top 93 nursing skills, procedures and normal values_ok

TOP 93 NURSING SKILLS, PROCEDURES and NORMAL VALUES

A1. ABDOMINAL ASSESSMENT

Procedure: I-A-Pe-PaRegular assessment: I-Pa-Pe-A

Sequence: RLQ RUQ LUQ LLQ Position: dorsal recumbent AVOID:

A – ppendicitis P – heochromocytoma A – bdominal Aortic Aneurysm W – ilm’s tumor

2. AMNIOCENTESIS vs. ULTRASONOGRAPHY

AMNIOCENTESIS VARIABLES ULTRASONOGRAPHYaspiration of amniotic fluid inside the amniotic sac through an outside puncture Definition

visualization of the uterine content including all the products of conceptus

1. If more than 20 weeks' gestation (empty bladder) – to prevent confusion between it and the amniotic sac

2. If less than 20 weeks' gestation (full bladder) – to elevate the uterus and increase visualization of the fluid pocket

Preparation of the mother

1. After 20 weeks (empty bladder)

2. Before 20 weeks (full bladder) to increase ultrasonic resolution and elevate the presenting head for biparietal diameter measurement

1. If done early in pregnancy: To detect chromosomal abnormalities

2. If done late in pregnancy: To detect fetal lung maturity and to resolve polyhydramnios

Purpose (s)

First Trimester1. Gestational age assessment2. Evaluation of congenital anomalies; 3. Confirm multiple pregnancy

Second Trimester1. Guidance of procedure (amniocentesis); 2. Assessment of placental location

Third Trimester***1. Determination of fetal position2. Estimation of fetal size/ weight

3. ARTERIAL BLOOD GAS (ABG) ANALYSIS Serum pH 7.35 – 7.45

CO2 35 – 45HCO3 22 – 26PaO2 85 – 95 mmHg

Increased: PolycythemiaDecrease: Anemia

BEFORE: Allen Test to assess patency of the RADIAL artery*** Avoid suctioning at least 20-30 minutes BEFORE procedure

AFTER: Apply pressure on puncture site for 5 minutes

First step in ABG analysis – determine pH***

4. ABDOMINAL PARACENTESIS Purpose:

Obtain fluid specimen To relieve pressure on the abdominal organs d/t the excess fluid

BEFORE: Ask client to void***

DURING: Position: Sitting position Common site: midway between the umbilicus and symphysis pubis Measure abdominal girth at the umbilical level Maximum amount to be drain is 1500 mL Strict STERILE technique

5. ASEPSIS1 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

MEDICAL ASEPSIS SURGICAL ASEPSISPurpose To reduce

microorganismTo destroy microorganism including spores

Indication Routine nursing care Procedure involving sterile areasTechnique Disinfection (clean) Sterilization (sterile)

B6. BARIUM SWALLOW AND BARIUM ENEMA

BARRIUM SWALLOW BARIUM ENEMAUSE Examination of UGT Examination of LGTBEFORE NPO 6 – 8 hours NPO at midnight (6 – 8 hrs)

DIET: Low residue diet, Clear liquid diet (1 – 3 days)Laxatives, Cleansing enema

AFTER Constipation: Increase fluids, LaxativeStool color: chalky white 1 – 3 days

7. BENNER’s STAGES OF NURSING EXPERTISE***

Stage 1 NoviceNo experienceLimited performanceInflexible

Stage 2 Advanced beginnerMarginally acceptable performanceRecognizes the meaningful “aspect” of a real situation

Stage 3 Competent2 or 3 years of experienceDemonstrates organizational and planning abilitiesCoordinates multiple complex care demands

Stage 4 Proficient

3 to 5 years of experiencePerceives situations as wholes rather in terms of parts, as in Stage 2Has holistic understanding of the client, which improves decision makingFocus on long term goals

Stage 5 ExpertPerformance is fluid, flexible, and highly proficientNo longer requires rules, guidelines, or maximsDemonstrates highly skilled intuitive and analytic ability in new situations

8. BLEEDING PRECAUTION (OPEN wounds) P – ressure over the injuryE – levate above the heartC – old compressA – rterial pressureT – orniquet

9. BLOOD TRANSFUSION BEFORE

Check order – 2 RN’so Client name and identification numbero Unit numbero Blood type matchingo Expiration dateo Doctor’s order/ Informed consent

Obtain baseline VS warm blood at room temperature for NOT more than 30 minutes

DURING STAY with the patient and Check every 15 minutes – 1st hour Check every hour – succeeding hours

BLOOD COMPONENTSBlood Component Infusion rate Volume

Whole blood 2 to 4 hours 450 mlPRBC 2 to 4 hours 250 mlCryoprecipitate 30 minutes 10 mlPlatelets Rapid 35 to 50 mlFresh frozen plasma Rapid of bleeding; 1 to 2 hours 250 ml

BT REACTIONREACTION CAUSE S/SX MANAGEMENT

C – irculatory overload/ congestion

too rapid dyspnea, HPN, increased PR Slow down the infusion rate

H – emolytic incompatibility jaundice, shock HA Stop the infusionA – llergic antigen/ antibody reaction urticaria, wheezing, facial edema Stop the infusion

AntihistamineP – yrogenic bacterial fever, chills Stop the infusion

ParacetamolSave unit of blood and return to blood bank for analysis.

2 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

BT REACTION MANAGEMENT: (in sequence)*** B – T stop L – et the tubings be changed O –pen NSS A – lways check the VS D – octor, where are you! S – cold the bank

OTHERS:*** Gauge: 18 or 19 Y set filter IV transfusion set IV fluid: NSS only (other solution like dextrose causes hemolysis) Start at KVO for 15 minutes Monitoring: 15 minutes for the 1st hours and hourly thereafter Time

o 4 hours: WBC, PRBCo Rapid: Plasma, Platelets, Cryoprecipitate

10. BONE MARROW BIOPSY/ ASPIRATION Bones commonly used: sternum, iliac crest, iliac spines, or proximal tibia (children) DURING

Position: site is iliac crest Prone site is sternum Supine

About 1 to 2 mL of bone marrow is obtained.

AFTER: PREVENT BLEEDING Bed rest for 30 minutes Ice bag on punctured site Pressure on the puncture site Position: Lie on operative/biopsied side for 10 to 15 minutes

11. BOWEL DIVERSIONS TYPES OF OSTOMY

Ileostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) Cecostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) Ascending colostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) Transverse colostomy mushy/ semi-formed Descending colostomy formed Sigmoid colostomy formed

STOMA Color brick red (May turn to pink after several months and years) Sensation normally no sensation Protrusion ½ to ¾ inches Drain 1/3 to ½ full Appliance size (pouch opening) 1/16 to 1/8 inches

COLOSTOMY IRRIGATIONS – needed by Descending and sigmoid colostomy 1st – stimulate 2nd – evacuate Position: sitting

FOODSCauses odor Beans

AsparagusGarlicEggsSpices

Causes gas CeleryCabbageCornCamoteCauliflowerChampagneCucumbersCarbonated drinks

Thicken stool TapiocaRiceYogurtApple and apple sauceBananaCheese

Permanent colostomy – Descending and sigmoid colostomy Colon cancer – sigmoid colostomy


12. BREASTFEEDING ASSESSMENT OF PROPER LATCHING

C – hin to breast – pen mouth widely L – ips turned outward A – reola is visible above only

Nipple – touches the posterior tongue 9to promote swallowing reflex)Nipple (bottle) – always filled with milk 9to prevent colic)

Color of stools: Breast fed: golden yellow Formula fed: pale yellow

13. BRONCHOSCOPY BEFORE: NPO for 6-12 hours prior to procedure; no dentures; maintain good oral hygiene DURING:

uses local anesthetic spray to minimize gagging while inserting the bronchoscope supine with head hyperextended

AFTER: POSITION: semi fowler's NPO till gag returns then start with ice chips then followed by sips of water soft diet regular diet ice bags to throat minimize talking, coughing, laughing; warm saline gargles; assess for respiratory distress

C14. CANCER SCREENING

PROCEDURE SCHEDULEBreast Self Exam (BSE) Monthly, 3 to 5 days after the onset of menstruationTesticular Self Exam (TSE) Monthly, after a warm bathMammogram 35 to 40 years – 1x (baseline)

41 to 50 years – every 2 years51 and above – yearly

Paps smear Onset – 40 – every 3 years41 and above – yearly

Digital rectal Exam (DRE) 50 and above – yearly40 and above – yearly (if high risk)

15. CHEMOTHERAPY SIDE EFFECTS

SIDE EFFECTS INTERVENTIONS

GATRO-INTESTINAL

Nausea and vomitingAnorexia

o Provide antiemetics 30 – 60 minutes before chemotherapyo AVOID: unpleasant odor, spicy foods, hoto Small Frequent Feedingso Diet: soft blando Ensure adequate fluid hydrationo Frequent oral hygiene

Oral thrush o Rinse mouth with ½ strength peroxide and NSSo Brush teeth with soft toothbrush and baking sodao USE: unwaxed dental floss, cotton-tip applicator for viscous xylocaine over lesions

HEMATOPOEITIC(Bone marrow suppression)

Neutropenia(WBC)

Neutropenic precautiono Handwashingo Neutropenic diet/ low-bacteria diet: cooked foods

AVOID: fresh flowers, fruits, vegetables, raw foods, vaccinationso Reverse isolation/ private roomo Assess vital signs every 4hours

Thrombocytopenia(Platelets)

Thrombocytopenic precautiono AVOID: aspirin, IM, invasive procedures, punctures, contact sportso Use soft bristled toothbrush, electric razor, stool softener

Anemia(RBC)

Blood transfusionBed rest

INTEGUMENTARY

Alopecia o Discuss potential TEMPORARY hair loss (2 to 4 weeks)o Use of wigso If hair grows back – color and texture changeso AVOID: excessive shampooing

GENITO-URINARYCystitis o Increase fluidsSterility/ infertility o Temporary

Nadir – lowest point of RBC, WBC and platelets after chemotherapy administration; occurs within 7 to 14 days after


16. CHESTPHYSIOTHERAPY (CPT)POSTURAL DRAINAGE PERCUSSION VIBRATION

Purpose To drain by GRAVITY To mechanically dislodge To loosen mucus secretionsMethod Positioning Striking by cupped hands Quivering palm on chest wallDuration 10 to 15 minutes per position 1 to 2 inches/ lung segment 5 exhalation*** Sequence:***

1 – postural drainage2 – percussion3 – vibration

done BEFORE meals ask patient to COUGH after chestphysiotherapy

17. CHEST TUBE a. DRAINAGE BOTTLE

NURSING CONSIDERATIONS: Keep at least 2 to 3 feet below the chest (to allow drainage by gravity)

NEVER raise the bottle above the level of the heart (to prevent reflux of air or fluid) NOTE:

COLOR: bloody drainage during the first 24 hours OUPUT: 500 – 1000 ml during the first 24 hours

FLUID DRAINAGE: the tube is inserted at 8th or 9th ICSAIR DRAINAGE: the tube is inserted 2nd or 3rd ICS

COMMON OBSERVATIONS NO DRAINAGE

Resolution Obstruction

b. WATER SEAL BOTTLENURSING CONSIDERATIONS:

Immerse tip of the tube in 2- 3 cm of sterile NSS to create water seal

COMMON OBSERVATION: INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration, fall during

expiration) NO FLUCTUATIONS

Obstruction – check and milk the tubing with CAUTION Low suction Re expand lungs – do chest X- ray for confirmation

CONTINUOUS BUBBLING Air leakage (except during suctioning)

c. SUCTION CHAMBERNURSING CONSIDERATIONS:

Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS (to stabilize the normal negative pressure in the lungs and protects the pleura from trauma if the suction pressure is inadvertently increased)

COMMON OBSERVATION: CONTINUOUS GENTLE BUBBLING (indicates adequate suction control)

NORMAL

d. CHEST TUBE REMOVAL Give analgesics 30 minutes before removal Clamp on bedside DURING removal: let the patient EXHALE and hold breath while doing VALSALVA MANEUVER Maintain dry, sterile, occlusive dressing

e. EMERGENCY SITUATION DISLODGE (chest tube removal FROM THE CLIENT)

AT BEDSIDE: vaselinized gauze Palm pressure (for splinting)

DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage) ATBEDSIDE: Extra bottle immersed in sterile water

Clamp (Hemostat)

f. ALERT! Never clamp the test tubes over an expanded period of time. Clamping the chest tubes IF a client with an air in the pleural space will cause increased pressure buildup and possible TENSION PHEUMOTHORAX

18. CEREBROSPINAL FLUID (CSF) ANALYSIS Protects from mechanical trauma Function of CSF: Carries nutrients to brain Characteristics

Normal pressure: 5 to 15 mmHg/ 70 to 180 mmH2O Normal volume: 100 to 200 ml WBC: 0 - 5 cells/mm


Glucose: 40 to 80 mg/dl (40 to 80 mg/100ml) Protein: 15 to 45 mg/dl (15 to 45 mg/100 ml)

Meningitis Increase protein content Decrease glucose content Increase WBC content Cloudy (bacterial meningitis) Clear (viral meningitis)

19. COMMUNICATION: ATTENTIVE LISTENING Absorbing both the CONTENT and the FEELING the person is conveying, without selectivity Listening actively, using all senses (as opposed to listening passively with just the ear) Active process that requires energy and concentration Paying attention to the total message (both verbal and non-verbal) and noting whether these communications are

congruent Conveys an attitude of caring and interest, thereby encouraging the client to talk

20. COMMUNICATION: PHYSICAL ATTENDING ***1) face the other person squarely2) adopt an open posture3) lean towards the person4) maintain good eye contact5) try to be relatively relaxed

21. CT SCAN X-ray Contrast medium – warm sensation AVOID: pregnant women Before: NPO After: increase fluid

22. CVP MONITORING Measure the pressure of the right atrium Place the zero level of the manometer at the level if the right atrium (4th ICS) AVOID: coughing and straining NORMAL: 2 -12 mmHg

23. CYSTOSCOPY Direct visualization of the LOWER urinary tract (bladder and urethra) PURPOSE:

specimen collection treatment of the interior of the bladder and urethra Prostate surgery

Local anesthesia – commonly used POSITION: dorsal recumbent CONTRAINDICATIONS: acute cystitis, bleeding disorders AFTER:

Assess VS urine characteristic (NORMAL: pink tinged or tea-colored urine) I&O Encourage fluids Sitz bath Observe for fever, dysuria, pain in suprapubic region

D24. DIALYSIS

Urgent indication for dialysis in patient with CRF is PERICARDIAL FRICTION RUB. Objectives of hemodialysis:

a. To extract toxic nitrogenous substances from the bloodb. To remove excess water

Principles of hemodialysis: Diffusion – toxic and wastes move from an area of higher concentration in the blood to an area of lower

concentration in the dialysate Osmosis – excess water is removed from the blood by osmosis Ultrafiltration – water moving under high pressure to an area of lower pressure accomplished by negative

pressure (suction)

Before peritoneal dialysis, patient should empty bladder and bowels.

E25. EAR


Ear bones (Ossicles) M – alleus Hammer A – nvil Incus S – tapes Stirrups

Position during drug administration: Below 3 years old – down and back Above 3 years old – up and back

Outer ear problem (otitis externa) – conductive hearing loss Middle ear problem (otitis media, otosclerosis) – conductive hearing loss Inner ear problem (labrynthitis, Meniere’s disease) – sensorineural hearing loss

26. ECG NORMAL

PR 0.12 – 0.20 seconds QT 0.32 – 0.40 seconds QRS 0.04 – 0.10 seconds

HYPERKALEMIA Tall T wave HYPOKALEMIA Flat T wave, presence of u wave HYPERCALCEMIA Short ST segment and QT interval*** HYPOCALCEMIA Lengthened ST segment and QT interval

Atrial flutter With P wave (saw tooth) Regular rhythm Normal QRS

Atrial fibrillation*** No P wave Irregular rhythm Normal QRS

Atrial tachycardia With P wave (different shape) Regular rhythm Normal QRS

Ventricular fibrillation No P wave Chaotic rhythm No QRS

Ventricular tachycardia No P wave Regular rhythm Wide and bizarre QRS

27. ENEMA TYPES:

Cleansing enema cleansing (3x) Carminative enema flatus Return flow/ Harris flush/ Colonel irrigation flatus (5 – 6x) Retention soften; lubricate (1 – 3 hours) VOLUME-based***

o Small volume (150 to 240 ml) – used to cleanse rectum and sigmoido Large volume (500 to 1000 ml) – used to cleanse entire colon

SOLUTIONS: Hypertonic sodium biphosphate Hypotonic tap water Isotonic NSS Irritants soapsuds, Bisacodyl/ Fleet Lubricants oil

Position: left-sidelying/ dorsal recumbent***

Enema tube – lubricate first; insert in rotating motion Infant 1 – 1.5 inches Child 2 – 3 inches Adult 3 – 4 inches

Cramping: Lower the solution Clamp and wait for 30 seconds*** Restart


Temperature: 100oF (37.7oC)

4 factors affecting Force of flow of the solution:(1) Height of the solution container(2) Size of the tubing(3) Viscosity of the fluid(4) Resistance of the rectum

28. E.S.S.R. feeding method of patients with cleft lip and cleft palate E – nlarge the nipple hole S – timulate the sucking S – wallow R – est

29. ESR (Erythrocyte Sedimentation rate) value: 30 to 40 mm/hr indicates mild inflammation 40 to 70 mm/hr indicates moderate inflammation, and 70 to 150 mm/hr indicates severe inflammation.

30. EXERCISES

TYPES OF EXERCISECHARACTERISTICS ISOTONIC ISOMETRIC ISOKINETIC

OTHER NAME Dynamic Static/Setting ResistiveJOINT MOVEMENT x

CONTRACTION

BENEFITS on MUSCLES

Increase strength Increase tone Increase mass Joint flexibility

Increase strength Increase endurance Increase heart rate and cardiac output

Increase strength Increase size Increase blood pressure and

blood flow to muscles

EXAMPLES

Use of trapeze Walking Swimming Cycling Running

Quadricep setting Squeezing on stress ball Kegel’s

May be isometric or isotonic with resistance

Weight-lifting

31. FIRE EXTINGUISHERType A – trash fire – paper, woods, leaves (water under pressure) B – fuel fires – oil, gasoline, kerosene (CO2) C – electric fire – appliances, wire (dry chemicals) D – any kind (graphite)

F32. FECAL

C-olor -----------brown/yellow – stercobilinO-dor------------aromaticC-onsistensy-----------solid-semi-formed moistA-mount ----------------100-400g/dayS-hape------------------cylindrical

33. FOODS rich in IRON *** Liver Green leafy vegetables Dried fruits Scallops, shrimps Oyster, clams molasses

34. PROBLEMS IN STOOL ELIMINATION M – elena dark colored stool (upper Gi bleeding) A – cholic stool gray colored stool (bile obstruction) S – teatorrhea fat containing stool (malabsorption) H – ematochezia bright red colored stool (lower GI bleeding)

G35. GTPALM

G – Gravida refers to the number of pregnancies regardless of outcome P – Para refers to the number of deliveries that reached viability (20 weeks gestation)


born dead or alive; multiple births count as 1 delivery regardless of the number of newborns delivered

T – Term deliveries number of TERM births (infants born after 37 weeks and above) P – Preterm deliveries number of PRETERM births (infants born between 20 to 37 weeks) A – Abortions number of pregnancies that end in spontaneous or therapeutic abortion prior to

age of viability (20 weeks) L – Live number of children currently alive M – Multiple gestations number of pregnancy with more than one newborn

(regardless of the number of neonates delivered)

36. GLOVING *** Open-glove technique used when:

o Gloving another team membero Changing a glove DURING a procedure (self or team member)***o A sterile scrub or gown is not required

Closed-glove technique used when:o Anytime you are initially applying sterile gown and gloves

CHANGING GLOVES “DURING” A PROCEDURE1. Ask the Circulating Nurse (CN) to remove contaminated glove2. CN should wear gloves

CN – grasp contaminated glove at palm Scrubbed person – holds onto the sleeve of the gown (to prevent riding over)

3. Using OPEN-GLOVE method, reapply sterile glove***

H37. COLORS OF HOSPITAL TANKS

Nitrous oxide (laughing gas) Blue Oxygen Green Cyclospropane Orange Nitrogen Black Carbon dioxide Grey Helium Brown Medical air Yellow Halothane Red

38. HOSPITAL COLOR CODES Code blue – cardiac arrest, medical emergency Code pink – infant abduction Code red – fire Code yellow – bomb threat Code silver – combative person with weapon

I39. IMMUNIZATION

SENSITIVITY MOST SENSITIVE to heat OPV, measlesLEAST SENSIITVE to heat DPT, Hepa B, BCG, TT

FORM: Toxoid Diphtheria and Tetanus killed bacteria Pertusis live attenuated OPV freeze dried measles and BCG

40. INFORMED CONSENT Purpose:

To ensure the client’s understanding of the nature of the surgery To indicate the client’s decision To protect the client against unauthorized procedure To protect the surgeon and hospital against legal action


2 TYPES:1) Express consent – may be either an oral or written agreement2) Implied consent – nonverbal behaviour indicates agreement

General guidelines/ content of informed consent: Diagnosis or condition that requires treatment Purpose of the treatment What the client can expect to feel or experience The intended benefits of the treatment Possible risks or negative outcomes of the treatment Advantages and disadvantages of possible alternatives to the treatment (including no treatment)

4 elements of informed consent:*** Voluntary – no force, coercion, or manipulation Comprehension – all interior and exterior impediments to comprehension have been assessed and removed

Interior – anxiety, pain, sedative medication Exterior – transcultural barrier, terminology, speed of presentation

Competence Can give consent:

must be at least 18 years old emancipated minor: a person under 18 who is self supporting or married

Cannot give consent: Unconscious Sedated mentally ill and judged to be incompetent

Discloure – all possible options and outcomes

Circumstances requiring an Informed Consent: R – adiation or cobalt therapy A – nesthesia use B – lood administration I – nvasive procedure

o E – ntrance into a body cavityo S - urgical procedure using scalpel, scissors, suture (Invasive procedures)

Requisites for validity of informed consent Legal age Mentally capacitated Secured within 24 hours before the surgery Secured before pre-op medication administration Written permission Signature Witness – nurse, physician

For minors (under 18), unconscious, psychologically incapacitated permission from responsible family member For emancipated minors (married, college student living away from home, in military service, any pregnant female or

any who has given birth)

4 Criteria are needed to be met if consent is NOT needed anymore: There is an immediate threat to life Experts agree that it is an emergency Client is unable to consent A legally authorized person cannot be reached

Surgery without consent-- BATTERY! Role of the physician: to obtain the informed consent Role of the nurse:

Witness a client’s signature after the physician has explained the procedure Place informed consent in the client’s chart Respond to any questions the client have about the procedure Notify the physician if the client appears to have concerns

41. ISOLATION PRECAUTION Tier 1: Standard Precaution

to all blood and body fluids except for sweat to all clients regardless of diagnosis hand washing and PPE (clean)

Tier 2: Transmission-based precaution10 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

Airborne > 3 feetDroplet nuclei < 5 microns

N95 MeaslesTBVaricella (chickenpox)

Droplet < 3 feetDroplet nuclei > 5 microns

Mask Meningitis, mumosPertussis, pneumoniaGerman measles, GABHS (Scarlet fever, pharyngitis)Diptheria

Contact Skin Glovesgown

MRSA (Staph)ImpetigoScabiesHerpes SimplexHepatitis ADiarrhea

Immunocompromised – first Infectious - last

42. IV SOLUTIONS HYPOTONIC ISOTONIC HYPERTONIC

Characteristics Solute < solvent Solute = solventO pressure of solution

Solute > solvent

Fluid movement from Intravascular TO cells No movement From Intracellular TO IntravascularEffect to the cell Swell expand the intravascular

compartmentshrink/ crenation

Indications Dehydrated patients HypovolemiaBurns (resuscitative stage)

Edema

Examples Distilled water 0.45% NSS0.33% NSS2.5% dextrose

D5WLRNSSD5 0.225% NSS

10% dextrose in water5% dextrose in 0.9% saline solution5% dextrose in 0.45%5% dextrose in LRTPNDialysate

contraindicated for clients with increased intracranial pressure, clients at risk of 3rd space fluid shift

Avoid D5W if the client is at risk of increased intracranial pressure (ICP)

Use LR for BURNS

43. IV THERAPY COMPLICATIONS: COMPLICATIONS MANIFESTATIONS ACTIONS

Circulatory overload Dyspneaincreased BPSOB, crackles

slow downcontact physicianelevate HOBgive oxygen

Air embolism Dyspneadecreased BP

DiscontinueLeft sidelying and trendelenburg

Phlebitis Swelling + Heat DiscontinueColdElevateRestart (another site)

Infiltration Swelling + CoolDecrease infusion rate***

DiscontinueWarm/ Moist heat (due to edema)ElevateRestart (another site)

Pyrogenic reaction Fever, chills DiscontinueRetain IV equipment for C&S

METHODS OF IV ADMINISTRATION1. Large volume infusion safest and easiest2. IV Bolus fastest effect3. Intermittent Venous Access (heparin lock/ Saline lock) increase mobility and comfort

Sequence: SASH methodso S - Saline

A - AntibioticS - SalineH - Heparin

4. Volume controlled infusions5. Piggy back

SELECTING A VEIN First verify the order for I.V. therapy unless it is an emergency situation. Explain the procedure to the patient. Select a vein suitable for venipuncture.

o Back of hand (metacarpal vein.) Avoid digital veins, if possible. (The advantage of this site is that it permits arm movement.)

If a vein problem develops later at this site, another vein higher up the arm may be used.


Forearm (basilic or cephalic vein)o Inner aspect of elbow, antecubital fossa, median basilic and median cephalic for relatively short-term

infusion. However, use of these veins prevents bending of arm. Lower extremities.

o Foot - venous plexus of dorsum, dorsal venous arch, medial marginal veino Ankle - great saphenous vein

Central veins are used:o When medications and infusions are hypertonic or highly irritating, requiring rapid, high-volume dilution to

prevent systemic reactions and local venous damage (eg, chemotherapy and hyperalimentation).o When peripheral blood flow is diminished (eg, shock) or when peripheral vessels are not accessible (eg,

obese patients).o When CVP monitoring is desired.o When moderate or long-term fluid therapy is expected.

NURSING ALERTo The median basilic and cephalic veins are not recommended for chemotherapy administration due to the

potential for extravasation and poor healing resulting in impaired joint movement. In addition, these veins may be needed for intermediate or long-term indwelling catheters.

o Use lower extremities as a last resort. A patient with diabetes or peripheral vascular disease is not a suitable candidate. Obtain an order from the health care provider for the I.V. site and monitor lower extremity closely for signs of phlebitis and thrombosis.

L44. LASER

a. L – ightA – mplification byS – timulatedE – mission ofR – adiation

b. TYPES Carbon dioxide – gas (clear goggles) ND:YAG – Neodymium: Yttrium Alluminum garnet) – bright lamp (green goggles) Argon – gas (orange goggles)

c. HAZARDSEyes gogglesSkin gown and glovesLungs mask

45. LEVEL OF CONSCIOUSNESS a. GLASGOW COMA SCALE

GLASGOW COMA SCALEEYE OPENING VERBAL RESPONSE MOTOR RESPONSE

4 – Spontaneous3 – To verbal command2 – To pain1 – No response

5 – Oriented, converses4 – Disoriented, converses3 – Uses inappropriate words2 – Makes incomprehensible sounds1 – No response

6 – To verbal command5 – To localized pain4 – Withdraws3 – Flexes abnormally (Decorticate)2 – Extends abnormally (Decerebrate)1 – No response


7 and below - in a comatose state 3 – lowest score 15 – highest score

b. A.V.P.U. (for Pediatric client) use to assess neurologic condition (like Glasgow Coma Scale) Usually used in infants

A – Alert and AwakeV – Verbal response to stimuliP – Pain response in stimuliU – Unresponsive

c. Level I (conscious) – 3 C’s: conscious, cognitive, coherentLevel II (lethargic) – drowsy, sleepy, obtunded, confusedLevel III (stuporous) – responds to strong stimuli onlyLevel IV (coma) – unresponsive; absent protective reflexes

46. LEOPOLD’s MANEUVER BEFORE: patient void first

Nurse warm hands

47. LIVER BIOPSY BEFORE: Note COAGULATION PROFILE (clotting factors, PT, PTT, APTT and platelet count* DURING: exhale and hold breath AFTER: Position: Right side-lying position

48. LUMBAR PUNCTURE (LUMBAR TAP) PURPOSE: To withdraw CSF to determine abnormalities

Measures CSF pressure (normal opening pressure 60-150 mm H2O) Obtain specimens for lab analysis (protein [normally not present], sugar [normally present], cytology, C&S) Check color of CSF (normally clear) and check for blood Inject air, dye, or drugs (anesthesia) into the spinal canal

AREA: Insert needle between L3 – L4 or L4 – L5 (spinal cord ends in L2)

BEFORE PROCEDURE: Obtain consent Empty bladder

DURING PROCEDURE: 13 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

MANEUVER PURPOSE NURSING CONSIDERATIONS1. First maneuver

to determine fetal presentation

While facing the woman, place the hands on top and side of the uterus (fundus) and palpate.

HEAD - smooth, hard/firm, and round, freely movable and ballotable.

BREECH - irregular, rounded, softer, and is less mobile.

2. Second maneuver

to determine the fetal position

to determine fetal back (heart)

Still facing the woman, place hands on either side at the middle of the abdomen. Determine what fetal body part lies on the side of the abdomen.

If firm, smooth, and a hard continuous structure – FETAL BACK

If smaller, knobby, irregular, protruding, and moving, EXTREMITIES

3. Third maneuver

To determine engagementto determine fetal

presentation

While facing the woman, grasp the part of the fetus situated in the lower uterine segment between the thumb and middle finger of one hand.

Using firm, gentle pressure, determine if the head is the presenting part.

HEAD - will feel firm and globular.

If immobile, engagement has occurred. This maneuver is also known as Pallach's maneuver or grip

4. Fourth maneuver

to determine fetal attitude The examiner faces the woman's feet.

The examiner palpates the abdomen along the side of the uterus below the umbilicus towards the symphysis pubis (pelvic inlet) to detect head’s degree of flexion, position and even station.

Position of the patient: C-position (flex the shoulders, not the head) Position of the nurse: infront of the patient Position of the doctor: at the back of the patient

AFTER PROCEDURE: prevent spinal headache Position: flat for 6-12 hours (to prevent spinal headache) Force fluids (to maintain pressure and prevent spinal headache) Blood patching label specimen

M

49. MAGNETIC RESONANCE IMAGING (MRI)/ NUCLEAR MAGNETIC RESONANCE (NMR) Uses radio waves BEFORE:

remove metals: jewelry, hairpins, glasses, wigs (with metal clips), and other metallic objects.

AVOID: patients with orthopedic hardware intrauterine devices pacemaker internal surgical clips or other fixed metallic objects in the body (braces, retainers)

BEFORE: Have client void before test.

DURING remain still while completely enclosed in scanner throughout the procedure, which lasts 45-60 minutes. Teach relaxation techniques to assist client to remain still and to help prevent claustrophobia*** NORMAL: audible humming and thumping noises from the scanner during test.

Sedate client if ordered.

50. MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) Test Route: ID, 0.1 mL of PPD is injected INTRADERMALLY, creating a wheal or bleb Read: 48 to 72 hours Result: (+) to exposure

10 mm and above not immunocompromised 5 mm and above immunocompromised (HIV, with history of TB, pediatric and geriatric clients) 0 - 4 mm= NOT SIGNIFICANT Erythema without induration is NOT considered significant***

51. MASLOW’s HIERARCHY OF NEEDS Physiologic needs – basic survival needs

Air, Food, Water Shelter Rest, Sleep Activity Temperature

Safety and Security needs physical aspects: comfort***, protection from

bodily harm psychological aspects: security and stability

Love and belonging needs (Social Acceptance)*** Giving and receiving affection

Attaining a place in a group Maintaining the feeling of belonging Acceptance by others

Self-esteem needs Self-esteem: feelings of independence,

competence, self-respect Esteem from others: recognition, respect,

appreciation, feel they are valued and worthwhile

Self-actualization The innate need to develop one’s maximum

potential and realize one’s abilities and qualities the need to function at one’s optimal level, and to

be personally fulfilled.

52. MEDICATION a. Drug interaction

Additive effect 1 + 1 = 2eg. diazepam + alcohol = increase sedation

Synergism/ potentiation 1 + 1 = 3eg. codeine + aspirin = intense pain relief

Antagonist 1 + 1 = 0eg. Coumadin + Vitamin K


Interference increase or decrease metabolism/ excretioneg. Probenecid decrease excretion of Penicillin

b. Medication order STAT (“statim”) immediate/ once

eg. Magnesium sulfate (preeclampsia) Single order/ one time once

eg. Anxiolytic (pre-surgery) Standing / routine carried out indefinitely

eg. antibiotics PRN (“Pro Re Nata”) no specific time of administration/ as needed

eg. Pain relievers Telephone order within 24 hours

SignedIndicate as Telephone OrderPut decimal number

c. Components of Medication order (Drug prescription)*** Clients name Date and time of order Name of drugs Dose and route Time of frequency Signature

d. Drug effects Therapeutic – desired Side effects – 2nd effect, expected Adverse effects – severe side effect, unexpected Allergic reaction – immunologic response

N53. NAEGELE’s RULE

If LMP is from APRIL TO DECEMBER, use the formula: o - 03 + 07 + 01 (MM, DD, YY)

If LMP is from JANUARY TO MARCH, use the formula: o + 09 + 07 (MM, DD)

54. NASOGASTRIC TUBE (NGT) TYPES

Levin - single lumen Salem sump – double lumen

INSERTION Measurement: adult (N.E.X.), pedia (N.E.M.U.X.) Position: high-fowlers and neck hyperextended Instruction: ask to swallow Placement:

1- X-ray2- Aspirate and pH test

normal gastric pH = 1 to 4 (acidic)3- Listen/ auscultate for borborygmi sound – after introduction of 10 – 30 ml of air (20 ml)4- Listen/ auscultate for breath sounds (to double check)

REMOVAL Instil 50 ml of air Take deep breath and hold pinch catheter withdraw Mouth care and blow nose

FEEDING Check placement Position: sitting/ upright/ fowlers Check for RESIDUAL CONTENT dont discard; above 100ml – STOP Hang: 12 inches from point of insertion Flush : 50 to 100 ml of water Remain upright – 30 minutes

55. NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST)

NON STRESS TEST vs. CONTRACTION STRESS TESTNon Stress Test DIFFERENTIATION Contraction Stress Test

Fetal movement and fetal heart rate Variables compared Uterine contraction and fetal heart rateNORMAL (Reactive/ Positive) Increase FM Increase FHR (acceleration)

NORMAL (Non-reactive/ Negative) Increase UC Decrease FHR (deceleration)


Decrease FM Decrease FHR (deceleration)

ABNORMAL (Nonreactive/ Negative) Increase FM Decrease FHR (deceleration) Decrease FM Increase FHR (acceleration)

Result Decrease UC Increase FHR (acceleration)

ABNORMAL (Reactive/ Positive) Increase UC Increase FHR (acceleration) Decrease UC Decrease FHR (deceleration)

2 FHR accelerations within a 10min period, each acceleration increasing to 15bpm and lasting at least 15 sec Desired response

Two ways: Nipple Rolling and Intravenous Oxytocin Delivery

3 contractions within 10min, lasting 40 to 60 sec is needed

Abnormal or non reactive result needs further evaluation that same day; usually needs contraction stress testing

Management Not performed until about 38+week Watch out for Preterm labor

FETAL HEART RATE DECELERATIONSCAUSE MANAGEMENT

EARLY Head compression ObservationLATE Uteroplacental insufficiency Side-lying position

OxygenationIncreased IV fluidsStop Oxytocin (Pitocin)Call the MDCaesarean if not corrected

VARIABLE Cord compression Trendelenburg/ Knee-chest/ Side-lying positionOxygenationIncreased IV fluidsStop Oxytocin (Pitocin)Call the MDCaesarean section if not corrected

56. NORMAL VALUES serum protein = 6.0 to 8.0 g/dL. albumin level = 3.4 and 5 g/dL. BUN: creatinine ration = 10:1 to 20:2 Electrolytes:

K = 3.5 – 5.5 mEq/L Na = 135 – 145 mEq/ L Ca = 4.5 – 5.5 mEq/ L Mg = 1.5 – 2.5 mEq/ L Ph = 2.5 – 4.5 mEq/ L Cl = 98 – 108 mEq/ L

serum amylase level = 25 to 151 units/L. In chronic pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal

value. In acute pancreatitis, the value may exceed five times the normal value.

Therapeutic serum drug level Carbamazepine = 3 to 14 mcg/mL Phenytoin = 10 and 20 mcg/mL Magnesium sulfate = 4 to 8 mg/dL Lithium = 0.5 to 1.5 mEq/L*** Digoxin = 0.5 to 2 ng/dl Acetaminophen = 10 – 30 mg/dL Theophylline = 10 – 20 mcg/ml

57. O.R. TEAM MEMBERSSCRUB NON SCRUB

SurgeonSurgical assistantScrub nurse

AnesthesiologistBiomedCirculating nurse

SCRUB NURSE CIRCULATING NURSEo Performs complete scrubo Prepares and hands out instrumentso Hands instruments while maintaining sterile

techniqueo Ensures everybody in the scrub team practices

sterile techniqueo Partner in OS and instrument countingo Anticipates the needs of the teamo Patient advocate (act in behalf of the patient);

GUARDIAN OF THE PATIENT; doing something that patient can’t do

o Greets the client upon arrival – 1st primary responsibility of circulating nurse

o Checks client identificationo Sponge counting together with scrub nurse o Monitors the urine output and blood loss together

with anesthesiologisto Ensures the consent form is signedo Documents the entire procedure

*Scrub and Circulating Nurses – best tandem in OR***


P

58. PACEMAKER: CONTRAINDICATIONS Strong magnetic fields – MRI Electrical fields – high powered instruments (microwave oven, TV, radio, vacuum cleaners) Cellular phones – do not place near chest; place in the ear farthest in the pacemaker implant

59. PAIN LOCATION:

Referred pain – appear to arise in different areas*** Cardiac pain left shoulder, left arm Gallbladder right shoulder

Visceral pain – pain arising from organs or hollow viscera

60. PERSONAL SPACE/ COMMUNICATION ZONES Intimate distance

Touching to 1.5 feet

Body contactHeightened sensations of body heat and smellVoice tone low

Cuddling a babyTouching a blind clientPositioning a clientObserving an incisionRestraining a toddler for injectionLovemakingConfiding secretsSharing confidential information

Personal distance

1.5 to 4 feet Body heat and smell noticed lessVoice tone moderatePhysical contact is allowed (handshake or touching a shoulder)

Communication between nurse and patient/ facilitates sharing of thought and feelings (interviewing)Sitting with a clientGiving medicationsEstablishing IV infusionsBanteringPhysical assessment

Social distance

4 to 12 feet Body heat and smell re imperceptibleVoice tone loud enough to be overheard by othersClear visual perception of the whole person

Nurses roundsWave a greeting

Public distance

12 to 15 feet Loud, clear vocal tones with careful enunciation Public talk/ giving speechGathering of strangers

61. PRESSURE ULCERS Stage 1 – non-blanchable, erythema 2 – epidermis and dermis involvement, shallow water blister 3 – subcutaneous involvement, deeper crater 4 – muscles and bone involvement, tissue necrosis

62. PULSE OXIMETRY/ O 2 SATURATION Measures:

1) Oxygen saturation2) Pulse rate

Site: Adult: finger Pedia: toes Other sites: nose, earlobe or forehead

Normal: 95 to 100%70% and below – life threatening

SaO2 and SpO2 same***

AVOID: Sudden movement Nail polish Light

R63. RADIATION THERAPY


Radiation therapy uses high-energy ionizing rays that destroys the cell’s ability to reproduce by damaging the cell’s DNA

TELETHERAPY BRACHYTHERAPYExternal SOURCE Internal

Not radioactive PATIENT RadioactiveCobalt therapy, Linear Accelerated Radiation EXAMPLES 1. Unsealed – oral, IV radioactive iodine 131,

Vitamin B122. Sealed – implant (seeds) cesium, iridium

ALLOW Leave markings Vitamin A and D Soap and water and

pat dry

AVOID Sunlight Alcohol Lotion, powder, cosmetics Adhesive tape Tight clothing

S – hield: lead + Dosimeter badgeT – ime: 5 min/visit; 30 min/ shift; 1 pt/ dayD – istance: 3 feet away

At bedside: forceps and lead containerAVOID: pregnant and childrenAratula: “Caution”

64. RESTRAINTS PURPOSE: to prevent injuring self and others

CLASSIFICATION:1. Physical – manual/ physical device2. Chemical – substances/ medications

2 standards for applying restraints:1. behavioural management standard – when the client is a danger to self or others2. acute medical and surgical care standard – temporary immobilization of a client is required to perform a procedure

Guidelines:1. Obtain consent

o Should be RENEWED DAILYo PRN order is PROHIBITED

2. Use clove-hitch knot***3. Tie the free ends of the restraints on MOVABLE part of the bed frame***4. Assess skin integrity per agency protocol (every 15 to 30 minutes)

Release restraints every 2 hoursReassess the need for restraints every 8 hours

S65. SENTINEL EVENT

Is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. (by The Joint Commission

66. SCHILLING’s TESTPART 1

(CONFIRMATORY)PART 2

(IDENTIFICATION OF CAUSE)Vitamin B12 Vitamin B12 and Intrinsic factor(+) vitamin B12 in urine normal (+) vitamin B12 in urine Pernicious Anemia is stomach in origin(-) vitamin B12 in urine (+) Pernicious Anemia (-) vitamin B12 in urine Pernicious Anemia is small intestine in origin

67. SLEEP Promoting Sleep: SLEEP PATTERN

Establish a regular bedtime and wake-up time Establish regular, relaxing bedtime routine Provide short daytime nap (15 to 30 minutes)***

Promoting Sleep: ENVIRONMENT Adequate exercise during the day. Avoid exercise at least 3 hours before bedtime Associate bed for sleep Keep noise to minimum. Use white noise from a fan, air conditioner, or white noise machine Sleep on comfortable mattress and pillow

Promoting Sleep: DIET AVOID heavy and spicy meals 2 to 3 hours before bedtime AVOID alcohol and caffeine-containing foods (coffee, tea, chocolates) at least 4 hours before bedtime Alcohol and caffeine act as DIURETICS If bedtime snacks are necessary: consume light carbohydrates or a milk drink

Promoting Sleep: MEDICATION Sleeping pills last resort Take analgesics before bedtime to relieve pains

68. Specimen collection: STOOL Defecate in a clean bed pan or bedside commode. Void before the specimen collection (to prevent urine contamination) QUANTITY:

SOLID STOOL: About a pea-size or 1 inch (2.5cm) LIQUID STOOL: 15 to 30 mL

Refrigerate and label


a. FECAL OCCULT BLOOD TESTING (Guaiac Test) Occult = hidden Uses a chemical reagent which detects the presence of the enzyme peroxidase in the hemoglobin molecule. RESULTS:

Changes in color like blue indicates a guaiac positive result No change or any other color than blue indicates a negative result.

Avoid contaminating the specimen with urine or toilet tissue. Label Avoid specified foods and vitamin C 3 days prior to collection and specified medication 7 days prior to collection.

FALSE POSITIVE FALSE NEGATIVE RED MEAT (Beef, liver, and processed meats) RAW VEGETABLES or FRUITS (Particularly radishes, turnips, horseradish, and melon) MEDICATIONS (NSAIDs, IRON preparations, and ANTICOAGULANTS)

VITAMIN C

69. Specimen collection: SPUTUM Sputum – arises from the tissue of the respiratory tract

Saliva – excreted by the salivary and mucus glands BEST TIME: early morning BEFORE: Mouth care DURING:

o Deep breaths then cough up 15 to 30 mL (1 to 2 tablespoons).o Wear gloves when collection.o Ask the client to expectorate, not spito Should be cough directly into the specimen container

70. Specimen collection: URINESPECIMEN PURPOSE CONSIDERATIONS WHEN COLLECTING

CLEAN VOIDED For routine examination Usually collected by the client with minimal assistance

Preferably done on the first voided specimen in the morning but it can be collected anytime if needed

At least 10 to 30 mL Clean container is used

CLEAN-CATCH or MIDSTREAM URINE

For urine cultures Done when a woman has menstrual

period

BEST TIME: early morning – concentrated urine Sterile specimen container Place specimen during midstream flow. QUANTITY:

30 to 50 ml – routine urinalysis5 to 10 ml – C&S

CATHETER Collection of sterile specimen usually done when client’s are catheterized for other reasons

Nurse aspirates from the lumen of a latex catheter or from a self-sealing port

24-HOUR To determine the ability of the kidneys to concentrate urine

To determine disorders of glucose metabolism

To determine levels of specific constituents

Collection of all urine produced in 24 hours The first voided urine is discarded; last urine

voided included Either refrigerated or preservative is added

71. SPONGE COUNTING 1 – Before the operation starts (immediately preceding incision) – to establish a baseline2 – Before closure of body cavity3 – Before the skin is closed/ before wound closure starts

The SCRUB and the CIRCULATING nurses should count audibly and concurrently***

72. SUCTIONING Endotracheal/ tracheostomy Naso-/ oro- pharyngeal

Time per attempt 5 to 10 seconds 5 to 10 secondsInterval 2 to 3 minutes 20 to 30 secondsinsertion 5 inches and withdraw 1 to 2 cm 4 to 6 inches

Endotracheal Position: semi-fowlers Time: 5 to 10 seconds/ 5 minutes Interval: 20 to 30 seconds DURING

Lubricate the catheter with water-soluble lubricant (2 to 3 inches) Insert during INHALATION in CIRCULAR motion*** DO NOT insert during swallowing (it may enter the esophagus)

o But in NGT let the patient swallow to promote entrance in stomach Apply suction: during withdrawal GLOVE: dominant hand

Hyperoxygenate BEFORE and AFTER suctioning


Conscious: DBE Unconscious: ambubag, 3 to 5 times (12 – 15 LPM)

73. SUTURES (catgut) – a thread, wire, or other material used in the operation of stitching parts of the body togetherTYPES OF SUTURES:

Absorbable – digested by body enzyme plain gut (yellow) chromic gut (brown)

Non-absorbable – become encapsulated by tissue and remains unless removed (removed 7 days after) silk (light blue) nylon (green) cotton (pink) Prolene (royal blue) Mersilenne (Turquoise) Vicryl (purple) Dacron (orange)

T74. T-TUBE

PURPOSE: To maintain patency*** To drain To prevent bile leakage to the peritoneum

DRAINAGE Color: 1st 24 hours – reddish brown Amount: 1st 24 hours – 500 to 1000 ml

Normal color of stool after removal – “brown” Draining – does not need doctors order

75. TELEPHONE ORDER Only RN’s may receive telephone orders The order should be countersigned by the physician within 24 hours

76. TENSILON TEST edrophonium chloride (Tensilon) IV evaluation of muscle strength USE: To diagnose myasthenia gravis At bedside:

resuscitation equipment atropine sulfate on bedside for possible CHOLINERGIC CRISIS neostigmine for possible MYASTHENIC CRISIS

Results: (+) diagnosis = improvement on muscle function after administration of drug (-) diagnosis = muscle fasciculations occur as a result of the drug

77. THORACENTESIS Purpose: To remove excess fluid or air from the pleural space to ease breathing POSITION: sitting while leaning forward over a pillow Chest X-ray identifies best insertion site Within the first 30 minutes, not more than 1000 mL should be removed AVOID: coughing , deep breathing AFTER: Unaffected side with head elevation of 30o for at least 30 minutes

78. THYROIDECTOMY: Complications Bleeding – Feeling of fullness at incision site

Check soiled dressing at nape area, sandbag

Accidental removal of parathyroid – Hypocalcemia – classic sign tetany Calcium gluconate, slowly administer- to prevent arrhythmia

Laryngospasm – DOB, SOB tracheostomy at bedside, suction

Accidental damage of the laryngeal nerve – Hoarseness of voice Encourage patient to talk post op asap to determine laryngeal nerve damage

Thyroid storm – Fever, Irritability, Agitation, restlessness, Tachycardia beta blockers

79. TOTAL PARENTERAL NUTRITION (TPN)/ PN/ IV HYPERALIMENTATION Dextrose content 10 to 50% Duration of TPN – 24 hours Site: central veins (SVC) subclavian vein (an x-ray is done to confirm its placement)*** Position during insertion: trendelenburg Complication:


Thrombophlebitis due to hypertonicity of the solution change access site Hyperglycemia rapid infusion regulate Hypoglycemia abrupt discontinuation hyperinsulinism don’t stop abruptly Infection unsterile procedure sterile technique Fluid overload rapid infusion regulate Air embolism Allergy

If empty, give hypertonic solution: D10W – pedia D50W – adult

BEFORE: check label of solution and rate of infusion with medical order inspect TPN bottle for precipitates or turbidity administer via an infusion pump

DURING: Initially administered at 50 ml/hr*** for the FIRST hour Monitor glucose Monitor vital signs every 4 hours

AFTER: Monitor WBC PRIORITY NURSING DIAGNOSIS: High risk for infection Do not overcorrect flow rate if too slow or fast STERILE technique*** Use transparent air-occlusive dressing***

80. TRACHEOSTOMY CARE 1) Position2) Open sterile packages3) Pour soaking solutions4) Suction5) Remove inner cannula and place in soaking

solution

6) Remove dressing7) Clean inner cannula8) Replace9) Clean incision site and flange10) Apply dressing11) Change ties

81. TRACTIONS TYPES

Skin traction – impaired skin integrity Skeletal traction – risk for infection

Counter traction – weight of the patient Bucks – not more than 8 to 10 lbs of weight should be applied Crutchfield tongs (skull tongs) – used to immobilize the cervical spine (indicated for unstable fractures or dislocation of

the cervical spine) Crutchfield tongs/ Gardner-Wells skull tongs POSITION: supine

82. TRANSFERRING Patient from BED to WHEELCHAIR 1 – assist patient into sitting position2 – position chair parallel to the bed (strong side***)

- Client with walking difficulty, angle the chair to 45 degrees***3 – use transfer belt

- NURSE: hold belt- PATIENT: hold shoulder of nurse

4 – pivot towards the wheelchair

83. TRANSFERRING Patient from BED to STRETCHER 1 – lower HOB2 – raise bed slightly higher than stretcher3 – stretcher – parallel to the bed4 – nurse – press own body against stretcher to secure it against the bed Client – flex neck and arms across chest5 – roll both sides of pull sheet towards the patient6 – grasp and pull the pull sheet towards the stretcher

84. TRIAGE “trier”- to sort To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be

addressed

3 CATEGORIES IN TRIAGE in E.R.EMERGENT URGENT NON-URGENT

Color Red Yellow GreenUrgency Life, limb, eye threatening

Needs immediate attentionNeeds treatment in 20 minutes to 2 hours

Can wait hours or days

Examples Chest pain, cardiac arrest, severe respiratory distress, chemicals in the eye, limb amputation, penetrating trauma,

Fever >40oC, simple fracture, abdominal pain, asthma with no respiratory distress

sprain, minor laceration, rash, simple headache. Toothache, sore throat


severe hemorrhage

4 CATEGORIES IN TRIAGE in DISASTERIMMEDIATE DELAYED MINIMAL EXPECTANT

Number 1 2 3 4Color Red Yellow Green BlackExamples Chest wounds, shock, open

fractures, 2-3 burnsStable abdominal wound, eye and CNS injuries

Minor burns, minor fractures, minor bleeding

Unresponsive, high spinal cord injury

85. TUNNING FORK TEST b. WEBER’S TEST – To test for bone conduction by examining lateralization of sound.

Hold and place the base of the tunning fork on top of the client’s head; ask the client where he/she hears the noise.

Results: Weber negative – if sound is heard on both sides or localized at the center of the ear. Weber positive – sound heard better on the impaired ear – bone-conductive hearing loss; – sound heard on the normal ear – sensorineural disturbance

c. RINNE TEST –To compare air conduction from bone conduction. Ask client to block one ear intermittently (move a fingertip in and out of the ear) Hold the handle of the activated tuning fork against the mastoid process (until vibrations can no longer be

felt/heard by the client). Immediately hold the vibrating fork with the prongs in front of the client’s ear canal.

Results: Positive Rinne – Air conduction (AC) is greater than bone conducted (BC). Negative Rinne – BC is equal to or longer than air conduction – indicating a conductive hearing loss.

Infants: ring a bell or have the parent call the child’s name (to assess gross hearing); newborns may become silent or open their eyes wide; by 3 or 4 months, child will turn his/her head toward the sound.

VITAL SIGNS

86. BLOOD PRESSURE a. Systolic – contraction – depolarization

Diastolic – relaxation – repolarization

b. DETERMINANTS OF BLOOD PRESSURE*** Pumping action of the heart

strong pumping – BP increases weak pumping – BP decreases

Peripheral Vascular Resistance (PVR) increased vasoconstriction – BP increases

decreased vasoconstriction – BP decreases

Blood volume BV increases – BP increases BV decreases – BP decreases

Blood viscosity blood highly viscous – BP increases blood less viscous – BP decreas

c. ASSESSING BLOOD PRESSURE*** The cuff should wrap (A) 40% of the arm length and (B) 80% should encircle the adult’s arm (arm

circumference)/ 100% of the child’s arm The lower border of the cuff should be 2.5 cm above the antecubital space. Use the bell of the stethoscope low pitched sounds

Pump about 30 mmHg more from the point the pulse has disappeared. Deflate the cuff at a rate of 2 to 3 mmHg per second. Rest the arms for 1 to 2 minutes before taking the blood pressure again, in cases reading is not certain. Calibrate the sphygmomanometer every 6 months Allow 30 minutes for resting if the client has exercise, smoking or ingested caffeine Read lower meniscus of the mercury to prevent error of parallax

o error of parallax – if the eye level is higher than the level of lower meniscus

d. KOROTKOFF PHASES*** Phase 1 – a sharp thump determines the systole Phase 2 – a blowing or whooshing sound (increasing sound) Phase 3 – a crisp, intense tapping (loud tapping) Phase 4 – a softer blowing sound that fades (muffled sound)


B 80%

A 40%

Phase 5 – Silence determines the diastole

e. Taking BP in thigh1 – Position patient

Prone (best) Supine with legs flexed

2 – Expose thigh3 – Locate popliteal pulse4 – Wrap the cuff

f. Common mistakesFALSE-LOW FALSE-HIGH

Bladder of cuff too wide Bladder of cuff narrowArm above heart level Arm below heart levelDeflating cuff too quickly Deflating cuff too slowly

Inflating too slowlySmoking, caffeine and exercise for the last 30 minutes

g. Systolic in legs is higher compared to brachial around 10 to 40mmHgh. 3 years old and above - Start taking BP routinelyi. BP of 120/100/80 phase 1/4/5

87. TEMPERATURE a. ORAL – accessible and convenient

S – Smoking*N – NewbornO – Oral surgeryU – Ulceration/injury to the mouthT – Tremors/convulsionsH – Hot/cold foods & fluids just ingested wait

for 15 to 30 minutes before taking temperature

b. AXILLARY – Safe and non-invasiveA – Axillary injuryX – eXercise/activityI – Inadequate circulationL – Laging basa (moist pits)A – After bathing

c. RECTAL – Reliable measurement (Inconvenient and more unpleasant)R – Rectal disease/diarrheaI – ImmunosuppressedC – Clotting disordersT – Turning to the side is difficultH – HemorrhoidsU – Undergone rectal surgeryM – Myocardial infarction

d. TYMPANIC – Readily accessible, reflects the core temperature, very fast 9 Risk of injuring the membrane)E – Evident cerumenA – An ear infection is presentR – Reading may vary between left and right measurement

88. PULSE – the wave of blood created by the contraction of the left ventricle. Wait for 10 to 15 minutes if he client has been physically active. Use 2 or 3 middle fingertips lightly over the pulse site. Doppler ultrasound stethoscope (DUS): transducer probe (gel may be applied) and stethoscope headset; when using a

DUS, hold the probe lightly over the pulse site. Apical pulse

7 years old and above – located at the 5th ICS LMCL below 7 years old – located at the 4th ICS LMCL

PULSE SITES Infants, palpable: brachial and femoral Allens test: radial CPR, infants: brachial CPR, adults: carotid

89. RESPIRATIONS – The act of breathing. 2 Types of breathing

Costal – thoracic Diaphragmatic – Abdominal

First to take BEFORE invasive procedures Physiologic apnea

a. RATE – Eupnea (breathing that is normal in rate and depth), bradypnea (abnormally slow), tachypnea (abnormally fast), and apnea (absence of breathing).

b. DEPTH – Hyperventilation (rapid and deep breaths), hypoventilation (very shallow respirations), and Kussmaul’s breathing (hyperventilation associated with metabolic acidosis).


C

D

EF

HI

APNEABRADYPNEA

EUPNEA

TACHYPNEA

HYPERVENTILATION

c. RHYTHM – Cheyne-Stokes breathing (regular rhythm from very deep to very shallow respirations then temporary apnea) and Biot’s respiration (shallow breaths interrupted by apnea).

U

90. URINARY CATHETERIZATION: TYPES TYPES Straight Catheter Indwelling Catheter (Foley or Retention catheter)NO. OF LUMENS

SINGLE: only for drainage DOUBLE: urine drainage for inflation of balloon (serves as an anchor)

ORTRIPLE: urine drainage for inflation of balloon (serves as an anchor) for continuous irrigation

PURPOSE Inserted only as much times as it takes to drain the bladder or obtain a urine specimen

Inserted and stays connected to the bladder for a long time

SPECIAL CONISDERATIONS

Coude catheter is a variation of straight catheter which has a curved and tapered tip, usually used for male patients with prostatic hypertrophy

Secure catheter tubing: male - upper thigh or abdomen Female - inner thigh

NO TUB BATHS, shower is preferable

Collection bag should always be below bladder Position during procedure: FEMALE – Dorsal Recumbent MALE – Supine Lubricate catheter Catheter accidentally slips into vagina: leave the catheter in vagina, get

new catheter and insert to urethra then remove the catheter from vagina Increases susceptibility to infection

2 Main Principles observed:1) Principle of sterility2) Principle of gravity

Replace urinary catheter every 5 to 10 days

91. URINE ELIMINATION Color – amber/straw, transplant Order – aromatic pH – 4.5 to 8 Amount – 1200-1500 ml/day (30-60 ml/hr) Sp.gr – 1.010-10.25

92. PRESENTING UTI W – ash before and after sexO – n time voiding M – ake us of cotton undergarment A – lways wipe from anterior to posteriorN – o sprays, harsh soaps, powder.

W

93. WRITING NURSING DIAGNOSIS INCORRECT CORRECT

1. Write the diagnosis in terms of response rather than need.

Needs assistance with bathing related to bed rest

Self care deficit: bathing related to immobility

2. Use related to rather than due to or caused by to link etiology to problem statement

Noncompliance due to hostility towards nursing staff

Noncompliance related to hostility towards nursing staff

3. Write diagnosis in legally advisable terms. AVOID libellous words or would imply

Spouse abuse related to husband’s immaturity and violent temper.

High risk for violence: spouse abuse related to husband’s reported inability to control


HYPOVENTILATION

CHEYNE-STOKES

BIOT’S

nursing negligence.

Impaired skin integrity related to client’s lying back all night

behaviour

Impaired skin integrity related to immobility.

4. Include in the problem statement only client responses that are unhealthy or that the client wants to change.

Mild anxiety related to impending surgery. ---

5. AVOID including signs and symptoms of illness in the problem statement.

Cough related to long history of smoking. Ineffective airway clearance related to 20 year history of smoking.

6. Express the client statement and etiologic factors in terms that can be changed; otherwise, nursing energies are being directed to a hopeless task

Alterations in Bowel elimination: Permanent colostomy related to cancer of the bowel

Self-care deficit: Care of colostomy, related to feeling s of powerlessness

7. Express the problem statement in terms of unhealthy client responses rather than environmental conditions

Cluttered home related to inability to discard anything

High risk for injury related to cluttered home (inability to discard anything)

8. AVOID reversing the problem statement and etiologic statement

Impaired swallowing related to possible aspiration.

Risk for aspiration related to difficulty swallowing.

9. Make sure that the 2 parts of the diagnosis do not mean the same thing

Alteration in comfort related to pain. Unrelieved incisional pain related to fear of drug addiction

10. Write diagnosis without value judgments. WATCH OUT for your ADJECTIVES!

Poor home maintenance management related to laziness.

Impaired home maintenance management related to low value ascribed to home safety and cleanliness

11. DO NOT include medical diagnosis. Impaired home maintenance management related to arthritis.

Impaired home maintenance management related to mobility, endurance and comfort alterations.
