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FUNDAMENTALS OF NURSING

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Page 1: Fundamentals of Nursing 1

FUNDAMENTALS OF NURSING

Page 2: Fundamentals of Nursing 1

To assist clients (sick or well) in the performance of activities contributing to health, it recovery or peaceful death that the clients will perform unaided, if they had the necessary will, strength or knowledge

Nursing

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Caregiver Communicator Educator/Teacher Counselor Manager/Coordinator Change Agent Leader Clinician Advocate

Roles and Responsibilities of Nurses

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P- articipation of client in his own care ensured

R- rights of the client protected A- utonomy is safeguarded N- eeds of client communicated I- nformations related to condition is provided

N- urture therapeutic alliance G- iven opinions and choices

ADVOCATE (PRANING)

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P-erson E- nvironment H-ealth N-ursing

Scopea. Health promotionb. Disease preventionc. Health restorationd. Care of the death and suffering individuals

Major concepts

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ID- I want- pleasure principle Ego- reality, arbiter Superego- moral principle

PERSON

ID EGO SUPEREGO

Manic Schizo BulimiaAntisocial OCNarcisistic anorexia

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Foundation of Nursing Profession“DYNAMIC”Systematic and rational

Nursing Process

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Systematic Use of critical Thinking Client Centered Universal (individual, family, community)

Characteristics

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C-ollection of data O- bservation of data V- alidation of data I- dentification of data

Types of dataa. Subjectiveb. Objective

ASSESSMENT

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T- rust R-apport U- nconditional regards S-et limits T-herapeutic communication C-onfidentiality P-roximities A-ctive listening and observation T- ouch S-et limits

Phases of Communication

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Proximities◦0-18 inches (intimate)◦18-36 inches (personal)◦4-12 ft ( social)◦12-40 ft(public)

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Observation (senses) Interview- purposeful conversation

◦Formal- highly structured, questionnaire, limited time, yes or no

◦Informal- rapport building, free flowing, open ended

Methods of data collection

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Physical Assessment (IPPA)La and Dx resultRecords review

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Nursing Care Models

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Total Patient Care- All aspect of one or more patient

care- Continuous care (endorsement)- Shift based focus- Does not necessitate care (same

nurse)

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Functional nursing◦Division of task◦Task focused◦Nurses are more competent for repeated actions

◦Absence of hollistic care

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Team Nursing◦RN’s lead the team and other assistive personnel

◦Charge nurse◦Coordination of client’s care plan◦collaboration

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Limitations of Team Nursing◦Role confusion◦Lack of time of the team leader to client

◦Non-continuity of care

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Case Management◦Coordinates and links health care service

to patient and family◦Rn responsible for care from admission

up to following up of discharge◦Group of clinicians- collaborative group

who oversees the management of case◦Case-type-based care

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Primary Nursing◦Aim to place RN at bedside and improves professional relationship between staff

◦Assumes caseload of patients◦Designed to maintain continuity of care

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A nursing care that focuses on the relationship of the nurse with her client with the same nurse rendering care all throughout the client’s hospitalization.

a. Total patient care c. Team Nursingb. Functional Nursing d. Primary Nursing

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d. Primary Nursing

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Theorists

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Theorist ModelDorothea Orem Self care and self

care deficitFlorence Nightingale

Environmental Theory/Nurturing Environment

Roy Adoptation ModelHildegrad Peplau NPI

Nursing Theories

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Faye Abdellah 21 Nursing Problems/patient care approaches to nursing model

Imogene King Goal Attainment Theory

Martha Roger Humanistic Science Theory/Science of Unitary Human Being

Leininger Transcultural NursingWatson Human Caring Theory

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Ida Jean Orlando Dynamic Nurse Patient Relationship ModelValidation and evaluation of interactionDeliberative Nursing Process Theory

Rosemarie Parse Human Becoming Theory

Dorothy Johnson Behavioral System Model (7 subsystems)

Neuman Stress Adaptation Model

Myra Levine Conservation Model

Page 28: Fundamentals of Nursing 1

Patricia Benner Primacy of Caring Model/novice-expert

Lydia Hall Core-Care-CureMargareth Neuman Health as Expanding

Consciousness Theory

Joyce Travelbee Humanistic Revolution Theory

Ernestine Wiedenbach

Prescriptive theory (Philosophy, Purpose, practice, art)

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Patricia Benner

Florence Nightingale

Abdella WatsonImogene King

Martha Roger

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A. Temperaturea. Core temperature- deep tissueb. Surface temperature- surface tissue

Factors affecting heat lossb. Conduction- from one place to anotherc. Evaporation- insensible heat lossd. Radiation- with contacte. Convection- air current

Cardinal Signs

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◦ Sites A. Rectal- most accurate

- 2-3 mins, CI to quadriplegic client B. Tympanic- quickest C. Oral- most accessible D. Axillary- safest and non invasive Types of fever1. Intermittent- fever with periods of normal

and subnormal temp2. Remittent- fluctuations for about 2 degrees

Celsius but with no area where temp is normal

3. Relapsing- fever for few days 1-2 days normal temperature

4. Constant- constantly high

Page 32: Fundamentals of Nursing 1

B. Respiration- medulla oblongata12-20cpm- eupnea

>20- tachypnea <12- bradypnea

0- apneaRhytym 1. Cheyne-stoke- waxing and waning

- very deep-very shallow-apnea- Irreversible shock

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◦2. Kussmaul’s- DKA, deep labored breathing

◦3. Biot’s respiration- very shallow apnea

3. Pulse- wave of contractions produced by left ventricle

Page 34: Fundamentals of Nursing 1

I. Guidelines a. Psychological preparation b. Physical preparation (empty

the bladder) c. Environment d. equipment e. Positioning

Physical Assessment

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Registered Nursea. Maintain proper body mechanicsb. Widen base of supportc. Bend kneesd. Do no bend your backe. Avoid stretching/reachingf. Maintain Good body alignment

Basic principles in positioning

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F. Abdomen (IAPePa) G. if female (16y/o)+male md+female RN (witness)

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I. Inspection – use of SightII. Palpation- touch

I. Light/superficial- press the area lightly (circles)

II. Deep/bimanual- Direct hand-palpate, NDH-support the organ or mass

Points: a. Light first before deep b. Wilm’s tumor, appendicitis, abdominal aneurysm

III. Percussion- striking or tapping of body parts

Sequence- IPPA

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Direct- frontal sinus, direct Indirect- pleximeter (middle finger of NDH), plexor (middle finger of DH)

Blunt- Use of percussion hammer, Deep tendon reflex

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Listening to body sounds produced by the body

Types◦a. Direct- use of unaided ear◦Indirect- use of stethoscope

Auscultation

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Color◦Yellow◦Bluish◦Redness Note: Asses for burns

Skin

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Strawberry Tongue Red Beefy tongue Black hairy tongue

Ears Weber- equal laterization of sound Rhine

Tongue/Mouth

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A-ortic- 2nd intercostal space @ right sternal boarder

P- ulmonic- 2nd ICS left sternal boarder Erb’s point- 3rd ics left sternal boarder T-ricuspid- 4th ics left sternal boarder M-itral- pmi, 4th-5th ics midclavicular line left

side

Thorax

Page 43: Fundamentals of Nursing 1

GCS Reflexes Superficial- cremasteric reflex

- Babinski (+) 10 months- cerebral palsy

Neuro

Page 44: Fundamentals of Nursing 1

One of the responsibilities of Mr. Cyrile,RN, an industrial nurse, is to conduct physical head to toe assessment, he took the vital signs. Which of the four assessment techniques did he utilize?

Auscultation 3. Palpation Percussion 4. Inspection

◦ 1,2,3 c. 1,2◦ 3,4 d. 1,3,4

Page 45: Fundamentals of Nursing 1

d. 1,3,4

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Infection Control

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STANDARD PRECAUTIONS: “All patients at all times” (formerly Universal Precautions)

1.       Handwashing2.       Gloves3.       Goggles4.       Gowns5.       Patient-care equipment6.       Environmental control

Infection Control

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7.       Linen8.       Occupational health and bloodborne pathogens

9.       Patient placement10.      Respiratory hygiene11.      Safe injection practices

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               In Case of Needle Puncture:                        W-ash with soap and running

water                        R-eport without delay                        A-ssess the source                        P-ost Exposure Prophylaxis

(PEP) in 1 to 2 hours 12. Lumbar puncture practices

Page 50: Fundamentals of Nursing 1

AirBorne Precaution: “Microorganisms that can survive during out”

  RI: Respiratory Isolation ROOM: Private SP: Small Particles DOOR: Closed HP: Hepa filter / N95 /

Particulate Respirator

TRANSMISSION BASED PRECAUTIONS: “Used in addition to Standard Precautions” 

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DISEASES {CAMPS}           C- hickenpox (Disseminated varicella)          A- nthrax          M- easles          P- ulmonary Tuberculosis          S- ARS

Page 52: Fundamentals of Nursing 1

ROOM: PrivateC: CohortingDISTANCE: 3 feet separation with privacy curtain

drawn in between, individual use of equipmentGGG: gown, gloves, gogglesDISEASES {MRSA}          M- RSA          R- otavirus and RSV          S- cabies          A- bscess or wounds with uncontained

drainage

Contact Precaution: “Microorganisms that are easily spread by contact with hands or object”

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 ROOM: PrivateC: CohortingDistance: 3 feet separation with privacy

curtain drawn in betweenLP:  Large ParticleSM: Surgical mask

Droplet Precaution: “Microorganisms that are easily spread by contact with hands or object”

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DISEASES: All respiratory infections except RSV {DROPLETISM}

           D- iphtheria (pseudomembrane)           R- ubella (German measles)           O- ral pharyngitis           P- ertussis/ Pneumonia           L- egionnaire’s disease           E- rythema infectiosum (Fifth disease)           T- onsillitis           I- nfluenza           S- carlet fever           M- eningitis

Page 55: Fundamentals of Nursing 1

Enteric Precaution: “When the infectious agent is transmitted in feces”

ROOM: PrivateC: CohortingFO: Fecal-oral routeGG: Gloves and GownsDISEASES: GIT infections

Page 56: Fundamentals of Nursing 1

 (formerly Compromised Host Precautions, Transplantation Precautions, and Bone Marrow Transplant Precautions)

Avoid the following:§  Crowds: flu and colds§  Fresh flowers, vegetables and fruits: molds

and fungi§  Live immunizations: (OPV, MMR, BCG, Varicella

vaccines)

Frotective Precaution/ Reverse Isolation/ Neutropenic Precaution:“To protect the patient with impaired resistance to infection”

Page 57: Fundamentals of Nursing 1

§  Stagnant water: Legionnaire’s disease/ Pneumonia

§  Pets with ticks: Scabies§  Bird droppings: Histoplasmosis§  Raw meat, potted plants, fish tanks, cat

litter box and gardening: Toxoplasmosis

Page 58: Fundamentals of Nursing 1

Patient’s Bill of Rights◦Reflects acknowledgement of a client’s right to participate in her of his health with an emphasis in client autonomy

◦Morality- behavior (customs, traditions)

◦Values (beliefs and attitudes-decision making)

Ethics

Page 59: Fundamentals of Nursing 1

Ethical PrinciplesAutonomy Self determinationNonmaleficence Cause no harmBeneficence Duty to maintain do

good to othersJustice Equitable distribution

of benefits and tasks (according to care)

Veracity truthFidelity Duty to do what one

has promised

Page 60: Fundamentals of Nursing 1

According to the code of ethics, which of the following is the primary responsibility of the nurse?a. Assist towards peaceful deathb. Preservation of health at all costc. Health is a fundamental rightd. Promotion of health prevention of illness,

alleviation of suffering and restoration of health

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c. Health is a fundamental right

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R-escue- remove all clients in the vicinity

A-larm- Activate fire alarm

C- onfine- close all doors and windows

E- xtinguish- fire extinguisher

Fire Safety

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P- pull the pin A- im at the base of fire S-queeze the handles S- weep the fire from

side to side

Fire Extinguisher

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Type Class of FireA Wood,cloth,

upholstery,paper, rubbish,plastic

B Flammable liquids or gases, grease, tar, oil-based paint

C Electrical equipment

Types of Fire Extinguisher

Page 65: Fundamentals of Nursing 1

Nursing Procedures

Page 66: Fundamentals of Nursing 1

Nursing considerations1. No smoking2. Don not use wool blanket/metal objects

Treatment Modalitya. High O2 delivery

a. Venturi mask- COPD/CALb. Incubator, o2 hood-pedia

Oxygen Treatment Modality

Page 67: Fundamentals of Nursing 1

b. Low o2 delivery1. Nasal cannula- 40-60%2. Simple Face mask- 60-80%3. Partial rebreather mask- 80-90%4. Non rebreather mask-90-95%

Page 68: Fundamentals of Nursing 1

Suctioning

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Patients SizesInfants French 5-8Children French 8-10Adults French 12-18

Suctioning

Page 70: Fundamentals of Nursing 1

Conscious with gag reflex-semifowler’s with head on one side (oral),Neck hyperextended (nasal)

Dyspnea, drooling of saliva, low abg and BS

Application (5-10 seconds)Suctioning (10-15 seconds)Interval (20-30 seconds each)

Position

Page 71: Fundamentals of Nursing 1

Ambu BAG (100% oxygen)

Tracheostomy/endotracheal suctioning

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Parts◦ Inner Cannula◦ Outer Cannula◦ Obturator

Position (insertion) Fowler’s

Time: 2-3 minutes each suction◦ 5-10 seconds suction

Tracheostomy Care

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Tube destruction◦DOB◦Noisy◦Dificulty in suctioning (insertion)

◦Thick,dry secretions◦Mech vent (increased peak pressure)

Complications

Page 74: Fundamentals of Nursing 1

Assist in coughing and deep breathing Provide humidification and suctioning Clean inner cannula regularly The physician repositions or replaces the

tube

Prevention

Page 75: Fundamentals of Nursing 1

Secure the tube in place Instructional policy First 72 hours nurse manually ventilates

while the other call resuscitation team After 72 hours extend the neck and open

the tissue of the stoma Grasp retention sutures Use a dilator Prepare to insert Ventilate

Tube Dislodgement

Page 76: Fundamentals of Nursing 1

Note: do not deflateCoughOral HygieneFeeding

Causes of Dislodgement

Page 77: Fundamentals of Nursing 1

NEX High fowler’s neck hyperextended STOP (CYANOTIC and COUGH) PLACEMENT

A-spirate gastric secretionsA-uscultateI-nject airXRAY (the best!!!)

NGT

Page 78: Fundamentals of Nursing 1

Fowlers If 100 ML????

Tube Feeding

Page 79: Fundamentals of Nursing 1

Positioning

Page 80: Fundamentals of Nursing 1

Appendicitis: Any position if unruptured, and semi fowler if ruptured.

Asthma: Sitting position, leaning forward, to promote patient breathing

Autonomic dysreflexia: High fowler. It will prevent patient from hypertension stroke.

Bronchoscopy: Semi Fowler, to prevent aspiration after procedure.

Page 81: Fundamentals of Nursing 1

Cast: elevate extremity to prevent edema. Cataract surgery: Semi fowler to prevent

edema at the operative site. Cerebral aneurysm: Semi fowler to promote

venous drainage and decrease ICP Cleft lip: Supine after operation, prevent

pressure on the suture line. Cleft palate: Prone/side lying position for

drainage of mucus and/or blood.

Page 82: Fundamentals of Nursing 1

Increased Intracranial Pressure (ICP): Elevate head of the bed.

Mastectomy: Elevate the extremity of the affected side (on pillow) to prevent lymphedema.

Radium implant in the cervix: Flat to prevent dislodge of the implant.

Shock: Modified trendelenburg to promote venous return.

Spinal cord injury: Immobilize the patient

Page 83: Fundamentals of Nursing 1

Which of the following is the correct guideline when positioning patients?a. Put pillows above the joint to immobilize itb. Position of the joints should be slightly

extendedc. Joints of the patients are to be supported with

pillowsd. Patients position should be changed at least

three or four times a day

Page 84: Fundamentals of Nursing 1

c. Joints of the patients are to be supported with pillows

Page 85: Fundamentals of Nursing 1

Client’s approval to have his/her body touched by specific individual

Informed Consent

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Admission Agreement Blood transfusion Surgical Consent Research Consent Special Consents (restraints, photographing

the patient, disposal of body parts, donating organs,autopsy)

Types of Consents

Page 87: Fundamentals of Nursing 1

Physical-restrict client movement through the application of a device

Chemical- medications given to inhibit a specific behavior or movement

Behavioral management, medical standard care standard (12 hours with procedure)

Restraints

Page 88: Fundamentals of Nursing 1

jacket- confused and sedated in bed Belt- transporting Mittens or hand- scratch and injure oneself Limb- immobilize the limb for one hour Elbow infants and small children Mummy- blanket around the body, blood

extraction◦ 24 hours, pad bony prominences

Kinds

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Physician’s order Specific time frame Not PRN Give reason Safe knot (quick release) Neurovascular,circulatory (q30mins) Remove (q2hours)

Interventions

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The following can be alternative to restraints, except;a. The nurses places large plants or furniture as

barriers or division on patient’s roomb. Two nurses in pairs act as buddies to watch out

agitated patientsc. Nurse offers warm beverages, soft lights, and

back rubd. Place television set to distract attention

Page 94: Fundamentals of Nursing 1

d. Place television set to distract attention

Page 95: Fundamentals of Nursing 1

Cleansing enemaCarminative Enema- flatusRetension/Emollient enema- oil or antibiotic

Medicated Enema

Enema

Page 96: Fundamentals of Nursing 1

SizesInfant 12 catheterChildren 14 to 18 catheterAdult 22 to 32 catheter

AmountInfant 50-150mlChildren 250-350 mlAdolescent 300-500 mlAdult 750- 1000ml

Page 97: Fundamentals of Nursing 1

Solution 18 inches in height Insertion 3-4 inches in adult, 2-3, 1 Encourgae to hold the solution (5-10 mins

for cleansing, 30 mins for retention) Position: left lateral sims with right knee

flexed NEVER (APPENDICITIS,ABDOMINAL PAIN<

NAUSEA AND VOMITTING)

REMEMBER

Page 98: Fundamentals of Nursing 1

Amputation TorniquetAutonomic dysreflexia

catheter

Chest Tube Drainage Extra bottle/clamp/forcep/vaselinized gauze

CVA Suctioning equipmentCholinergic crisis Tracheostomy/etDVT Tape measure

Bedside Equipment

Page 99: Fundamentals of Nursing 1

Epiglotitis Tracheostmoy/ET

Hydrocephalus Tape measureLTB TracheostmoyMyasthenic Crisis

Et

Parkinson’s disease

Suction apparatus

PIH Padded mouth gage

Page 100: Fundamentals of Nursing 1

Radium implant Lead container, forceps

Sengstaken-blakemore tube

Scissors

Spinal cord injury TracheostomyThyroidectomy TracheostomyTonsillectomy FlashlightTracheostomy tube Obturator,

hemostatWired jaw Wire cutter

Page 101: Fundamentals of Nursing 1

Oral SL SQ-tubercullin-heparin, rotate site IM

◦ Vastus lateralis- 7 months and below◦ Ventrogluteal◦ Dorsogluteal- 3yo below◦ Deltoid-hep b for adult◦ Z track-seal off

Medication

Page 102: Fundamentals of Nursing 1

a. Right patientb. Right medication- label twice, generic name

always, check handbookAnticoagulant

SE: Bleeding (PR)Aspirin (CI), green leafy

Drug Administration

Heparin Warfarin

PTT (40-70 seconds) PT 10-14 seconds

Protamine SO4 Vitamin K

Page 103: Fundamentals of Nursing 1

c. Right frequencyd.Right rate (don’t eat don’t chew don’t swallow- SL,Buccal)

e. Right dosef. Right approachg. Right to refuse h. Right for educationi. Right documentation

Page 104: Fundamentals of Nursing 1

ROUTE SIZE GAUGE

Degrees

VOLUME

ID 3/8- 5/8

26-27 15 1

SQ 5/8- ½ 25-26 45 2

IM 1/2-1/2 C- 24-25A- 23-24

90 2-5

Page 105: Fundamentals of Nursing 1

The nurse prepares an IIM injection for an adult client using Z-track. 4 ml of the medication is to be administered to the client. Which of the following site will you choose?a. Deltoidb. Rectus Femorisc. Ventrogluteald. Vastus Lateralis

Page 106: Fundamentals of Nursing 1

c. Ventrogluteal

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In infants 1 year old and below, which of the following is the site of choice for intramuscular injection.

a. Deltoidb. Rectus Femorisc. Ventrogluteald. Vastus Lateralis

Page 108: Fundamentals of Nursing 1

d. Vastus Lateralis

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The rationale in giving medication via Z track isa. It decreases leakage of discolouring and

irritating medication into the subcutaneous tissue

b. It allows a faster absorption of the medicationc. The Z track technique prevent irritation of the

muscled. It is more convenient

Page 110: Fundamentals of Nursing 1

a. IT decreases leakage of discolouring and irritating medication into the

subcutaneous tissue

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Allen’s Test Ph- 7.35-7.45 PCO2- 35-45 mmHg HCO3- 22-26 meq/L

ABG reading

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In a client in the health care clinic, arterial blood gas analysis gives the following esluts: PH 7.48, PCO2 32mmhg HCO3 24 meq/L. the nurse interprets that the client has:a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis

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b. Respiratory alkalosis

Page 115: Fundamentals of Nursing 1

Urination- micturition,voiding◦ Poyluria◦ Anuria, oliguria

◦ Medications that can cause retention Anticcholinergic,antispamodic

(papaverine,atrophine) Antidepressant, antipsychotic (MAO) Antihypertensive (hydralazine, methyldopa) Beta blockers Opiods hydrocodone (vicodine)

Elimination

Page 116: Fundamentals of Nursing 1

24 hours urine collection (composition)

Nursing considerationa. Early in the morning

a. All voided specimen must be saved except first urine voided

b. Proper labeling date and time startedc. Send specimen immediately to the lab

(Refrigirate)

Urine collection

Page 117: Fundamentals of Nursing 1

Clean catch/mid stream◦Identify causative agent of UTI◦First urine voided◦Midstream urine savedProper labelingSend to lab (30mins)

Page 118: Fundamentals of Nursing 1

Mr. Ai, 35 y/o, complains of a burning sensation on urination and a sense of urgency. A urine specimen is to be collected. Which of the following is the most appropriate way of collecting the specimen?a. Catheterizationb. Voiding into clean urinal from where sample

urine is to be collectedc. clean catch” urine collectiond. 24 hour urine collection

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c. clean catch” urine collection

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Normal saline Gauge 18 Close monitoring for Bt

reaction Increase circulatory blood

volume Increase o2 capacity of

blood

Blood transfusion

Page 121: Fundamentals of Nursing 1

PRBC, whole blood- blood volume (4 hours) FFP expland blood volume (20 mins) Platelets- bleeding Clotting factor and cryo precipitate

Common blood products

Page 122: Fundamentals of Nursing 1

Proper refrigiration Crossmatching Prepare equipments aseptically KVO Close observation 5 mins, after 15 mines, vs

q30

Principles

Page 123: Fundamentals of Nursing 1

Acute hemolytic reaction- chills,fever,◦ H-emolytic reaction- lower back pain◦ A-llergic reaction- plasma protein◦ P-yrogenic- fever◦ C-irculatory overload-fast blood administration◦ H-yperkalemia- hemolysis,coagultae◦ A-ir embolism◦ S-eptic reaction- contaminated blood

Common BT reaction

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S-top P-ulse check V/S I-nfuse NSS N-otify

Management

Page 125: Fundamentals of Nursing 1

During the blood transfusion, the patient manifest tachycardia, istended neck vein and increase CVP reading, the nurse should;

a. Obtain VSb. Increase the rate of infusionc. Stop the infusiond. Decrease the rate of infusion

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c. Stop the infusion

Page 127: Fundamentals of Nursing 1

Male FemaleSupine Dorsal

recumbment6-9” 3-4”Inject 5-10 ml Inject 5-10mlLower Abdomen Inner thighUrine bag (bed frame)

Bed frame

Catheterization

Page 128: Fundamentals of Nursing 1

After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory”. Mark has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?

a. Empty a sample of urine from the collecting bag into the specimen container

b. Disconnect the drainage tube from the indwelling catheter and allow the urine to flow from the catheter into the specimen container

c. Remove urine from the drainage tube with sterile needle and empty urine from the syringe into the specimen container

d. Disconnect the drainage from the collecting bag then allow the urine to flow from the catheter into the specimen container

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c. Remove urine from the drainage tube with sterile needle and empty

urine from the syringe into the specimen container

Page 130: Fundamentals of Nursing 1

Position◦M-Left lateral position with legs flexedProstate- standing position, bending on the table

F- Dorsal recumbment position and hips externally rotates

Digital Rectal Exam

Page 131: Fundamentals of Nursing 1

Dependent measure Cupping- (popping sound, 1-2 mins, 3-5

minutes,tenaciuos secretion Vibration- flat against chest wall,exhalation Postural drainage- 10-15 minutes, 3-4x a

day, 2-3 hours after meals Increase OFI Admnister adjunct therapy

Chest Physiotherapy

Page 132: Fundamentals of Nursing 1

◦ mucolytic drug◦ Expectorant◦ Bronchodilators

S-ympathomimetic A- minophylline X- anthine

Contraindicated R-ib fracture A-ctive tb P- regnant

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Postural Drainage◦Position and locationApical- high fowler’s, sittingPosterior- sidelying, pillow under chest wall

Lower trendelenberg

Page 134: Fundamentals of Nursing 1

Prevents lung collapseImproves pulmonary vetilation

Upright,sittingHold breath for 2-6 seconds

Incentive Spirometer

Page 135: Fundamentals of Nursing 1

Closed Continuous irrigation◦To maintain patent urinary catheter and tubing

Open Irrigation- free blockage3-way foley catheter-1st drainage- bloody-pink-removed after 3 days-voids 4-6 days

Cystoclisis

Page 136: Fundamentals of Nursing 1

Clamp for 4 hoursRelease after 30 minutesAssess for pain and bladder distension

Bladder training

Page 137: Fundamentals of Nursing 1

Skin◦ First line of defense

- Inflammatory response- 2nd line of defense- Immune response- 3rd line of defense

TYPES of wounda. According to purposeb. According to depthc. According to contamination

Skin integrity and wound care

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A. Inflammatory phase- immediately after injury 3-6 days

B. Proliferative phase- 3-4 days up to 21 days - collagen deposition

C. Maturation- day 21 up to 1-3 years

Phases of wound healing

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Red- wound in early regeneration◦Gentle wound care◦Alcohol free barrier◦Fill dead space- hyrodgel,tegaderm- liquify necrotic tissue and hydration

Code RYB

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S- ensory- decrease sensation and mental status

M-oisture- fecal and urinary incontinence A-ctivity- excessive heat M-obility- excessive heat N-utrition- decrease

tissues,hyponatremia,edema, low vitamin c and zinc

F-riction

Pressure ulcer

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I. Ampula-redness, non blanchable erythema

II. B-lister III. C-rater- full

thickness involvement

IV. D-ischarges- foul smelling

Stages

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Patient Kulas, 70 years old is bedridden, upon bed bath reveals a 5cm pressure ulcer that is characterized by a liquid to semi liquid slough with purulent discharge. According to the RYB color code, a guide for wound care. What color classification is ita. Redb. Yellowc. Blackd. Blue

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b. Yellow

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Sublavian, intrajugular Indications:

◦ Severe malnutrition◦ Severe burns◦ Bowel disease◦ ARF◦ Hepatic failure◦ Infection control

TPN

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Complication◦Insertion- pneumothorax, hemothorax

◦Infusion- air embolism-valsalva maneuver, infection,hyperglycemia

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A nurse is caring for a group of adult clients on an acute crae in the unit. As a nurse you understand that which of the following clients would be the least likely candidate for parenteral nutrition?a. 66 year-old client with extensive burnsb . A 42 year-old client who has had an open

cholecystectomyc. A 27 year-old client with severe exacerbation of

chron’s diseased. A 35 year-old client with persistent nausea and

vomiting from chemotherapy

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b . A 42 year-old client who has had an open cholecystectomy

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A client receiving TPN complains of headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distension, and crackles bilaterally. The nurse interprets that the client is experiencing which complication of TPN?a. Sepsisb. Air embolismc. Hypervolemiad. Hyperglycemia

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c. Hypervolemia

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A client with TPN infusing has disconnected the tubing from the central line catheter. A nurse assesses the client and suspects air embolism. The nurse should immediately place the client

a. On the left side, with the head lower than the feetb. On the left side, with the head higher than the feetc. On the right side, with the head lower than the feetd. On the right side, with the head higher than the feet

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a. On the left side, with the head lower than the feet

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Temporary Permanent- non functioning rectum or anus,

colon CA, Bowel CA

Colostomy

Colostomy IleostomyColonLarge bowelSemi solid fecal materialWith irrigation

IleumSmall bowelWet fecal materialOstomy applianceMeticulous skin care

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Red to pink Pale- decrease vascularization Purple- impede circulation Normal- red to pink

◦ No burning sensation◦ moist

Stoma

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A- fluidT- MushyD- MucoidS- Solid

Stool form

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The nurse is teaching a client how to irrigate his stoma, which indicates that the client needs more teaching?a. Washing hands with soap and water when

finishedb. Stopping irrigation for cramps and clamping

the tubing until cramps passc. Filling the irrigation bag with 500 to 1000 ml of

lukewarm waterd. Hanging the irrigation bag 24” to 36” (60-90

cm) above the stoma

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d. Hanging the irrigation bag 24” to 36” (60-90 cm) above the stoma

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The client ask the nurse, when is the best time to perform irrigation, is during

a. Early morning, before mealsb. Early morning, before meals upon arisingc. Early morning, after mealsd. Early morning

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c. Early morning, after meals

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Appliance 7 days Change 1/3-half fullReminders

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3 chambers◦Collection◦Water sealedFlactuation (upon expiration)

Rise and FallIntermittent bubbling (respiration)

Chest Tubes

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Suction Controlled◦20 cm water◦Continuous bubbling

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Pleur-Evac First Best

Disconnected from patient

Cover with any cleanest material possible

Cover opening with sterile gauze/vaselinized gauze

Disconnected from CTT

Insert tip in a glass of sterile NSS

Clamp the tube farthest from the patient

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Upon assessment of patient Julio, the nurse noticed that he is breathing a little more effort and at a faster rate. The client’s pulse is also increased. Which of the following actions should the nurse implement?a. Check the tubing to ensure that there is no kink and

patient is not lying on itb. Increase the suctionc. Lower the drainage bottles 2-3 feet below the level

of the client’s chestd. Ensure that the tube has two clamps in it to prevent

air leaks

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a. Check the tubing to ensure that there is no kink and patient is not lying on it

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You are assigned to patient Julio who has a water seal drainage system and you noted that the fluid in the chest tube and water seal column has stopped fluctuating. Which is the explanation?a. The lung has fully expandedb. The lung has collapsedc. The chest tube is in the pleural spaced. The mediastinal space has decreased

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a. The lung has fully expanded

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NPO for 6 hours and until gag reflex returns

Expect sore throat Observe respiratory

difficulties

Bronchoscopy

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Following a bronchoscopy, which of the following complains by Ryan should be noted?

a. Nausea and vomitingb. Shortness of breath and laryngeal stridorc. Blood tinged sputum while coughingd. Sore throat and hoarseness

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d. Sore throat and hoarseness

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PARACENTESIS

THORACENTESIS

Semi-fowlers Sitting over bedside table

Empty bladder Local Anesthesia

Check VS (BP,RR,Temp)

>1 L at a time within 30 mins

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Right after thoracentesis, which of the following is the most appropriate nursing intervention?a. Instruct the patient not to cough or deep

breath for two hoursb. Observe for symptoms of tightness of chest or

bleedingc. Place an ice pack on puncture sited. Remove dressing to check for bleeding.

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b. Observe for symptoms of tightness of chest or bleeding

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Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is:a. Keep the sterile equipment from contaminationb. Assist the physicianc. Open and close the three way stop cockd. Observe the patient’s vital signs

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d. Observe the patient’s vital signs

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Report abdominal pain

Monitor VS

Monitor Urine output, puncture site

Lie flat on affected side (head elevated 30 deg 30 minutes)

Measure Abdominal girth

Check leak of fluid

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CrutchesA.Initial positionB. 30 degrees flexedC. Weight- crutch paralysisD. Crutch tips

Assistive devices

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Canes- 91 cm, standard, quad cane

Rubber tip Permit elbow to flex Hold cane on the stronger side of the body Side of the foot 15cm and 15 cm in front

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Walkers◦Four legs with rubber tips◦3 point gait, 2 point gait- walker 15 cm ahead

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Crutches◦ Patient supine position and the nurse measures

from the anterior fold of the axilla and adds 2.5 cm

◦ 2.5-5 cm below the axilla or three finger folds◦ Elbow flexion 30 degrees◦ Gaits

Four point Three point Two point Swing to gait Swing through

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Three-point gait

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A client being measured for crutches asks the nurse why the crutches cannot rest underneath the arm for extra support. The nurse’s response is based on the following understanding that this will result it:

a. A fall and injuryb. Injury to the brachial plexus nervesc. Skin breakdown in the area of the axillad. Impaired range of motion while the client

ambulates

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b. Injury to the brachial plexus nerves

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A nurse has given a client instructions about crutch safety. The nurse determines that the client needs reinforcement of information if the client states:a. That he or she will not use someone else’s

crutchesb. The crutch tips will not slip even when wetc. The need to have spare crutches and tips will

be availabled. The crutch tips should be inspected

periodically for wear

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b. The crutch tips will not slip even when wet

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Four- point gait

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Skin test Mantoux Test

Allergy test PPD, TB test

ID, no red ink Determine tb exposure,dormant/active TB5-10 mm iduration>10 mmHIV- 5mm

Evaluate after 30 minutes

Evaluate after 48- 72 hours

Antibiotic- 7 day treatment

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Hypoxemia 95-100%

Sites:1. Fingers <ring,middle, index>2. Nose3. Earlobe4. Forehand5. Toes

Pulse Oximeter

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Partsa. 2 leadsb. Photodetector

Nursing Consideration1. Cover probe with towel from external

sourse2. Remove nail polish

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DABDA

Concept of death and dying

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Operative consentWHO?? Obtains:surgeon

Witness: Nurse Secure Give: patient

a. consciousb. legal agec. sound mindemergency: doctor

Perioperative Nursing

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WHAT??- name/age/sex - diagnosis - procedure - benefits and risks - alternative - signature

WHEN?? Major/minor anesthesia invasive procedure (body cavity) radiologic procedure and dye

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3 zonesa. unrestricted- unsterile, street clothesb. semirestricted- scrub shoes, OR suit, and capc. restricted- + mask

Intraoperative

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a. Gownb. Glovesc. Drapesd. Accidental puncturee. When in doubt throw it outf. Prepare sterile field closest in timeg. Movement-sterile to sterile,unsterile to

unterile

Principles of Sterility

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A. Surgeon- captain

- responsible for decisions to make -Respondeat superior- let the master answer the situation - res ipsa liquitor- let the damage speak for itself - extension doctrine- consent from s.o.

OR TEAM

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B. Assistant to the surgeon(intern/MD/surgeon)C. Anesthesiologist (MD/Nurse Anes)- LOC,IO,Blood

loss, O2 Saturation, VSD. Circulatory Nurse- Setup or

- Skin prep- Ensures sterility of the team

E. Scrub Nurse- sets up the field- Assist in draping the patient- Handles sterile equipments- sponge count- after care

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Counting◦ Initial- manufacturer◦ Baseline- set up◦ Closing- first closing- peritoneum, final- skin

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Induced state of partial/total loss of sensation, with or without loss of consciousness

Anesthesia

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Sedation Analgesia Mucsle relaxant

Loss of protective reflex

General + + + (RR) +

Local X + Localized X

Regional Epidural Spinal

XX

++

++ (output below l3-l5)

XX

Conscious sedation

X + + +

Techniques

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I. Onset/Induction- time anest is induced, loss of consciousness

II. Delirium/Excitement- loss of consciousness, muscles relaxation,breathing pattern

III. Operative/Surgical- generalized muscle relaxation and dep vs

IV. Danger/Recovery- cardiac and respiratory arrest, pupils fixed and dilated

- Increased loc- wearing out from patient’s body

Stages (GA)

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Safety- side rails Airway patency- suctioning or intubation CPR (danger) Recovery (Safety)

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SIGN IN BEFORE INDUCTION OF ANESTHESIA

P-aitent confirmedA-irway/aspiration riskA-llergyA-nesthesia safety checklistS-ite marked

WHO surgical check list

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TIME OUT- before incisionS-terility observedI-ntroduce OR teamI-maging displayedA-ntibiotics given for the last 60 mins

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SIGN OUT- transferR-ecord name of the procedureI- nstrument, sponge,sharp count completeS-pecimenE-ndorse equipment problem

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PACU/RRa. Name of surgeon/procedure

B. Evalutae with anes,VS, IO,hemodynamic status

C. Evaluate contraption D. Supine with head on the side E. Once conscious orient

Post Operative Phase

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I. VS-Q15-1 hour - q30min- 2 hours -q1hour- 4 hours -4 hours- shift -q5mins- critical

II. Respiratory system- airway patency -rr, pattern and depthrr-12-20cpm

<12cpm- drug induced respiratory depression

> 12 cpm- pain,metabloic rate

System assessment

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III. Cardio- rate, rhythm, grade, pulse Absent- o Weak- +1 Normal- +2 Strong- +3 Bounding- +4

SHOCK- pulse deficit, apical and radial pulse 1. decrease circulating blood volume 2. possible obstruction Complcation-DVT/Thrombophlebitis

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Thrombolytics- destroy clots-KINASE (TPA) Anticougulants heparin (PTT-20 36 secs- effective

40-72 seconds), warfarin PT (9.6-12.1 seconds x 1.5-2)

IV. Neuro-LOC, order of return of sense Touch Pain Warmth Cold Movement

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V. Renal- UO-30-60cc/hour, skin turgor VI. GI- NPO- clear liquid-soft-DAT

◦ 1. positive gag reflex◦ 2. bowel sound- 5-20 seconds◦ 3. passage of flatus

(-2,3, abdominal distension, N/v- paralytic ileus)-bowel resection

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VII. Integumentary- incision site◦Drainage,redness,sweeling pain, purulent

discharge- infection◦Separtion of suture line, drainage-

dehiscence◦Protrusion of Abdominal Contents-

evisceration- sterile water, low fowler’s with knees bend

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A-ctivity 0-1-2 R-espiration- 0-1-2 Circulation 0-1-2 C-onsciousness 0-1-2 O2 saturation

◦ 95-100%- capillary test◦ ABG- 80-100%◦ Allen’s test- collateral circulation-impede ulnar

artery

Adnettes scoring- 15 minute interval

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Drug of Choice

Disease/Condition/Antidote

Drug of Choice

Hypercalcemia PhosphateHypermagnesemia Calcium Gluconate

HyperK KayexelateMetabolic Acidosis Na BicarbonateAngina NTGChole,Pancreatitis Demerol

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MI Morphine SulfateChron’s Disease, U. Collitis

Steroids

Diabetes Insipidus VasopressinHeparin Protamine SulfateWarfarin Vit KLead Toxicity EDTADigoxin Toxicity DigibindICP MannitolCholinergic Crisis Atrophine SulfateHyperthyroidism Synthroid

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Trichomoniasis MetronidazoleSyphilis PenicillinRheumatoid Arthritis AspirinParkinson LevodopaAlcoholism DisulfiramWithdrawal from Alcohol

Librium

Withdrawal from Opiods

Narcan/Naloxone

UTI PyridiumMegaloblastic Anemia Vit

b12/CyanocobalaminAnemia rt ESRD EPOGEN

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Narcotic Overdose NarcanMuscle Spasticity BaclofenAcetaminophen AcetylcysteinMalaria QuininesFilariasis HetrazanDiptheria PenicillinScabies Benzyl BenzoateGonorrhea CeftriaxoneToxoplasmosis SulfanamideInduction of Labor Oxytocin

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Preterm Labor TerbutalineFetal Lung Maturity SteroidsBT reaxtion EpinephrineAnaphylactic Shock EphinephrineAntipsychotic for Elderly

Haldol

Manic Episodes LithiumThyroid Storm Lugol’s Solutionh. Pylori MetronidazoleStatus Asthmaticus EpinephrineMestinon Athropine Sulfate

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Lithium Toxicity MannitolCHF DigoxinChicken Pox Zovirax/Acyclovir