NURSING WALL NOTES

POTASSIUM 3.5-5 mEq/L CHLORIDE 95-105 mEq/L

SODIUM 135-145 mEq/L MAGNESIUM 1.5-2.5
mEq/L
CALCIUM 9-10 mg/dL PHOSPHORUS 2.5-4.5
mg/dL

Urine pH 4.6-6.5
Specific Gravity 1.010-1.030
GFR 90-120 mL/min
BUN 10-20 mg/dL
CREATININE 0.6-1.2 mg/dL

ALT 7-56 u/L ALBUMIN 3.5-5 g/dL

AST 5-40 u/L BILIRUBIN 0.1-1.2
mg/dL

CHOLESTEROL <200 mg/dL

TRIGLYCERIDE <150 mg/dL
LDL (BAD) <100 mg/dL
HDL (GOOD) >50 mg/dL
 BLOOD PRESSURE 120/80 mmHg
HEART RATE 60-100 bpm
RESPIRATIONS 12-20 bpm
O2 SATURATION 95-100%
TEMPERATURE 36.5-37.2 C

FEMALE MALE
RBC 4.5-5.5 5-6
WBC 5,000-10,000
PLATELETS 150,000-450,000
Hgb 12-16 14-18
Hct 36-46 41-51

BLEEDING TIME 1-10 min

PROTHROMBIN TIME (W) 10-12 sec
PARTIAL THROMBOPLASTIN
TIME (H) 60-90 sec
ACTIVATED PTT (H) 30-45 sec
Not on Warfarin: < 1 sec
INR (W) On Warfarin: 2-3 sec
 MEDICINE ACT (RA 8423)
L.U.B.B.Y. S.A.N.T.A.
● Fever
● Cough/Colds
LAGUNDI ● Asthma
● Headaches
● Itchiness
ULASIMANG BATO ● Decrease Uric Acid
BAWANG ● HPN
● Toothache
BAYABAS ● Wound Cleaning
● Body Pain
YERBA BUENA ● Bites
● Bleeding
SAMBONG ● Diuretic
AMPALAYA ● Decrease Blood Sugar
(Regulate/Maintain)
NIYOG-NIYOGAN ● Parasitism
TSAANG GUBAT ● Diarrhea
AKAPULKO ● Fungal Infection
 CONTACT PRECAUTIONS
M.R.S. W.E.E.
MULTIDRUG RESISTANT WOUND INFECTION
ORGANISM
RESPIRATORY INFECTION ENTERIC (CLOSTRIDIUM
DIFFICILE)
SKIN INFECTION EYE INFECTION
(CONJUNCTIVITIS)
AIRBORNE PRECAUTIONS
M.T.V.
MEASLES
TUBERCULOSIS
VARICELLA
DROPLET PRECAUTIONS
S.P.I.D.E.R.M.AN.
SEPSIS/SCARLET EPIGLOTTITIS
FEVER/STREP. PHARYNGITIS
PNEUMONIA/PERTUSSIS/PAR RUBELLA
VOVIRUS B19
INFLUENZA MUMPS/MENINGITIS/
MYCOPLASMA/MENINGEAL
PNEUMONIA
DIPHTHERIA ADENOVIRUS
 SHOCK/FLUID ● IVC to IST Compartment
ACCUMULATION/ ● Hypovolemia
RESUSCITATIVE/EMERGENT ● Metabolic Acidosis
● High Hct, K
● Low UO, Na
ACUTE/DIURETIC/FLUID ● IST to IVC Compartment
REMOBILIZATION/ ● Hypervolemia
INTERMEDIATE ● Metabolic Acidosis
● High UO
● Low Hct, K, Na
RECOVERY ● Low Ca, K
● Negative Nitrogen
Balance
 MANDATORY BASIC IMMUNIZATION LAW
(RA 10152)
VACCINE f ROUTE MONTH DOSAGE
BCG 1 ID BIRTH 0.05
HEPA B 1 IM BIRTH 0.5
PENTAVALENT 3 IM 6,10,14 0.5
OPV 3 PO 6,10,14 2-3
MMR - V 2 SQ 9,12 mos 0.5
IPV 2 IM 14,36 wks 0.5
PCV 3 IM 6,10,14 0.5
ROTAVIRUS 2 PO 6,10 1.5
 PD 856 SANITATION CODE OF THE
PHILIPPINES
PD 825 ANTI LITTERING LAW
RA 9003 SOLID WASTE MANAGEMENT
ACT
RA 8749 CLEAN AIR ACT
RA 9275 CLEAN WATER ACT
RA 9516 NAT’L ENVIRONMENTAL
AWARENESS ACT
EO 26 NAT’L SMOKING BAN
RA 10611 FOOD SAFETY ACT
PROVISION OF CLEAN
RA 11211 TOILETS IN PUBLIC
TRANSPORTATION TERMINALS
 THEORIST THEORY
PATRICIA BENNER 5 LEVELS OF
COMPETENCE
MYRA ESTRIN LEVINE CONSERVATION MODEL
MARTHA ROGERS THEORY OF UNITARY
HUMAN BEINGS
DOROTHEA OREM SELF-CARE THEORY
IMOGENE KING GOAL ATTAINMENT
THEORY
BETTY NEUMAN SYSTEMS MODEL
FLORENCE ENVIRONMENTAL
NIGHTINGALE THEORY
HILDEGARD PEPLAU THEORY OF
INTERPERSONAL
RELATIONS
VIRGINIA HENDERSON 14 NURSING NEEDS
THEORY
FAYE GLENN ABDELLAH 21 NURSING PROBLEMS
THEORY
ERNESTINE HELPING ART OF
WIEDENBACH CLINICAL NURSING
SISTER CALLISTA ROY ADAPTATION MODEL
DOROTHY JOHNSON BEHAVIORAL SYSTEMS
MODEL
NOLA PENDER HEALTH PROMOTION
MODEL
MADELEINE LEINENGER TRANSCULTURAL
NURSING THEORY
ROSEMARIE RIZZO HUMAN BECOMING
PARSE THEORY
LYDIA HALL CARE, CORE, CURE
JOYCE TRAVELBEE HUMAN-TO-HUMAN
RELATIONSHIP
KATHRYN BARNARD CHILD HEALTH
ASSESSMENT MODEL
IDA JEAN ORLANDO NURSING PROCESS
THEORY
JEAN WATSON THEORY OF HUMAN
CARING
MARILYN ANNE RAY THEORY OF
BUREAUCRATIC CARING
0-1 mo Head Lag
2 mo Lifts Head
3 mo Lifts Head and Chest
4 mo Supine to Prone
5 mo Prone to Supine
6 mo Sits with Support
7 mo Sits without Support
8 mo Crawling
9 mo Creeping
10 mo Stands with Support
11 mo Cruising
12 mo Stands without Support
15 mo Walks with Support
18 mo Jump
3 y/o Run/Tri-bike
4 y/o Bicycle
1-3 mo Closed Fist/
Arm Movement
5 mo Close + Open Hands/
Hold Objects
7 mo Crude Pincer Grasp
9 mo Neat Pincer Grasp
12 mo Throws a Ball/
Use Spoon Only
2 y/o Draws Vertical/Horizontal
Lines
3 y/o Draws Circle, Curves,
Cross
4 y/o Draws Square, Rectangle
5 y/o Draws Pointed Objects
6 y/o Draws All Shapes
 LANGUAGE DEVELOPMENT

1-2 mo Loud Cry

(Open Mouth)
3 mo Cooing Sounds
4 mo Babbling
5 mo Vowel Sounds
(A,E,I,O,U)
6 mos Consonant Sounds
7 mo MMM Cry
9 mo 2 words/2 syllables
(Ma-ma, Da-da)
12 mo 4 words
(Mama, Dada, +2 Words)
2 y/o 50 words
3 y/o 100 words
4 y/o 200-300 words
 FETAL MILESTONES
End of 4th Week ● Spinal Cord
● Rudimentary Heart
End of 8th Week ● Organogenesis
(6-8 weeks)
End of 12th Week ● FHR heard via Doppler
(10-12 weeks)
End of 16th Week ● Lanugo
● Sex determined
End of 20th Week ● Quickening
● Eyebrows formed
● Vernix Caseosa
● Meconium
End of 24th Week ● Surfactant Production
End of 28th Week ● Blood Vessels of Retina are
formed
End of 32nd Week ● (+) Moro Reflex
● Fingernails reach end of
Fingertips
End of 36th Week ● Sole of Foot: ½ crisscross
creases
● Decreased Lanugo
● Straw-Colored AF
End of 40th Week ● Fingernails Extended
● Creases on Sole of Feet
Cover at least ⅔
● Descended Testes,
Increased Scrotal Rugae
 DEFENSE MECHANISMS
REPRESSION Unconsciously Forgetting Dissociative Amnesia

SUPPRESSION Consciously Forgetting Anorexia Nervosa

REACTION Expressing Opposite of True Bipolar Disorder

FORMATION Emotions (Plastic)

RATIONALIZATION Reasoning Out Antisocial Disorder

Projection Blaming others for Own Mistakes Paranoid Disorder

Introjection 1. Blaming Self

2. Exact Replica of Another

Compensation Weak on One;

Strong on Other
Small to Big

Denial Unacceptance of Truth

Displacement Channeling Anxiety/Anger to Less

Threatening Object

Regression Going back to Earlier Dev’t Stage

Undoing Doing Something to Relieve Guilt Obsessive-Compulsiv

e Disorder

Conversion Anxiety turns into Physical

Symptoms

Intellectualization 1. Reasoning out with References

2. Acknowledging without
Emotions

Substitution Make unavailable to Available

Big to Small

Sublimation Make unacceptable to Acceptable

Bad to Good

Identification Idolization Stockholm Syndrome

Adopt behavior/Features

Splitting Gaslighting Borderline Disorder

 DISTURBANCES IN APPEARANCE
AUTOMATISMS repeated purposeless behaviors (Mannerisms)

PSYCHOMOTOR slowed movements (depressed)

RETARDATION

WAVY FLEXIBILITY maintenance of awkward posture

moved -> retained position

CATATONIA maintenance of awkward posture

moved -> goes back to original

ECHOPRAXIA purposeless imitation (mirror-like)

DISTURBANCES IN COMMUNICATION
MUTISM mute, sign of regression (toddler)

NEGATIVISM always says “no”, sign of regression (toddler)

CIRCUMSTANTIALITY Beating around the bush (ligoy-ligoy); with answer

TANGENTIALITY Beating around the bush (ligoy-ligoy); without answer

STILTED LANGUAGE Flowery Words, Common in Males

FLIGHT OF IDEAS Slightly related; with meaning

LOOSE ASSOCIATION Not Related; without meaning (statements)

PRESERVATION Goes back to same topic over and over

ECHOLALIA Parrot-like imitation

PALILALIA Repetition of Stereotyped words (last syllable)

VERBIGERATION Repeating same words over and over (sirang-plaka)

COPROLALIA Copro (feces); Lalia (Logic/Speech) - Bad Words

NEOLOGISM Coins New Words

BLOCKING Sudden cessation of Thought

WORD SALAD Mixture of Unrelated Words

CLANG ASSOCIATION Rhyming of Words

 DISTURBANCES IN PERCEPTION
DELUSIONS Fixed false beliefs

MAGICAL THINKING Beliefs in magic

PARANOIA Extreme Suspiciousness

RELIGIOSITY Obsession in Religious ideas

PHOBIA Irrational Fear

OBSESSION Persistent Thought

COMPULSION Persistent Actions

PREOCCUPATION Idea with Intense Desire

THOUGHT Others know what I am Thinking

BROADCASTING

DELUSIONS OF Talk of the Town

REFERENCE

DISTURBANCES IN AFFECT
INAPPROPRIATE Incongruent (Sad story but Laughs)

BLUNTED Little Response (Correct but Kulang)

RESTRICTED Displays One type of Expression

LABILE MOOD Unpredictable (Mood Swings)

APATHY Absence of Emotions

AMBIVALENCE Opposing Feelings, Mixed Emotions

ANHEDONIA Absence of Pleasure

EUPHORIA Extreme Pleasure

 Rheumatoid Osteoarthritis Gouty Arthritis
Arthritis

Cause Autoimmune Disease Wear & Tear Altered Purine

Degenerative Metabolism

Age Young 40s 30s

Weight Tends to be Tends to be Obese -

Underweight

ESR Always Elevated Normal Elevated during

Attacks

Labs Rheumatoid Factor - Increased Uric Acid

Nodules Subcutaneous Heberden’s - D Tophi

Nodules Bouchard’s - P

Morning (+) more than 30 (-) or sometimes (-)

Stiffness minutes (+), (+) crepitus

Reversibility (-) (-) (+)

Treatment Corticosteroids NSAIDs Anti-Gout Meds

Diet - Control Obesity Low-Purine

Symmetric Symmetric Unilateral Asymmetric

Distribution Bilateral Depends on Joint
Stress
Systemic Weakness, None Possible Renal
Symptoms Hepato-Splenomegaly Localized Damage/Stones
Lymphadenopathy

Joints Smaller joints of Weight-bearing Big toe, Foot, Knee,

Affected hands and feet Joints Helix of Ear

Joint Synovitis Osteophyte Tophi, Outside

Appearance Pannus Formation Formation Red, Dusky, Tender
Fibrous/Bony Bone Spurs
Ankylosis

Joint Pain/ Early morning, Dec Pain after Activity During night time
Stiffness with Activity Intense Pin
< 15-30 mins > 15-30 mins
 PHASES OF NURSE-CLIENT RELATIONSHIP
Pre-interaction/pre-orientation ● no contact
● data: secondary sources
● self-awareness

Orientation/Interaction ● establish frust

● assess client
● establish mutual agreement
● (inform about termination)

Working ● longest phase

● achieving goals/sharing facts
● resolve problems

Termination ● moving towards independence

● observe for regressive
behaviors (going back to
previous stage)
● reinforce previous
management

NON VERBAL COMMUNICATION

PROXEMICS ● physical space
● (3-6 ft/1 arm and half)

KINETICS ● body movements

● (gestures, facial
expressions,mannerisms)

TOUCH ● intimate physical contact

● (consent)

SILENCE ● conveys listening

● encourage patient to
talk(share)

PARALANGUAGE ● voice quality (tone, inflection)

● how message is delivered
 VERBAL COMMUNICATION
OFFERING SELF Let me sit with you for 5
minutes
ACTIVE LISTENING Ah huh, Yes, No
EXPLORING Can you describe her?
BROAD OPENING Where would you like to
begin?
MAKING OBSERVATIONS I noticed you have combed
your hair today
SUMMARIZING In the past 15 minutes, we
have talked about..
Encouraging Description of What are the voices telling
Perception you?
Presenting Reality I know the voices seem
real to you, but there are
no voices here.
SEEKING CLARIFICATION Do you mean?
REFLECTING Direct back to Client
RESTATING Repeating Main Idea
GENERAL LEADS Go on../Tell me more..
FOCUSING Let us look at it more
closely
 REPUBLIC ACTS
RA 10152 Mandatory Infant and Children
Health Immunization
RA 10173 Data Privacy Act
RA 10175 Cybercrime Prevention Act
RA 10354 Responsible Parenthood and
Reproductive Health Act
RA 10912 Continuing Professional
Development Act
RA 11036 Mental Health Act
RA 11332 Mandatory Reporting of
Notifiable Disease and Health
Events Act
RA 11469 Bayanihan to Heal as One Act
RA 11494 Bayanihan to Recover as One
Act
RA 6675 Generics Act of 1988
RA 7610 Anti-Child Abuse Act
RA 7277 Magna Carta of Persons with
Disability
RA 7305 Magna Carta of Public Health
Workers
RA 8981 PRC Modernization Act
RA 9173 Philippine Nursing Act