Supplements For Theoretical Foundations

SUPPLEMENTS FOR THEORETICAL FOUNDATIONS SAFE AND EFFECTIVE CARE ENVIRONMENT HEALTH PROMOTION AND MAINTENANCE FUNDAMENTAL CONCEPTS REDUCTION OF RISK POTENTIAL THERAPIES AND PROCEDURES

MANAGEMENT OF CARE C OMPETENCE,CONFIDENTIALITY AND PRIVACY A DVOCACY AND ACCOUNTABILITY R ESPECTFUL CARE AND RESPONSIBILITY P ROTECTED RELATIONSHIP AND PROMOTION OF PUBLIC HEALTH E THICAL STANDARDS OF CARE

INFORMED CONSENT CAPACITY AND COMPETENCE INCLUDES EXPLANATION OF B ENEFITS, E XPECTED R ESULTS,ALTERNATIVES AND R ISK VOLUNTARY INFORMATION UNDERSTOOD CANNOT SIGN IF UNDER ALCOHOL OR PREMEDICATED

Which statement about consent is not accurate: It includes explanation of benefits and disadvantages It states that consent cannot be withdrawn anytime It requires a competent adult who can make voluntary choices Married minors and pregnant minors can sign own consent for treatment

MANAGED CARE WORK ALLOCATION PATIENT NEEDS AND CONDITIONS ABILITIES OF STAFF CONTINUITY OF CARE KNOWLEDGE OF STAFF AND QUALIFICATIONS\ RIGHT TASK- FUNCTION , ACTIVITY , DECISION…….INFORMATION , SUPERVISION , FOLLOW-UP DON’T DELEGATE ASSESSMENT,TEACHING EVALUATION,PLANNING

DELEGATION BUILDS TRUST EMPOWERS OTHERS TEACHES AN MOTIVATES TEAMWORK DEVELOPS ENHANCE COMMUNICATION RAPID PRODUCTIVITY AND RAISED SKILL

WHICH OF THE FOLLOWING IS NOT TRUE ABOUT MANAGED CARE? In delegation , responsibility is transferred, accountability is shared Responsibility is determined by Nurse practice acts, standards of care, job description and policy statement In delegating identify variables nevertheless this would not change authority and responsibility Delegate to the lowest person on heirarchy that has the required skills and abilities who is allowed to do the task legally and according to the organization

Example: “ feed client if coherent and awake, if confused do not feed and notify me asap. IN PLANNING FOR STAFFING ALWAYS TAKE INTO CONSIDERATION CAPACITY / ABILITY OF THE STAFF.

SCOPE R.N.- PLANNING AND HEALTH TEACHING LICENSURE REQUIREMENTS ASSESSMENT AND EVALUATION NEED FOR KNOWLEDGE AND SKILL LPN/LVN- STABLE PATIENTS STANDARD UNCHANGING PROCEDURES SIMPLE MONITORING AND IMPLEMENTATION SEQUENCED/PREDICTABLE OUTCOMES STATE PRACTICE ACT INCLUSION UAP -DIRECT PATIENT CARE ACTIVITY AND STANDARD OPERATING UNCHANGING PROCEDURES

INCIDENT REPORTS SEQUENCE-UNEXPECTED OR UNPLANNED OCCURENCE RISK MANAGER SITUATIONS-STATEMENT OF FACTS AND PATIENT PHYSICAL RESPONSE ACTUAL AND POTENTIAL-REPORT WITHIN 24 HOURS-INVESTIGATION OF REFERRING TEAM MANAGEMENT(RISK MANAGER)

In writing an incident report the nurse manager should state the following guidelines on charting except Don’t include words such as error or inappropriate Don’t include judgemental statements Only actual risks should be reported within 24 hours to the risk manager Documentation of clients status should be continuous

RESTRAINTS LIABLE FOR FALSE IMPRISONMENT L AST RESORT I NFORMED CONSENT(PROXY) A LTERNATIVE MEASURES FIRST B ENEFITS> RISKS L ENGTH OF TIME AND CIRCUMSTANCES SPECIFIED E NSURE SAFETY – CIRCULATION CHECKS,SKIN CARE, ROM AND REMOVE Q2H

RESTRAINTS IS USED FOR: THE PURPOSE OF DISCIPLINE COMFORT AND CONVENIENCE OF PROVIDER REQUIRED TO TREAT MEDICAL SYMPTOMS MEASURE USED TO CONTROL BEHAVIOR PREVENT BREACH IN SAFE AND EFFECTIVE DELIVERY OF MEDICAL THERAPY. ENSURE SAFETY OF OTHER PATIENTS MEDIUM OF LIMIT SETTING AND PROVISION OF EXTERNAL CONTROLS

COMPLAINTS C OMPROMISE / COLLABORATIVE AGREEMENT L ISTEN ATTENTIVELY E XPLAIN SCOPES AND LIMITATIONS A SK AND RELAY EXPECTED SOLUTIONS AND TERMS N ON-DEFENSIVE

A CLIENT WHO IS ABOUT TO BE BATHED BY A NURSE STATES;”You are too young to know how to do this, get me someone who knows what they are doing”.the nurse best response is: We do this procedure daily, I have done this several times, tell me what are you afraid of? I can see you are upset , can we talk about it? You’re concerns show you are upset, we will talk about this after I have demonstrated the procedure. Can you be more specific about you’re concerns?

Health teaching C-CONSIDER SUPPORT SYSTEMS / COMPLIANCE H- olds MOTIVATION AND INSIGHT A- ALLOW FEEDBACK N-NEEDS MET AND ASSURED G- GOALS AND PRIORITIES SET w/ pnt. E- EMPATHETIC AND ENSURES COLLABORATION

Patient Education Type of learning: Cognitive Psychomotor Affective Patients motivation –PRIORITY FACTORS – DURATION , COMPLEXITY AND SIDE EFFECTS Discharge planning Begins with first encounter Functional level considered Referrals and preferrences Compromised plan

WHAT IS THE BEST GAUGE THAT THE CLIENT UNDERSTANDS DISCHARGE TEACHING? PATIENT VERBALIZES INTEREST PATIENT ASKS QUESTIONS RELATED TO ADAPTATION TO NEEDED CHANGE IN BEHAVIOR ACCURATE DEMONSTRATION OF PROCEDURE PLANS FOR PRACTICE SESSIONS RELATED TO HEALTH CARE SUGGESTIONS TAUGHT BY THE R.N.

SAFETY AND INFECTION CONTROL pg.27-49 UNIVERSAL PRECAUTIONS STANDARD PRECAUTIONS – BARRIER COMMUNICABLE DISEASE CONCEPTS CLINICAL MANIFESTATIONS-INITIAL,PATHOGNOMONIC/OUTSTANDING DIAGNOSTIC TESTS AND ETIOLOGY CARE ESSENTIALS AND IMPLICATIONS MANAGEMENT SEQUELAE

category-specific isolation strict- prevents transmission of highly contagious or virulent infections spread by air or direct contact(diptheria and chickenpox) Contact-prevents transmission of highly transmissible infections spread by close or direct contact to skin and mucous membranes that do not warrant strict precautions respiratory – prevents trans mission of infectious diseases over short distances through air droplets(measles, meningitis,mumps, pneumonia and H. Influenza) airborne droplet

enteric precautions – prevents transmission of infections by direct or indirect contact with feces(oral-fecal)( cholera,infectious diarrhea , hepa A , infectious AGE) AFB isolation-prevents spread of pulmonary tuberculosis( laryngeal TB) drainage and secretion precautions- prevents transmission by direct or indirect contact with purulent material or drainage from an infected body site(abcess, burn infection,and infected wound)

Universal blood and body fluid precautions- prevents contact with pathogens transmitted by direct/indirect contact with infective blood or body fluids containing blood( AIDS, HEPA-B,SYPHILIS) care of severely immunocompromised clients- protects client with lowered immunity and resistance from acquiring infectious organism( LEUKEMIA, LYMPHOMA, APLASTIC ANEMIA)

WHICH OF THE FOLLOWING IS AN INCORRECT STATEMENT MADE BY THE STUDENT NURSE ABOUT INFECTION CONTROL HANDWASHING IS THE SINGLE MOST EFFECTIVE WAY OF PREVENTING THE SPREAD OF INFECTION AUTOCLAVING KILLS ALL PATHOGENIC MICROORGANISMS INCLUDING SPORES AUTOCLAVED ITEMS IS CONSIDERED STERILE UNTIL 6 MOS. ONLY THE SKIN CAN NEVER BE STERILE

THE FOLLOWING PATIENTS ARE INCLUDED IN REVERSE ISOLATION PRECAUTIONS EXCEPT: BURN PATIENTS PATIENTS WITH APLASTIC ANEMIA PATIENT WHO ARE ON STEROID THERAPY PATIENTS WHO ARE ON CHEMOTHERAPY PATIENTS WHO ARE ON RADIATION THERAPY PATIENTS WITH LEUKEMIA PATIENTS WITH LYMPHOMA

POISONING CHILD PROOF REFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ WATER/MILK/ACTIVATED CHARCOAL

THE NURSE SHOULD INTERVENE IF A MOTHER OF A VICTIM OF POISONING VERBALIZES TO DO THE FOLLOWING: PLANS TO INDUCE VOMITING FOR PATIENT WITH ASPIRIN POISONING PLANS TO INDUCE VOMITING WHEN SHE IS CERTAIN THAT HER CHILD’S GAG REFLEX AND LOC ARE INTACT WILL NOT GIVE IPECAC IF CHILD IS EXHIBITING NARROWED PULSE PRESSURE WILL WAIT FOR THE SEIZURE TO END BEFORE ADMINISTERING IPECAC

CONTRAINDICATIONS OF IPECAC / INDUCTION OF VOMITING SEIZURE SUBNORMAL LOC AND GAG REFLEX SUBSTANCE CORROSIVE/PETROLEUM DISTILATE SHOCK-SEVERE

DISASTER PLANNING TRIAGE-GREATEST GOOD FOR THE GREATEST NUMBER OF PEOPLE PRINCIPLES- ABCD , MASLOWS RED-UNSTABLE – IMMEDIATE CARE YELLOW- STABLE – CAN WAIT 30-60 MIN GREEN –STABLE- CAN WAIT LONGER BLACK- UNSTABLE – FATAL, LAST SEEN DOA – SUPPORTIVE COMFORT MEASURES

DURING FIRE WHICH SET OF PATIENTS WILL THE NURSE MOBILIZE FIRST AMBULATORY BEDRIDDEN CRITICAL TERMINAL

WHICH STEP IN FIRE MANAGEMENT COMES LAST? ALARM CONTAIN MOBILIZE EXTINGUISH

PREVENTION AND EARLY DETECTION OF DISEASE

Medical Asepsis/ Clean Technique Principles:  Pathogens move through spaces or air current  Pathogens are transferred from one surface to another whenever objects touch.  Hand washing removes microorganism  Pathogens are released into the air on droplet nuclei when person speaks, breaths, and sneeze.  Pathogens are transferred by virtue of gravity  Pathogens move slowly on dry surface but very quickly through moisture.

Surgical Asepsis/ Sterile Technique  Areas of the body considered sterile are: o Blood stream o Spinal Fluid o Peritoneal Cavity o Urinary Tract o Muscles o Bones o Chamber of the Eyes

Sterile object remains sterile when touched by another sterile object  Sterile objects or fields, which falls out of the range of vision or below one’s waist, are considered contaminated.  Sterile items become contaminated when they come in contact with microorganism transported through the air.  When sterile object/ field come in contact with another surface, it becomes contaminated.  Fluids flows in the direction of gravity. The edges of the sterile field are considered unsterile

Isolation Practices  Strict Isolation- prevents transmission of highly communicable disease by contact and airborne transmission  Respiratory isolation- prevents transmission by droplet  Enteric precaution- prevents transmission through ingestion  Wound and skin precaution- prevents cross-infection by direct contact with wounds and contaminated articles  Discharge precaution- prevent cross-infection by secretions-contaminated articles Blood precaution- prevent transmission by contact with blood or items contaminated with blood

GROWTH AND DEVELOPMENT DEVELOPMENTAL TASKS---MILESTONES ----DELAYS(FIXATIONS/LAG) IQ = MA / CA X 100 JUDGEMENT , COMPREHENSION AND LISTENING DDST – BIRTH TO 6 YEARS PERSONAL SOCIAL, FINE , GROSS MOTOR AND LANGUAGE SKILL AREAS

HEALTH SCREENING OB – GYNE / REPRODUCTIVE TESTS UTZ-5 WKS CONFIRM PREGNANCY AND AOG AMNIOCENTESIS – 16 WKS-DETECT GENETIC DISORDERS – 30 WEEKS – L/S RATIO ( 2-4 WKS RESULT)(EMPTY Bladder) OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN 10 MINUTES- REACTIVE NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR ACCELERATION OF 15BPM/MORE LASTING 15 SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE – REACTIVE DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION) AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE DEFECTS – 16-18 WKS CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-12 WKS

NEWBORN/INFANT HEALTH SCREENING PKU – GUTHRINE BLOOD TEST-EAT CHON FOR 2 DAYS MIN.(PHEONISTICS – DIAPER) SICKLE CELL DISEASE –ABNORMALLY SHAPED Hg , ELISA AND WESTERN BLOT CARRIER SCREENING FOR CYSTIC FIBROSIS AND SWEAT CHLORIDE TEST

SCHOOL AGE HEARING AND VISION TESTS ALLEN PICTURE CARDS SNELLEN CHART-20/40 AT TODDLER AND 20/20 AT SCHOOL AGE WEBER’S-SENSORINEURAL AND CONDUCTIVE RINNE’S- CONDUCTIVE DENTAL EXAM – STARTS AT 2 YEARS

ADOLESCENT PPD – INDURATION – 72 HOURS BSE – (18-20 YRS.) POST MENSTRATION/MONTHLY TSE – MONTHLY (18-20 YRS) PELVIC EXAM WITH PAP SMEAR – IF SEXUALLY ACTIVE OR 18 Y.O. ANNUALLY

IN TEACHING AN ADOLESCENT PROPER BSE TECHNIQUE THE NURSE SHOULD INSTRUCT THE CLIENT TO PERFORM BSE IN THE FOLLOWING POSITIONS EXCEPT: STANDING WITH ARMS ON THE HIPS FACING THE MIRROR LYING DOWN WITH PILLOW UNDER THE SHOULDERS ARMS AT THE BACK OF THE HEAD RAISE THE ARM OF THE SIDE TO EXAMINED ABOVE THE HEAD POSITION THE ARMS WITH THE BODY IN ANATOMICAL POSITION

ADULT/ELDERLY HPN , DM, HEARING AND VISION PROSTATE –ANNUALLY@40 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS FECAL OCCULT BLOOD TEST- > 50 = ANNUALLY DIGITAL RECTAL EXAM - > 40 Y.O. = YEARLY PELVIC EXAM – 18-40 Y.O. =PERFORMED Q 1 – 3 YEARS WITH PAP TEST MAMMOGRAM – 35-39 = BASELINE 40-49 = Q2Y 50 AND OLDER = QYEAR

BP SCREENING(mmHg) IMMEDIATELY 120 >210 1 WEEK 110-119 180-209 EVALUATE AND REFER 1 MOS. 100-109 160-179 2 MOS. 90-99 140-159 1 YEAR 85-89 130-139 2 YEARS <85 < 130 FOLLOW-UP DIASTOLIC SYSTOLIC

UPON INITIAL ASSESSMENT THE PATIENT HAS A BLOOD PRESSURE OF 170/90 mmHg. WHAT IS THE FOLLOW-UP REFERRAL FOR THIS PATIENT? REFER AFTER 1 WEEK EVALUATE AND REFER FOR FOLLOW-UP AFTER 2 WEEKS EVALUATE AND REFER FOR FOLLOW-UP IN 2 MONTHS EVALUATE AND REFER FOR FOLLOW-UP IN 1 MONTH

IMMUNITY pg 127-130 CONTRAINDICATIONS: SEVERE FEBRILE ILLNESS LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED ALLERGIES RECENTLY ACQUIRED PASSIVE IMMUNITY(BLOOD TRANSFUSION AND IMMUNOGLOBULINS) if child –no evidence of immunization <7 y.o. Give DPT,TOPV,TINE 4-6 WKS LATER MMR 1 MONTH AFTER DPT AND TOPV REPEATED IN ANOTHER MONTH AGAIN IN 10-16 MOS. CAN GIVE DPT,MMR,TOPV, AND TINE SIMULTANEOUSLY

TD- 2 DOSES 4-8 WKS APART;3 RD DOSE 6-12 MOS;BOOSTER AT 10 YRS FO LIFE OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3 RD DOSE 2 -12 MOS AFTER 2 ND (OPV NOT USED IN US) MMR-ONE DOSE – 12 MOS VARICELLA – TWO DOSES 4-8 WEEKS APART STARTS AT 12 MOS. HEPA B – 3 DOSES;2 ND 1-2 MOS AFTER;3 RD 4-6 MS AFTER PPV- ONE DOSE ;IF 65 AND RECEIVED > 5YEARS – ADMINISTER INFLUENZA –ANNUALLY EACH FALL

ALLERGY CONTRAINDICATIONS EGGS – INFLUENZA , MMR NEOMYCIN – VARICELLA,IPV,MMR YEAST – HEPA-B GELATIN – VARICELLA PREGNANCY C/I: MMR AND VARICELLA IMMUNOSUPPRESSED; VARICELLA WITH Ig or BT PREVIOUS 3-11 MOS – MMR AND VARICELLA

CONSIDERATIONS-IMMUNIZATION DPT - IM – ANTERIOR OR LATERAL THIGH FEVER AND SWELLING 24-48 H POTENTIAL SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC AND SCREAMING MMR – SC – ANTERIOR OR LATERAL THIGH RASH, FEVER ARTHRITIS-10DAYS-2 WKS TRIVALENT OPV – PO PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS – EVALUATED 48-72 HOURS

A PATIENT WITH HIV-AIDS IS POSITIVE FOR PPD WHEN THERE IS: PRESENCE OF INDURATION OF 10 MM PRESENCE OF INDURATION OF 15 MM PRESENCE OF INDURATION OF 5 MM WHEAL FORMATION OF 10MM OR VESCICULAR PROLIFERATION

PHYSICAL ASSESSMENT TEACHING OPPURTUNITY INSPECTION –VISUALLY PALPATION-WARM HANDS DORSUM OF FINGERS FOR TEMP PERCUSSION-DIRECT,INDIRECT,BLUNT RESONANCE-MODERATE LOW PITCHED CLEAR HOLLOW(LUNG) HYPERRESONANCE-OVERINFLATED(EMPHYSEMA) TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL) DULL-SOFT MUFFLED,DENSE FLUID FILLED TISSUE(LIVER) FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-(MUSCLE/BONE) AUSCULTATION-DIAPHRAGM- HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW PITCHED(HEART MURMURS)

VITAL SIGNS TEMPERATURE: ORAL – 98.6 ‘F / 37 ‘C RECTAL – 99.6 ‘F / 37.6’C AXILLARY – 97.6’F / 36.5’C

Body Temperature  The balance between heat produce by the body and heat loss from the body  Types of body temperature  Core temperature- deep tissue temperature of the body  Surface temperature- temperature of the skin, subcutaneous tissue, and fats  The normal core body temperature is between 36.7 °C (98.7°F)- 37°C (98.6°F).  The thermoregulation center of the body is the hypothalamus

 Types of fever:  Constant- temperature is constantly high  Intermittent- the temperature fluctuates between periods of fever and periods of normal temperature  Relapsing- increase in temperature alternated with 1 or 2 days normal temperature Remittent fever- the temperature fluctuates with in a wide range over 24 hours period but remains above normal temperature

 Routes of Temperature –Taking  Oral o Most accessible and most convenient o Temperature is taken in 2-3 minutes time o 15 minutes before taking the oral temperature, don’t allow the client to take hot or cold foods and fluids  Rectal o Most accurate measurement o Thermometer is inserted 0.5-1.5 inches o Temperature is taken in 2 two minutes time.

Axillary o The most non-invasive and the most safest o Temperature is taken in 5-9 minutes time  If the body temperature declines suddenly, it is termed as crisis and this indicates hypothalamic disturbances; while if there is a gradual decline of fever, we term that as lysis that indicates normal functioning of the hypothalamus  Antipyretic is the drug of choice for patients with fever

Pulse  It is the wave of blood created by the contraction of the left ventricle  Pulse rate is regulated by the autonomic nervous system (ANS)  The normal pulse rate of an adult ranges from 60-100 beats per minute  Pulse amplitute describes the quality of the pulse in terms of its fullness

Number Definition Description 0 absent no pulsation 1 thready not easily felt 2 weak stronger than thready 3 normal easily felt 4 bounding stronger pulsation

 Pulse deficit is the difference between the apical pulse and radial puls  Pulse rate vary in different age levels:  1 year old- 80-180 beats per min (BPM)  2 years old- 80-140 BPM  6 years old- 75-120 BPM  10 years old – 50-90 BPM  Adult - 60-100  When palpating for the pulse, use two to three finger tips. Don’t use the thumb

 Pulse sites and reasons for use:  Temporal- used when radical pulse is not accessible  Carotid- used for infants, in cases of cardiac arrest, to determine the circulation of the brain  Apical- routinely used for infants and children up to three years old; to determine discrepancies with radial pulse; used in conjunction with some medications.  Brachial- used to measure blood pressure; during cardiac arrests of infants  Radial- readily accessible and routinely used  Femoral- used in cases of cardiac arrest, infants children, determine the circulation of the legs  Popliteal- to determine circulation of the lower leg and the site for the measurement of BP in the lower extremities  Posterior Tibial- to assess for the circulation of the foot  Pedal- to assess for the circulation of the foot

Respiration  It is the act of breathing: breathing in (Inhalation), breathing out (Exhalation)  Types of Respiration:  External Respiration- exchanges of gasses (oxygen and Carbon Dioxide) that happens in the alveoli of the lungs Internal Respiration- exchange of gasses that happens in the cell

Types of breathing:  Costal (thoracic) breathing-involves the movement of the chest  Diaphragmatic (abdominal)- involves the movement of the abdomen  The medulla oblongata is the primary respiratory center of the body  There are three(3) processes involved in respiration  Ventilation- the movement of gasses in and out of the lungs  Diffusion- exchange of gasses from an area of greater pressure to an area of lower pressure. It occurs at the alveolo-capillary membrane.  Perfusion- movement of blood for transport of gasses, nutrients, and metabolic wastes products  Normal adult breathes 16-20 times per minute

Blood Pressure  It is the pressure exerted by the blood in the arteries  Normal adult’s BP is 120/80  Systolic Pressure is the pressure resulting from the contraction of the ventricles  Diastolic pressure is the pressure when the ventricles are at rest. (Normal: 60-90 mm Hg)  Pulse pressure is the difference between the systolic and diastolic pressure (Normal: 30-40)  Hypertension – abnormally high blood pressure over 140/90 mm Hg for at least two consecutive readings  Hypotension- abnormally low blood pressure, systolic pressure below 100mm Hg  Postural/ orthostatic hypotension is a sudden drop in blood pressure caused by a sudden changed in position

 If the BP cuff is too small for a patient, the BP reading may result to false high measurement; if the BP cuff is too big for a patient, the BP reading may result I false low measurement  Women usually have lower BP than men  The series of sounds that the nurse listens during BP reading is called Korotkoff sounds  In assessing the BP, use the bell-shaped diaphragm of the stetoscope since BP is a low frequency sound Always read the lower meniscus of the mercury of the BP apparatus at eye level to prevent error

NORMAL VITAL SIGNS NEWBORN=30 – 50 / MIN; 120 – 140 / MIN; 60/40 – 80/50 mmHg 1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN; 90/60 – 99/65 mmHg 5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60 mmHg ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –140 / 90 mmHg

BREATHING PATTERNS CHEYNE STOKES – PERIODIC BREATHING CHARACTERIZED BY RHYTMIC WAXING AND WANING DYSPNEA - LABORED PAINFUL BREATHING HYPERVENTILATION – ABNORMALLY RAPID DEEP PROLONGED BREATHING KUSSMAULS – AIR HUNGER , MARKED INCREASE IN DEPTH AND RATE TACHYPNEA – FAST SHALLOW BREATHING PARADOXICAL – FLAIL CHEST , DEFLATES DURING INHALATION BIOT’S – SHALLOW BREATHS INTERRUPTED BY APNEA

NORMAL FINDINGS PULSE PRESSURE – 30-40 mmHg Intracranial pressure – 10 mmHg PULSE DEFICIT – MINIMAL(3-5 ACCEPTABLE) IDEAL BODY WEIGHT – MALES -106 LBS FOR 1 ST 5FT THEN ADD 6LBS/INCH FEMALE – 100LBS FOR 1 ST 5 FT THEN ADD 5LBS/INCH ADD OR SUBTRACT 10% DEPENDING ON BODY FRAME. OBESE AND UNDERWEIGHT IF DEVIATION IS > 20%

SKIN SCARS,BRUISES AND LESIONS CHECK COLOR EDEMA – GRADING 0-NO EDEMA 1-BARELY DETECTABLE 2-INDENTATION<5MM 3-INDENTATION 5-10MM 4-INDENTATION >10MM PRESSURE SORE –GRADING 1-NONBLANCHABLE ERYTHEMA 2-EPIDERMIS,PARTIAL THICKNESS 3-FULL DERMIS AND SQ 4- SUPPORTING TISSUES AND BONES TURGOR-PINCH SKIN TENTED 3 SECS NORMAL(ELDERLY-OVER STERNUM)

skin lesions macule patches papule plaque nodule tumor vescicle bullae pus

HAIR AND NAILS HIRSUTISM-EXCESS ALOPECIA-THINNING SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING ANGLE > 180 DUE TO PROLONGED DECREASED OXYGENATION BLANCHING =< 3 SECS-NORMAL

HEAD SYMMETRY, SIZE AND SHAPE CRANIAL NERVE ASSESSMENTS OPTIC-SNELLEN OCULOMOTOR- PERRLA TRIGEMINAL – BITE DOWN AND STROKES WITH COTTON FACIAL – FACIAL MOVEMENT AND TASTE ACCOUSTIC – HEARING AND BALANCE(WATCH TICK TEST,OTOSCOPIC EXAMS AND POSTURE TESTS) GLOSSOPHARYGEAL-GAG AND SWALLOW VAGUS- SWALLOWING AND SPEAKING

EYES PTOSIS-DROOPING OF THE UPPER EYELID ASTIGMATISM – UNEVEN CURVATURE OF CORNEA LEADING TO REFRACTION ERRORS NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE MOVEMENTS STRABISMUS-ASSYMETRICAL LIGHT EFLECTION ON EACH CORNEA RED REFLEX FROM RETINA-NORMAL COVER UNCOVER TEST – DET.EYE ALIGNMENT SNELLEN – FAR DISTANCE VISION/VISUAL ACUITY IOP-TONOMETRY TESTS INDENTATION(6-12)

EARS PINNA BACK-UP-ADULT;DOWN-BACK-CHILD RINNE TEST – COMPARES AIR CONDUCTION WITH BONE CONDUCTION,VIBRATING FORK PLACED ON THE MASTOID IF SOUND NO LONGER HEARD POSITIONED IN FRONT OF EAR CANNAL. SHOULD HEAR A SOUND= 2:1 ; AIR CONDUCTION > THAN BONE CONDUCTION ;= POSITIVE RINNE ASSESS CONDUCTIVE HEARING LOSS

EARS WEBER – SENSORINEURAL AND CONDUCTIVE HEARING LOSS FORK PLACED MIDDLE OF FORE HEAD,SHOULD BE HEARD EQUALLY=WEBER NEGATIVE IF NOT EQUAL=SENSORINEURAL HEARING LOSS. SOUND HEARD BETTER IN THE IMPAIRED EAR=BONE CONDUCTIVE HEARING LOSS, IF VICE VERSA = SENSORINEURAL DISTURBANCE

NECK,MOUTH AND PHARYNX TEETH-32 TONSILS – NO TPC , + GAG REFLEX CERVICAL LYMPH NODES=<1CM CAROTID – PALPATE THRILL,LISTEN BRUIT JUGULAR VEINS – NOT DISTENDED TRACHEA-MIDLINE

THORAX AND LUNGS APL DIAMETER-1:2 – 5:7 1:1 = BARREL CHEST TACTILE FREMITUS NORMAL-BRONCHOPHONY,EGOPHONY AND WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGS BREATH SOUNDS VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –PERIPHERAL LUNG SURFACES BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM BRONCHI BRONCHIAL- LOUD COARSE - TRACHEA ADVENTITIOUS BREATH SOUNDS RALES-FINE SHORT,CRACKLING OR HIGH PITCHED SOUNDS-INSPIRATION RHONCHI-CONTINOUS LOW PITCHED COARSEGURGLING HARSH SNORING BEST HEARD ON EXHALATION WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON INHALATION FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ LIKE VIBRATIONS – BOTH INHALATION AND EXHALATION

HEART SOUNDS AORTIC AND PULMONIC VALVE AREAS- 2 ND ICS, R AND L RESPECTIVEY ERBS POINT 3 RD ICS TRICUSPID AREA-4 TH / 5 TH ICS MITRAL AREA – 5 TH ICS , LEFT MCL PMI-5 TH ICS MCL –(INFANTS-LATERAL TO LEFT NIPPLE-4 TH ICS) S1LUBB-CLOSURE OFAV VALVES S2DUBB-CLOSURE OF SEMILUNAR VALVES MURMURS , GALLOP-ABNORMAL HEART SOUNDS

PERIPHERAL VASCULAR SYSTEM ASSESS PAIN,PALLOR,PARALYSIS,PARESTHESIASAND PULSES. ASSESS HOMAN’S SIGN PULSE DEFICIT

BREASTS START – UPPER OUTER CLOCKWISE ASSESS FOR SIZE,SHAPE,SYMMETRY AND NODES

ABDOMEN DORSAL RECUMBENT INSPECT,AUSCULTATE,PERCUSS AND PALPATE BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 5-25/MIN NORMAL) IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS. MORE. SEQUENCE IS CLOCKWISE FROM RLQ HYPOACTIVE < 3 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT TINKLING SOUND – BOWEL OBSTRUCTION

ABDOMEN REBOUND TENDERNESS- INFLAMMATION OF PERITONEUM KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLE KIDNEY PUNCH TEST

MUSCULOSKELETAL SYSTEM MUSCLE TONE AND STRENGTH 0=COMPLETE PARALYSIS 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT 3=50% - NORMAL MOVEMENT AGAINST GRAVITY 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE 5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS ARE ABNORMAL FASCICULATION ABNORMAL CONTRACTIONS AND SHORTENING OF MUSCLE FIBERS TREMOR-INVOLUNTARY TREMBLING TEST FOR ROM AND ASSESS FOR ATROPHY/HYPERTROPHY/CONTRACTURES

NEUROLOGIC TESTS MENTAL STATUS- LANGUAGE-CEREBRAL CORTEX-APHASIA ORIENTATION(TIME,PLACE,PERSON)(CONFUSION) MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY ATTENTION SPAN AND CALCULATION JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL VIEWS PERCEPTION – SENSORY ANALYSIS AND INTEGRATION CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING MOVEMENTS,GAIT CRANIAL NERVE FUNCTIONS SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSE- RHOMBERG’S TEST)

NEUROLOGIC TESTS DEEP TENDON REFLEX 0-NO REFLEX +1 – MINIMAL ACTIVITY(HYPOACTIVE) +2 – NORMAL RESPONSE +3 – MORE ACTIVE THAN NORMAL +4 – MAXIMUM ACTIVITY ( HYPERACTIVE) PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY

LEVEL OF CONSCIOUSNESS GLASGOW COMA SCALE=15 POINTS, 7 COMA EYE OPENING SPONTANEOUS=4 TO VERBAL COMMAND=3 TO PAIN=2 NO RESPONSE=1 MOTOR RESPONSE TO VERBAL COMMAND=6 TO PAINFUL STIMULI/LOCALIZES PAIN=5 FLEXES AND WITHDRAWS=4 DECORTICATE=3 DECEREBRATE=2 NO RESPONSE=1 VERBAL RESPONSE ORIENTED,CONVERSES=5 DISORIENTED,CONVERSES=4 USES INAPPROPRIATE WORDS=3 USES INCOMPREHENSIBLE SOUNDS=2 NO RESPONSE=1

ASSESSING MOTOR FUNCTION WALKING GAITS ROMBERGS TEST- STAND FEET TOGETHER ARMS RESTING AT THE SIDES,EYES OPEN THEN CLOSED. NEG. ROMBERG – MAY SWAY BUT KEEPS BALANCE. SENSORY ATAXIA-CANNOT BALANCE EYES SHUT CEREBELLAR ATAXIA-CANNOT BALANCE EYES SHUT OR EPON HEEL-TOE WALKING AND VICE VERSA FINGER TO NOSE TEST AND OTHER SENSORY FUNCTION TEST (ONE AND TWO POINT DISCRIMINATION) EXTINCTION PHENOMENON-SYMMETRICAL AREAS ARE TOUCHED BUT SENSATION ON ONE SIDE CANNOT BE FELT INDICATES LESIONS OF SENSORY CORTEX

GENITALIA , ANUS AND RECTUM ASSESS APPEARANCE AND ORIFICES AND INGUINAL LYMPH NODES INSPECT CERVICAL OS AND VAGINA-SPECULUM DEVIATIONS CYSTOCELE, RECTOCELE,ENTEROCELE HYPO AND EPISPADIAS-URETHRAL OPENING DISPLACED HERNIAS-DIRECT,INDIRECT , FEMORAL INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE DIGITAL RECTAL EXAM –INSPECTION AND PALPATION –POSITION BOTH=SIM’S , FEMALES – LITHOTOMY;MALES =STAND AND BEND FORWARD PROSTATE GLAND-4 CM ;CERVIX = 2-3 CM HEMORRHOIDS =DILATED VEINS

ADDITIONAL SUPPLEMENTALS NORMAL VALUES - PG 25 SIGNIFICANCE OF DIAGNOSTICS AND LABORATORY EXAMS –PG 26 HISTORY SIGNIFICANCE – PG.28 INITIAL MANIFESTATIONS PG 29-30 UNIVERSAL PRECAUTIONS PG48-51 THE REST IN “ must knows” AND COMPARISONS OF SIGNS AND SYMPTOMS

MOBILITY AND IMMOBILITY POSTURE AND BODY ALIGNMENT-ERECT JOINT MOVEMENTS=RANGE OF MOTION CONNECTIVE TISSUE BONE TO BONE-LIGAMENT BONE TO MUSCLE – TENDON COVERS BONES/JOINTS - CARTILAGE TYPES OF JOINT SYNARTHROSES(CARTILAGENOUS) DIARTHROSES( SYNOVIAL) AMPIARTHROSES(FIBROUS)

ERGONOMICS-BODY POSITIONING AND MECHANICS PRIORITY-ASSESS PERSONAL CAPACITY 1 ST USE PROTECTIVE DEVICES/ TRANSFER AIDS CHANGE POSITION SLOWLY-ORTHOSTATIC HYPOTENSION(DANGLE LEGS FIRST) PIVOT ON THE STRONGER SIDE,MOVE PNT TOWARDS STRONGER SIDE USE LARGER MUSCLES OF THE BODY AND FACE THE DIRECTION OF THE MOVEMENT PULL SHEETS ARE BETTER METHOD THAN SLIDING ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE AN ASSISTANT STANDING BY. ROCK FROM FRONT TO BACK/VICE VERSA.WIDE BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF THE BODY.USE APPROPRIATE TRANSFER AND AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE BOARD, DRAW SHEET AND TRANSFER BELT

Body Mechanics  It is the efficient, coordinated, and safe use of the body to produce motion and maintain balance during activity. Principles of Body Mechanics When the line of gravity passes through the base support, balance is maintained and stability can be maintained with the least amount of effort. A wider base support increases stability of the body. When then center of gravity is close to the base of support, a person and an object is more stable. Enlarging the base of support in the direction of force to be applied maintains stability with minimal effort. Tightening the abdominal muscles upward and contracting the gluteal muscle downward requires less energy to move something and the less likelihood of musculoskeletal injury.

Synchronize use of muscle groups’ decreases muscle fatigue. Objects can be moved easily on a flat surface rather than on an inclined surface against gravity. It is easier to lift when the larger leg muscles are used, rather than using the smaller back muscles. The lesser friction when moving objects facilitates motion. It is better to pull than to push because pulling creates lesser friction, hence movement. In lifting and moving objects, the body’s weight must be used to assist. Alternate rest periods with periods of muscle exertion may be used to prevent muscle fatigue. Greater force is required to move a heavy object.

THERAPEUTIC EXERCISES PASSIVE ROM-RETENTION OF ROM AND MAINTENANCE OF CIRCULATION ASSISTIVE- INCREASES MOTION , MAINTAINS MUSCLE TONE ACTIVE – MAINTAINS MOBILITY OF THE JOINT AND MAINTAINS MUSCLE STRENGTH RESISTIVE – INCREASES MUSCLE POWER ISOMETRICS- MAINTENANCE OF STRENGTH AND PREVENTS MUSCULAR ATROPHY

DANGERS OF IMMOBILITY DECUBITUS ULCER-OSTEOMYELITIS OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND RENAL CALCULI INCREASED CARDIAC WORKLOAD- TACHYCARDIA CONTRACTURES- DEFORMITIES THROMBUS FORMATION-PULMONARY EMBOLISM ORTHOSTATIC HYPOTENSION-WEAKNESS,FAINTNESS AND DIZZINESS RESPIRATORY STASIS – HYPOSTATIC PNEUMONIA CONSTIPATION – FECAL IMPACTION URINARY STASIS-URINARY RETENTION NEGATIVE NITROGEN BALANCE-WEIGHT LOSS/DEBILITATION

A COMPLICATION OF IMMOBILITY IN WHICH THE BLOOD VESSELS FAIL TO IMMEDIATELY ACCOMMODATE TO THE CHANGES IN POSITION LEADING TO DIZZINESS,FAINTNESS AND WEAKNESS. THE NURSE KNOWS THAT THIS IS DUE TO: VENOUS STASIS IN THE LOWER EXTREMITIES VENOUS POOLING OF BLOOD IN THE LEGS INCREASED VASOCONSTRICTION OF THE PERIPHERAL BLOOD VESSELS ACTIVATION OF THE PARASYMPATHETIC NERVOUS SYSTEM

SPECIFIC THERAPEUTIC POSITION HIGH FOWLERS-60-90’ FOWLER-45-60’ SEMI-FOWLERS-30-45’ LOW-FOWLERS-15-30’ SUPINE DORSAL RECUMBENT LITHOTOMY TRENDELENBURG SIMS LATERAL MODIFIED TRENDELENBURG PRONE KNEE-CHEST SIDE-LATERAL ORTHOPNEIC

FOR PATIENTS POST SUBTOTAL GASTRECTOMY WHICH POSITION SHOULD THE NURSE PLACE THE CLIENT IN AFTER MEALS? UPRIGHT POSITION LEFT SIDELYING POSITION HIGH FOWLERS POSITION DORSAL RECUMBENT POSITION

ASSISTIVE DEVICES CRUTCHES CRUTCH HEIGHT- STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 CM TEACH MUSCLE STRENGTHENING EXERCISES PRIOR TO AMBULATION.WEIGHT ON THE HAND GRIP (TO AVOID CRUTCH PALSY) ELBOWS SHOULD BE FLEXED 20-30’ AND CRUTCHES SHOULD BE KEPT 6 INCHES LATERALLY AND 6 INCHES TO THE FRONT=TRIPOD POSITION(8-10 INCHES-OK) INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTURE

CRUTCH WALKING GAITS FOUR POINT-SLOW SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS TWO POINT- FASTER SAFE-WEIGHT BEARING ALLOWED FOR BOTH LEGS THREE-POINT-NON WEIGHT BEARING OF ONE LEG SWINGTO/SWINGTHROUGH-PARTIAL WEIGHT BEARING ALLOWED FOR BOTH LEGS GETTING INTO A CHAIR –BOTH CRUCHES TO THE WEAK SIDE , STRONGER ARM HOLDS THE ARMREST GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1 ST AND BAD GOES DOWN 1 ST .

WALKER - PROVIDES STABILITY AND BALANCE MOVE WALKER AHEAD 15 CM (6INCHES-8-10 INCHES)WHILE WEIGHT IS BORNE BY BOTH LEGS.THEN ALTERNATE WEIGHT BEARING ASSISTED BY THE ARMS ELBOWS SHOULD BE FLEXED-20-30’ IF ONE LEG IS WEAKER MOVE THAT LEG TOGETHER WITH THE WALKER

CANE HOLD CANE ON THE STRONGER SIDE FLEX ELBOW 30’ AND TIP OF CANE 15 CM LATERAL TO THE SIDE OF THE 5 TH TOE. ADVANCE CANE AND AFFECTED LEG ,WEIGHT ON CANE WHEN MOVING THE GOOD LEG BUT FOR MAXIMUM SUPPORT ADVANCE CANE 1 FEET ,MOVE AFFECTED LEG THEN THE STRONGER LEG GOING UP AND DOWN THE STAIRS –SAME WITH CRUTCHES

IN TRANSFERRING A HEMIPLEGIC CLIENT WITH RIGHT HEMISPHERE LESION FROM BED TO THE WHEELCHAIR, THE NURSE SHOULD POSITION THE WHEELCHAIR: ON THE RIGHT SIDE 90’ FROM THE BED ON THE LEFT SIDE PERPENDICULAR TO THE BED ON THE LEFT SIDE 45’ FROM THE BED ON THE AFFECTED SIDE

TRACTIONS TRAPEZE BAR OVER HEAD REQUIRES FREE HANGING WEIGHTS ANALGESIC GIVEN TO RELIEVE PAIN CHECK PATIENTS CIRCULATION( 5p’S) TEMPERATURE MONITORING INFECTION PREVENTION OUTPUT AND INTAKE MONITORING Nutrition needs Skin must be frquently checked

TYPES OF TRACTIONS SKIN TRACTION SKELETAL TRACTION BUCKS BRYANTS RUSSELS CRUTCHFIELD TONGS PELVIC HALO VEST

NUTRITION PREMATURE INFANTS-LESS THAN37WKS/2,500G-100-200 CAL/KG/DAY AND HIGHER Na,Ca AND CHON FULL TERM-120 CAL/KG/DAY PREGNANCY + 300CAL/DAY LACTATION+ 500CAL/DAY

ENTERAL FEEDINGS CONDITIONS PREOPERATIVE NEED FOR NUTRITIONAL SUPPORT GI PROBLEMS ONCOLOGY THERAPY ALCOHOLISM,CHRONIC DEPRESSION AND EATING DISORDERS HEAD,NECK DISORDERS OR SURGERY COMPLICATIONS ASPIRATIONTUBE DISPLACEMENT CRAMPING,VOMITING,DIARRHEA HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE INTOLERANCE

TOTAL PARENTERAL NUTRITION TYPES OF SOLUTIONS TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE BACTERIAL FILTER USED TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID, DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTER PERIPHERAL=NO >10% DEXTROSE AND 2 WKS ONLY CENTRAL – INCOMPATIBLE WITH MEDS AND BLOOD IF SINGLE LUMEN USED ATRIAL-HICKMAN/BIOVAC AND GROSHONG- HUBBER NEEDLE USED TO ACCESS PORT THROUGH SKIN

TPN INITIAL RATE OF INFUSION 50 ML/HR THEN 100-125/HR. COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS, PNEUMOTHORAX FAST RATE=HYPEROSMOLAR STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS) SLOWED RATE=REBOUND HYPOGLYCEMIA X-RAY CONFIRMS PLACEMENT ATTACH TO PUMP IV TUBING AND FILTER CHANGED Q24 HOURS ALLOW SOLUTION TO WARM IMMEDIATELY BEFORE USE IF NO SOLUTION USE DEXTROSE 10% W SOLUTION CHECK DAILY CBG,WEIGHT,TEMP. I AND O , CHECK 3X A WEEK BUN, ELECT, ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND PT,PTT

OSTOMIES PERMANENT/TEMPORARY STOMA RED AND SLIGHT BLEEDING WHEN TOUCHEDBURNING SENSATION UNDER FACEPLATE INDICATES SKIN BREAKDOWN,REFER ABDL DISTENTION/DISCOMFORT, KARAYA POWDER(DEC.IRRITATION), CHARCOAL/BISMUTH CARBONATE-DEODORIZER APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-72H AND 24-48H IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODED ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODOR COLOSTOMY-FORMED , CAN BE IRRIGATED 300-500ML AND REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCE

URINARY ELIMINATION BUN – 10-20 MG/DL CREA – 0.7 – 1.4 MG/DL 24 HOUR URINE PRODUCTION-1000-1500CC ANURIA<100ML/24H OLIGURIA< 400 ML/24H POLYURIA > 2000 ML/24H

KEGELS –STRENGTHEN MUSCLES OF THE PELVIC FLOOR-TIGHTEN FOR 3 SECS THEN RELAX FOR 3 SECS PERFORM LYING DOWN, SITTING AND STANDING FOR TOTAL OF 45 BLADDER RETRAINING INTERMITTENT CATHETERIZATION AFTER ATTEMPTING TO VOID Q 2-3H, TIME INCREASES GRADUALLY BUT NO MORE THAN 8 HOURS BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H THEN ATTEMP TO VOID 30 MINS LATER-TIME GRADUALLY INCREASED TRIGGERING TECHNIQUES-CREDES MANEUVER AND VALSALVA CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE TO VOID 3-4 HOURS AFTER REMOVAL

4 HOURS AFTER FOLEY CATHETER REMOVAL THE PATIENT STILL HASN’T VOIDED. THE NURSE IS EFFICIENT IF SHE DID WHICH OF THE FOLLOWING NURSING ACTIONS FIRST? PREPARE FOR STRAIGHT CATHETER INSERTION ASK THE PATIENT INCREASE ORAL FLUID INTAKE POUR WARM WATER OVER PERENIUM OR TURN ON FAUCET. INSPECT THE PATIENTS SYMPHYSIS PUBIS

HEMODIALYSIS DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS

PERITONEAL DIALYSIS TENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES: CAPD(4-6H INDWELLING), AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING

COMFORT AND PAIN Pain  The noxious stimilation of threatened or actual tissue damage (Geach, 1987)  Whatever the experiencing person says it is, existing whenever he or she says it does (McCaferry, 1979)  It is highly subjective and individual and that is one of the body’s defense mechanism indicating that there is a problem.  It is protective as it gives warning or signal for tissue injury

Classifications of Pain  Superficial Pain- in the surface of the skin  Radiating Pain- pain that extends in the surrounding tissues  Somatic Pain- pain that occurs in the muscles, joints, and bones  Visceral pain- pain that occurs internally (abdominal cavity and thoracic cavity)  Referred pain- pain that is felt on the other part of the body other than the source of injury  Intractable pain- pain that is resistant to intervention  Psychogenic Pain- emotional pains  Intermittent pain- pain that stops and recurs again and again.  Phantom pain- pain is felt in the absence of a part of the body causing the pain.

Assessment of Pain  Precipitating Factors- “ What triggers the pain or makes it worse?”  Quality of Pain- “Tell me what the pain feels like”  Alleviating Factors- “What measures relieve your pain”  Meaning of pain- “ How do you interpret the pain?”  Pattern  Location Pain- “Where is your pain” Periodicity- “How long have you felt the pain sensation

PREOP CARE INFANT-DISTRACT TODDLER-ALLOW REGRESSION AND INVOLVE PARENTS,CONSISTENT CAREGIVER PRE-SCHOOL-LET CHILD HANDLE EQUIPMENT,EXPRESSION OF FEELINGS THROUGH PLAY DEMOFAMILIAR SORROUNDINGS SCHOOL AGE- EXPLAIN SIMPLY AND ALLOW CHOICES ADOLESCENTS- INVOLVE AND POINT OUT STRENGTHS AND BENEFITS,EXPECT RESISTANCE

PREOP CHECKLIST CONSENT HEALTH TEACHING (SPEC. POST OP PROCEDURES) LAB TESTS,ECG,X-RAY SKIN PREP BOWEL PREP IV’S NPO PREOP MEDS,SEDATION AND ANTIBIOTICS REMOVAL OF DENTURES,NAILPOLISH AND JEWELRY NUTRITION-TPN OR ENTERAL FEEDINGS PREOP

WHICH OF THE FOLLOWING INTERVENTIONS BY THE NURSE CARING FOR A PATIENT WHO IS SCHEDULED TO HAVE EXPLORATORY LAPAROTOMY IN 8 HOURS IS CORRECT? PLACING THE PATIENT ON NPO 4 HOURS PRIOR TO THE TEST AND REMOVING JEWELRY,DENTURES AND NAIL POLISH. INSERTING AN 18G IV CATHETER CONNECTED TO PNSS OPPOSITE THE ARM WITH A 22 G IV CATHETER CONNECTED TO A TPN SOLUTION. TEACH THE PATIENT DEEP BREATHING EXERCISES AND EXPLAIN THE PROCEDURE TO BE DONE ON THE PATIENT INCLUDING RISKS AND BENEFITS. HAVE THE PATIENT SIGN THE CONSENT AFTER EXPLAINING THE CONSEQUENCES AND RISKS AS WELL AS THE BENEFITS.

INTRAOP- MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT STATUS,, APPROPRIATE GROUNDING DEVICES, FLUID BALANCE AND SPONGE/INSTRUMENT COUNT SCRUB NURSE – HANDLES EQUIPMENT , MATERIALS TO THJE SURGEON, SPONGE AND INSTRUMENT COUNT ( STERILE) CIRCULATING NURSE- ENSURES ADEQUACY OF SUPPLIES, SKIN PREP , DOCUMENTATION , HANDLES STERILE EQUIPMENTS BY FORCEPS

POST OP POST OP- MONITOR VS Q15X4;Q30X2;Q1HX2 THEN PRN MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC RESPIRATORY PHYSIOTHERAPY,TCBD INCENTIVE SPIROMETRY-20 SECS INHALATION ENCOURAGE AMBULATION REFER IF UNABLE TO VOID IN 8 HOURS APPLY TED HOSE AND PNEUMATIC COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGN

WOUNDS NOTE DRESSING AND INCISION FEVER 1-2 DAYS POST OP-ATELECTASIS/ DEHYDRATION 3-7 DAYS – INFECTION UPPER GI TUBES-GASTRIC DECOMPRESSION LOWER GI TUBES – BOWEL DECOMPRESSION WOUND HEALING BY 1 ST INTENTION-SUTURED AND APPROXIMATED ; 3 RD INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINS WOUND HEALING BY 2 ND INTENTION-INCREASED INCIDENCE OF INFECTION , INCREASED SCARRING AND LONGER HEALING TIME

POST-OP COMPLICATIONS SHOCK PARALYTIC ILEUS ATELECTASIS AND PNEUMONIA - 2ND DAY EMBOLISM- 2ND DAY WOUND INFECTION-3-5D DEHISCENCE AND EVISCERATION-5-6D PSYCHOSIS CARDIOVASCULAR COMPROMISE URINARY RETENTION-8-12H URINARY INFECTION -5-8 D DVT-6-14 DAYS-1 YEAR

anesthesia Halothane-respiratory and cardiovascular depression-monitor VS, open IV site-ABC’s prevent aspiration Nitrous Oxide- Hypotension and nausea and vomiting- adequate O2 IV thiopental Na- decreased BP , respiratory depression, laryngospasm- ABC spinal and saddle – hypotension and HA- increased OFI conduction block/epidural block- hypotension and respiratory depression-HA not experienced local – excitability and hypersensitivity;no epinephrine on fingers

WHICH OF THE FOLLOWING STATEMENTS IS NOT TRUE REGARDING POST OPERATIVE COMPLICATIONS OBESITY OR MALNUTRITION INCREASES THE INCIDENCE OF POST-OPERATIVE COMPLICATIONS THE MAIN PURPOSE OF PRE-OPERATIVE TEACHING IS TO PREVENT POST-OP COMPLICATIONS high pitched tympany is abnormal in the abdominal quadrants put on TED or pneumatic compresion devices to prevent venous stasis notify physician if unable to void in 10 hours 1 st dressing should be done by RN

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