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Nursing process - framework of systematic problem solving and actions to be used by nurses in identifying, preventing or treating individual health needs.
Assess for signs of illness, diagnose alterations in health, determine interventions to restore health, conceptualize a targeted health outcome moving away from illness, and evaluate the treatment plan for nurse-determined modifications
Assess, Diagnose, Plan, Implement, Evaluation, Documentation...the framework for nursing
Nursing process and current emphasis -
Process: assess, diagnose, intervetnion
- Historical perspective: absense of disease and presence of optimal funcitoning. Currative approach, medical model; one-way channel of communication between dominant more knowledgeabel, powerful provider to patient...power rested with medical staff.
- Current process: Changing from linear (begging to end) - illness to wellness, to shared experience of transending or controlling health threat and changing into one of pruposeful meaning. Nurse/pt relationship is now circular to motivate
Family Centered Care
Placing family relationships, coping mechanisms, values, priorities, and perceptions at the center of a patient's health care needs. Community health map is a tool the nurse can use to assess the family structure, function, and support networks.
Three levels of Prevention
- Primary: health promotion as well as activities specifically meant ot prevent disease from occurring.
- Secondary: early identification and prompt treatmetn of a health problem before it has an opoortunity to spread or become more serious.
- Tertiary: to restore health to the highest functioning state possible.
Four basic Ethical Principals
- Beneficence: acting for patients benefit
- Nonmaleficence: Do no harm
- Respect for Autonomy: patients rights
- Justice or fairness: treated equally
Precise, disciplined thinking that promotes accuracy and depth of data colleciton and seeks to clearly identify the problems, issues, and risks at hand
Discuss personal skills that help build critical thinking analysis?
Self-reflectionopen-mindednesspersistence in seeking the most reasonable answercomfort and confidence with calculated risk-takingdevotion to listening with a passion for true comprehension and understanding.
Discuss the four avenues for developing successful analytical critical thinking?
Experienceknowledge seekingpracticed hands-on workcontextual discernment
- A composite of ongoing or potential enemy actions; environmental, occupational, and geographic and meteorological conditions; endemic diseases; and employment of nuclear, biological, and chemical weapons (to include weapons of mass destruction) that can reduce the effectiveness of joint forces through wounds, injuries, illness, and psychological stressors.
(culture is the context by which family behavior is understood)
Understanding prevailing concepts of acculturation: changes in on's cultural pattern to math those of the new culture, assimilation identity, time, connectedness, communication, and social class.
the greatest deterant to health care is lack of health insurance
The third most common type of developmental delay in the US. Autisim presents as solitary child who notably lacks social responsiveness to others. affects language - absent, abnormal, or delayed. strong resistance to change, abnormal attachment to objects.
An arrangement in which the grandparents rear grandchildren with or without the parent's help.
Family of choice
THe family adopted through marriage or cohabitation.
Two or more members who self-identify as a "family" and interact and depend on one another socially, emotionally, and financially.
Occures when two family members focus on or team up against a third family member to compensate for friction between the tewo members.
Infant immune system matureity Normally occurs at:
Roll over time frame
3 - 7 months
- Kcal/mL X total ml of formula/ weight
Cholestasis, cholecystitis, cholelithaiasis
gall bladder becomes relaxed because progesteron slows things down and relaxes the smooth muscle and this alteration can lead to inefficient emptying causing stasis (inflammaiton), cystitis (infection), lithaiasis (stone formation)
a transient loss of consciousness and postural tone with spontaneous recovery - contributing to orthostatic hypotension and or inferior vena cava compression by the gravid uterus p growing uterus plases pressure on the vagus nerve. s/s that precede lightheadness, sweating, nausea, yawining, and feeling of warmth.
Urinary Frequency, urgency, nocturia
Caused by pressure, progesteron relaxes urethra and bladder spincters
S/S of pregnancy
- Presumptive: amenorrhea, N/V, Urinary frequency, Breast tenderness
- Probable: Piskacek sign - uterine asymentry, Hegar sign - softening of lower uterine segment, Chadwick sign - violet-bluish color of vaginal mucosa and cervix.
- Positive: fetal heartbeat, fetal movements, visualization of fetus
Pregnancy test: HCG
Nosebleeds - an effect of estrogen which causes edema of the nasal mucosa along with vascular congestion.
server itching caused by stasis of ble in the liver due to altered liver function.
excesssive saliva production often with a bitter taste
heartburn caused by the effect of progesterone on smooth muscle causing relaxation of the esophagus. the movement of food is slowed and the gastroesophageal or cardiac spincter weakens.
red, raised nodules at the gum line, bleed easy, usually regress within 2 months after child birth
Smoking during pregnancy
smoking is associated iwth spontaneous abortion, low birth weight, intrauterin growth restriction, preterm labor and birth, placenta previa, plancental abrupiton, and premature rupture of the membranes. Infatns are likely to be small fo rgestional age.
Drugs and pregancy
- no proven effects of marijuana however, women who use marijuana may engage in othe high risk behaviors.
- cocain risk fo rcongenital anomalies, cardiac, cns, complications such as stillbirth, abruptio placentae, preterm labor, preterm birth, small gestation age
if a women contracts rubella during the first 12 weeks of pregnancy, the fetus has a 90% chance of beign adversely affected, later exposure decreases risk. patients who are not immune should be offered vacination after pregnancy
father experiences symptoms of pregancy
fear of gaining weight...effects the developing fetus as nurtrients are not consumed or quickly elimanited.
Plencental fluid - amniotic fluid
- Protects and cushions fetus
- Maintains normal body dtemperature
- symmetrical fetal growth
- Freedom of movement
- Essential for normal fetal lung development
- 800 ml at 24 wks
- Fetal urine and lung secretion primary contributors
- slightly alkaline
- contains antibacterial, other protective substances
- Frank - most common, fetal legs are completely extended up toward the fetal sholders, hips are flexed, knees are extended and buttocks presents first.
- Complete (full) - legs are flexed and fetal buttocks presents first, reversal of cephalic
- Footiling - one or both leg(s) are extended with one or both feet presenting first
when the widest diameter of the fetal presenting parat has passed through the pelvic inlet. usually occurs approximately 2 wks before due date.
Lightening - beginning of engagement "baby dropped"
- leg cramps or pains
- increased pelvic pressure
- increased urinary frequency
- increased benous stasis, causing endema in lower extremities
- increased vaginal secreations
Braxton - Hicks "false Labor"
- felt in abdomen or groin
- may occur every 10 - 20 min
- ischial spines 0 station
- above ischial spines - minus station
- below ischial spines + station
- +4 cm means
level of the presenting part in relation to the maternal ischial spines. When the presenting part lies above the maternal ischial spine it is at a minus station. Engagement has occurred when the presenting part is at zero station. positive numbers indicate when the presenting part decends into the pelvis.
the artificial rupture of the membranes
about 38 weeks the presenting part settles downward into the pelvic cavity causing the uterus to move downward as well...this marks the begging of engagement adn is when the baby "drops"
labor support person , a woman who has professional training and is experienced in childbirth who's role is to provide continuous information and phyusical and emotional support
What is gained by vaginal exam.
assessment of cervical dilation, effacement, station, position, presentation of fetus, rupture of membrane, and prolapse of umbilical cord
used to assess for DVT, foot is dorsalflexed back by the examiner quickly, if pain is present in the calf...this is a positive sign.
- Intermittent uterine contractions during involution
- breastfeeding (release of oxytocin)
- duration 2 to 3 days
- Mild analgesics
When is best time to feed baby?
The optimal time to breastfeed is when the baby is i a quiet alert state, crying is usally a late sign of hunger and achieving satisfactory latch-on at this time is difficult.
Infant sleeping postion
all newborns should sleep on their back, avoid placing the intfant in a prone postion.
Milia (neonatal acne)
small white papules or sebaceous cysts on infant's face that resemble pimples, related to excessive amount of maternal hormones, overtime neotatal acne dissappears.
a transient rash that coers the face and chest with spread to the entire body most common normal skin eruption in term neonates .small irregular flat red patches o the checks that develop into singular, small yellow pimples apppearing the the chest abdomen, and extremities.
african american...freckles or dark spots