Download TOP 85 NURSING SKILLS, PROCEDURES and NORMAL VALUES

TOP 85 NURSING SKILLS, PROCEDURES and NORMAL VALUES
A
1. ABDOMINAL ASSESSMENT




Procedure:
I-A-Pe-Pa
Regular 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
aspiration of amniotic fluid inside the
amniotic sac through an outside puncture
1. If more than 20 weeks' gestation (empty
bladder) – to prevent confusion between it
and the amniotic sac
VARIABLES
2. If less than 20 weeks' gestation (full
bladder) – to elevate the uterus and
increase visualization of the fluid pocket
1. If done early in pregnancy: To detect
chromosomal abnormalities
Preparation of
the mother
2. If done late in pregnancy:
To detect fetal lung maturity and to resolve
polyhydramnios
Purpose (s)
Definition
ULTRASONOGRAPHY
visualization of the uterine content including all the
products of conceptus
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
First Trimester
1. Gestational age assessment
2. Evaluation of congenital anomalies;
3. Confirm multiple pregnancy
Second Trimester
1. Guidance of procedure (amniocentesis);
2. Assessment of placental location
Third Trimester
1. Determination of fetal position
2. Estimation of fetal size/ weight
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NON STRESS TEST vs. CONTRACTION STRESS TEST
Non Stress Test
VARIABLES
Contraction Stress Test
Comparing the degree of heart
 Comparing the fetal heart response to
rate increase in relation to fetal
Purpose
the stress of uterine contractions
movement
In healthy fetus fetal movement
 Late deceleration in response to stress
causes accelerated heart (reactive,
contractions, (positive CST finding,
normal)
Result
abnormal)
Normal heart rate and no
deceleration (negative, abnormal)
 Normal heart rate and no deceleration
(negative, normal)
2 FHR accelerations within a
 Two ways: Nipple Rolling and
10min period, each acceleration
Intravenous Oxytocin Delivery
increasing to 15bpm and lasting at
Desired
least 15 sec
response
 3 contractions within 10min, lasting 40 to
60 sec is needed
Abnormal or non reactive result
needs further evaluation that
 Not performed until about 38+week
same day; usually needs
Management  Watch out for Preterm labor
contraction stress testing
3. ARTERIAL BLOOD GAS (ABG)

Serum pH
CO2
HCO3
7.35 – 7.45
35 – 45
22 – 26
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 1
PaO2
85 – 95 mmHg
Increased:
Polycythemia
Decrease:
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
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
 Strict sterile technique
 Measure abdominal girth at the umbilical level
 Maximum amount drained is 1500 mL
 Instruction:
5. ASEPSIS
Purpose
Indication
Technique
MEDICAL ASEPSIS
To reduce microorganism
Routine nursing care
Disinfection (clean)
SURGICAL ASEPSIS
To destroy microorganism including spores
Procedure involving sterile areas
Sterilization (sterile)
6. A.V.P.U. SCALE – use to assess neurologic condition (like Glasgow Coma Scale)


Usually used in infants
A – Alert and Awake
V – Verbal response to stimuli
P – Pain response to stimuli
U – Unresponsive
B
7. BARIUM SWALLOW AND BARIUM ENEMA
USE
BEFORE
AFTER
BARRIUM SWALLOW
Examination of UGT
NPO 6 – 8 hours
BARIUM ENEMA
Examination of LGT
NPO at midnight (6 – 8 hrs)
DIET: Low residue diet, Clear liquid diet (1 – 3 days)
Laxatives, Cleansing enema
Constipation: Increase fluids, Laxative
Stool color: chalky white 1 – 3 days
8. BLEEDING PRECAUTION (OPEN WOUND)
P – ressure over the injury
E – levate above the heart
C – old compress
A – rterial pressure
T – orniquet
9. BLOOD TRANSFUSION

BEFORE
 Check order – 2 RN’s
o Client name and identification number
o Unit number
o Blood type matching
o Expiration date
o 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
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 2

BLOOD COMPONENTS
Blood Component
Whole blood
PRBC
Cryoprecipitate
Platelets
Fresh frozen plasma

Infusion rate
2 to 4 hours
2 to 4 hours
30 minutes
Rapid
Rapid of bleeding; 1 to 2 hours
BT REACTION
 C – irculatory overload
 H – emolytic
 A – llergic
 P – yrogenic
Volume
500 ml
250 ml
10 ml
35 to 50 ml
250 ml
too rapid
incompatibility
antigen/ antibody transfusion
bacterial

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 causes hemolysis)
 Time
o 4 hours: WBC, PRBC
o Rapid: Plasma, Platelets, Cryoprecipitate
dyspnea, HPN, increased PR
jaundice, shock HA
urticaria, wheezing
fever, chills
10. BONE MARROW BIOPSY/ ASPIRATION
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
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
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TYPES OF OSTOMY
 Ileostomy
 Cecostomy
 Ascending colostomy
 Transverse colostomy
 Descending colostomy
 Sigmoid colostomy
STOMA
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watery (prone to Fluid Volume Deficit and Impaired skin integrity)
watery (prone to Fluid Volume Deficit and Impaired skin integrity)
watery (prone to Fluid Volume Deficit and Impaired skin integrity)
mushy/ semi-formed
formed
formed
Color
Sensation
Protrusion
Drain
Appliance size (pouch opening)
brick red (May turn to pink after several months and years)
normally no sensation
½ to ¾ inches
1/3 to ½ full
1/16 to 1/8 inches

COLOSTOMY IRRIGATIONS – needed by Descending and sigmoid colostomy
 1st – stimulate
 2nd – evacuate
 Position: sitting

FOODS
Causes odor
Causes gas:
Beans
Asparagus
Garlic
Eggs
Spices
Celery
Cabbage
Corn
Camote
Cauliflower
Champagne
Cucumbers
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 3
Thicken stool:
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Carbonated drinks
Tapioca
Rice
Yogurt
Apple and apple sauce
Banana
Cheese
Permanent colostomy – Descending and sigmoid colostomy
Colon cancer – sigmoid colostomy
12. BREASTFEEDING

ASSESSMENT OF PROPER LATCHING
C – hin to breast
O – 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
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13. BRONCHOSCOPY
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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
C
14. CANCER SCREENING
PROCEDURE
Breast Self Exam (BSE)
Testicular Self Exam (TSE)
Mammogram
Paps smear
Digital rectal Exam (DRE)
SCHEDULE
Monthly, 3 to 5 days after the onset of menstruation
Monthly, after a warm bath
35 to 40 years – 1x (baseline)
41 to 50 years – every 2 years
51 and above – yearly
Onset – 40 – every 3 years
41 and above – yearly
50 and above – yearly
40 and above – yearly (if high risk)
15. CHANGING GLOVES “DURING” A PROCEDURE
1.
2.
Ask the Circulating Nurse (CN) to remove contaminated glove
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***
16. CHEMOTHERAPY SIDE EFFECTS
Side effects
Nausea and vomiting
Anorexia
GATRO-INTESTINAL
Oral thrush
HEMATOPOEITIC
(Bone marrow
suppression)
Neutropenia
(WBC)
Interventions
Provide antiemetics 30 – 60 minutes before chemotherapy
AVOID: unpleasant odors, spicy foods, hot
SFF
Diet: soft bland
Ensure adequate fluid hydration
Frequent oral hygiene
Rinse mouth with ½ strength peroxide and NSS
Brush teeth with soft toothbrush and baking soda
USE: unwaxed dental floss, cotton-tip applicator for viscous xylocaine over
lesions
Neutropenic precaution
o
Handwashing
o
Neutropenic diet/ low-bacteria diet: cooked foods
o
o
o
o
o
o
o
o
o
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 4
Thrombocytopenia
(Platelets)
Anemia
(RBC)
Alopecia
INTEGUMENTARY
GENITO-URINARY

Cystitis
Sterility/ infertility
o
AVOID: fresh flowers, fruits, vegetables, raw foods, vaccinations
o
Reverse isolation/ private room
o
Assess vital signs every 4hours
Thrombocytopenic precaution
o
AVOID: aspirin, IM, invasive procedures, punctures, contact sports
o
Use soft bristled toothbrush, electric razor, stool softener
Blood transfusion
Bed rest
o
Discuss potential TEMPORARY hair loss
o
Use of wigs
o
If hair grows back – color and texture changes
o
AVOID: excessive shampooing
o
Increase fluids
o
Temporary
Nadir – lowest point of RBC, WBC and platelets after chemotherapy administration; occurs within 7 to 14 days after
17. CHESTPHYSIOTHERAPY (CPT)
POSTURAL DRAINAGE
Purpose
To drain by GRAVITY
Method
Positioning
Duration
10 to 15 minutes per position

Sequence:
1 – postural rainage
2 – percussion
3 – vibration

PERCUSSION
To mechanically dislodge
Striking by cupped hands
1 to 2 inches/ lung segment
VIBRATION
To loosen mucus secretions
Quivering palm on chest wall
5 exhalation***
done BEFORE meals
18. 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 ICS
AIR DRAINAGE: the tube is inserted 2nd or 3rd ICS
COMMON OBSERVATIONS

NO DRAINAGE
 Resolution
 Obstruction
b.
WATER SEAL BOTTLE
NURSING 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)
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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 CHAMBER
NURSING 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 OBSERVATIONS

CONTINUOUS GENTLE BUBBLING (indicates adequate suction control)
 NORMAL
d.
CHEST TUBE REMOVAL
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Give analgesics 30 minutes before removal

Clamp on bedside
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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)
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 5

f.
ATBEDSIDE:
Extra bottle immersed in sterile water
Clamp (Hemostat)
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
19. CEREBROSPINAL FLUID (CSF) ANALYSIS
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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)
20. CT SCAN
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X-ray
Contrast medium – warm sensation
AVOID: pregnant women
Before: NPO
After: increase fluid
21. CVP MONITORING
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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
22. CYSTOSCOPY
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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
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Encourage fluids
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Sitz bath
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Observe for fever, dysuria, pain in suprapubic region
D
23. DIALYSIS
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Urgent indication for dialysis in patient with CRF is PERICARDIAL FRICTION RUB.
Objectives of hemodialysis:
a. To extract toxic nitrogenous substances from the blood
b. 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.
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 6
E
24. EAR
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
Ear bones (Ossicles)
 M – alleus
 A – nvil
 S – tapes
Hammer
Incus
Stirrups
Position during drug administration:
 Below 3 years old – down and back
 Above 3 years old – up and back
25. ECG

NORMAL
 PR
 QT
 QRS
0.12 – 0.20 seconds
0.32 – 0.40 seconds
0.04 – 0.10 seconds
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HYPERKALEMIA
HYPOKALEMIA
HYPERCALCEMIA
HYPOCALCEMIA

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
Tall T wave
Flat T wave, presence of u wave
Short ST segment and QT interval
Lengthened ST segment and QT interval
26. ENEMA
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TYPES:
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Cleansing enema
Carminative enema
Return flow/ Harris flush/ Colonel irrigation
Retention
SOLUTIONS:
 Hypertonic
 Hypotonic
 Isotonic
 Irritants
 Lubricants
cleansing (3x)
flatus
flatus (5 – 6x)
soften; lubricate (1 – 3 hours)
sodium biphosphate
tap water
NSS
soapsuds, Bisacodyl/ Fleet
oil

Position: left-sidelying/ dorsal recumbent

Enema tube – lubricate first; insert in rotating motion
 Infant 1 – 1.5
 Child
2–3
 Adult
3–4

Cramping:
 Lower the solution
 Clamp and wait for 30 seconds***
 Restart
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 7

Temperature: 100oF (37.7oC)
27. E.S.S.R.  feeding method of patients with cleft lip and cleft palate

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E – nlarge the nipple hole
S – timulate the sucking
S – wallow
R – est
28. ESR value:


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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.
29. EXERCISES
TYPES OF EXERCISE
CHARACTERISTICS
OTHER NAME
JOINT MOVEMENT
CONTRACTION
BENEFITS on
MUSCLES
EXAMPLES
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ISOTONIC
Dynamic
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Increase strength
Increase tone
Increase mass
Joint flexibility
Use of trapeze
Walking
Swimming
Cycling
Running




ISOMETRIC
Static/Setting
x

Increase strength
Increase endurance
Increase heart rate and
cardiac output
 Quadricep setting
 Squeezing on stress ball
 Kegel’s
ISOKINETIC
Resistive


 Increase strength
 Increase size
 Increase blood pressure and
blood flow to muscles
 May be isometric or isotonic with
resistance
 Weight-lifting
30. FIRE EXTINGUISHER
Type 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)
F
31. FECAL
C-olor -----------brown/yellow – stercobilin
O-dor------------aromatic
C-onsistensy-----------solid-semi-formed moist
A-mount ----------------100-400g/day
S-hape------------------cylindrical
32. FOODS rich in IRON
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Liver
Green leafy vegetables
Dried fruits
Scallops, shrimps
Oyster, clams
molasses
33. PROBLEMS IN ELIMINATION
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
Melena
Acholic stool
Steatorrhea
hematochezia
G
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 8
34. GTPALM


G – Gravida
P – Para
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

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 and births (not the number of neonates delivered)


refers to the number of pregnancies regardless of outcome
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
H
35. COLORS OF HOSPITAL TANKS
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Nitrous oxide (laughing gas)
Oxygen
Cyclospropane
Nitrogen
Carbon dioxide
Helium
Medical air
Halothane
Blue
Green
Orange
Black
Grey
Brown
Yellow
Red
36. HOSPITAL COLOR CODES
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Code blue – cardiac arrest, medical emergency
Code pink – infant abduction
Code red – fire
Code yellow – bomb threat
Code silver – combative person with weapon
Code white
I
37. IMMUNIZATION
SENSITIVITY


Allergy?
FORM:




MOST SENSITIVE to heat
LEAST SENSIITVE to heat
Toxoid
killed bacteria
live attenuated
freeze dried
OPV, measles
DPT, Hepa B, BCG, TT
Diphtheria and Tetanus
Pertusis
OPV
measles and BCG
38. 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

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 cavity
o 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
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 9


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
Signature
Witness – nurse, physician
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!
39. 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 precaution
Airborne
> 3 feet
Droplet nuclei < 5 microns
N95
Droplet
< 3 feet
Droplet nuclei > 5 microns
Mask
Contact
Skin
Gloves
gown


Measles
TB
Varicella (chickenpox)
Meningitis, mumos
Pertussis, pneumonia
German measles, GABHS
(Scarlet fever, pharyngitis)
Diptheria
MRSA (Staph)
Impetigo
Scabies
Herpes Simplex
Hepatitis A
Diarrhea
Immunocompromised – first
Infectious - last
40. IV THERAPY
Characteristics
HYPOTONIC
Solute < solvent
Fluid movement
from Intravascular TO cells
Effect to the cell
Swell
Indications
Dehydrated patients
Examples
Distilled water
0.45% NSS
0.33% NSS
2.5% dextrose
contraindicated for clients with
increased intracranial pressure,
clients at risk of 3rd space fluid
shift
ISOTONIC
Solute = solvent
O pressure of solution
No movement
expand the intravascular
compartment
Hypovolemia
Burns (resuscitative stage)
D5W
LR
NSS
D5 0.225% NSS


HYPERTONIC
Solute > solvent
From Intracellular TO
Intravascular
shrink/ crenation
Edema
10% dextrose in water
5% dextrose in 0.9%
saline solution
5% dextrose in 0.45%
5% dextrose in LR
TPN
Dialysate
Avoid D5W if the client is at
risk of increased intracranial
pressure (ICP)
Use LR for BURNS
EXAMPLES:

D5W/ D10W/ D50W – red

NSS – green

D5NSS – yellow

D5LR – pink

Plain LR – blue

0.45 NSS – sky blue

D5NM – orange
COMPLICATIONS:
Circulatory overload
Air embolism
Phlebitis
Dyspnea
increased BP
SOB, crackles
Dyspnea
decreased BP
Swelling + Heat
slow down
Discontinue
Left sidelying and trendelenburg
Discontinue
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 10
Pyrogenic reaction
Fever, chills
Infiltration
Swelling + Cool
Cold
Elevate
Restart
Discontinue
Retain IV equipment for C&S
Discontinue
Warm/ Moist heat (due to edema)
Elevate
Restart (another site)
METHODS OF IV ADMINISTRATION
1. Large volume infusion  safest and easiest
2. IV Bolus  fastest effect
3. Intermittent Venous Access (heparin lock/ Saline lock)  increase mobility and comfort

Sequence: SASH methods
o S - Saline
A - Antibiotic
S - Saline
H - Heparin
4. Volume controlled infusions
5. Piggy back
L
41. LASER
a.
L – ight
A – mplification by
S – timulated
E – mission of
R – adiation
b.
TYPES

Carbon dioxide – gas (clear goggles)

ND:YAG – Neodymium: Yttrium Alluminum garnet) – bright lamp (green goggles)

Argon – gas (orange goggles)
c.
HAZARDS
Eyes  goggles
Skin  gown and gloves
Lungs  mask
42. LEVEL OF CONSCIOUSNESS
a.
GLASGOW COMA SCALE
EYE OPENING
4 – Spontaneous
3 – To verbal command
2 – To pain
1 – No response



GLASGOW COMA SCALE
VERBAL RESPONSE
5 – Oriented, converses
4 – Disoriented, converses
3 – Uses inappropriate words
2 – Makes incomprehensible sounds
1 – No response
MOTOR RESPONSE
6 – To verbal command
5 – To localized pain
4 – Withdraws
3 – 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)
A – Alert and Awake
V – Verbal response to stimuli
P – Pain response in stimuli
U – Unresponsive
c.
Level I (conscious) – 3 C’s: conscious, cognitive, coherent
Level II (lethargic) – drowsy, sleepy, obtunded, confused
Level III (stuporous) – responds to strong stimuli only
Level IV (coma) – unresponsive; absent protective reflexes
43. 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
44. 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)
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 11


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:
 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
45. 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.
46. MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) Test



Route:
Read:
Result:




ID, 0.1 mL of PPD is injected INTRADERMALLY, creating a wheal or bleb
48 to 72 hours
(+) to exposure
10 mm and above  not immunocompromised
5 mm and above  immunocompromised (HIV, pedia, with history of TB, geriatric clients)
0 - 4 mm= NOT SIGNIFICANT
Erythema without induration is NOT considered significant
47. MEDICATION
a.
b.
c.
Drug interaction
 Additive effect

Synergism/ potentiation

Antagonist

Interference
Medication order

STAT (“statim”)

Single order/ one time

Standing / routine

PRN (“Pro Re Nata”)

Telephone order
1+1=2
eg. diazepam + alcohol = increase sedation
1+1=3
eg. codeine + aspirin = intense pain relief
1+1=0
eg. Coumadin + Vitamin K
increase or decrease metabolism/ excretion
eg. Probenecid decrease excretion of Penicillin
immediate/ once
eg. Magnesium sulfate (preeclampsia)
once
eg. Anxiolytic (pre-surgery)
carried out indefinitely
eg. antibiotics
no specific time of administration/ as needed
eg. Pain relievers
within 24 hours
Signed
Indicate as Telephone Order
Put decimal number
Components of Medication order (Drug prescription)***
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 12






d.
Clients name
Date and time of order
Name of drugs
Dose and route
Time of frequency
Signature
Drug effects

Therapeutic – desired

Side effects – 2nd effect, expected

Adverse effects – severe side effect, unexpected

Allergic reaction – immunologic response
N
48. 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)
49. 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-ray
2- Aspirate and pH test

normal gastric pH = 1 to 4 (acidic)
3- Listen/ auscultate – after introduction of 10 – 30 ml of air (20 ml)

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
50. NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST)
Variables
Results
NST
FM andFHR
NORMAL (Reactive/ Positive)
Increase FM  Increase FHR (acceleration)
Decrease FM  Decrease FHR (deceleration)
ABNORMAL (Nonreactive/ Negative)
Increase FM  Decrease FHR (deceleration)
Decrease FM  Increase FHR (acceleration)
2 FHR acceleration/ 10 minutes
Each acceleration increase to 15 bpm/ 15 sec.
CST (OCT)
UC and FHR
NORMAL (Non-reactive/ Negative)
Increase UC  Decrease FHR (deceleration)
Decrease UC  Increase FHR (acceleration)
ABNORMAL (Reactive/ Positive)
Increase UC  Increase FHR (acceleration)
Decrease UC  Decrease FHR (deceleration)
3 contraction/ 10 minutes
Each contraction = 40 to 60 seconds
FETAL HEART RATE DECELERATIONS
EARLY
LATE
CAUSE
Head compression
Uteroplacental insufficiency
MANAGEMENT
Observation
Side-lying position
Oxygenation
Increased IV fluids
Stop Oxytocin (Pitocin)
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 13
VARIABLE
Cord compression
Call the MD
Caesarean if not corrected
Trendelenburg/ Knee-chest/ Side-lying position
Oxygenation
Increased IV fluids
Stop Oxytocin (Pitocin)
Call the MD
Caesarean section if not corrected
51. 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.
 With chronic cases of 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***
52. OR TEAM MEMBERS
SCRUB
Surgeon
Surgical assistant
Scrub nurse
o
o
o
o
o
o
o
SCRUB NURSE
Performs complete scrub
Prepares and hands out instruments
Hands instruments while maintaining sterile technique
Ensures everybody in the scrub team practices sterile
technique
Partner in OS and instrument counting
Anticipates the needs of the team
Patient advocate (act in behalf of the patient); GUARDIAN
OF THE PATIENT; doing something that patient can’t do
NON SCRUB
Anesthesiologist
Biomed
Circulating nurse
o
o
o
o
o
o
CIRCULATING NURSE
Greets the client upon arrival – 1st primary responsibility
of circulating nurse
Checks client identification
Sponge counting together with scrub nurse
Monitors the urine output and blood loss together with
anesthesiologist
Ensures the consent form is signed
Documents the entire procedure
P
53. 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
54. STAGES OF 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
55. PULSE OXIMETRY/ O2 SATURATION



Measures:
1) Oxygen saturation
2) Pulse rate
Site: finger, toes, nose, earlobe or forehead
Normal: 95 to 100%
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 14


70% and below – life threatening
SaO2 and SpO2  same***
AVOID:
 Sudden movement
 Nail polish
 Light
R
56. RADIATION THERAPY

Radiation therapy uses high-energy ionizing rays that destroys the cell’s ability to reproduce by damaging the cell’s
DNA
TELETHERAPY
External
Not radioactive
Cobalt therapy, Linear Accelerated Radiation
ALLOW
 Leave markings
 Vitamin A and D
 Soap and water and
pat dry





SOURCE
PATIENT
EXAMPLES
AVOID
Sunlight
Alcohol
Lotion, powder, cosmetics
Adhesive tape
Tight clothing
BRACHYTHERAPY
Internal
Radioactive
1. Unsealed – oral, IV  radioactive iodine 131,
Vitamin B12
2. Sealed – implant (seeds)  cesium, iridium
S – hield:
lead + Dosimeter badge
T – ime:
5 min/visit; 30 min/ shift; 1 pt/ day
D – istance: 3 feet away
At bedside: forceps and lead container
AVOID: pregnant and children
Aratula: “Caution”
57. RESTRAINTS

PURPOSE: to prevent injuring self and others

CLASSIFICATION:
1. Physical – manual/ physical device
2. Chemical – substances/ medications

Guidelines:
1. Obtain consent
o Should be RENEWED DAILY
o PRN order is PROHIBITED
2.
3.
4.
Use clove-hitch knot***
Tie the free ends of the restraints on MOVABLE part of the bed frame***
Assess skin integrity every 15 to 30 minutes
Release restraints every 2 hours
Reassess the need for restraints every 8 hours
S
58. 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)
59. SCHILLING’s TEST
PART 1
(CONFIRMATORY)
Vitamin B12
(+) vitamin B12 in urine  normal
(-) vitamin B12 in urine  (+) Pernicious Anemia
PART 2
(IDENTIFICATION OF CAUSE)
Vitamin B12 and Intrinsic factor
(+) vitamin B12 in urine  Pernicious Anemia is stomach in origin
(-) vitamin B12 in urine  Pernicious Anemia is small intestine in origin
60. Specimen collection: STOOL




a.
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
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.
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 15



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
RED MEAT (Beef, liver, and processed meats)
RAW VEGETABLES or FRUITS (Particularly radishes, turnips, horseradish, and melon)
MEDICATIONS (NSAIDs, IRON preparations, and ANTICOAGULANTS)



FALSE NEGATIVE
VITAMIN C
61. 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 spit
o Should be cough directly into the specimen container
62. Specimen collection: URINE
SPECIMEN
CLEAN VOIDED

PURPOSE
For routine examination


CLEAN-CATCH or
MIDSTREAM URINE


For urine cultures
Done when a woman has menstrual
period
CATHETER

24-HOUR

Collection of sterile specimen usually
done when client’s are catheterized for
other reasons
To determine the ability of the kidneys
to concentrate urine
To determine disorders of glucose
metabolism
To determine levels of specific
constituents












CONSIDERATIONS WHEN COLLECTING
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
BEST TIME: early morning – concentrated urine
Sterile specimen container
Place specimen during midstream flow.
QUANTITY:
30 to 50 ml – routine urinalysis
5 to 10 ml – C&S
Nurse aspirates from the lumen of a latex catheter
or from a self-sealing port
Collection of all urine produced in 24 hours
The first voided urine is discarded; last urine
voided included
Either refrigerated or preservative is added
63. SPONGE COUNTING
1 – Before the operation starts (immediately preceding incision) – to establish a baseline
2 – Before closure of body cavity
3 – Before the skin is closed/ before wound closure starts

The SCRUB and the CIRCULATING nurses should count audibly and concurrently***
64. SUCTIONING
Time per attempt
Interval
insertion
Endotracheal/ tracheostomy
5 to 10 seconds
2 to 3 minutes
5 inches and withdraw 1 to 2 cm
Naso-/ oro- pharyngeal
5 to 10 seconds
20 to 30 seconds
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)
65. SUTURES (catgut) – a thread, wire, or other material used in the operation of stitching parts of the body together
TYPES OF SUTURES:

Absorbable – digested by body enzyme
 plain gut (yellow)
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 16

 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)
T
66. 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
67. TELEPHONE ORDER


Only RN’s may receive telephone orders
The order should be countersigned by the physician within 24 hours
68. 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
69. 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
70. 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
71. 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
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 17
 Hypoglycemia
abrupt discontinuation hyperinsulinism
 Infection
unsterile procedure
 Fluid overload
rapid infusion
 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***








don’t stop abruptly
sterile technique
regulate
72. TRACHEOSTOMY CARE
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
Position
Open sterile packages
Pour soaking solutions
Suction
Remove inner cannula and place in soaking solution
Remove dressing
Clean inner cannula
Replace
Clean incision site and flange
Apply dressing
Change ties
73. 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
74. TRANSFERRING Patient from BED to WHEELCHAIR
1 – assist patient into sitting position
2 – 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
75. TRANSFERRING Patient from BED to STRETCHER
1 – lower HOB
2 – raise bed slightly higher than stretcher
3 – stretcher – parallel to the bed
4 – nurse – press own body against stretcher to secure it against the bed
Client – flex neck and arms across chest
5 – roll both sides of pull sheet towards the patient
6 – grasp and pull the pull sheet towards the stretcher
76. 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.
URGENT
Red
Yellow
Life, limb, eye threatening
Needs treatment in 20 minutes
Needs immediate attention
to 2 hours
Chest pain, cardiac arrest,
Fever >40oC, simple fracture,
EMERGENT
Color
Urgency
Examples
NON-URGENT
Green
Can wait hours or days
sprain, minor laceration, rash,
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 18
severe respiratory distress,
chemicals in the eye, limb
amputation, penetrating trauma,
severe hemorrhage
IMMEDIATE
Number
Color
Examples
1
Red
Chest wounds, shock, open
fractures, 2-3 burns
abdominal pain, asthma with no
respiratory distress
simple headache. Toothache,
sore throat
4 CATEGORIES IN TRIAGE in DISASTER
DELAYED
MINIMAL
2
3
Yellow
Green
Stable abdominal wound, eye
Minor burns, minor fractures,
and CNS injuries
minor bleeding
EXPECTANT
4
Black
Unresponsive, high spinal
cord injury
77. 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
78. 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 decreases
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
A 40%
B 80%
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 19
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)

Phase 5 – Silence  determines the diastole
e.
Taking BP in thigh
1 – Position patient

Prone (best)

Supine with legs flexed
2 – Expose thigh
3 – Locate popliteal pulse
4 – Wrap the cuff
f.
Common mistakes
FALSE-LOW
Bladder of cuff too wide
Arm above heart level
Deflating cuff too quickly
g.
h.
i.
FALSE-HIGH
Bladder of cuff narrow
Arm below heart level
Deflating cuff too slowly
Inflating too slowly
Smoking, caffeine and exercise for the last 30 minutes
Systolic in legs is higher compared to brachial around 10 to 40mmHg
3 years old and above - Start taking BP routinely
BP of 120/100/80  phase 1/4/5
79. TEMPERATURE
a.
ORAL – accessible and convenient
S – Smoking*
N – Newborn
O – Oral surgery
U – Ulceration/injury to the mouth
T – Tremors/convulsions
H – Hot/cold foods & fluids just ingested  wait for 15 to 30 minutes before taking temperature
b.
AXILLARY – Safe and non-invasive
A – Axillary injury
X – eXercise/activity
I – Inadequate circulation
L – Laging basa (moist pits)
A – After bathing
c.
RECTAL – Reliable measurement (Inconvenient and more unpleasant)
R – Rectal disease/diarrhea
I – Immunosuppressed
C – Clotting disorders
T – Turning to the side is difficult
H – Hemorrhoids
U – Undergone rectal surgery
M – Myocardial infarction
d.
TYMPANIC – Readily accessible, reflects the core temperature, very fast 9 Risk of injuring the membrane)
E – Evident cerumen
A – An ear infection is present
R – Reading may vary between left and right measurement
80. 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
81. RESPIRATIONS – The act of breathing.

2 Types of breathing
 Costal – thoracic
 Diaphragmatic – Abdominal
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 20


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).
EUPNEA
APNEA
BRADYPNEA
b.
TACHYPNEA
DEPTH – Hyperventilation (rapid and deep breaths), hypoventilation (very shallow respirations), and Kussmaul’s
breathing (hyperventilation associated with metabolic acidosis).
HYPERVENTILATION
HYPOVENTILATION
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).
CHEYNE-STOKES
BIOT’S
U
82. URINARY CATHETERIZATION: TYPES
TYPES
NO. OF
LUMENS
Straight Catheter
SINGLE: only for drainage
PURPOSE
Inserted only as much times as
it takes to drain the bladder or
obtain a urine specimen
Coude catheter is a variation
of straight catheter which has
a curved and tapered tip,
usually used for male patients
with prostatic hypertrophy
SPECIAL
CONISDERATIONS
Indwelling Catheter (Foley or Retention catheter)
DOUBLE:
 urine drainage
 for inflation of balloon (serves as an anchor)
OR
TRIPLE:
 urine drainage
 for inflation of balloon (serves as an anchor)
 for continuous irrigation
Inserted and stays connected to the bladder for a long time
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 sterility
2) Principle of gravity

Replace urinary catheter every 5 to 10 days
83. 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
84. PRESENTING UTI
W – ash before and after sex
O – n time voiding
M – ake us of cotton undergarment
A – lways wipe from anterior to posterior
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 21
N – o sprays, harsh soaps, powder.
W
85. WRITING NURSING DIAGNOSIS
1. Write the diagnosis in terms of
response rather than need.
2. Use related to rather than due to or
caused by to link etiology to problem
statement
3. Write diagnosis in legally advisable
terms. AVOID libellous words or would
imply nursing negligence.
4. Include in the problem statement only
client responses that are unhealthy or
that the client wants to change.
5. AVOID including signs and
symptoms of illness in the problem
statement.
6. Express the client statement and
etiologic factors in terms that can be
changed; otherwise, nursing energies
are being directed to a hopeless task
7. Express the problem statement in
terms of unhealthy client responses
rather than environmental conditions
8. AVOID reversing the problem
statement and etiologic statement
9. Make sure that the 2 parts of the
diagnosis do not mean the same thing
10. Write diagnosis without value
judgments. WATCH OUT for your
ADJECTIVES!
11. DO NOT include medical diagnosis.
INCORRECT
Needs assistance with bathing related
to bed rest
Noncompliance due to hostility towards
nursing staff
CORRECT
Self care deficit: bathing related to
immobility
Noncompliance related to hostility
towards nursing staff
Spouse abuse related to husband’s
immaturity and violent temper.
High risk for violence: spouse abuse
related to husband’s reported inability to
control behaviour
Impaired skin integrity related to client’s
lying back all night
Mild anxiety related to impending
surgery.
Impaired skin integrity related to
immobility.
---
Cough related to long history of
smoking.
Ineffective airway clearance related to
20 year history of smoking.
Alterations in Bowel elimination:
Permanent colostomy related to cancer
of the bowel
Self-care deficit: Care of colostomy,
related to feeling s of powerlessness
Cluttered home related to inability to
discard anything
High risk for injury related to cluttered
home (inability to discard anything)
Impaired swallowing related to possible
aspiration.
Alteration in comfort related to pain.
Risk for aspiration related to difficulty
swallowing.
Unrelieved incisional pain related to fear
of drug addiction
Impaired home maintenance
management related to low value
ascribed to home safety and cleanliness
Impaired home maintenance
management related to mobility,
endurance and comfort alterations.
Poor home maintenance management
related to laziness.
Impaired home maintenance
management related to arthritis.
FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 22