53119942 fundamentals of nursing nursing board review

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Fundamentals of Nursing

Nursing Board Review


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Outline of review for the boards

History of Nursing- World and Philippines

The Nursing theories

Concepts of Health and Illness

Human Basic Needs

Stress and Adaptation


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ASSESSING HEALTH STATUS

VITAL SIGNS

PHYSICAL ASSESSMENT


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CLIENT CARE

ASEPSIS

SAFETY

HYGIENE

MEDICATIONS

SKIN INTEGRITY

TERMINAL CARE


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HEATH PROMOTION AND DISEASEPREVENTION

ACTIVITY and EXERCISE

REST and SLEEP

PAIN managementNUTRITION

FECAL ELIMINATION

URINARY ELIMINATION

OXYGENATIONCIRCULATION

Fluids and Electrolytes


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History of Nursing

Intuitive Nursing

Apprentice Nursing

Dark Period of Nursing

Educated Nursing

Contemporary Nursing


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History of Nursing

Intuitive Nursing

Primitive and untaught

Code of HAMMURABI

Moses- Father of Sanitation

Hippocrates- Developed standards for clientcare, medical standards and need for nurses


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History of Nursing

Educated Nursing Florence Nightingale- born May 12, 1820 in

Florence ITALY

Trained: Germany at Kaiserswerth School Founded the St. Thomas School of Nursing

in England Teachers are devoted clinical instructors solely

for teaching The first nurse to exert political pressure on

government


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Nursing in the PHILIPPINES

First School of Nursing= ILOILO MISSIONhospital school of nursing

Anastacia Giron-Tupas= Founder of the PNA

Rosario Delgado= first PNA president


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Theories in Nursing

Four concepts Central to Nursing:

P-E-H-N

Person

Environment

Health

Nursing


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Theories in Nursing

ENVIRONMENTAL THEORY

Relate nature with the bird- Nightingale

The act of utilizing the environment of the

patient to assist him in his recovery


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Theories in Nursing

INTER-PERSONAL RELATIONS Model Remember PEP talk

Hildegard PEPLAU

Therapeutic relationship:

Orientation= assist client tounderstandproblem

Identification= Client dependence, inde andinter he recognizes his problems in this phase

Exploitation/Exploration= Derives full valueini-exploit!!

Resolution= old andnew goalsput aside


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Theories in Nursing

Nature of Nursing- Definition of Nursing

The meaning of Nursing is VIRGIN

Recall the 14 needs!!!!!

Associate 14 virgin HENS VirginiaHENDERSON

She believes that clients need to express theiremotions, remain independent, autonomous

They must work in such a way that they feel a senseof accomplishment


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Theories in Nursing

21 nursing problems

Faid 21

Faye Abdellah


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Theories in Nursing GENERAL THEORY OF NURSING-

SELF- CARE Associate Self care to ORAL care or

per orem

Dorothea OREM 1. WHOLLY compensatory= unable to

control

2. PARTLY compensatory= unable to

performSOMEself care 3. SUPPORTIVE- EDUCATIVE= who

needs to learn and needs assistance


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Theories in Nursing

BEHAVIORAL SYSTEM MODEL

Associate behavior with John (inJohn and Marsha)

kaya JOHN(son) magsumikap ka Dorothy Johnson


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Theories in Nursing

Conservation Theory

the Divine is Conservative

Levin levine, divine


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Theories in Nursing

GOAL ATTAINMENT

Recall that the KING of the land has aGOAL to attain for his kingdom

IMOGENE KING!

Her theory is applicable to the child

bearing women and their families


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Theories in Nursing

UNITARY BEING: Man as theCENTRAL Focus

Roger , Roger, let us unite our Man

in the center of the battlefield

The whole is greater than its parts

Martha ROGERS

She believes in the use of theprinciples of NON CONTACTtherapeutic touch


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Theories in Nursing

HEALTH CARE SYSTEMS model

Betty NEUMAN

Stresses, reactions to stress andadaptation to stressors

After overcoming the stresses you willbecome a NEW-Man

Intrapersonal stressor= illness

Extrapersonal stressors= financialconcerns, community resources

Interpersonal stressor= unrealistic roleexpectations


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Theories in Nursing

ADAPTATION MODEL

Individual is a BIOPSYCHOSOCIAL

ADAPTIVE system with input andoutput

associate this with a Nun

SISTER ROY= nag a adopt ng mgabata

Her theory supports the unitybetween the client and God


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Theories in Nursing

CULTURAL CARE DIVERSITY

Transcultural Nursing

Madeleine LEININGER


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Theories in Nursing

Nursing Process theory and CARE,CORE and CURE

The nurse who coined the wordnursing process and stated I care, Icore and I cure

Hall of Fame award!!!

LYDIA HALL


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Theories in Nursing

DYNAMIC NURSE-PATIENTRelationship

Associate dynamic action to theteam of ORLANDO

Ida Jean ORLANDO!!!

Go Orlando, the dynamic team!!!!!


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Theories in Nursing

HUMAN BECOMING THEORY

Remember to become a rose per se ,

you must be a bud first!!!!!!!!!!!!

Rosemarie Parse

Her theory emphasizes that clients arethe AUTHORITY figures and decision

makers for their personal health


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Theories in Nursing

HUMAN CARING THEORY

Whatis caring?

Jean WATSON Caring for clients during their end-of-

life experiences


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Patricia Benners Stages of nursing

expertise (NACPE)

Stage 1 = novice No experience, performance is limited,inflexible

Stage 2= advanced

beginner

Demonstrates MARGINALLYacceptableperformance, recognizes the meaningful

aspects of a real situationStage 3=competent

Has 2-3 years experience, demonstratesORGANIZATIONAL and planning abilities

Stage 4= proficient Has 3-5 years of experience, perceives

situations as whole, has HOLISTICunderstanding of patient

Stage 5= expert Performance is FLUID, flexible and HIGHLYProficient, No longer requires rules,maxims.Demonstrates HIGHLY skilled

intuitive and analytic ability


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Health Definition

A state of complete physical,mental and social well-being and

not merely the absence of diseaseor infirmity

WHO, 1948


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Wellness

State of well-being

Seven Components- seven wishingWELL

Physical= carry out task

Social= interact with peopleEmotional= express feelings

Intellectual= learn and use info

Spiritual= belief in supernatural

Occupational= leisure and work

Environmental= standard of living incommunity


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Health Theories

CLINICAL

Health is absence of disease

ROLE PERFORMANCE Health is ability to fulfill societal

functions

ADAPTIVE Heath is a creative process of

adaptation


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Health Theories

EUDEMONISTIC

Health is a condition of self-actualization

ECOLOGIC

Health is interaction of three elements:

1. Agent

2. Host

3. Environment


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Health Theories

Dunn

doon, dito, dine and dire

Four quadrants

HIGH level Wellness is functioning at the BESTpossible level


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Illness and Disease

DISEASE

Alteration in body functions

ILLNESS

A state of physical, social, emotional,intellectual, developmental or spiritualfunctioning is DIMINISHED


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Stages of Illness: S-A-M-D-R

SYMPTOM experiences

Client believe something is wrong

ASSUMPTION of the sick role Excuse form work and family role

MEDICAL care contact

DEPENDENT CLIENT role RECOVERY or REHABILITATION


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Abraham Maslows Hierarchy of needs

Physiologic needs- oxygen, water, food

Safety and security

Love and belonginess Self esteem

Self actualization


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Safety and security

Physical safety

Psychological safety

Shelter from harm


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Love and belonginess

Need to love Need to belong

Need for affection


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Self esteem

Self-worth

Self-identity

Self-respect

Self-image


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Self actualization

Self-fulfillment

Spiritual fulfillment


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Man and His needs

Self-

Actualization

Self-Esteem

Love and Belongingness

Safety and Security

Physiologic Needs


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Mans Need

Need is something desirable anduseful

Needs are UNIVERSAL

Needs are MET in different WAYS Needs are influenced by different

FACTORS

Priorities may be CHANGED Needs may be POSTPONED

Needs are INTER-RELATED


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Mans Need

Need is something desirable anduseful

Prioritization of needs mat be dictatedby the clients perception


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Mans Need

Nursing goal is this area is to:

Meet the PHYSIOLOGICAL needs of thepatient

Assess the patient's perception of hisother needs

Employ nursing Interventions according to

the PERCEIVED NEEDS of the patient NOTof the nurse


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Evaluation Parameters of nursing care

The nurse checks if the desired criteriadictated by patients needs are achieved

Check which interventions were helpful

Revise the plan as needed


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Man achieves self-actualization

(Udan)

A self-actualized person is basically a

MENTALLY healthy person

And self-actualization is the essence ofmental Health


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Cultural care nursing

It is the provision of nursing care acrosscultural boundaries and takes into accountthe context in which the client lives

It is professional nursing that is culturallysensitive, culturally appropriate, and culturally

competent


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Cultural care nursing

The suggested steps for culture care are:

1. Become aware of ones own culture heritage

2. Become aware of the clients heritage and health

tradition3. Identify clients preference in health practices, diet,

hygiene, etc. These will affect their healthpractices

4. Formulate a culture care plan


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STRESS A condition in which the person responds to

changes in the normal balanced state

Selye: non specific response of the body to anykind of demand made upon it

STRESSOR

Any event or stimulus that causes an individual toexperience stress


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SOURCES OF STRESS

1. Internal

2. External

3. Developmental

4. Situational


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Physiological indicators of stress: Sympatheticresponse

Dilated pupils

Diaphoresis

Tachycardia, tachypnea, HYPERTENSION,

increased blood flow to the muscles Increased blood clotting

Bronchodilation

Skin pallor

Water retention, Sodium retention Oliguria

Dry mouth, decrease peristalsis

Hyperglycemia


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S d Ad i


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SELYES General Adaptation Theory

A-R-E

ALARM:sympathetic system is mobilized!RESISTANCE:adaptation takes place

EXHAUSTION: adaptation cannot be

maintained

ANXIETY


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ANXIETY

CATEGORY MILD MODERATE SEVERE PANIC

Perceptionandattention

Increasedarousal

Narrowedfocus

Inability tofocus

Distortedperception

Communication

Increasedquestioning

Voicetremors

Focus onparticularobject

Difficult tounderstand

Easilydistracted

Tremblingunpredictable response

VS changes NONE SlightIncrease

Tachycardia,Hyperventilation

Palpitation,choking,chest pain

A i f


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Anxiety versus fear

ANXIETY FEAR

State of mental uneasiness Emotion of apprehension

Source may not beidentifiable

Source is identifiable

Related to the future Related to the present

Vague Definite

Result of psychologic oremotional conflict

Result of discrete physicalor psychological entity,definite and concreteevents


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VS


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VS

T

P

R

BP

TEMPERATURE


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TEMPERATURE

Reflects the balance between the heatproduced and the heat lost from the body

CORE TEMPRATURE: deep tissues of body

T M i i


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Temperature Monitoring

Oral- accessible and convenient

Rectal- very accurate

Axillary- preferred for newborns

Tympanic- reflects core temperature

B d t t h di l i ti


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Body temperature has a diurnal variation

POINT of Highest body temperature isBETWEEN 8 pm to 12 midnight

POINT of Lowest body temperature isBETWEEN 4 am to 6 am

T Al i


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Temperature Alteration

FEVER, PYREXIA, HYPERTHERMIA

1. Intermittent:Periods of fever and normaltemp

2. Remittent: Fever fluctuates BUT abovenormal

3. Relapsing: Fever for few days, thennormal for few days

4. Constant: ALWAYS above normal,minimal fluctuation

H t l


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Heat loss

Mechanism Description

Conduction Transfer of heat form one object toanother by direct contact

Convection Movement of air and heat by air current

Evaporation Loss of heat through evaporation ofwater/sweat

Radiation Transfer of heat from warm objects tocool objects in the form ofelectromagnetic waves

P l


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Pulse

A wave of blood created by contraction of theleft ventricle of the heart

Normal range: 60-100 BPM

P l


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Pulse

Pulse pressure: Systolic pressure MINUS diastolic pressure

Pulse deficit

Apical pulse MINUS peripheral pulse Pulsus paradoxus

Systolic pressure falls by more than 15mmHg during INHALATION

Pulsus alternans Alternating strong and weak pulses

Li id Di t V S ft di t


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Liquid Diet Vs Soft diet

Clear liquid Full liquid Soft diet

Coffee

Tea

Carbonated

drinkBouillon

Clear fruit juice

Popsicle

Gelatin

Hard candy

Clear liquidPLUS:

Milk/Milk prod

Vegetablejuices

Cream, butter

Yogurt

PuddingsCustard

Ice cream andsherbet

All CL and FLplus:

Meat

VegetablesFruits

Breads andcereals

Pureed foods

F d G id p r id


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Food Guide pyramid

Bread, cereals, rice and pasta= 6-11 servings

Fruit and vegetables

Meat, poultry, fish, dry beans, eggs

Milk, yogurt, cheese

Fats, oils and sweets


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Primary Prevention Health promotion andSpecific protection

Secondary Prevention Health maintenance

Screening and casefinding

Early diagnosis

Prompt treatment

Tertiary Prevention Rehabilitation


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Primary

PreventionEducation, Exercise, Diet and

Nutrition, Immunization

Secondary

Prevention

Physical Examination, Paps

smear, BSE, TSESputum AFB, DRE

Providing medication andtreatment

Tertiary

PreventionPhysical therapy, Self-monitoring

of DM, Speech therapy

Levels of Prevention


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1. ENCOURAGING MEDICALCONSULTATIONS AND DENTAL CHECK-UPS



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1. ENCOURAGING MEDICALCONSULTATIONS AND DENTALCHECK-UPS

Secondary Prevention



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2. Assessing growth and development ofchildren for nutritional evaluation



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2. Assessing growth and development ofchildren for nutritional evaluation

Secondary Prevention



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3. Family Planning and marriage counseling



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3. Family Planning and marriage counseling

primary prevention



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4. Teaching a client with diabetes self-monitoring of glucose level



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4. Teaching a client with diabetes self-monitoring of glucose level

Tertiary prevention


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DIAGNOSTIC

EXAMINATIONS

Duke J. Trillanes III, RN, MAPRA Gapuz Review Center

MUST KNOWS


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MUST KNOWS

KNOW NORMAL VALUES FIRST

DISEASE CONDITIONS AND THESIGNIFICANCE OF CERTAINLABORATORY DATA

POSITIONING FOR THIS TESTS

PURPOSE AND NURSING ALERT

SPECIMEN COLLECTION AND PATIENT

PREPARATION

POST TEST RESPOSIBILITIES

SPECIMEN COLLECTION


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SPECIMEN COLLECTIONUrine

Clean-catch urine specimen For routine urinalysis and culture and sensitivity test

Perineal care before collection

The best time to collect the specimen is early in the

morning (first voided-specimen) Amount needed: 30-50 cc for urinalysis; 5-10 ml for

culture and sensitivity test

24 Hours urine Specimen

discard the first voided urine

Soak specimen in a container of ice

Add preservative as ordered and indicate in the labelthe type of preservative added.


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Second voided Urine Specimen

Ask the patient to urinate and discard the first

urine specimen and offer a glass of waterafterwards

After few minutes, ask the client to void again andcollect the specimen

Catheterize Urine Specimen

Clamp the catheter for 45 mins

Practice aseptic technique

Do not collect specimen from the urine bag Obtain 3-5 ml of specimen for culture and

sensitivity test and 10-15 ml for urinalysis


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Stool Specimen


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Routine Fecalysis Use to assess gross appearance, and presence of ova

or parasite in the stool Sterile specimen container must be secured Instruct the client to defecate in the bedpan and obtain

1tbsp or 1 inch long stool specimen using a steriletongue depressor

Label the specimen and bring immediately to thelaboratory

Stool Culture and Sensitivity Test This is done to assess for specific microorganisms and

etiologic agents causing gastroenteritis, and bacterial

sensitivity to various antibiotics Sterile technique must be employed Label the specimen properly and send immediately to

the laboratory

Guiac Stool Exam (Occult Blood)


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( )

It detects bleeding at the GI tract and

cancer of the stomach Meatless diet for 3 days prior to the

procedure

No to red or dark colored foods tom preventfalse positive result

No to iron: discontinue temporarily for 3days prior to the procedure


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Sputum specimen


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Sputum specimen

Gross Appearance

Collect early morning specimen Sterile container must be used

Mouth care before: gargle only with water (no tomouthwash, or toothpaste)

Instruct the client to deep breath and hack-upsputum from the lungs.

Sputum Culture and Sensitivity test

Used to assess the etiologic agent causingRespiratory tract infection and bacterialsensitivity to various antibiotics

Acid Fast Bacillus (AFB) staining


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Acid Fast Bacillus (AFB) staining

To determine active PTB

Sputum specimen is collected in 3consecutive mornings

Papanicolao or Cytologic Examination of thesputum

To assess for cancer cells

Blood Specimen


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p

Blood Tests that does not require fasting:

Complete Blood Count

Hemoglobin

Hematocrit Level test

Clotting studies

Enzyme studies

Serum electrolyte studies

Requires Fasting

Fasting Blood Sugar

Blood Urea Nitrogen

Serum Creatinine

Serum lipids (cholesterol level, glyceride level)


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Body Secretions

Culture and sensitivity test

To assess causative agent causing infection, and

bacterial sensitivity to various antibiotics Practice aseptic technique

Arterial blood gas analysis


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PURPOSE: To monitor the patients response tooxygen therapy and detects the presence of acid-

base balance. NURSING KEYPOINTS:

No to Suctioning prior to obtaining blood specimen

Assess for bleeding and hematoma at the puncturesite

Apply firm pressure at the puncture site for 5-10minutes

Specimen should be placed in iced-container

Assess for metabolic alkalosis for patient withvomiting, and on the other hand, observe for signs andsymptoms of metabolic acidosis for patients withdiarrhea.

Barium enema


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PURPOSE: To assess the large intestines

NURSING KEYPOINTS:

Provide a Liquiddietbefore the procedure.

Ensure that a laxative is given before theprocedure to promote better visualization, and

after the procedure to prevent constipation Report to the doctor if bowel movement does

not occur in 2 days

Instruct the patient to increase fluids and eat

foods rich in fiber The patient should also increase intake of

fluids


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Friends and Enemas What is an ENEMA?

A solution introduced into the rectum andlarge intestine for the purposes of:

1. To relieve constipation2. To relieve flatulence

3. To administer medication

4. To evacuate feces in diagnostics or surgery


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Enema types


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yp

1. Cleansing Enema= intended to remove

feces to prevent escape during surgery,for visualization procedure andconstipation

Purposes To1. Prevent escape of feces duringsurgery

2. Prepare intestines for diagnostics

and surgery3. Remove feces inconstipation/impaction

Enema types


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yp

2. Carminative enema= to expel flatus, 60-80mL of fluids instilled

3. Retention enema= oil or medication is

instilled to treat infection4. Return flow enema= also to expel flatus,

repeated 6 times

Enema Solutions


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Hypertonic Draws water into thecolon

SE: Retention of sodium

Hypotonic Distends colon, softensfeces

SE:F and E imbalance,water intoxication

Isotonic Distends colon SE: possible sodiumretention

Soap suds Irritates colon SE: May damage mucosa

Oil enema Lubricates feces

The Height of the ENEMAS


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g

During MOST enemas For HIGH enema

No higher than 30 cm above rectum Up to 45 cm above rectum

The TIME of the ENEMAS


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Cleansing Enema For Oil retention enema

5-10 minutes 30 minutes

The Length of the ENEMA tube


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g

insertion

The rectal tube isinserted 3 to 4 inches

Barium swallow

PURPOSE T f th h


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PURPOSE: Toassess for the esophagus,stomach, and some portion of the small

intestines. NURSING ALERT:

NPO for 6-8 hours before the procedure

Laxative is administered after the procedureto counteract the constipating effects of thebarium

Withhold anticholinergics and narcotics for 24

hours before the test Instruct patient to increase fluids and intake

of fiber-rich foods

Cardiac catheterization PURPOSES: To measure oxygen concentration, saturation,

i d i i h b f h h T


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tension and pressure in various chambers of the heart. Todetermine a need for cardiac surgery.

NURSING KEYPOINTS: Check for informed consent Assess allergy to iodine NPO for 6-8 hours before the procedure Check for distal pulses after the procedure

Check for bleeding at the arterial puncture site and applypressure Keep a 20 lbs sandbag at the bedside as a pressure instrument

if bleeding occurs Keep the patient flat on bed with the lower extremities

hyperextended for 4-6 hours Neurovascular assessment must be performed distal to the

catheter insertion site and report any abnormal findings

Catheterization, urinary PURPOSE: To determine residual urine and obtain sterile specimen. It can

b t i ht th t bi i d lli th t d t l d i


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be a straight catheter, suprapubic, indwelling catheter, and external devicecatheter.

NURSING ALERT:

Know the necessary facts:

Principles Male Female Position Supine Dorsal recumbent Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in. French number or

Circumference #14- 16 #18 Length of tube to be inserted 2-3 in. 6-9 in. Balloon size 5-10 ml. 5-10 ml (30 ml)Can be used to achieve hemostasis of the prostatic area following prostatectomy Place to secure lower abdomen Inner thigh


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The procedure is sterile

Maintain a close system

The draining bag must always be below thebladder

The catheter bag should not be allowed to lieon the floor

Do not allow the drainage spout to touch the

collection receptacle or on the toilet bowlwhen draining it


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Chest X-RAY

PURPOSE: To detect abnormalities of theorgans in the thoracic area

NURSING KEYPOINTS:

Remove any metallic object before theprocedure

Lead shield for women of childbearing age

Computerized Tomography (CT)


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Definition1. Cross-sectional visualization of the brain determined

by computer analysis of relative tissue density as anx-ray beam passes through; also known ascomputerized axial tomography (CAT) scan

2. Provides valuable information about location andextent of tumors, infarcted areas, atrophy, andvascular lesions

3. May be done with or without intravenous injection of

dye for contrast enhancement



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Nursing care

1. Explain procedure; inform the client that it will benecessary to lie still and that the equipment is complexbut will cause no pain or discomfort; infants andcognitively impaired or anxious clients may need to besedated

2. If the facility is small, arrange transportation to a largerfacility that has the required equipment3. Evaluate for possible allergy to iodine, a component of

the contrast material4. Withhold food for approximately 4 hours prior to testing;

dye may cause nausea in sensitive patients5. Remove wigs, clips, and pins prior to the test6. Evaluate client's response to procedure


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NURSING ALERT:

If contrast medium will be used, assess for anyallergy to iodine and instruct the patient to beon NPO for 4 hours prior to the procedure

Assess for any fear of close spaces

(claustrophobia)

This procedure is contraindicated to patientswho are pregnant and obese (>300 lbs)

Let the patient lye still during the whole courseof the procedure

CVP (Central Venous Pressure) monitoring


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CVP (Central Venous Pressure) monitoring PURPOSE: It measures the pressure of the Right

Atrium NURSING KEYPOINTS:

The nurse should place the zero level of themanometer at the level of the Right atrium at the 4thintercostals space to get an accurate reading

Instruct the client to avoid coughing and straining asit alters the readings

Normal CVP reading is 2-12 mm Hg ( when the tubeis at the superior vena cava)

Cystoscopy


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PURPOSE: To assess the bladder and urethra

NURSING KEYPOINTS: Check for the informed consent.

If general anesthesia will be used have the clienton NPO; liquid diet if local anesthesia will be used.

Monitor intake and output. After: Force fluids as prescribed.

Administer sitz bath for abdominal pain.

Pink-tinged or tea-colored urine is expected.

Notify the doctor if bright red urine or clots occur.


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Doppler ultrasound

PURPOSE: Evaluates patency of veins andarteries in the lower extremities.

NURSING KEYPOINT:

Inform the patient that it is painless.

Doppler UTZ


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ECG (Electrocardiogram)


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ECG (Electrocardiogram)

PURPOSE: Records electrical waves of theheart.

NURSING KEYPOINTS:

Instruct the patient to lie still, breathenormally during the procedure

Let the patient refrain from talking duringthe test.

ST segment elevation or T wave inversion,indicates MI


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EEG (Electroencephalogram)

PURPOSES: Records the electrical activity of


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PURPOSES: Records the electrical activity ofthe brain, detects intracranial hemorrhage and

tumors NURSING KEYPOINTS:

Advise the client to shampoo hair before andafter the procedure

If the electrode gel is non removed byshampooing, the patient may use acetone

Withhold stimulants, antidepressants,

tranquilizers, and anticonvulsants for 24-48hours prior to the test


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Fasting Blood Sugar level PURPOSE: Detects diabetes mellitus

NURSING KEYPOINTS:

Normal blood sugar level is 80-120 mg/dl A blood sugar level of more than 140 mg./dl

confirms diabetes.

Gastric analysis


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y

PURPOSES: This test is used to detect

ulcers, and to rule-out pernicious anemia. Itmay also be done to analyze acidity,appearance and volume of gastricsecretions

NURSING KEYPOINTS:

In gastric ulcer, HCL is normal,

In duodenal ulcer, HCL is elevated.

Refrigerate gastric samples if NOT testedwithin 4 hours.

IVP (Intravenous pyelography)

PURPOSE: Visualization of the urinary tract


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y

NURSING KEYPOINTS:

Check for the consent. NPO for 8-10 hours before the procedure

Administer laxative to clear bowels before the procedure.

Check for allergy to iodine, seafoods or shellfish beforethe procedure since the procedure requires the use of iodine

based dye. Keep epinephrine at the bedside to counteract possible

allergic reaction. IVP requires the use of a contrastmedium while KUB does not.

Inform the patient about the possible salty taste that may

be experienced during the test. Increase fluid intake after the procedure to facilitate excretion

of the dye.


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KUB PURPOSE: Determines the size, shape and

position of kidneys, ureters and bladder.

NURSING KEYPOINT: No special preparation needed.


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Liver biopsy

PURPOSE: To determine liver disorders


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PURPOSE: To determine liver disorders.

NURSING KEYPOINTS:

Check for the consent.

Obtain the result of blood tests before biopsy sincebleeding may occur

Let the patient assume left side or supine duringbiopsy

Instruct the patient to inhale, exhale and hold breathduring the insertion of to stabilize position of the liverand prevent accidental puncture of the diaphragm

Position the patient on the Right side after liver biopsywith pillows underneath to prevent bleeding

Bedrest for 24 hours after the procedure

Lumbar Puncture


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PURPOSE: To withdraw CSF to determine

abnormalities. NURSING KEYPOINTS:

Before the procedure: empty bladder and bowel.

Position: C-position. (fetal posistion)

During the procedure: needle is inserted between L3 -L4 or L4-L5 to prevent accidental puncture to thespinal cord since the spinal cord ends at L2.

After: Position the patient flat for 6-12 hours to preventspinal headache. Increase fluid intake.


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Mammography


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PURPOSE: Detects the presence of breast tumor.

NURSING KEYPOINTS: Instruct the patient not to use deodorant, talcum

powder, lotion, perfume or any ointment on the day ofexam as these may give false-positive result

Let the patient know that her breasts will be

compressed between 2 x-ray plates Provide teachings related to Self-breast examination

Done 7 days after menstruation Position: lying down with pillow under the shoulder of

the breast being examined or sitting in front of a mirrorwhile raising the hands of the side of the breast beingexamined.


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Mantoux test PURPOSE: A test to determine exposure to TB NURSING KEYPOINTS: A positive test yields an induration of 10 mm. or more for foreign

born children below 4 years old An induration of 5 mm or more is considered positive in patients

with HIV, with treated TB, and if he has had a direct exposure TBPatients.

BCG may cause false positive reaction. Assess for previous history of PTB and report immediately to the

doctor

Result is read after 48-72 hours


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MRI (Magnetic Resonance Imaging) PURPOSE: Provides cross-sectional images of

brain tissues, more detailed than a CT scan. NURSING KEYPOINTS: Contraindications:

pregnant women, obesity (more than 300 lbs.), claustrophobic patients, patients with unstable vital signs

patients with metal implants like pacemaker, hipreplacements and jewelries.

Magnetic Resonance Imaging (MRI)


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Definition1. This procedure utilizes magnetism and radio wavesto produce images of cross-sections of the body

2. The MRI machine registers the existence of odd-numbered atoms in the cross sections of the body,

yielding data about the chemical makeup of thetissues

3. MRI can produce accurate images of blood vessels,bone marrow, gray and white brain matter, the spinalcord, the globe of the eye, the heart, abdominalstructures, and breast tissue, and can monitor bloodvelocity


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Nursing care1. Assess ability to withstand confining surroundings

because client must remain in the tunnel-like machinefor up to 90 minutes; open MRI may be an option for

clients who cannot tolerate closed spaces2. Instruct client to toilet prior to test, since this will be

impossible during the procedure

3. Advise client to remove jewelry, clothing with metalfasteners, dentures, hearing aids, and glasses prior toentering scanner



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4. Since this procedure is contraindicated for certainclients, before the test assess for:a. Metal prostheses, such as orthopedic screws,

since the magnetic force can dislodge thedevices

b. Pacemakers, since the scanner deactivatespacemaker

c. Dysrhythmias, because the magnetic field canaffect the conduction system of the heart

d. Unstable medical conditions, since monitoringof the client is limited during the test5. Evaluate client's response to procedure


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Stool analysis PURPOSE: Assessment of bacteria, virus,

malabsorption and blood.

NURSING KEYPOINT: Avoid aspirin, red meat and vitamin C

three days before the test as these may givea false positive result.


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Tonometry PURPOSE: Measures intraocular pressure.

NURSING KEYPOPINTS:

Normal reading is 12-21 mm Hg A reading of 25 mm Hg indicates glaucoma.

Urinalysis

PURPOSE: To assess characteristics of urine


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PURPOSE: To assess characteristics of urine.

NURSING KEYPOINTS: First voided morning sample preferred: 15 ml.

Use clean container

Decreased specific gravity: diabetes insipidus Increased specific gravity: diabetes mellitus,

dehydration, SIADH

(+) Protein: PIH, nephrotic syndrome. (+) Glucose: Diabetes mellitus, Infection

Urine Collection


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As fresh as possible

Mid stream cleancatch

First morningspecimen best, but formost purposesdoesnt make much

difference


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HematuriaEven small amounts of blood are visible

1 part per 1000 is easily seen

Urine collection 24 hour


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Urine collection, 24 hour

PURPOSE: Determines the excretion of substancesfrom the kidneys, adrenal glands and the stomach.

NURSING KEYPOINT:

Required for ACTH test and schillings test (B12

absorption),

Discard the first voided urine

Place urine output in a clean container preserved in

ice chest

Thank


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You!

53119942 fundamentals of nursing nursing board review

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