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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 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 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 Cecostomy Ascending colostomy Transverse colostomy Descending colostomy Sigmoid colostomy STOMA 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: 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 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 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) 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 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) 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 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 X-ray Contrast medium – warm sensation AVOID: pregnant women Before: NPO After: increase fluid 21. 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 22. 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 D 23. DIALYSIS 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 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 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 TYPES: 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 E – nlarge the nipple hole S – timulate the sucking S – wallow R – est 28. ESR 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. 29. EXERCISES TYPES OF EXERCISE CHARACTERISTICS OTHER NAME JOINT MOVEMENT CONTRACTION BENEFITS on MUSCLES EXAMPLES ISOTONIC Dynamic 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 Liver Green leafy vegetables Dried fruits Scallops, shrimps Oyster, clams molasses 33. PROBLEMS IN ELIMINATION Melena Acholic stool Steatorrhea hematochezia G FINAL REVIEW NOTES Prepared by: Prof. Brian Yu | 8 34. GTPALM G – Gravida P – Para 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 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 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 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