Fundamentals of Nursing PNLE November 2024 PDF

FUNDAMENTALS OF NURSING TOPRANK REFRESHER PHASE PNLE NOVEMBER 2024 Lecturer: Mr. Jessie Daclis Fall Safety Intrinsic Factor Extrinsic Factor (Environmental) Fire...

FUNDAMENTALS OF NURSING TOPRANK REFRESHER PHASE PNLE NOVEMBER 2024 Lecturer: Mr. Jessie Daclis Fall Safety Intrinsic Factor Extrinsic Factor (Environmental) Fire Dizziness Rags Fire extinguishers Blood Wet shiny floors For incipient fire pressure Dark environment If the doorknob is hot to touch, the fire has already Mobility side rails down spread. Disorientation Wrong type can worsen fire. Morse Fall Risk/ Scale CLASS used every shift score > 50 = higher risk 🔼A Ordinary, Combustibles (woods, paper, plastic, cloth) ⬜️B Flammable liquids (alcohol, diesel , paint etc) ⚪️C Electrical fires (office equipments) ⭐️D Metal fires (sodium, aluminum, magnesium, potassium) Fall Prevention Fall alert Patient should be near nurses station 2 to 3 side rails vp Call bell within reach ○ Respond immediately Supervise when possible ○ Dementia patient cannot distinguish cafe and not Gait belt for ambulation Nurse behind the affected side MADURO,K. 1  Assessment Key Points: Relaxed position Respiration: Upright Position Standard Assessment (IPaPeA) Abdominal: Dorsal recumbent Inspection Supine with knee flexed Observation ○ Color ○ Size Breast Self Examination Palpation Detect breast cancer Masses Start: 20 years old Tenderness Monthly: 5 to 7 days after LMP Organ enlargement ○ Example: LMP June 6, BSE@ June 11 Percussion Menopausal: same day each month Tap ○ Dull sound➡ soft tissue Inspection ○ Resonant➡ lungs (Air) Mirror ○ Hyperresonant➡High air (COPD) ○ Size ○ Tympany➡ fluids (stomach, ascites) Normal: Slight asymmetry Auscultation Abnormal: Profound asymmetry Listen sounds ○ Color Wipe earpiece with alcohol Abnormal: Peau d' orange (orange ○ Bell➡low pitched sounds (pulse) peel skin) ○ Diaphragm ➡ high pitched sound (lung Dimpling on skin upon chest sounds) contraction Abdominal Assessment (IAPePa) Palpation Inspection Shower (soapy) Observation Supine in bed with small pillow under shoulder ○ Color ○ Size ○ Contour Auscultation Bowel sounds Listen to each area for at least 5 minutes Normal Bowel Sounds 5-20 bowel sounds Hypoactive Bowel Sound 20 bowel sounds/min Rapid Diarrhea Pattern 1. RLQ 2. RUQ Most common site of nodules 3. LUQ Upper outer quadrant 4. LLQ ○ Tail of spence -group of lymph node in axilla Percussion Palpation From least painful to most painful MADURO,K. 2 Mammography Stool Exam/Guaiac Test X-ray of the breast. FOBT: Fecal occult blood test Detect lump earlier before it is palpated. Baseline: once between 34-39 years old Preparation: Regular: Annually at 40 years old Increase fiber intake Instructions: Avoid to prevent the ff: No deodorant, lotion and powder as it can obscure False Positive Avoid 3 days before procedure: the view Red meat Inform that it will squeeze the breast and may feel Organ meat a discomfort Avoid 7 days prior procedure: (GI Bleeding) Pap smear Aspirin Detect cervical cancer NSAIDS Age : 21 years old Mefenamic Acid Frequency: every 3 years Ibuprofen Anticoagulant Equipment: Steroids Vaginal speculum Colchicine Cotton application Slide False Negative Vitamin C > 250 mg Lubricant Melons, turnips, radish water -based lubricant Positioning: Lithotomy position Positive result: Blue/green Put legs in the stirrups together to prevent tearing Negative result: No color change of round ligament Urine Exam Testicular Self Exam Midstream Urine Collection Detect testicular cancer Clean Catch Urine Age: 13 years old Routine Urinalysis: 30 to 50 ml Frequency: Monthly Culture and sensitivity: 5 to 10 ml Best time: After warm shower Best time: Early morning Perineal care: mild soap and water to meatus Inspection Mirror 24-hour urine specimen Size Example: 8AM to 8AM next day ○ Normal: Asymmetrical To test for Left is lower Creatinine Clearance Palpation Schilling's Test : (Pernicious Anemia) One at a time Vanillylmandelic Acid Test: (Pheochromocytoma) Painless lump 24-Hour Container Use thumb and index finger Male: Urinal Rolling motion Female: Urine hat Use clean technique Put in ice to preserve specimen Discard first void Diagnostic Examinations Repeat if there’s missed specimen Sputum Exam Culture and sensitivity Catheterized Urine Specimen Sterile Technique ○ Culture: determines causative agent Collect from self sealing rubber port/ luer lock ○ Sensitivity: determine best antibiotic ○ Self sealing rubber port: Use syringe and Best time: Early in the morning needle, diagonal Gargle with water ○ Luer lock: syringe only ○ Do not perform mouth care before the procedure Clamp for 10-20 min below draining port to Use sterile container accumulate urine Sterile technique MADURO,K. 3 Blood Exam White Blood 5,000 to 10,000/ul Fasting Blood Sugar Cell: Fasting blood sugar: post midnight Withhold ⬆️ ⬇️ Leukocytosis = infection, inflammation Leukopenia = Risk for infection (reverse Insulin OHA isolation) Normal: 50 mg/dl Risk Infection Mild 1000-1500 Lipoprotein: Transporter of fats HDL: Good (Fats move from blood vessels to liver) Moderate 500-1000 Reverse Isolation LDL: Bad (Fats move from liver to blood vessels) Protective Isolation Severe 10% band cells m/mm3 ○ Immature WBC Hematocrit Male: 41%- 51% +55 Female: 36 % - 46% Platelets 150,00 to 450,00 Hemoglobin Male: 14 g/ dL to 18 g/ dL +2 ⬇️ Thrombocytopenia= Platelets ○ Risk for bleeding Female: 12 g/ dL to 16 g/ dL No contact sports Use electric razor Use soft bristle toothbrush Hct: RBC concentration to blood Non invasive procedure Relationship: Directional ⬆️RBC: Polycythemia ⬆️ HCT Arterial Blood Gasses ⬇️ RBC: Anemia ⬇️HCT From radial artery Allen's test ○ Check if radial and ulnar circulation is Hct: Plasma concentration to blood adequate Relationship: Inversely ○ Close open FVD DHN ⬆️ HCT ○ Press both arteries ○ Open hands ○ Release one artery Bleeding ○ Repeat, releasing the opposite artery. DI FVE ⬇️HCT MADURO,K. 4 ABG Analysis Barium Studies 1. Identify pH: Acidic or Alkalotic Fluoroscopy = series of x-rays If normal, look at other parameters Contraindicated: Pregnant women If other parameters are abnormal, indicate pH range Barium Swallow ○ 7.35-7:40 Lower range NPO: Post midnIght ○ 7:41-7:45 Higher range Assess for allergy to barium 2. ROME Position: Fowler's Respiratory Opposite pH After: encourage excretion blo it can cause Metabolic Equal or same direction with pH obstruction and megacolon arrow White, chalky stool = normal If both meet ROME, mixed Increase fluids and fiber Buffers: Laxatives (excrete within 24 to 48 hours) Respiratory PaCO2 metabolic HCO3 Barium Enema Parameter that meets ROME=PROBLEM Low residue diet Parameter that fails ROME= other values Laxative NPO: post midnight 3. Degree of Compensation Cleansing enema Check other value Barium infused via colonoscopy If other value is normal: uncompensated UGIS (Swallow) If other value is abnormal: check pH: if pH UGIS (Enema) is normal Fully compensated Val (enem precedes If pH is abnormal :partially compensated Same post proc considerations as UGIS Endoscopy Respiratory Procedures Upper Respiratory Chest Physiotherapy ○ Laryngoscopy Postural Drainage- a technique in which different ○ Bronchoscopy positions are assumed to facilitate the drainage of GI: Esophagogastrophagoduodeno secretions from the bronchial airways. ○ Always elevate the affected side Preparation: If affected side is anterior, place 1. Consent the patient in supine position 2. NPO post midnight (6 to 8 hrs) until gag reflex returns If affected side is posterior, place (posterior 1/s of tongue) the patient in prone position 3: Medications: If congestion is in left posterior, Atropine - anticholinergic right sim’s lateral position ○ Less salivation Valium = conscious sedation Percussion- to dislodge secretions Anesthetic spray (Lidocaine) ○ No bare skin, bony prominence Assess complications ○ Going up ○ Bleeding: Frequent swallowing ○ 5 mins gross blood ○ Perforation: severe abdominal Vibration-loosen or mobilize secretions pain ○ Palm/heel of the hand ○ Boardlike abdomen ○ Vibrate only during exhalation Lower: Colonoscopy ○ Going down Preparation: ○ 5 mins 1. Low residue diet (3 days) 2. Laxative (night before) Gross blood can Indicate perforation MADURO,K. 5 Best time to do: Oropharyngeal Nasopharyngeal Naso ET/TT Before meals or before bedtime Route Route tracheal 2 hrs after meals After nebulization Clean Sterile Sterile Sterile Time: 10-15 minutes Entire chest physiotherapy should not be more Semi-fowler Semi-fowler Semi-fowler than 30 mins position if position if position if Vest: Increase frequency chest wall osallanon conscious conscious conscious (suction after) (Head @ side) (Hyperextend (No ) movement) Suctioning To clear airway and to maintain patent airway Lateral/side lying facing the nurse if unconscious Who needs suctioning? Dyspnea Nose-Earlobe Nose- Nose- Until you Drooling or Earlobe Earlobe meet Decreased Breath Sounds (Adventitious Breath Mouth- Earlobe 4-6 inches -side of resistance, Sounds) 4-6 inches neck withdraw 1-2 Decreased 02 Saturation inch before suctioning Complications in Suctioning Hypoxia- we should hyperoxygenate Timing: 5-10 seconds suctioning 02 Saturation: 95% below hypoxia 90% below severe hypoxia Maximum of 15 seconds if more Maximum of secretion 10 seconds If the patient is using : Bag Valve Mask (BVM)- Ambu Bag- there should be 3 Interval: 20-30 secs 2-3 mins hyperinflation before suctioning the patient Total Suctioning Time: Not more than 5 mins O2 Tank-increase rate 10-15 lpm for 1 full min before suctioning Apply suction during withdrawal in a twisting, Mechanical Ventilation- hyperoxygenate button circular,rotating, spiral motion Trauma/Bleeding Prevention No suction during insertion of catheter Portable Suction Machine Wall Type Suction Check for nicks (cuts) before suctioning Machine Pressure: Catheter Size Infant 2-5 mmHg Infant 50-95 mmHg Infants Fr 5 to 8 Child 5-10 mmHg Child 95-110 mmHg Child Fr 8 to 10 Adult 10-15 mmHg Adult 100-120 mmHg Adult Fr 12 to 18 Thoracentesis Remove pleural fluid Orotracheal Oroparhyngeal Indication: Pleural effusion Mouth- Mouth- Normal volume: 5 to 10 ml Earlobe-midsternum Earlobe Preparation Consent Lidocaine allergy Coag studies UTZ (during) = x-ray ( after) Position: sitting ○ Lateral recumbent if affected is expose Advise not to move MADURO,K. 6 Post procedure -best is to submerge or soak in a basin or glass of water Px on unaffected side Apply pressure dressing Dislodge ⬆️ Complication monitoring: RR, blood expectorate -removed from the patient -cover with Sterile dry dressing, non-occlusive dressing, petrolatum gauze Chest Tube Thoracostomy -tape at 3 sides For pneumothorax, pyothorax and hemothorax CTT to be transported to x-ray department, cover with hand of the nurse. Tracheostomy For artificial airway Laryngospasms 1st Bottle ( Drainage Bottle): Part of I&O Monitor Drainage: every hour If >100 ml, report to Dr. 2nd Bottle ( Water Seal Bottle): Tube immersed in 2cm Intermittent, Fluctuating, Tidaling, Oscillating Bubbling ○ Complication: Tension pneumothorax ○ If continuous bubbling, there is air leakage ○ If no tidaling/bubbling, check for kink, report to Dr. if no kink, the lungs re-expanded, x-ray. 3rd Bottle (Suction Machine): 15-20 ml water Bubbling depends on suction machine IF ON: Continuous bubbling IF OFF: No bubbling Problems: Blood clots in the tubing A. Clamp B. Squeeze C. Flush D. Milk No clamping, milking, in CTT Pinch or squeeze clot towards the drainage Clamping can cause tension pneumothorax. Disconnection -tubing was disconnected -air can enter -we can reconnect but not the best answer MADURO,K. 7 Outer Cannula Input-output has a flange and hole where inner is inserted. Salem-sump Tube: Blue pigtail Inner Cannula Double lumen tube Removable Input-output Lock: Clockwise Vent: equalizes the build up of pressure in stomach Unlock: Counterclockwise Tracheostomy Care Done every shift Use sterile technique CLEANING INNER CANNULA SOAK → Hydrogen peroxide (Half-strength) ○ RINSE → NSS OUTER CANNULA ○ BRUSH/ PIPE CLEANER Do not clamp ○ DRY → Do not use gauze ○ → Mesh gauze, tap dry Nasointestinal Tube. Miller-Abbott: Removing Tracheostomy Ties Weighted tip Ties changed when necessary Double lumen tube ○ Input-output If two nurses ○ Weight 1. Hold the flange Indication: Intestinal obstruction 2. Remove old ties and insert new ties If one nurse only Sengstaken-Blakemore: Insert new tie before removing old tie Indication: Esophageal Varices Ties fit snugly if 2 fingers can be inserted Triple lumen tube Tied at the side of the neck. ○ Input-output ○ Gastric balloon (anchor) ○ Esophageal balloon “FATHER DON’T WAIT” Precaution: Always keep a pair of scissors at 1. Tie \ bedside 2. Tie NEW 3. Knot /—slide 1-2 fingers to make sure not too tight, not too loose 1. Knot / 2. Untie \ OLD 3. Untie / Prepare at bedside: Nasogastric Tube Insertion Suction machine Position: Obturator Conscious: Upright/ High-fowlers Inner cannula Unconscious: Upright/ high-fowlers with head turned to RIGHT. Nasogastric Tube (NGT) Length of Tube: Purposes: Tip of the nose > earlobe > xiphoid process To Feed (Nutrition: Gavage) Always use the nostril with better patency Yield/expel foreign substances: (Lavage) ○ IMCI alert: NGT insertion (only for severe Assessment: Bleeding dehydration) if Plan C IV is not available) Neutralize/decompress pressure Procedure: Advance tube until it reaches back of the throat Types of NGT: Conscious: Instruct patient to swallow or take a sip Levin Tube: of water Red/orange tip Unconscious: Flex the neck forward Single-lumen tube MADURO,K. 8 Considerations: ○ Bleeding slightly when touch Hyperextension of neck can help with insertion into ○ Slight protrusion on the skin throat ○ Reddish/Pinking Dec. discomfort: Advance 2-4 inches of segment Abnormal: everytime the patient swallows ○ Pale Pink: Anemia If there are signs and symptoms of respiratory ○ Bluish/Black/Dusky: Necrotic/Ischemia distress, stop and withdraw the tube. Appliance: NGT Placement Verification Wafer: ⅛ inch larger than stoma X-ray: most accurate, ideal after initial placement Bag: ⅓-½ full=empty pH: Stomach pH