICATE=3
DECEREBRATE=2
NO RESPONSE=1

VERBAL RESPONSE

ORIENTED,CONVERSES=5
DISORIENTED,CONVERSES=4
USES INAPPROPRIATE WORDS=3
USES INCOMPREHENSIBLE SOUNDS=2
NO RESPONSE=1

ASSESSING MOTOR FUNCTION

 WALKING GAITS
ROMBERGS TEST- STAND FEET TOGETHER ARMS RESTING AT
THE SIDES,EYES OPEN THEN CLOSED. NEG. ROMBERG – MAY
SWAY BUT KEEPS BALANCE.
SENSORY ATAXIA-CANNOT BALANCE EYES SHUT
CEREBELLAR ATAXIA-CANNOT BALANCE EYES SHUT OR EPON

 HEEL-TOE WALKING AND VICE VERSA

FINGER TO NOSE TEST AND OTHER SENSORY FUNCTION TEST
(ONE AND TWO POINT DISCRIMINATION)
 EXTINCTION PHENOMENON-SYMMETRICAL AREAS ARE
TOUCHED BUT SENSATION ON ONE SIDE CANNOT BE FELT
INDICATES LESIONS OF SENSORY CORTEX
GENITALIA , ANUS AND RECTUM
ASSESS APPEARANCE AND ORIFICES AND INGUINAL LYMPH NODES
INSPECT CERVICAL OS AND VAGINA-SPECULUM
DEVIATIONS
CYSTOCELE, RECTOCELE,ENTEROCELE
HYPO AND EPISPADIAS-URETHRAL OPENING DISPLACED
HERNIAS-DIRECT,INDIRECT , FEMORAL
INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE

DIGITAL RECTAL EXAM –INSPECTION AND PALPATION –POSITION

BOTH=SIM’S , FEMALES – LITHOTOMY;MALES =STAND AND BEND
FORWARD
PROSTATE GLAND-4 CM ;CERVIX = 2-3 CM
HEMORRHOIDS =DILATED VEINS

STRESS , ANXIETY AND CRISIS

SELF- AWARENESS
SELF CONCEPT – COLLECTION OF FEELING BELIEFS
ABOUT ONE’S SELF
SELF ESTEEM – CONFIDENCE IN ONE’S ABILITIES AND
JUDGEMENT

 ASSERTIVENESS

 + SELF - EVALUATION
STRESS
GAS – ALARM-RESISTANCE-EXHAUSTION
COPING AND STRESS MANAGEMENT
ANXIETY-
MILD – SLIGHT AROUSAL AND INCREASED PERCEPTION
MODERATE-INC. TENSION AND SELECTIVE INATT.
SEVERE – DEC. PERCEPTION AND FOCUSSED ENERGY
PANIC – OVERPOWERING AND LOSS OF CONTROL

STRESS MANAGEMENT
 RELAXATION TECHNIQUES
RELAXATION BREATHING
PROGRESSIVE MUSCLE SETTING
AUTOGENIC TRAINING(SELF-SUGGESTIONS)
IMAGERY(MENTAL VACATION)
DISTRACTION

 GRIEF AND LOSS

Loss is a universal experience that occurs throughout life span
Grief is a form of sorrow involving feelings, thoughts, and behaviors
caused by bereavement
Responses to loss are strongly influenced by one’s cultural background
The grief process involves a sequence of affective, cognitive, and
psychological states as a person responds to, and finally accepts a loss.
Responses to loss and patterns of coping with loss are developed early in
life.

Stages of Grieving (Kubler-Ross)

Denial- refuses to believe that the loss has occurred
Anger- the individual resists the loss and may “act out” feelings.
Bargaining- the individual attempts to make a deal in an attempt to
postpone the reality of loss.
Depression- overwhelming feeling of loneliness and withdrawal from
others
Acceptance- the individual comes to terms with loss, or impending loss,
psychological reactions to loss to the loss cease, and the interaction to other
people resumed.

LOSS ,GRIEVING AND DEATH

 DEATH CONCEPTS
 1-5Y.O – IMMOBILITY AND INACTIVITY Wishes and unrelated
action responsible for action
5-10 – final but can be avoided
9-12 – understands own mortality and fears death
12 – 18 – fears and fantasizes avoidance
18-45 – increased attitude awareness
45-65 – accepts mortality
Above 65 – multiple meanings, encounters and fears

KUBLER ROSS – STAGES OF GRIEF

D – SUPPORTIVE


A- PROVIDE STRUCTURE AND CONTINUITY



B – LISTEN AND ENCOURAGE



D- ALLOW EXPRESSION AND PROVIDE FOR SAFETY



A- ENCOURAGE PARTICIPATION


CONCEPTS
6 MOS – 2 YEARS
PROVISION OF DIGNIFIED PAIN FREE DEATH( QUEST.
ANSWERED AND EMT. SUPPORT)
DNR- COMFORT AND HYGIENE NEEDS ON-GOING
CURE GOALS ----- COMFORT GOALS

CONCEPTS
HINDU – REINCARNATION , AUTOPSY , ORGAN
DONATION, CREMATION
ISLAM – NO TO ORGAN DONATION , CREMATION AND
AUTOPSY …..CONFESS AND TURN TO MECCA
JUDAISM – WASHED
NATIVE AMERICAN – NOT TO AUTOPSY
BUDDIST – OK – EUTHANASIA AND WITH LAST RITES

SAFETY AND INFECTION CONTROL

 PROTECTING HEALTH
NON – SPECIFIC AND SPECIFIC
CHAIN OF INFECTION

UNIVERSAL PRECAUTION
PRINCIPLES OF SURGICAL ASEPSIS
INFECTION CONTROL MEASURES

ISOLATION – CATEGORY SPECIFIC

AND DISEASE SPECIFIC
MEDICAL AND SURGICAL ASEPSIS

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)
Universal Precautions
 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
Universal Precautions
 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
Universal Precautions
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
Universal Precautions
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 )
Universal Precautions
Drainage / Secretions precautions – patients with wound drainage
or infected wounds
 Gloves, gowns indicated if clothing is likely to be contaminated
Burns

Universal Precautions
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 , STD’s
Reverse Isolation
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

Infectious agents- pathogens (bacteria, fungi, virus, protozoa)

Reservoirs-
Reservoirs- sources or places for growth of the pathogens
Portal of Exit and Entry-
Entry- provides the way for the pathogen to leave one host and enter
another host
Modes of transmission-
transmission- vehicles of transmission of the pathogens
Susceptible Host-
Host- a carrier capable of supporting and transmitting microorganism

Body Defenses Against Infection



Normal Flora
Intact Skin
Saliva and Mucus Membrane
Cilia of the Upper Respiratory Tract Infection
Inflammatory process
Immune Response

Medical Asepsis/ Clean Technique

Principles:
Pathogens move through spaces or air current
Pathogens are transferred from one surface to another whenever objects
touch.
Hand washing removes microorganism
Pathogens are released into the air on droplet nuclei when person speaks,
breaths, and sneeze.
Pathogens are transferred by virtue of gravity
Pathogens move slowly on dry surface but very quickly through moisture.

Surgical Asepsis/ Sterile Technique

Areas of the body considered sterile are:
Blood stream
Spinal Fluid
Peritoneal Cavity
Urinary Tract
Muscles
Bones
Chamber of the Eyes

Sterile object remains sterile when touched by another sterile object

Sterile objects or fields, which falls out of the range of vision or below
one’s waist, are considered contaminated.
Sterile items become contaminated when they come in contact with
microorganism transported through the air.
When sterile object/ field come in contact with another surface, it becomes
contaminated.
Fluids flows in the direction of gravity.
The edges of the sterile field are considered unsterile.
Isolation Practices
Strict Isolation- prevents transmission of highly communicable disease by contact and
airborne transmission
Respiratory isolation- prevents transmission by droplet
Enteric precaution- prevents transmission through ingestion
Wound and skin precaution- prevents cross-infection by direct contact with wounds and
contaminated articles
Discharge precaution- prevent cross-infection by secretions-contaminated articles
Blood precaution- prevent transmission by contact with blood or items contaminated
with blood
COMFORT AND PAIN
*COMFORT AND PAIN
PQRST AND QUEST
PHARMACOLOGICAL Tx
PAIN GATEWAY CONTROL THEORY
PLAN AND PREVENT INJURY/HARM
PROVIDE ALTERNATIVE MEASURES
PROPHYLACTIC/PREVENTIVE
PCA
PREFERENCE AND PARTICIPATION

Pain
The noxious stimilation of threatened or actual tissue damage
(Geach, 1987)
Whatever the experiencing person says it is, existing whenever he
or she says it does (McCaferry, 1979)
It is highly subjective and individual and that is one of the body’s
defense mechanism indicating that there is a problem.
It is protective as it gives warning or signal for tissue injury

Assessment of Pain
Precipitating Factors- “ What triggers the pain or makes it worse?”
Quality of Pain- “Tell me what the pain feels like”
Alleviating Factors- “What measures relieve your pain”
Meaning of pain- “ How do you interpret the pain?”
Pattern
Location Pain- “Where is your pain”
Periodicity- “How long have you felt the pain sensation?”

REST AND SLEEP

*REST AND SLEEP
REM – DREAM PARADOXICAL SLEEP
PRIMARY AND SECONDARY SLEEP DISORDERS

RESTFUL ENVT.
RITUALS
RELAXATION
RELEVANT MEDS AND
RELATED THERAPY & NON PHARMACOLOGIC Tx
RECORD ASSESSMENTS AND HISTORY

Stages of Sleep:
Non-Rapid Eye Movement (NREM)- for body restoration
Very Light Sleep- drowsy, and readily awakened
Light Sleep- Heart and respiratory rate decreases and the body temperature gradually
falls.
PNS domination- Difficult to arouse
Deep Sleep- Decrease metabolism and very difficult to arouse

Rapid Eye movement (REM)- increase synthetic processes of the brain

Paradoxical Sleep
Dream state of the sleep
Close to wakefulness but difficult to arouse

Common Sleep Disorders

Insomia- sleeplessness
Hypersomia- Excessive sleep at day time
Narcolepsy- Sleep attack
Parasomias
Somnambolism- sleep walking
Soliloqy- Sleep talking
Bruxism- clenching and grinding of teeth
Night Terrors- bad dreams
Nocturnal Erections- wet dreams
 Nocturnal Enuresis - BEDWETTING
SAFETY

Rest is the diminished state of activity

Sleep is a state of decreased perception and reaction to the
environment
There are theories of sleep:
Active theory- there are parts of the brain that inhibit other brain parts
Passive theory- the reticular activating system of the brain fatigues and
becomes depressed, thus sleeps occurs
*SAFETY
TRIAGE
DISASTER MANAGEMENT -=A,B,C

P REVENT ABSORPTION
O FF AND OUT
I DENTIFY
S UPPORT AND SUPPLY ANTIDOTE
O NGOING MONITORING
N OTIFY

POISONING
CHILD PROOF
REFER - POISON CONTROL CENTER
IDENTIFY AND BRING AGENT
SECURE SAFETY AND ABC’S
INDUCE VOMITING W/ IPECAC
STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED
CHARCOAL
THE NURSE SHOULD INTERVENE IF A MOTHER OF A
VICTIM OF POISONING VERBALIZES TO DO THE
FOLLOWING:
PLANS TO INDUCE VOMITING FOR PATIENT WITH ASPIRIN
POISONING
PLANS TO INDUCE VOMITING WHEN SHE IS CERTAIN THAT HER
CHILD’S GAG REFLEX AND LOC ARE INTACT
WILL NOT GIVE IPECAC IF CHILD IS EXHIBITING NARROWED
PULSE PRESSURE
WILL WAIT FOR THE SEIZURE TO END BEFORE ADMINISTERING
IPECAC
CONTRAINDICATIONS OF IPECAC /
INDUCTION OF VOMITING
SEIZURE
SUBNORMAL LOC AND GAG REFLEX
SUBSTANCE CORROSIVE/PETROLEUM DISTILATE
SHOCK-SEVERE

DISASTER PLANNING
TRIAGE-GREATEST GOOD FOR THE GREATEST NUMBER OF
PEOPLE
PRINCIPLES- ABCD , MASLOWS

RED-UNSTABLE – IMMEDIATE CARE

YELLOW- STABLE – CAN WAIT 30-60 MIN
GREEN –STABLE- CAN WAIT LONGER
BLACK- UNSTABLE – FATAL, LAST SEEN
DOA – SUPPORTIVE COMFORT MEASURES

DURING FIRE WHICH SET OF PATIENTS

WILL THE NURSE MOBILIZE FIRST
AMBULATORY
BEDRIDDEN
CRITICAL
TERMINAL

WHICH STEP IN FIRE MANAGEMENT

COMES LAST?
ALARM
CONTAIN
MOBILIZE
EXTINGUISH
READ
ENSURE SUPERVISION
LOCK
AVOID TRANSFERING
TEACH AND
EDUCATE
MANAGEMENT
IPECAC
ACTIVATED CHARCOAL
H2O OR MILK
NA SO4
SPECIFIC ANTIDOTE OR ANTAGONIST

POISONING
CHILD PROOF
REFER - POISON CONTROL CENTER
IDENTIFY AND BRING AGENT
SECURE SAFETY AND ABC’S
INDUCE VOMITING W/ IPECAC
STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED
CHARCOAL
SAFETY
 FALLS(RAT) RISK ASSESSMENT TOOL

ALTERATION IN SENSATION AND PERCEPTION

AWARENESS LEVEL
ABILITY TO COMMUNICATE
ALTERED GAIT AND POSTURE
AMBULATION NEEDS
ANXIETY AND EMOTIONAL STATE
ASSOCIATED INJURY AND DISEASE
ACCESS(LIFESTYLE)
BEDSIDE SAFETY/EMERGENCY
MATERIALS / EQUIPMENTS
AMPUTATION – TOURNIQUET
AUTONOMIS HYPERREFLEXIA – CATHETER
CHEST TUBE DRAINAGE- EXTRA BOTTLE- FORCEPS –
VASELINIZED GAUZE
CHOLINERGIC AND MYASTHENIC CRISIS – ENDOTRACHEAL
TUBE / TRACHEOSTOMY SET
EPIGLOTITIS - ENDOTRACHEAL TUBE / TRACHEOSTOMY SET
PIH – PADDED MOUTH GAG
PARKINSONS – SUCTION APPARATUS

BEDSIDE SAFETY/EMERGENCY
MATERIALS / EQUIPMENTS
RADIUM IMPLANT – LEAD CONTAINER , FORCEPS
SENGSTAKEN BLAKEMORE TUBE – SCISSORS
SCI AND THYROIDECTOMY – TRACHEOSTOMY
TONSILLECTOMY – FLASHLIGHT
TRACHEOSTOMY TUBE – OBTURATOR , HEMOSTAT

PREVENTION OF FALLS
L IGHTING
L OWER BED POSITION
L OCATE GRAB BARS AND CALL BELL
S UFFICIENT ORIENTATION
S IDERAILS
S UPERVISE AND ORIENT

RESTRAINTS
ASSIST FREQUENTLY
ASSIGN HEALTH CARE PROCEDURES IN PAIRS
AREA SUPERVISION
ADIMINISTRATION ADJUSTMENTS
ALLOW ROCKER CHAIR AND FREQUENT WALKS
APPLY PILLOW,WEDGE , PADS AND PROPER POSITIONING
ALLEVIATE AGITATION
ASSESS AND MONITOR
RESTRAINTS-(HALF BOW KNOT/CLOVE HITCH,SQUARE
OR REEF KNOT)

LIMB
MUMMY
ELBOW
MITT OR HAND
JACKET
BELT OR SAFETY STRAP

CONFUSED AND COMBATIVE

CONTROL IMMEDIATE SITUATION
OUT OF AREA
MAINTAIN CALM
BE FIRM AND SET LIMITS
ALTERNATIVE TO RESTRAINTS,ASSESS AND ASSIST
TRY POSITIVE CONSEQUENCES

HYGIENE
*HYGIENE AND COMFORT
INFANT BATHING
COMPLETE ADULT BED BATH
TUB BATH
THERAPEUTIC
SALINE
OATMEAL
CORNSTARCH
NACHO3
KMnO4

HYGIENE AND COMFORT

PERINEAL / GENITAL CARE
FOOT AND NAIL CARE
HAIR CARE
ORAL CARE
BEDMAKING

 PRESSURE ULCER
 GRADING
PREVENTION
TREATMENT

ACTIVITY AND EXERCISE

*ACTIVITY AND EXERCISE
 ERGONOMICS

 TYPES AND PRINCIPLES

 ROM AND ISOMETRICS
PROBLEMS OF IMMOBILITY AND NURSING
INTERVENTIONS

 ACTIVITY ORDERS
*MOBILITY AND IMMOBILTY
POSITIONING
MOVING AND LIFTING

AMBULATION
AMBULATION AIDS

TRANSFERS
TRANSFER AIDS

THERAPEUTIC EXERCISES
PASSIVE ROM-RETENTION OF ROM AND MAINTENANCE OF
CIRCULATION
ASSISTIVE- INCREASES MOTION , MAINTAINS MUSCLE TONE
ACTIVE – MAINTAINS MOBILITY OF THE JOINT AND MAINTAINS
MUSCLE STRENGTH
RESISTIVE – INCREASES MUSCLE POWER
ISOMETRICS- MAINTENANCE OF STRENGTH AND PREVENTS
MUSCULAR ATROPHY
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

POSITIONING FOR SPECIAL CONDITIONS

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

POSITIONING FOR SPECIAL CONDITIONS

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
POSITIONING FOR SPECIAL CONDITIONS
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

POSITIONING FOR SPECIAL CONDITIONS

 SEIZURE – SIDE-LYING
SHOCK – MODIFIED TRENDELENBURG
SCI – IMMOBILIZE
TONSILLECTOMY – SIDELYING / PRONE
THYROIDECTOME – SEMI – FOWLERS
THROMBOPHLEBITIS – ELEVATE LEG
TPN – TRENDELENBURG – DURING INSERTION
THORACENTESIS – FOWLER’S(DURING)
AFTER – POSITION OF COMFORT

MOBILITY AND IMMOBILITY

POSTURE AND BODY ALIGNMENT-ERECT
JOINT MOVEMENTS=RANGE OF MOTION
CONNECTIVE TISSUE
BONE TO BONE-LIGAMENT
BONE TO MUSCLE – TENDON
COVERS BONES/JOINTS - CARTILAGE

 TYPES OF JOINT
SYNARTHROSES(CARTILAGENOUS)
DIARTHROSES( SYNOVIAL)
AMPIARTHROSES(FIBROUS)

ERGONOMICS-BODY POSITIONING AND MECHANICS

PRIORITY-ASSESS PERSONAL CAPACITY 1ST
USE PROTECTIVE DEVICES/ TRANSFER AIDS
CHANGE POSITION SLOWLY-ORTHOSTATIC HYPOTENSION(DANGLE LEGS
FIRST)
PIVOT ON THE STRONGER SIDE,MOVE PNT TOWARDS STRONGER SIDE
USE LARGER MUSCLES OF THE BODY AND FACE THE DIRECTION OF THE
MOVEMENT
PULL SHEETS ARE BETTER METHOD THAN SLIDING
ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE AN ASSISTANT STANDING
BY.
ROCK FROM FRONT TO BACK/VICE VERSA.WIDE BASE OF SUPPORT,
WEIGHT NEAR MIDLINE OF THE BODY.USE APPROPRIATE TRANSFER AND
AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE BOARD, DRAW SHEET
AND TRANSFER BELT
DANGERS OF IMMOBILITY
DECUBITUS ULCER-OSTEOMYELITIS
OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND RENAL CALCULI
INCREASED CARDIAC WORKLOAD- TACHYCARDIA
CONTRACTURES- DEFORMITIES
THROMBUS FORMATION-PULMONARY EMBOLISM
ORTHOSTATIC HYPOTENSION-WEAKNESS,FAINTNESS AND DIZZINESS
RESPIRATORY STASIS – HYPOSTATIC PNEUMONIA
CONSTIPATION – FECAL IMPACTION
URINARY STASIS-URINARY RETENTION
NEGATIVE NITROGEN BALANCE-WEIGHT LOSS/DEBILITATION

SPECIFIC THERAPEUTIC POSITION

HIGH FOWLERS-60-90’
FOWLER-45-60’
SEMI-FOWLERS-30-45’
LOW-FOWLERS-15-30’
SUPINE
DORSAL RECUMBENT
LITHOTOMY
TRENDELENBURG
SIMS LATERAL
MODIFIED TRENDELENBURG
PRONE
KNEE-CHEST
SIDE-LATERAL
ORTHOPNEIC

ASSISTIVE DEVICES
 CRUTCHES
CRUTCH HEIGHT-

STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA OR SUPINE ;MEASURE FROM
THE ANTERIOR FOLD OF THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 CM
 TEACH MUSCLE STRENGTHENING EXERCISES PRIOR TO
AMBULATION.WEIGHT ON THE HAND GRIP (TO AVOID CRUTCH PALSY)
ELBOWS SHOULD BE FLEXED 20-30’ AND CRUTCHES SHOULD BE KEPT 6
INCHES LATERALLY AND 6 INCHES TO THE FRONT=TRIPOD POSITION(8-
10 INCHES-OK)
INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTURE

 CRUTCH WALKING GAITS

FOUR POINT-SLOW SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS
TWO POINT- FASTER SAFE-WEIGHT BEARING ALLOWED FOR BOTH
LEGS
THREE-POINT-NON WEIGHT BEARING OF ONE LEG
SWINGTO/SWINGTHROUGH-PARTIAL WEIGHT BEARING ALLOWED FOR
BOTH LEGS
GETTING INTO A CHAIR –BOTH CRUCHES TO THE WEAK SIDE ,
STRONGER ARM HOLDS THE ARMREST
ST
GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1 AND BAD GOES
ST
DOWN 1 .
 WALKER-
PROVIDES STABILITY AND BALANCE
MOVE WALKER AHEAD 15 CM (6INCHES-8-10
INCHES)WHILE WEIGHT IS BORNE BY BOTH LEGS.THEN
ALTERNATE WEIGHT BEARING ASSISTED BY THE ARMS
ELBOWS SHOULD BE FLEXED-20-30’
IF ONE LEG IS WEAKER MOVE THAT LEG TOGETHER
WITH THE WALKER

CANE
HOLD CANE ON THE STRONGER SIDE
FLEX ELBOW 30’ AND TIP OF CANE 15 CM LATERAL TO THE SIDE
OF THE 5TH TOE.
ADVANCE CANE AND AFFECTED LEG ,WEIGHT ON CANE WHEN
MOVING THE GOOD LEG
BUT FOR MAXIMUM SUPPORT ADVANCE CANE 1 FEET ,MOVE
AFFECTED LEG THEN THE STRONGER LEG
GOING UP AND DOWN THE STAIRS –SAME WITH CRUTCHES

*NUTRITION
*NUTRITION
PREMATURE INFANTS-LESS THAN37WKS/2,500G-100-200
CAL/KG/DAY AND HIGHER Na,Ca AND CHON
FULL TERM-120 CAL/KG/DAY
PREGNANCY + 300CAL/DAY
LACTATION+ 500CAL/DAY

ENTERAL FEEDINGS
CONDITIONS

PREOPERATIVE NEED FOR NUTRITIONAL SUPPORT
GI PROBLEMS
ONCOLOGY THERAPY
ALCOHOLISM,CHRONIC DEPRESSION AND EATING DISORDERS
HEAD,NECK DISORDERS OR SURGERY

COMPLICATIONS

ASPIRATIONTUBE DISPLACEMENT
CRAMPING,VOMITING,DIARRHEA
HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE INTOLERANCE
 NUTRITION
SPECIFIC NUTRIENT MODIFICATION
CALORIC MODIFICATION
CONSISTENCY

SPECIAL DIETS FOR SPECIFIC DISEASES

DIETARY MODIFICATIONS FOR SPECIAL CONDITIONS

NUTRIENT MODIFICATION
 INCREASE,DECREASE,RESTRICTED

CA,K,NA,Fe,FOLIC ACID,VIT C&B COM.,ADEK,

CHOLESTEROL,GLUTEIN
FIBER, PHENYLALAMINE,TYRAMINE
CHO,FATS/LIPIDS,CHON

THERAPEUTIC DIET FOR SPECIFIC

CONDITIONS
AGE – CLEAR LIQUID
AGN – LOW NA , LOW CHON
ADDISON’S – 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
MENIERE’S LOW NA
MI AND HPN – LOW CHOL.,FATS,NA
HYPERTHYROIDISM- HIGH CAL. AND CHON
HYPOTHYROIDISM – LOW CAL. , LOW CHOL, LOW SAT. FAT

THERAPEUTIC DIET FOR SPECIFIC

CONDITIONS
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

THERAPEUTIC DIET FOR SPECIFIC

CONDITIONS
 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
TOTAL PARENTERAL NUTRITION
TYPES OF SOLUTIONS

TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE BACTERIAL FILTER USED
TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID, DEXTROSE AND LIPIDS-1 LITER /24
HOURS – NO FILTER

PERIPHERAL=NO >10% DEXTROSE AND 2 WKS ONLY

CENTRAL – INCOMPATIBLE WITH MEDS AND BLOOD IF SINGLE LUMEN
USED
ATRIAL-HICKMAN/BIOVAC AND GROSHONG- HUBBER NEEDLE USED TO
ACCESS PORT THROUGH SKIN
TPN
INITIAL RATE OF INFUSION 50 ML/HR THEN 100-125/HR.
COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS, PNEUMOTHORAX
FAST RATE=HYPEROSMOLAR STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS)

SLOWED RATE=REBOUND HYPOGLYCEMIA


X-RAY CONFIRMS PLACEMENT ATTACH TO PUMP


IV TUBING AND FILTER CHANGED Q24 HOURS
ALLOW SOLUTION TO WARM IMMEDIATELY BEFORE USE
IF NO SOLUTION USE DEXTROSE 10% W SOLUTION
CHECK DAILY CBG,WEIGHT,TEMP. I AND O ,
CHECK 3X A WEEK BUN, ELECT,
ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND PT,PTT

*ELIMINATION
BOWEL ELIMINATION
TOILET TRAINING

FACTORS AFFECTING

PROBLEMS
MANAGEMENT-CATHARTICS , ENEMA , SURGERY
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
ENEMA
COLOSTOMY/ILEOSTOMY,OTHER SURGERIES
BARIUM STUDIES
SCOPIC EXAMS
ROENTOLOGIC EXAMS

ENEMA
They act by distending the intestines that increases peristalsis and expulsion
of feces and flatus.
Enemas serve the following purpose:
Relief of constipation
Relief of flatulence
Lowers down body temperature
Evacuates feces in preparation for diagnostic procedures
Administration of medications

ENEMA
Take note of the general principles of Enema:
Tube: lubricate and insert 3-4 inches
Position: adult- left lateral; infants and children- dorsal recumbent
Administration- administer the enema in a minimum of 15 minutes
duration.
Conatainer’s Height- 12 inches above the rectum
Temperature- 42°C or less

OSTOMIES
PERMANENT/TEMPORARY
STOMA RED AND SLIGHT BLEEDING WHEN TOUCHEDBURNING SENSATION
UNDER FACEPLATE INDICATES SKIN BREAKDOWN,REFER ABDL
DISTENTION/DISCOMFORT,
KARAYA POWDER(DEC.IRRITATION), CHARCOAL/BISMUTH CARBONATE-
DEODORIZER
APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-72H AND 24-48H
IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODED
ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE
CONTINOUS,MINIMAL ODOR
COLOSTOMY-FORMED , CAN BE IRRIGATED 300-500ML AND
REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCE
URINARY ELIMATION
 BLADDER TRAINING

 LABS AND DIAGNOSTIC TESTS

 CONDITIONS

 CATHETERIZATION AND IRRIGATIONS

URINARY ELIMINATION
BUN – 10-20 MG/DL
CREA – 0.7 – 1.4 MG/DL
24 HOUR URINE PRODUCTION-1000-1500CC

ANURIA<100ML/24H
OLIGURIA< 400 ML/24H
POLYURIA > 2000 ML/24H

KEGELS –STRENGTHEN MUSCLES OF THE PELVIC FLOOR-TIGHTEN FOR 3

SECS THEN RELAX FOR 3 SECS PERFORM LYING DOWN, SITTING AND
STANDING FOR TOTAL OF 45
BLADDER RETRAINING
 INTERMITTENT CATHETERIZATION AFTER ATTEMPTING TO VOID Q 2-3H, TIME
INCREASES GRADUALLY BUT NO MORE THAN 8 HOURS
BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H THEN ATTEMP TO VOID 30
MINS LATER-TIME GRADUALLY INCREASED
TRIGGERING TECHNIQUES-CREDES MANEUVER AND VALSALVA
CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE TO VOID 3-4 HOURS AFETR
REMOVAL

HEMODIALYSIS
DONE 3-5 HOURS – 2-3 TIMES A WEEK
AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS
PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H
MONITOR FOR HEMORRHAGE
DISEQUILIBRIUM
SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR
EMBOLISM AND SEPSIS-COMPLICATIONS
PERITONEAL DIALYSIS
TENCKOFF,GORE-TEX CATHETER
WEIGH BEFORE AND AFTER, WARM DIALYSATE
CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) ,
FEVER , ABDL TENDERNESS AND N & V
PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN
STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION
TYPES: CAPD(4-6H INDWELLING),AUTOMATED 30MINS EXCHANGES,
INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING
OXYGENATION
OXYGENATION
PULMONARY FUNCTION TESTS
DIAGNOSTIC LABORATORIES(ABG, SPUTUM CS AND THROAT
CULTURE)
VISUALIZATION
AUSCULTATION

OXYGEN DELIVERY EQUIPMENT

CHEST PHYSIOTHERAPY
ARTIFICIAL AIRWAYS
THORACOCENTESIS,THORACOSTOMY.TRACHEOSTOMY AND ET
INTUBATION
SUCTIONING
CHEST TUBES AND DRAINAGE SYSTEMS

CHEST PHYSIOTHERAPY
TURNING COUGHING DEEP BREATHING
POSTURAL DRAINANGE
PERCUSSION AND VIBRATION
INCENTIVE SPIROMETRY
SUCTIONING
TRACHEOSTOMY CARE
OXYGEN THERAPY
VENTILATOR CARE AND MANAGEMENT

Chest Physiotherapy
It is the combination of percussion, vibration, and postural drainage
Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be
performed for 3-5 minutes
Vibration is done during 5 exhalations
Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.
Instruct the client to increase fluid intake to liquefy secretions
This procedure should not be performed in clients who are pregnant, with chest injuries,
dizzy, with pulmonary embolism and abdominal surgery.
This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy
Indicated to clients who needs additional oxygen, those clients who have
reduced lung diffusion of oxygen through the respiratory membrane, heart
failure leading to inadequate transport of oxygen.
Humidify the oxygen first before you administer.
Check for bubbles in the humidifier to promote adequate flow of oxygen
Check for kinks in the tubing
Position: semi-fowlers/ high fowlers position
Place cautionary readings: “NO smoking: Oxygen is in used”
Instruct the client not to use woolen blankets as this may create static
electricity
pulmonary function tests
tidal volume- 500
residual volume- 1200
expiratory reserve volume –1200
inspiratory reserve volume – 3100

Vital Capacity- tidal volume + IRV + ERV = 4800

Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000
 Forced Residual Capacity – ERV + RV

incentive spirometry – hold 2-6 sec; 4-5 times/H (TO MAXIMIZE

RESP.&MOBILIZE SECRETIONS
endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and
aerosol, deflate cuff occasionaly
visualization –
X ray
Lung Scxan – 20-40mins isotopes in body for 8 H
laryngoscopy
Bronchoscopy
Thoracentesis- consent, VS and baseline X-ray + post Procedural

Tracheostomy Care
tie new trache tie before removing the old tie to prevent accidental
dislodgement.ALLOW 2 FINGERS TO BE INSERTED UNDER TIE
use precut gauze and perform care OD at least.
soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well
suction prn, oral care prn(PROCEDURE DONE q8h AND PRN)

Oxygen Delivery Equipment

cannula – 2-6 LPM – 24-45%
Mask – 5-8 LPM – 40-60%
parial rebreather – 6-10 LPM – 60-90%
non rebreather – 10-15 LPM – 95-100%
tent – 4-8 LPM – 30-50 %
Venturi mask –
2-3 LPM – 24-28%
4 LPM – 30%
6 LPM – 35%
8 LPM – 45%
14LPM – 55%

Suctioning
PURPOSE: To obtain sputum sample.
NURSING ALERT:
ASSESS BREATH SOUNDS

Hyperoxygenate the patient before and after the procedure.
Apply intermittent suction on withdrawal of the catheter.
Do not suction the patient for more than 15 seconds. IDEAL
10 SECS

Thoracentesis
PURPOSE: Aspiration of fluid and /or air from the pleural space. space.
NURSING ALERT:
Check the consent.
Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table.
If the patient unable to sit, the patient may lie in his/her side with hands on the side
resting on opposite shoulder.
Instruct the patient not to cough, breath deeply or move during the procedure.
After the procedure: Position the patient on the unaffected side/puncture site up.
Check for bleeding at the puncture site and monitor the respiratory function.
Notify the physician if signs of pneumothorax, air embolism and pulmonary edema
occur.

*PERI-OPERATIVE NURSING
PREOP CARE
INFANT-DISTRACT
TODDLER-ALLOW REGRESSION AND INVOLVE
PARENTS,CONSISTENT CAREGIVER
PRE-SCHOOL-LET CHILD HANDLE EQUIPMENT,EXPRESSION OF
FEELINGS THROUGH PLAY DEMOFAMILIAR SORROUNDINGS
SCHOOL AGE- EXPLAIN SIMPLY AND ALLOW CHOICES
ADOLESCENTS- INVOLVE AND POINT OUT STRENGTHS AND
BENEFITS,EXPECT RESISTANCE

 PREOP CHECKLIST
CONSENT
HEALTH TEACHING (SPEC. POST OP PROCEDURES)
LAB TESTS,ECG,X-RAY
SKIN PREP
BOWEL PREP
IV’S
NPO
PREOP MEDS,SEDATION AND ANTIBIOTICS
REMOVAL OF DENTURES,NAILPOLISH AND JEWELRY
NUTRITION-TPN OR ENTERAL FEEDINGS PREOP
 INTRAOP- MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT
STATUS,, APPROPRIATE GROUNDING DEVICES, FLUID
BALANCE AND SPONGE/INSTRUMENT COUNT
POST OP- MONITOR VS
Q15X4;Q30X2;Q1HX2 THEN PRN
MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH
SOUNDS AND LOC
RESPIRATORY PHYSIOTHERAPY,TCBD
INCENTIVE SPIROMETRY-20 SECS INHALATION
ENCOURAGE AMBUALTION
REFER IF UNABLE TO VOID IN 8 HOURS
APPLY TED HOSE AND PNEUMATIC COMPRESSION
DEVICE,CHECK FOR HOMAN’S SIGN

WOUNDS
NOTE DRESSING AND INCISION
FEVER 1-2 DAYS POST OP-ATELECTASIS/ DEHYDRATION
3-7 DAYS – INFECTION
UPPER GI TUBES-GASTRIC DECOMPRESSION
LOWER GI TUBES – BOWEL DECOMPRESSION
ST
WOUND HEALING BY 1 INTENTION-SUTURED AND APPROXIMATED ; 3RD
INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINS
ND
WOUND HEALING BY 2 INTENTION-INCREASED INCIDENCE OF
INFECTION , INCREASED SCARRING AND LONGER HEALING TIME
POST-OP COMPLICATIONS
SHOCK
PARALYTIC ILEUS
ATELECTASIS AND PNEUMONIA - 2ND DAY
EMBOLISM- 2ND DAY
WOUND INFECTION-3-5D
DEHISCENCE AND EVISCERATION-5-6D
PSYCHOSIS
CARDIOVASCULAR COMPROMISE-
URINARY RETENTION-8-12H
URINARY INFECTION -5-8 D
DVT-6-14 DAYS-1 YEAR

WOUND CARE
 WOUND TYPES AND
HEALING


DRESSING


DRAINS


SENSORY PERCEPTION AND COGNITION

SENSORY DEPRIVATION


SENSORY OVERLOAD


SENSORY DEFICITS


THERAPEUTICS
MEDICATION ADMINISTRATION


IVF INFUSIONS(INCLUDING MIO)



BLOOD TRANSFUSION


PHYSICAL AND OCCUPATIONAL THERAPY



SUPPLEMENTS
NORMAL VALUES


DIAGNOSTIC TESTS


THERAPEUTIC PROCEDURES
