Fundamentals of Nursing (NCLEX-RN)
I. CULTURAL DIVERSITYII. ETHICAL AND LEGAL ISSUES III.
LEADERSHIP AND MANAGEMENT IV. BASIC PHARMACOLOGY (including Herbal
Medicines) V. ASEPSIS AND INFECTION CONTROL VI. COMPUTATION OF
DOSAGE OF MEDICATIONS VII. NORMAL VALUES VIII. NUTRITION AND DIET
IX. THERAPEUTIC DIETS X. POSITIONSXI. PROCEDURES
Fundamentals of Nursing consist of: 1. Cultural Diversity 2.
Ethical and Legal Issues 3. Leadership and Management Issues 4.
Basic Pharmacology (Including herbal medicines, computation, IV and
Blood Transfusion Therapy) 5. Asepsis and Infection Control 6.
Normal Values 7. Nutrition (including Therapeutic Diets) 8.
Positioning 9. Diagnostic Tests
What is the content of NCLEX-RN examination and how does the
examinee answer those questions? Questions of the actual NCLEX-RN
Examination were distributed to the following category: Safe
Effective Care Environment, under this category is the following
sub-category
-- Management of Care
-- Infection Control
Health Promotion and Maintenance
Physiological Integrity, under this category is the following
sub-category
-- Basic Care and Comfort
-- Pharmacological and Parenteral Therapies
-- Reduction of Risk Potential
-- Physiological Adaptation
An update you must know about the actual NCLEX-RN examination:
Last April 2010, the questions about Management of Care were
increased and questions about Reduction of Risk Potential were
decreased. And according to the newsletter disseminated by NCSBN,
the passing standard also increases. But do not be disturbed with
this new info at hand, if you learn how to master the different
concepts of nursing, starting with this concept Fundamentals of
Nursing. Whatever type of questions you might encounter with the
actual exam, I am sure that you can answer it correctly. Processes
Integrated into all Client Needs Categories
Nursing Process
Caring
Communication and Documentation
Teaching and Learning
The Test Duration is six (6) hours
Minimum number of questions that you may answer is seventy five
(75)
And the maximum number of questions that you may answer is two
hundred sixty five (265)
The computer automatically stops when: Maximum number of
questions has been answered
Six hours have elapsed
Examinees minimum level of competency has been established
Examinees lack of competency has been established
NCLEX-RN also uses Computer Adaptive Testing (CAT) and the
decision if you pass or fail is based on how many questions you
answer correctly and the difficulty of the questions a candidate
answers correctly. The Examination will not end until certainty of
the pass/fail result is assured. I. CULTURAL DIVERSITY
African-Americans
Direct eye contact with authority is viewed as rude; but it is
an important part of communication among family members/significant
others.
Personal questions are considered intrusive during initial
contact; e.g. relationships, divorce, conflicts.
Touching anothers hair is offensive.
Illness is believed to be caused by demons/spirit
Folk healer/herbalist may be consulted before seeking medical
treatments
Native Americans/American Indians
silence indicate respect for the speaker
eye contact as a sign of disrespect
They value the practice of massage to promote bonding between
mother and newborn. Rooming-in is preferred for the mother and the
newborn
integration of religion and healing practices is observed
Illness is caused by supernatural forces and disequilibrium
between person and environment.
Asian Americans
Direct eye contact with authority is viewed as rude
head nodding does not necessarily mean agreement
saying NO is considered as disrespect for others
do not touch member of the opposite sex
illness is believed to be an imbalance between positive (+) and
negative (-) energy forces
Promotion of healing by Yin and Yang principle
Cold foods (Yin) Hot foods (Yang)
Cold foods are given for hot illness
Hot foods are given for cold illness Hispanic Americans
Do not admire a child. They believe that you may afflict the
child with evil eye, it will cause an illness to the child
they avoid eye contact with authority to show respect
they use embraces/handshakes; they are very tactile
they believe that health results from balance between hot/cold,
wet/dry forces
illness is a result of Gods punishment
communicate with male head of the family especially for major
decisions, like signing consent for procedures because they have
patriarchal society
the most valued members of the family is the children
religious practices are related to treatment of illness
European (White)-Origin Americans
eye contact indicates trustworthiness
they primarily depend on modern western health care services
Autopsy is prohibited among:
Eastern Orthodox
Muslims
Jehovahs Witness (NO BLOOD TRANSFUSION)
Orthodox Jews
ORGAN DONATION:
Jehovahs Witness (prohibited)
Muslims (prohibited)
Buddhists (act of mercy)
CREMATION:
Hindus (cast ashes in Holy River, they believe that they can
join the Creator faster this way)
Mormons (prohibit cremation)
Eastern Orthodox (prohibit cremation)
Islam/Muslims (prohibit cremation)
Jews (prohibit cremation)
RELIGION AND DIETARY PRACTICES:
Baptist
prohibits alcohol; discourages tea and coffee
Buddhist
prohibits alcohol and drug use
most of them are vegetarians
Hinduism
considered the cow as sacred animal that is why they prohibit
eating of beef and veal
most of them are vegetarians
Islam
prohibits pork, alcohol and drugs
daytime fasting is practiced during the time of Ramadan
Jehovahs Witness
prohibits food to which blood has been added
allow animal flesh that has been drained from blood
Judaism
KOSHER DIET: prohibits meat and milk combination
Prohibits pork and scavenger fish (shrimps, squids, crabs,
fishes with no scales)
Meat is allowed if from animals that are vegetable-eaters,
cloven-hoofed, and ritually slaughtered
Mormon
prohibits alcohol, tea and coffee
practice of fasting every first Sunday of the month
encourages limited consumption of meat
Roman Catholicism
No meat on ash Wednesday and Good Friday (abstinence)
Optional fasting during lent season
Seventh day Adventist
prohibits alcohol, tea and coffee, meat, and scavenger fish
No surgeries or any procedures during Saturdays (Sabbath Day
sundown Friday to sundown Saturday).
CULTURAL BELIEFS AND PRACTICES ON DEATH AND DYING:
Chinese
When a Chinese client dies, they cover him/her with mirror with
white cloth
Islam/Muslim
A dying client must face East (Middle East) or West/Southwest
(North America). The dead body will be washed by a family member of
the same sex and then covered with white cloth
Buddhists
The dead body is blessed by Spiritual Adviser
Roman Catholics
Anointing of the sick is done by the priest, to a dying
clientTIME FOR A SHORT QUIZ. QUESTIONS
A nurse is providing discharge instructions to a Chinese client
regarding prescribed dietary modifications. During the teaching
session, the client continuously turns away from the nurse. Which
nursing action is appropriate?
Continue the instructions, verifying client understanding
Walk around the client so that the nurse constantly faces the
client
Give the client a dietary booklet and return later to continue
with the instructions
Tell the client about the importance of the instructions for the
maintenance of health care
2. A nurse is preparing a plan of care for a client who is
Jehovahs Witness. The client has been told that surgery is
necessary. The nurse considers the clients religious preferences in
developing the plan of care and documents that:
Faith healing is practiced primarily
Medication administration is not allowed
Surgery is prohibited in this religious group
The administration of blood and blood products is forbidden
3. Which of the following meal trays would be appropriate for
the nurse to deliver to a client of Jewish faith who follows kosher
diet?
Pork roast, rice, vegetables, mixed fruit, milk
Crab salad on a croissant, vegetables with a dip, potato salad,
milk
Sweet and sour chicken with rice and vegetables, mixed fruit,
juice
Fettucini alfredo with shrimp and vegetables, salad, mixed
fruit, iced tea
4. An ambulatory care nurse is discussing preoperative
procedures with a Chinese-American client who is scheduled for
surgery the following week. During the discussion, the client
continually smiles and nods the head. The nurse interprets this
nonverbal behaviour as:
Reflecting a cultural value
An acceptance of the treatment
The client is agreeable to the required procedures
The client understands the preoperative procedure 5. A
Chinese-American client experiencing anemia, which is believed to
be a yin disorder, is likely to treat it with:
Magnetic therapy
Intercessory prayer
Foods considered to be yin
Foods considered to be yang
ANSWERS AND RATIONALE
1) A - Most Chinese maintain a formal distance with others,
which is a form of respect. Many Chinese are uncomfortable with
face-to-face communications, especially when eye contact is direct.
If the client turns away from the nurse during a conversation, the
most appropriate action is to continue with the conversation.
Walking around to the client so that the nurse faces the client is
in direct conflict with the cultural practice. The client may
consider returning later to continue with the explanation as a rude
gesture. Telling the client about the importance of the
instructions for the maintenance of health care may be viewed as
degrading.
2) D - Among Jehovahs Witnesses, surgery is not prohibited, but
the administration of blood and blood products is forbidden. Faith
healing is forbidden in this religious group. Administration of
medication is an acceptable practice, except if the medication is
derived from blood products.
3) C - In the Jewish religion, those who are kosher believe that
the dairy-meat combination is not acceptable. Pork and pork
products are not allowed in the traditional Jewish religion. Only
fish that have scales and fins are allowed; meats that are allowed
include animals that are vegetable eaters, cloven-hoofed, and
ritually slaughtered.
4) A - Nodding or smiling by a Chinese-American client may
reflect only the cultural value of interpersonal harmony. This
nonverbal behavior may not be an indication of agreement with the
speaker, an acceptance of the treatment, or an understanding of the
procedure.
5) D - In the yin and yang theory, health is believed to exist
when all aspects of the person are in perfect balance. Yin foods
are cold and yang foods are hot. Cold foods are eaten when one has
a hot illness and hot foods are eaten when one has a cold illness.
Options A and B are not associated with the yin and yang
theory.
II. ETHICAL AND LEGAL ISSUES
Advance Directive It is a written document that provides
directions concerning the provision of care when a person is unable
to make his/her own treatment choices.
Two types of advance directive:
a) Living Will it is the expression of the persons wishes
regarding end-of-life care. It is prepared by a competent adult
that provides direction regarding medical care in the event of the
persons incapacitation or otherwise becoming unable to make
decisions personally.
b) Durable Power of Attorney I is an authorization that enables
any competent individual to name someone to exercise
decision-making on his/her behalf under specific circumstances.
Example, end-of-life situation.
Clarifying Unclear/Inappropriate Physicians Order Clarify the
order with the physician who gave the order
Contact nurse manager/supervisor if no resolution occurs
regarding the order in question
Floating It is acceptable and legal practice
Nurse cannot refuse to float; but the nurse should not assume
responsibility beyond level of experience or qualification
The nurse should inform the supervisor of any lack of experience
in caring for the type of clients on the new nursing units
The nurse should be given an orientation to the new unit
Floating nurse should be assigned with patients with stable
conditions; or similar to his/her training or experience
Floating nurse should not be assigned to patients who are for
discharge and who require patient teaching
Good Samaritan Laws - These laws encourage health care
professionals to assist in emergency situations without fear of
being sued for the care provided Informed Written Consent Physician
not the nurse, is the primary responsible to secure written
consent
Nurse may sign as a witness. It attests that the client signed
the consent
Written consent is legal when:
The person is in legal age (18 y/o and above)
The consent is secured without force, duress, or coercion
The person is not under the influence of drugs or alcohol
The person is not mentally incapacitated
Parents or guardian can signed for minors and persons who are
physically or mentally incapacitated
Minors who are married or emancipated from the parents and those
seeking for treatment for STDs can signed an informed consent
Written consent can be waived in time of emergency to save the
life of the person
Validity of informed consent is 24 hours. If the procedure is
postponed, secure another consent
Secure consent for each procedure
Organ Donation
Age requirement is 18 y/o and above before signing a form for
organ donation
Informed choice to donate an organ may be through written
document signed by the client prior to death, a will, a donor card,
or an advance directive
Family member or legal guardian may authorize organ donation if
the client is dead
Physicians Orders Nurses is duty-bound to carry out a doctors
order except when the nurse believes that the order is
inappropriate
Nurses who carry out inaccurate order is legally responsible for
his/her action
Telephone Orders
Date and time the entry
Repeat (read back) the order to the physician and record the
order
Sign the order begin with the t.o., write the doctors name, and
then sign the order; e.g. (t.o. Dr. Alec Tinio/ your signature
RN
It is necessary that the doctor countersign the order within the
time frame based on the agency policy (usually 24 hours)
Use of Restraints
Written consent is needed coming from relatives/significant
others
Secure consent for each episode of application of restraints
PRN order: legally unacceptable
Apply soft restraints
Secure restraints at he bed frame, not on the side rails
Check restraint application every 15-20 minutes
Release restraints every 2 hours for 30 minutes
Change restraints every 24 hours
Documentation For Narrative Documentation
it should be accurate, complete, factual, and objective
use a black pen
document care, medications, treatments, and procedures as soon
as possible, after completed
document responses to interventions
document consent for a refusal of treatments
document calls made to other health care providers
use appropriate abbreviations
in case of error, draw one line through the error, initial and
date
never erase any entry, do not use correction fluid
do not leave blank spaces on documentation forms. Avoid
judgmental or opinionated statements, such as uncooperative
client.
Do not document for others or change documentation for other
individuals
For Computerized Documentation use only the user identification
(ID) code, name, or password
maintain privacy and confidentiality of documented information
printed from the computer
Principle of Confidentiality Information about a client be kept
private
Information in the clients record is accessible only to those
providing care to the client
No one else is entitled to that information unless the client
has signed a Consent for Release of Information that identifies
with whom information may be shared and for what purpose.
Discussing clients outside the clinical setting, telling
friends, or family about clients or even discussing clients in the
elevator with other workers violates clients confidentiality.
The clients has a right to review the records pertaining to
his/her medical care and to have the information explained or
interpreted as necessary, except when restricted by law
Incident Reports/Variance Reports A tool used as a means of
identifying and improving care.
The reports should be complete, accurate, and factual.
The reports should not include opinions or interpretations.
The report form should not be copied or placed in the clients
record.
It is not a substitute for a complete entry in the clients
record regarding the incident.
Controlled Substances Nurses may administered controlled
substances (narcotics, depressants, stimulants, and hallucinogens),
only under the directions of a physicians or other authorized
providers.
Controlled substances must be kept securely locked, and only
authorized personnel should have access to them.
Reporting Responsibilities.
The following situations need to be reported to the Local
Authority. This is a LAW. Failure to report any of these situations
is a malpractice.
Communicable diseases
Abuse: sexual, child, wife, husband, elderly abuse. (Whenever
abuse is suspected, it should be reported to the local authority.
It will be the court to prove or disprove abuse.)
gunshot/ stab wounds
vehicular accidents
assault
homicides
Clients Advocacy
Involves concerns and actions on behalf of another person in
order to bring about change.
3 Elements of Advocacy 1. Mediate 2. Inform 3. Support
MORAL PRINCIPLES 1. Beneficence - means doing and promoting
good. e.g.,Administering pain medications. Practicing asepsis to
prevent infection. Promoting safety of restless and confused
clients. Providing psychosocial support to an anxious client.
2. Nonmalefincence - means to avoid doing harm, to remove from
harm, and to prevent harm. e.g., protecting the client from a
practitioner who practices drug abuse. Reporting abuse prevent
further victimization. 3. Autonomy right to make ones own decision
4. Fidelity being faithful to agreement and promises 5. Veracity
telling the truth 6. Justice - fairness
TORTS AND CRIMES - These are legal wrongs committed against a
person or property.
CRIME - Results in prison term or fine or short jail sentence to
punish offender. a. Felony - A crime of serious nature. b.
Misdemeanor - An offense punishable by imprisonment of less than
one year or a fine less than 1,000 dollars. Does not amount to a
felony.
c. Manslaughter - A second degree murder. It is unintentional
killing.
e.g., accidental administration of overdose narcotics that
resulted to death of the clients.
TORTS - Result in civil trial to assess compensation for
plaintiff 1. Intentional Torts: I. Assault and Battery a. Assault
is the threat of touching another person without his/her consent b.
Battery is the actual carrying out of such a threat II. Defamation
of Character - is a communication that is false or made with
careless disregard for the truth, and results in injury to the
reputation of the person a. Libel defamation by means of print,
writing, or pictures b. Slander - is defamation by spoken word,
stating unprivileged or false words by which the reputation of the
person is damaged
III.Fraud - is the wilful, purposeful misrepresentation of self
or an act that may cause harm to a person or property IV.Invasion
of Privacy - is disclosure confidential information to an
inappropriate third party (subjects the nurse to invasion of
privacy even if the information is true). V.False Imprisonment
occurs when a client is not allowed to leave a health care facility
when there is no legal justification to detain the client 2.
Unintentional Torts I.Negligence mistake or failure to be prudent.
An act of omission or commission
II.Malpractice is negligence in the practice of profession (e.g.
error in sponge counts)
To prove malpractice, four elements are necessary a. a duty of
the nurse to the client b. a breach of duty on the part of the
nurse c. an injury to the client d. a causal relationship between
the breach of duty and the client subsequent injury
Potential Malpractices Situations in Nursing
medication error
sponge count error
burning a client
client falls mistaken identity
loss/damage of clients property
failure in reporting crimes, torts, and unsafe practice
Only the Task not the Accountability may be Delegated to
anotherBest Practice: Always ensure client safetyDeath and Dying
Right of Informed Refusal a competent adult has the right to refuse
treatment, even life-sustaining treatment
Do Not Resuscitate (DNR) Order a written order must be present
and must be reviewed on a regular basis. The client or his/her
legal representative must provide informed consent for the DNR
status. Both DNR and cardiopulmonary resuscitation (CPR) must be
clearly defined so that other treatments, not refused by the client
will be continued.
Euthanasia physician or nurse-caused death (active euthanasia),
deliberately hastening a persons death, is considered murder in all
states and almost all other countries
Pronouncement of Death in some States, the nurse may pronounce
death at the bed side
in most States, however, the physician has the legal
responsibility of pronouncing the person dead. To be safe in
answering, always choose PHYSICIAN.
Death Certificate the physician is responsible for signing a
death certificate Care of the Body the nurse is responsible for
preparing the body for the morgue or mortuary. Consider the
cultural practices and wishes of the family. Treat the body with
dignity. Rigor Mortis stiffening of the body (occurs 2-4 hours)
position the body, the dentures, close the mouth and eyes before RM
set in
Algor Mortis decrease in body temperature (1C/hr) Livor Mortis
discoloration of the skin because of the RBC breakdown Management:
make the body appear natural and comfortable
allow the family to view the patients body
place the body in supine positions, the arms at the side and
palms down
place one pillow under the head and shoulder to prevent blood
from discoloring the face
place absorbent pads under the buttocks to take up any feces or
urine
apply identification tags, one on the ankle and one at the
wrist
wrap the body in shroud, place the third tag for
identification
III. LEADERSHIP AND MANAGEMENT
Priorities of Care
needs that are life threatening are given highest priority
actual before potential concerns
consider time constraints and available resources
needs that are identified as important by the client are given
highest priority
use Maslows hierarchy of needs (physiologic before psychosocial
needs)
use ABCs; patent airway is always priority
unstable before stable clients
client first before equipment
do not delegate client who need:
to be assessed
those who need health teachings
those who need to be evaluated
those with unstable conditions
DELEGATION
transference of responsibility and authority for the performance
of an activity to a competent individual
Five Rights of Delegation
Right Task appropriate activities
Right Circumstances assess health status. Match complexity of
activity with competency of the health care worker.
Right Person
Right direction and communication
Right supervision/evaluation
CNA/Unlicensed Nursing Assistant
Undergo certification examination
May care for clients with stable conditions
May perform standard nursing procedures:
VS - taking
Comfort measures
Hygienic measures
Activity, mobility, exercise
Collection of specimen
Enema administration
Obtaining equipment
LPN/LVN
Undergo licensure examination (NCLEX-PN/VN)
May perform standard nursing procedures and more complicated
nursing procedures:
Wound dressing changes
Irrigation of wounds
Colostomy care
Enteral feedings
Administration of medications (oral, subcutaneous,
intramuscular)
Administration of basic IV fluids (no IV meds and electrolytes
added to IV fluids like Potassium Chloride)
Catheterization
May care for clients with stable conditions
Leadership Theories
1. Bureaucratic relies on organizations rule and policy 2.
Autocratic make decision for the group 3. Laissez-faire recognizes
the groups need for autonomy and self-regulation; hands-off
approach 4. Democratic encourages group discussion and decision
making Principles of Management 1. Authority legitimate right to
direct the work to others 2. Accountability ability to assume
responsibility for ones action and its consequences 3.
Responsibility obligation to complete a task Principles in
Rooming-In Cohorts (similar medical diagnosis or mode of
transmission of disease) may be roomed-in as long as one does not
have another type of contagious infection.
Consider age and gender of clients. Clients of the same age
group and gender may be roomed-in
Clients with airborne infections should be confined in private
rooms
Immune-compromised clients should not be roomed-in with clients
who have infections.
Case Management
Assignment of health care provider to assist a patient in
assessing health and social service systems to assure that all
required services are obtained
Who requires Case Management?
age 65 with chronic diagnostic state, lives alone
newly diagnosed diabetic
limited income preventing prescription purchases
confused or unstable to make decisions
weakness related to CVA
may require change in living arrangements
may need medical equipment
may need home health follow-up
admitted from board and care
Let us evaluate . . . 1. A new unit nurse manager is holding her
first staff meeting. The manager greets the staff and comments that
she has been employed to bring about performance improvement. The
manager provides a plan that she developed, as well as a list of
tasks and activities for which each staff member must volunteer to
perform. In addition, she instructs staff members to report any
problems directly to her. What type of leadership style do the new
managers characteristics suggest?
autocratic
situational
democratic
laissez-faire
2. A new nursing graduate is attending an agency orientation
regarding the nursing model of practice implemented in the health
care facility. The nurse is told that the nursing model is a team
nursing approach. The nurse understands that planning care delivery
will be based on which characteristic of this type of nursing model
of practice?
a task approach method is used to provide care to clients
managed care concepts and tools are used in providing client
care
an RN leads nursing personnel in providing care to a group of
clients
a single RN is responsible for providing nursing care to a group
of clients
3. The nurse manager has implemented a change in the method of
the nursing delivery system from functional to team nursing. A
nursing assistant is resistant to the change and is not taking an
active part in facilitating the process of change. Which of the
following is the best approach in dealing with the nursing
assistant?
ignore the resistance
exert coercion with the nursing assistant
provide a positive reward system for the nursing assistant
confront the nursing assistant to encourage verbalization of
feelings regarding the change
4. The nurse manager of a critical care unit must speak to a
staff nurse about an employment issue, tardiness. Nearly every day
during the past week, the staff nurse has been from 5 to 20 minutes
late, missing portions of the daily client status conferences. The
manager had verbally counselled the staff nurse 3 months prior to
the latest incidence of tardiness about the same issue. When they
meet, the nurse managers best approach to the staff nurse is
to:
send the staff nurse to Human Resources Department for
counselling
ask the staff nurse to tell the manager about the facts
surrounding the tardiness
inform the staff nurse that, based on unreliability caused by
tardiness issues, the nurse is terminated
Provide the staff nurse with a detailed notice of intent to
terminate if any further incident of tardiness occurs. 5. A nurse
is giving a report to a nursing assistant who will be caring for a
client who has hand restraints. The nurse instructs the nursing
assistant to assess the skin integrity of the restrained hands
every:
2 hours
3 hours
4 hours
30 minutes ANSWERS AND RATIONALE 1) A - The autocratic leader is
focused, maintains strong control, makes decisions, and, addresses
all problems. Furthermore, the autocrat dominates the group and
commands rather than seeks suggestions or input. In this situation,
the manager addresses a problem (performance improvement) with the
staff, designs a plan without input, and wants all problems
reported directly back to her. A situational leader will use a
combination of styles, depending on the needs of the group and the
tasks to be achieved. The situational leader would work with the
group to validate that the information that the leader gained as a
new employee was accurate and that a problem existed, and would
then take the time to get to know the group and determine which
approach to change (if needed) would work best according to the
needs of the group and the nature and substance of the change that
was required. A democratic leader is participative and would likely
meet with each staff person individually to determine the staff
members perception of the problem. The democratic leader would also
speak with the staff about any issues and ask the staff for input
with developing a plan. A laissez-faire leader is passive and
nondirective. The laissez-faire leader would state what the problem
was and inform the staff that the staff needed to come up with a
plan to fix it.
2) C - In team nursing, nursing personnel are led by a
registered nurse leader in providing care to a group of clients.
Option A identifies functional nursing. Option B identifies a
component of case management. Option D identifies primary
nursing.
3) D - Confrontation is an important strategy to meet resistance
head on. Face-to-face meetings to confront the issue at hand will
allow verbalization of feelings, identification of problems and
issues, and development of strategies to solve the problem. Option
A will not address the problem. Option B may produce additional
resistance. Option C may provide a temporary solution to the
resistance but will not address the concern specifically.
4) D - In general, the process for corrective action begins with
an oral reprimand and then a written reprimand. In addition to the
written reprimand, the manager should be prepared to work with the
staff nurse to develop a plan of action. The manager must notify
the staff nurse, in writing, of the potential for termination based
on tardiness. If this were the first instance, the manager would
ask the staff nurse to describe the facts surrounding the tardiness
in order for the manager to assist the staff nurse with
problem-solving strategies or to examine the need for moving the
staff nurse to a different shift, if indicated. Managers are
expected to deal with personnel issues, and tardiness is a frequent
problem that managers face. Human resources serve as a support to
the actions of the manager, but do not assume the role of dealing
with the employee. Managers must give notice prior to termination
as a risk management strategy.
5) D - The nurse should instruct the nursing assistant to assess
restraints and skin integrity every 30 minutes. Agency guidelines
regarding the use of restraints should always be followed. IV.
BASIC PHARMACOLOGY (including Herbal Medicines)
Types of Doctors Order
Standing Order it is carried out until the specified period of
time or until it is discontinued by another order Single Order it
is carried out for one time only STAT Order it is carried out at
once or immediately PRN Order it is carried out as the patient
requires
Parts of Legal Doctors Order - Name of patient - Date and time -
Name of drug - Dose of drug - Route of administration - Times or
frequency - Signature of the physician
PRINCIPLES IN ADMINSTERING MEDICATION
1. Observe the 7 Rights of drug administration
Right drug read the label three times
Right dose know the usual dose of the drug. Calculate the
correct amount
Right time standard time may be followed in the institution
Right route check the route of administration
Right patient identify patient by: checking the ID band (most
accurate patient identifier) or asking him to state his/her name
(not accurate for confused clients)
Right recording sign medication sheet immediately after
administration
Right approach
2. Practice Asepsis wash hands before and after preparing
medications
Nurses who administer medications are responsible for their own
actions. Question any order that you consider incorrect (may be
unclear or inappropriate)
Be knowledgeable about the medications that you administer. Know
the action, indication, nursing responsibilities, side effects of
the drugs
Fundamental Rule: Never Administer an Unfamiliar Medication
3. Keep narcotics in locked place 4. Use only medications that
are clearly labelled container. Relabeling of drugs is the
responsibility of pharmacist
5. Return liquid that are cloudy in color to the pharmacy
6. Before administering the medication, identify the client
correctly
7. Do not leave the medications at the bed side. Stay with the
client until he actually takes the medications
8. The nurse who prepares the drug administers it. Only the
nurse who prepared the drug knows what that drug is. Do not accept
endorsement of medications.
9. If the client vomits after taking the medication, report this
to the nurse in charge or physician
10. Preoperative medications are usually discontinued during the
postoperative period unless ordered to be continued
11. When a medication is omitted for any reason, record the fact
together with the reason
12. When a medication error is made, report it immediately to
the nurse in charge or physician. To implement necessary measures
immediately. This may prevent any adverse effects of the drug
ROUTES OF DRUG ADMINISTRATION
1. Oral Medication
- Most common method of drug administration and generally the
safest route. Absorption will usually take in GIT. - Onset is
slower compare to others
Types of Oral Drugs
a. Solid Preparation tablets, capsules, and pills Remember:
enteric-coated tablets and time-released capsules are never crushed
or chewed
b. Liquid Preparation elixirs, syrups, and suspensions. They are
best administered by using calibrated cup (read at the eye
level).
Other Oral Form Drugs
a. Sublingual drugs are placed under the tongue
b. Buccal drugs are placed in the inner cheek Rule: never
swallow the drug and do not follow with water. If nitro-glycerine
is given, advise patient not to smoke. Safety in administering Oral
Medications
- might cause aspiration and choking (especially large capsules
and tablets)
- assess for gag reflex, dysphagia, or altered LOC
- client who is NPO
Note: if drug has offensive taste, offer oral hygiene.
2. Topical Medication - applied to the skin by spreading it over
an area, soaking or medicated bath (causes either local or systemic
effect depending on duration of application). Note: Nurse should
done gloves when administering this type of drug.
3. Inhalation Medication Nasal inhalation oxygen is administered
by this route Oral inhalation MDI (Metered-dose inhaler)
2 inches away from the mouth
Inhale 2-5 seconds
Hold breath for 10 seconds
Wait 1-2 minutes before each puff
Note: to know if the canister is still packed with drug, simply
put it in basin with water. If it floats, it is empty.
Nebulizer
Dilute to sterile 0.9% NaCl (2-5 ml)
Attach oxygen to nebulizer (8L/min)
Breathe normally through mask or mouthpiece for 5-15 minutes
Note: offer Oral Hygiene
4. Eye Medication (Optic) Effects: Miotics - pupil constriction
Mydriatics pupil dilation Types: Liquid 2 gtts (lower conjunctival
sac) Ointment 2 cm (inner to outer canthus) Note: no to cornea
press the nasolacrimal gland if drug will cause systemic
effect
dont let the tip of the canister touch any part of the eye
sitting position is required
Note: Eye assessment? Dim the light prior to eye examination 5.
Ear Medication (Otic)
Position: lateral position
Age below 3 y/o pull the pinna down and back
Above 3 y/o pull the pinna up and back
Solution - side of the ear
Temp of solution warm
Press the tarsus of the ear 3 times for absorption
Place earplug for 5 minutes
Note: if the ear canal is obstructed by seed, dont flush with
water. If an insect goes inside the ear, use flashlight 6.
Parenteral Route is a medication administration is by
needle.Intradermal route of medication administration- it is a
parenteral route of medication administration by injecting the
needle under the epidermis. The site are the inner lower arm, upper
chest and back, and beneath the scapula
Indicated for allergy and tuberculin testing and for
vaccinations
Use the needle gauge 25,26,27
needle length: 3/8", 5/8", or 1/2"
Needle at 10-15 degrees angle: bevel up
Inject a small amount of drug slowly over 3 to 5 seconds to form
a wheal or bleb
Do not massage the site of injection. To prevent irritation of
the site, and to prevent absorption of the drug into the
subcutaneous.
I. SUBCUTANEOUS route of medication administration - for
vaccines, heparin, preoperative medication, insulin, narcotics
The site: - outer aspect of the upper arms - anterior aspect of
the thighs - abdomen - scapular areas of the upper back -
ventrogluteal - dorsogluteal
Only small dose of medication should be injected via SC
route
Rotate site of injection to minimize tissue damage
Needle length and gauge are the same for ID injections
Use 5/8 needle for adults when the injection is to administer at
45 degree angle; 1/2 is use at 90 degree angle
For thin patients: 45 degree angle needle
For obese patient: 90 degree angle needle
For heparin injection: do not aspirate and do not massage the
injection site to prevent hematoma formation.
For insulin injection: do not massage to prevent rapid
absorption which may result to hypoglycemic reaction. Always inject
insulin at 90 degrees angle to administer the medication in the
pocket between the subcutaneous and muscle layer. Adjust the length
of the needle depending on the size of the client
II. INTRAMUSCULAR route of medication administration
needle length: 1", 1 1/2", 2" to reach the muscle layer
Clean the injection site with alcoholised cotton ball to reduce
microorganisms in the area
Inject the medication slowly to allow the tissue to accommodate
volume
Sites: a. Ventrogluteal site The area contains no large nerves,
or blood vessels and less fat. It is farther from the rectal area,
so it is less contaminated
Position the client in prone or side-lying
When in prone, curl the toes inward
When in side-lying, flex the knee and hip. These ensure
relaxation of the gluteus muscles and minimize discomfort during
injection
To locate the site, place the heel of the hand over the greater
trochanter, point the index finger toward the anterior superior
iliac spine, and then abduct the middle(third) finger. The triangle
formed by the index finger, the third finger and the crest of the
ilium is the site.
b. Dorsogluteal site Position the client similar to the
ventrogluteal site
The site should not be used in infant under 3 years old because
the gluteal muscles are not well developed yet
To locate the site, the nurse draws an imaginary line from the
greater trochanter to the posterior superior iliac spine. The
injection site is lateral and superior to this line
Another method of locating this site is to imaginary divide the
buttock into four quadrants. The upper most quadrant is the site of
injection. Palpate the crest of the ilium to ensure that the site
is high enough
Avoid hitting the sciatic nerve, major blood vessel or bone by
locating the site properly
c. Vastus Lateralis Recommended site for infant
Located at the middle third of the anterior lateral aspect of
the thigh
Assume back-lying or sitting position
d. Rectus Femoris site Located at the middle-third, anterior
aspect of the thighe. Deltoid site Not used often for IM injection
because it is relatively small muscle and is very close to the
radial nerve and radial artery
To locate the site, palpate the lower edge of the acromion
process and the midpoint on the lateral aspect of the arm that is
in line with the axilla. This is approximately 5cm(2 in) or 2 to 3
fingerbreadths below the acromion process
f. IM injection - Z tract injection Used for parenteral iron
preparation. To seal the drug deep into the muscles and prevent
permanent staining of the skin
Retract the skin laterally, inject the medication slowly. Hold
retraction of skin until the needle is withdrawn
Do not massage the site to prevent leakage into the
subcutaneous.
GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION
1. Check doctor's order 2. Check the expiration for medication -
drug potency may increase or decrease if outdated 3. Observe verbal
and non-verbal responses toward receiving injection. It can be
painful, client may have anxiety, which can increase the pain 4.
Practice asepsis to prevent infection. Apply disposable gloves5.
Use appropriate needle size. To minimize tissue injury 6. Plot the
site of injection properly. To prevent hitting nerves, blood
vessels, bones 7. Use separate needles for aspiration and injection
of medications to prevent tissue irritation 8. Introduce air into
the vial before aspiration. To create a positive pressure within
the vial and allow easy withdrawal of the medication 9. Allow a
small bubble (0.2 ml) in the syringe to push the medication that
may remain 10. Introduce the needle in quick thrust to lessen
discomfort 11. Either spread or pinch muscle when introducing the
medication. Depending on the size of the client 12. Minimized
discomfort by applying cold compress over the injection site before
introduction of medication to numb nerve endings 13. Aspirate
before introduction of medication. To check if blood vessel had
been hit 14. Support the tissue with cotton swabs before withdrawal
of the needle. To prevent discomfort of pulling tissues as needle
is withdrawn 15. Massage the site of injection to haste absorption
16. Apply pressure at the site for few minutes. To prevent bleeding
17. Evaluate effectiveness of the procedure and make relevant
documentation. METHOD OF DRUG ADMINISTRATION INTAVENOUSLY 1. A
mixture within large volumes of IV fluids 2. By injection of bolus,
or small volume, or medication through an existing intravenous
infusion line or intermittent venous access (heparin or saline
lock) 3. By "piggyback" infusion of solution containing the
prescribed medication and a small volume of IV fluid through an
existing IV line Most rapid route of absorption of medications
Predictable, therapeutic blood levels of medication can be
obtained
The route can be used for clients with compromised
gastrointestinal function or peripheral circulation
Large dose of medications can be administered by this route
The nurse must closely observe the client for symptoms of
adverse reactions
The nurse should double-check the six rights of safe medication
If the medication has an antidote, it must be available during
administration
When administering potent medications, the nurse assesses vital
signs before, during and after infusion
NURSING INTERVENTIONS IN I.V. INFUSION a. Verify doctor's order
b. Know the type, amount, and indication of IV therapy c. Practice
strict asepsis d. Inform the client and explain the purpose of IV
therapy to alleviate client's anxiety e. Prime IV tubing to expel
air. This will prevent air embolism f. Clean the insertion site of
IV needle from center to the periphery with alcoholized cotton ball
to prevent infection g. Shave the area of needle insertion if
hairy. Ask permission to the client h. Change the IV tubing every
72 hours. To prevent contaminationi. Change IV needle insertion
site every 72 hours to prevent thrombophlebitis j. Regulate IV
every 15-20 mins. To ensure administration of proper volume of IV
fluid as ordered k. Observe for potential complications. THREE
TYPES OF I.V. FLUIDS
a. Isotonic solution - it has the same concentration as the body
fluid.
D5W
NaCl 0.9%
Plain Ringer's lactate
Plain normosol M
b. Hypotonic - has lower concentration than the body fluids. Too
much of this fluid can swell the body's cell.
NaCl 0.3%
c. Hypertonic - has higher concentration than the body fluids.
Too much of this fluid can make the body's cell shrink.
D10W
D50W
D5LR
D5NM
COMPLICATIONS OF I.V. INFUSION
1. Infiltration - the needle is out of vein, and fluids
accumulate in the subcutaneous tissues.Assessment Pain, swelling,
skin is cold at needle site, pallor of the site, flow rate has
decreases or stops
Nursing Intervention: Change the site of the needle Apply warm
compress. This will absorb edema fluids and reduce swelling
2. Circulatory Overload- this complication of I.V. infusion
results from administration of excessive volume of I.V. fluids.
Assessment Headache, flushed skin, rapid pulse Increase BP,
weight gain, syncope and faintness Pulmonary edema, increase volume
pressure Coughing, tachycardia, shock
Nursing Intervention:Slow I.V. infusion to KVO - at least 10
gtts/min Place patient in high-fowler's position to enhance
breathing Administer diuretic, bronchodilator as ordered.
3. Drug Overload - this complication of I.V. infusion occurs
when the patient receives an excessive amount of fluid containing
drugs
Assessment Dizziness, shock Fainting
Nursing Intervention:Slow I.V. infusion to KVO Take vital signs
Notify the physician
4. Superficial Thrombophlebitis - this complication of I.V.
infusion is due to overuse of a vein, irritating solution or drugs,
clot formation, large bore catheters
Assessment Pain along the course of vein Vein may fell hard and
cordlike Edema and redness at needle insertion site Arm feels
warmer than the other arm
Nursing Intervention Change I.V. site every 72 hours Use large
veins for irritating fluids Stabilize venipuncture at area of
flexion Apply cold compress immediately to relieve pain and
inflammation; later with warm compress to stimulate circulation and
promotion absorption Do not irrigate the I.V. because this could
push clot into the systemic circulation
5. Air Embolism - air manage to get into the circulatory system;
5 ml of air or more causes air embolism. Take note that it is a
life-threatening conditio9n.
Assessment Chest, shoulder or back pain Hypotension Dyspnea
Cyanosis Tachycardia Increase venous pressure Loss of
consciousness
Nursing Intervention Do not allow the I.V. bottle to run dry
Prime I.V. tubing before starting infusionTurn patient to left side
in the trendelenburg position. To allow air to rise in the right
side of the heart. This prevent pulmonary embolism
6. Nerve Damage - this complication of I.V. infusion result from
trying the arm too tightly to the splint AssessmentNumbness of
fingers and hands
Nursing Intervention Massage the area and move shoulder through
its ROM Instruct the patient to open and close hand several times
each hour Physical therapy may be required Take note: apply splint
with the fingers free to move
7. Speed Shock - This complication of I.V. infusion result from
administration of I.V. push medication rapidly.
To avoid speed shock and possible cardiac arrest, give most I.V.
push medication over 3 to 5 mins.
OBJECTIVES OF BLOOD TRANSFUSION THERAPY 1. To increase
circulating blood volume after surgery, trauma, or hemorrhage 2. To
increase the number of RBC's and to maintain hemoglobin levels in
clients with severe anemia 3. To provide selected cellular
components as replacements therapy (e.g. clotting factors,
platelets, albumin)
Nursing Interventions of Blood Transfusion Therapy (note:
consent is needed) 1. Verify doctor's order. Inform the client and
explain the purpose of the procedure 2. Check for cross matching
and typing. To ensure compatibility 3. Obtain and record baseline
vital signs 4. Practice strict asepsis 5. At least 2 licensed
nurses check the label of the blood transfusion. Check the
following:
Serial number Blood component Blood type
Rh factor Expiration date
Screening test (VDRL, HBsAg, malarial smear) - to ensure that
the blood is free from blood-carried diseases and therefore, safe
from transfusion
6. Warm blood at room temperature before transfusion to prevent
chills 7. Identify client properly. Two nurses check the client's
identification 8. Use needle gauge 18 to 19. This allow easy flow
of blood 9. Use BT set with special micron mesh filter. To prevent
administration of blood clots and particles 10. Start blood
transfusion therapy slowly at 10 gtts/min. Remain at bedside for
15-30 mins. Adverse reaction usually occurs during the first 15 to
20 mins 11. Monitor vital signs. Altered vital signs indicate
adverse reaction: Do not mix medication with blood transfusion. To
prevent adverse effects
Do not incorporate medication into the blood transfusion
Do not use blood transfusion line for I.V. push of
medication
12. Administer 0.9% NaCl before, during, or after Blood
Transfusion Therapy. Never administer I.V. fluids with dextrose
because it causes hemolysis 13. Administer Blood Transfusion
Therapy for 4 hrs (whole blood, packed RBC). For plasma, platelets,
cryoprecipitate, transfuse quickly (20 mins) clotting factor can
easily destroyed.
COMPLICATIONS OF BLOOD TRANSFUSION 1 Allergic Reaction - this
type of complication of blood transfusion is caused by sensitivity
to plasma protein of donor antibody, which reacts with recipient
antigen Assessment: Flushing Rush, hives Pruritus Laryngeal edema,
difficulty of breathing
2. Febrile, Non-Hemolytic - this type of complication of blood
transfusion is caused by hypersensitivity to donor white cells,
platelets or plasma proteins. This is the most symptomatic
complication of blood transfusion
Assessment: Sudden chills and fever Flushing Headache
Anxiety
3. Septic Reaction - this type of complication of blood
transfusion is caused by the transfusion of blood or components
contaminated with bacteria
Assessment: Rapid onset of chills Vomiting Marked hypotension
High fever
4. Circulatory Overload - this type of complication of blood
transfusion is caused by administration of blood volume at rate
greater than the circulatory system can accommodate
Assessment:Rise in venous return Dyspnea Crackles or rales
Distended neck vein Cough Elevated blood pressure
5. Hemolytic Reaction - this type of complication of blood
transfusion is caused by infusion of incompatible blood
products
Assessment: Low back pain (first sign). This is due to
inflammatory response of the kidneys to incompatible blood Chills
Feeling of fullness Tachycardia Flushing Tachypnea Hypotension
Bleeding Vascular collapse Acute renal failure
NURSING INTERVENTIONS WHEN BLOOD TRANSFUSION COMPLICATIONS
OCCUR
1. The first thing to do when complications in blood transfusion
occurs is to STOP TRANSFUSION
2. Then start or open I.V. line (0.9%NaCl)
3. Place the client in fowler's position and administer oxygen
therapy depending in the hospital protocol
4. Check vital signs as often as 5 mins
5. Notify the doctor immediately about the complications of
blood transfusion
6. Carry out doctors order; prepare the emergency drugs like
antihistamines, vasopressor, fluids as protocol
7. Obtain urine specimen and send to the laboratory to determine
presence of hemoglobin as a result of RBC hemolysis
8. Blood container, tubing, attached label, and transfusion
record are saved and returned to the laboratory for analysis.
HERBAL MEDICINES Aloe Vera - treatment for minor burns, insect
bites, sunburns, dandruff, oily skin, psoriasis Chamomile - relief
of digestive and GI disturbances Dong Quai - treatment for
menstrual cramps and to regulate the menstrual cycle Echinacea -
Immune enhancer - Treatment for respiratory and urinary tract
infection - Treatment for snake bites Feverfew - relief of migraine
headache Garlic - To lower cholesterol and triglyceride levels - To
decrease BP; decrease clotting capability of the blood Ginger -
boosts the immune system - To treat stomach and digestive disorders
- Relief from nausea - Relief from pain, swelling, and stiffness
for arthritis Giangko - Antioxidant: peripheral vasodilatation and
increase blood flow to CNS; reduces platelet aggregation -
Treatment for allergic rhinitis, Alzheimers disease, anxiety,
stress, dementia, Raynaulds disease, tinnitus, vertigo, impotence,
poor circulation Ginseng - Relief of stress; to boost energy; to
give digestive support - supports immune system and prevents
chronic infection Goldenseal - To ward off infection and promote
wound healing - To treat congestion associated with common cold
Kava kava - Root promotes sleep and muscle relaxation - Treats UTI
Licorice - Effects are similar to aldostrone and corticosteroid -
relieves heartburns and indigestion - treat ulcers Milk Thistle -
To prevent liver damage Peppermint - stimulates appetite to eat;
aids in indigestion - Treatment of bowel disorders - stimulates
circulation; reduces fever; clears congestion; restores energy -
Peppermint oil is used as treatment for tension headache St. Johns
Wort herbal Prozac - Antidepressant, antiviral activity Saw
Palmetto plant catheter - relieves symptoms of BPH and urinary
conditions Valerian herbal valium - sleep-inducing agent Billberry
- promotes healthy vision; relieves diarrhea in children - Leaf is
used for diabetes, arthritis, dermatitis, gout Black Cohosh -
suppresses LH; increases estrogen level - has antispasmodic,
astringent, diuretic, vasodilator effects - relieves PMS,
dysmenorrheal, infertility, menopausal symptoms Cranberry -
Prophylaxis for UTI Evening Primrose - Natural estrogen promoter -
Treatment for PMS, diabetic neuropathies, chronic inflammatory
conditions Hawthorn - promotes peripheral vasodilation; increases
coronary circulation, acts as an antioxidant - Treatment for early
CHF, stable angina V. ASEPSIS AND INFECTION CONTROL Handwashing is
the single, most effective practice to prevent spread of
microorganisms. 4 Elements of Handwashing 1. Water 2. Friction 3.
Soap 4. Time
Body Defenses against Infection - Normal flora - Intact skin -
Saliva and mucus membrane - Cilia of the upper respiratory tract
infection - Inflammatory process - Immune response
ASEPSIS 1. Medical Asepsis Clean technique - reduces number of
pathogens -GIT - Handwashing removes microorganism 2. Surgical
Asepsis - Sterile technique - make object free of all
microorganisms - Dressing, catheterization and Surgical procedures
and Specimen collection Sterile Technique Guidelines 1. Never turn
your back on a sterile field 2. Avoid talking 3. Keep all sterile
objects within view 4. Moisture will carry bacteria across/ through
a cloth or paper barrier 5. Open all sterile packages away from the
sterile field to prevent crossover and contamination
Principles and Practices of Surgical Asepsis - All objects use
in the sterile field must be sterile - Sterile objects remain
sterile when touched by another sterile object - Sterile objects or
fields which fall out of the range of vision or below ones waist
are considered contaminated - Sterile items become contaminated
when they come in contact with microorganism transported through
the air - When sterile object/field comes in contact with another
surface, it becomes contaminated - The edges of the sterile field
are considered unsterile
Standard Precaution - To be used in all clients in the hospital
- To be used in the following situations: a. contact with blood,
body fluid, excretions and secretions b. contact with non-intact
skin c. contact with mucous membrane - wash hands after contact
with blood, body fluids, secretions, excretions, or contaminated
objects - wear gloves when touching blood, body fluids, secretions,
excretions or contaminated objects - wear mask, goggles, or face
shield if there is potential for splashes or sprays of blood, body
fluids, secretions or excretions to prevent splashing into the eyes
or mucous membranes - Use biohazard bag for linens soiled with
blood, body fluids, secretions, or excretions - Place sharps or
needles in puncture-resistant container - do not recap, bend, or
break needles
Airborne Precaution Measles
Varicella
Tuberculosis
- use private room (negative airflow room) - close the door at
all times
Use HEPA filters (High-Efficiency Particulate Air) - Particulate
respirator/mask for health care workers - Surgical mask for patient
during transport - discard tissue wipes with sputum in plastic
bags
Droplet Precautions Pneumonia
Meningitis
Rubella
Scarlet fever
Diphtheria
Pertussis
- use surgical mask Use disposable eating utensils
Contact Precautions Herpes simplex
Staphylococcal infection
Hepatitis A
Respiratory syncytial virus (RSV)
Wound/skin infection
Methicillin-resistant staphylococcal aureus (MRSA)
Vancomycin-resistant enterocolitis (VRE)
Rotavirus infection (most common cause of diarrhea in the
U.S.)
- use gloves, gown (if clothing comes in contact with patients,
environmental surfaces, or items in the room, if patient has
diarrhea, wound drainage, or GI surgery).
TIME FOR A SHORT QUIZ 1. Which of the following is an
appropriate nursing action when implementing standard precautions?
A. Consider all body substances potentially infectious B. wear
gloves whenever in contact with patient C. wear gown and gloves
when caring for a client in droplet precaution D. place a body
substance isolation sign on the client's door
2. Which of the following clients would qualify for hospice
care? A. a client with metastatic cancer B. a client with left-side
after a stroke C. a client who had coronary artery bypass surgery 1
week ago D. a client who is undergoing treatment for heroin
addiction
3. For a hospitalized client, which statement reflects
appropriate documentation in the client's medical record? A.
"client had a good day" B. "seems to be mad at the physician" C.
"small pressure ulcer noted at the lower back" D. "skin moist and
cool" 4. The nurse will administer the client's 9 A.M. medications.
The client is away from his room for ultrasound of the liver. Which
nursing action is appropriate? A. have the client skip that B. ask
the client's relatives to keep the medications for the client until
he returns C. lock the medications in the medicine preparation area
until the client returns D. leave the medications on the drawer of
the client's bedside table 5. The nurse is caring for a client
receiving patient-controlled analgesia (PCA) for pain management.
Which statement about PCA is true? A. the PCA pump cant' infuse
opioids continuously B. pain relief is initiated by the client as
needed C. no complications related to opioid delivery by the pump
exist D. the nurse prescribes the dosage of opioid for delivery
dose of medicationANSWERS AND RATIONALE 1. A - Rationale: standard
precautions are based on the concepts that all body substances are
potentially infectious. The nurse should wear gloves when contact
with body substances is potential, not when in contact with intact
skin. Mask should be used as a barrier to prevent transmission of
droplet infections. Signs on door are unnecessary for standard
precaution. 2. A - Rationale: hospices provide supportive,
palliative care to terminally ill clients and their families 3. D -
Rationale: documentation should be factual and accurate, what are
heard, seen, smelled, or felt. Documentation of ulcer should
include exact size and location. Interpretations, conclusions,
opinions should not be documented. 4. C - Rationale: the nurse must
put the medicines in the secured area. She should not leave the
medications at the bedside. The nurse should not omit doses of
medications without physician's order 5. B - Rationale: the client
pushes a button to self-administer narcotic analgesic. The PCA pump
also allows for continuous infusions of the medication. The client
may still experience complications of the medication. It is the
physician who prescribes the medication order VI. COMPUTATION OF
DOSAGE OF MEDICATIONS
1. Oral Medication: Solids Desired dose / stock dose = quantity
of drug D/S = Q
2. Oral/Parenteral Medications: Liquids Desired dose / stock
dose x dilution = quantity of drug D/S x dilution = Q
3. IV fluids Rate a. gtts/min = volume in cc x gtt factor no. of
hours x 60 min
b. cc/hr = volume in cc or gtts/min x 4 no. of hours
c. duration in hours = volume in cc cc/hr
4. Conversion of Temperature a. C to F = (C x 1.8) + 32 note:
(1.8 is 9/5) b. F to C = (F 32) (0.55) note: (0.55 is 5/9)
Time for a Short Quiz ! ! ! 1. An antihypertensive agent,
minoxidil (Loniten) 5mg p.o. is ordered. Stock is 2.5 mg/tab. How
many tablets should be administered?
2. The expectorant guiafenesin (Robitussin) 300 mg. p.o. has
been ordered. The bottle is labeled 100 mg/5 ml. How many ml should
be given?
3. The physicians order reads: Administer D5LR 3L for 24 hours.
a. to how many gtts/min will you regulate the IVF? b. how many
ml/hr will be infused?
4. 38.3C equals how many degrees Farenheit?
5. 108.6F equals how many degrees Celsius?
ANSWERS 1) D/S = Q 5mg . 2.5mg/tablet = 2 tablets
2) D/S x dilution = Q 300 mg x 5 ml 100 mg = 15 ml
3) a) vol. in cc x gtt factor = gtts/min no. of hours x 60 min
3,000 cc x 15 24 x 60 45,000/1440 = 31 gtts/min b) cc/hr vol in cc
no. of hrs = 3,000 cc / 24 hrs = 125 cc/hr
4) C to F = C x 1.8 + 32 = (38.3 x 1.8) + 32 = 68.9 + 32 = 100.9
F
5) F to C= (F 32) (0.55) = (108.6 32) (0.55) = (76.6) (0.55) =
42.1 F VII. NORMAL VALUES 1. Complete Blood Count (CBC) RBC
(erythrocytes) 4.5 5.5 million/cu.mm
WBC (leukocytes) 5,000 10,000/cu.mm
Platelet s (thrombocytes) 150,000 450,000/cu.mm
2. Hemoglobin (hgb) = 12 -17 G/dL 3. Hematocrit (hct) male: 42
52%
Female: 40 - 48%
4. Differential Count (Leukocytes) Neutrophils 60 70%
Eosinophils 1 -4%
Basophils 0 0.5%
Lymphocytes 20 30%
Monocytes 2 6%
5. Blood Coagulation Studies
Prothrombin Time (PT) = 11 16 sec
Partial Thromboplastin Time (PTT) = 60 70 sec
Activated Partial Thromboplastin Time (APTT) = 30 45 sec
Bleeding Time = 1 9 sec
Clotting Time = 8 15 sec
6. Blood Urea Nitrogen (BUN) = 8 -25 mg/dL 7. Blood Lipids Serum
Cholesterol = 150 200 mg/dL
Serum Triglycerides = 140 200 mg/dL
Low Density Lipoprotein (LDL) = less than 130 mg/dL
High Density Lipoprotein (HDL) = 30 70 mg/dL
8. Serum Enzymes Studies Aspartate Amino Transferase (AST/SGOT)
= 7 40 U/ml Alanine Aminotransferase (ALT/SGPT) = 10 -40 U/ml
Creatine Phosphokinase (CK-MB)
Male: 50 325 mU/ml
Female: 50 250 mU/ml
9. Troponin
Troponin I = less than 0.6 ng/ml (grater than 1.5 ng/ml
indicates myocardial infarction (MI)
Troponin T = 0 to less than 0.1 ng/ml (greater than 0.1 0.2
ng/ml indicate MI)
10. Blood Uric Acid (BUA) = 2.5 8mg/dl 11. Serum Electrolytes
Potassium (K+) = 3.5 5.5 mEq/L
Sodium (Na+) = 135 145 mEq/L
Calcium (Ca+) = 4.5 5.5 mEq/L
Magnesium (Mg+) = 1.5 2.5 mEq/L
12. ECG Complexes
P wave = 0.04 0.11 sec
PR interval = 0.12 0.20 sec
QRS complex = 0.05 0.10 sec
T wave = not exceed 5mm amplitude
13. Central Venous Pressure (CVP) = 5 12 cm H2O 14. Pulmonary
Artery Pressures Pulmonary Artery Pressure (PAP) = 4 12 mmHg
Pulmonary Capillary Wedge Pressure (PCWP) = 4 12 mmHg
15. Serum Ammonia = 40 80 mcg/dL
16. Blood Glucose Level Fasting Blood Glucose (FBG) = 70 110
mg/dL
Glycosylated Hemoglobin (HbAIc) = 4.4 6.4% (7.5% or less: good
diabetic control)
17. Thyroid Hormone Levels Triiodothroxine (T3) = 75 = 200
ng/dL
Thyroxine (T4) = 4.5 11.5 mcg/dL
18. Routine Urinalysis Color = amber/straw
pH = 4.5 8 (average: 6; slightly acidic)
specific gravity = 1.010 1.025
protein = absent
RBC = 0 5
Pus = absent
Ketones = absent
Casts = 0 4
19. Creatinine Clearance = 100 120 ml/min 20. Serum Creatinine =
0.7 1.4 mg/dL 21. Snellens Test = 20/20 22. Intraocular Pressure =
11 -21 mmHg 23. Cerebrospinal Fluid (CSF) Studies Opening pressure
= 0 15 mmHg or 75 180 mm H20
Glucose = 50 80 mg/dL
Protein = 20 50 mg/dL
24. Arterial Blood Gas Analysis
Blood pH = 7.35 7.45
Pa O2 = 80 100 mmHg
paCO2 = 35 45 mmHg
HCO3 = 22 26 mEq/L
O2 saturation = 95 100 %
Note: O2 saturation 90% and below indicate that hypoxia is
severe25. Therapeutic Serum Medication Levels Acetaminophen = 10 20
mcg/dL
Phenytoin (Dilantin) = 10 20 mcg/dL
Theophylline = 10 20 mcg/dL
Carbamazepine (tegretol) = 5 12 mcg/dL
Gentamycin Sulfate = 5 10 mcg/dL
Magnesium Sulfate = 4 7 mg/dL
Digoxin = 0.5 2 ng/ml
Lithium = 0.5 1.5 mEq/L
Coumadin = INR: 2 3
VIII. NUTRITION AND DIET
Macronutrients (energy nutrients)
1. Carbohydrates (Go) provides energy
Sources: cereals, fruits, vegetables, milk
Caloric deficiency is referred to as Marasmus, characterized by
loss of weight, skin turgor, old-man look, distended abdomen,
hypotonia
Nursing Considerations for Carbohydrates
High: bipolar disorder, manic phase; associated in obesity;
associated in colon and breast cancer; for Marasmus Low: diarrhea;
gas distention; diabetes mellitus
2. Fat (Glow) provides essential fatty acids and energy; absorbs
and transports fat-soluble vitamins (A, D, E, K); protects vital
body tissues; insulates body
Sources: fats and oils, meats, fish, nuts, some seeds, dairy
products
Nursing Considerations for Fats
High: dumping syndrome, ulcer, when taking ADEK Low: acne
vulgaris, pancreatitis, cholecystitis, cardiac patient
3. Protein (Grow) growth and repair of tissues; maintain fluid
and acid-base balances, provides energy.
Sources: meat, fish, dairy products, eggs, nuts, legumes,
cereals
Protein deficiency is referred to as Kwashiorkor, characterized
by lethargy, inadequate growth, loss of muscular tissue, increases
susceptibility to infection, EDEMA
Nursing Considerations for Protein
High: hepatitis, PIH, nephrotic syndrome, burn patient Low:
chronic renal failure, PKU, liver cirrhosis
MICRONUTRIENTS (VITAMINS AND MINERALS)
Fat Soluble Vitamins
1. Vitamin A (Retinol) affects vision; health of skin; growth of
hair, nails, bones, and glands; prevents infection
Sources: dairy product, liver, green, yellow and orange fruits
and vegetables
Deficiency: night blindness, xeropthalmia, poor growth, dry
skin
Toxicity: fetal malformations, hair loss, skin changes, bone
pain
Nursing Considerations for Vitamin A
Not to excessive especially amongst small children, it might
cause discoloration of the skin
2. Vitamin D (Ergocalciferol) Calcium not absorbed without Vit.
D. Calcium and phosphorus absorption; bone mineralization
Sources: dairy products, eggs, yolks, fatty fish
Deficiency: Rickets in children, Osteomalacia for adults
Toxicity: growth retardation, kidney damages, calcium deposits
in soft tissue
Nursing Considerations for Vitamin D
Breast-fed infant must be exposed to mild sunlight
Must receive by those who are receiving calcium supplement
3. Vitamin E (Tocopherol) Antioxidant: prevents cell damage
Sources: vegetable oils, nuts, seeds, whole grain
Deficiency: red blood cell destruction, nerve destruction
Toxicity: None, no supplements with anticoagulant drugs
Nursing Considerations for Vitamin E
To prevent premature aging
Commonly given to client with dementia
4. Vitamin K (Menadione) blood clotting
Sources: green vegetables, intestinal synthesis
Deficiency: hemorrhage
Toxicity: anemia, jaundice
Nursing Considerations for Vitamin K
Commonly given to neonate to prevent bleeding (note: neonates
have sterile intestine)
Antioxidant to Coumadin
Water Soluble Vitamins
1. Vitamin C (Ascorbic Acid) required for iron absorption.
Antioxidants: prevents cell damage; causes collagen formation;
affects health of teeth and gums Sources: citrus fruits, guava,
strawberries, tomatoes, broccoli, cabbage, greens, potatoes
Deficiency: Scurvy, poor wound healing, weakness, impaired
immune response, pin point hemorrhages, bleeding gums
Toxicity: more than 2g can cause diarrhea, kidney stone
formation. Most renal calculi thrive in acid urine. GI upsets,
fatigue
2. Vitamin B1 (Thiamine) muscle nerve function; co-enzyme for
energy metabolism Sources: pork liver, organ meats, nuts, legumes,
eggs, milk, whole and enriched grains. Potatoes
Deficiency: Beriberi, poor coordination, edema, weakness
Nursing Considerations for Vitamin B1
Those with increased metabolic rate should increase B1 (e.g.
pregnant women and client with fever)
Alcoholic client
3. Vitamin B2 (Riboflavin) coenzyme for energy metabolism
Sources: milk, dairy products, organ meats, lean meats, enriched
grains, green leafy vegetables, fish, eggs
For skin problem such as eczema and scabies
4. Vitamin B3 (Niacin) - coenzyme for energy metabolism Sources:
kidney, liver, poultry, lean meat, fish, peanut butter, dried peas
and greens, whole grain, nuts
Deficiency: ariboflavinosis, cheilosis, glossitis, seborrheic,
dermatitis, pellagra
Toxicity: vasodilation, liver damage
5. Vitamin B6 (Pyridoxine) supplemented in anti-TB therapy as
drugs compete with absorption of B6. Metabolism of amino acids and
protein, neurotransmitter synthesis. Sources: meats, poultry, fish,
organ meats, yeast, oats, corn, peanuts, bananas, egg yolk, whole
grain cereals, wheat germ, potatoes
Deficiency: headache, anemia, convulsion, nausea
Toxicity: nerve destruction if >2g/day
Nursing Considerations for Vitamin B6
For patient who is receiving INH to prevent peripheral
neuritis
For those who are taking contraceptives
6. Vitamin B9 (Folacin/Folic Acid) aids metabolism of DNA and
RNA; red blood cell maturation
Sources: green leafy vegetables, asparagus, organ meats, beef,
fish, legumes, eggs, yeast, wheat germ, grapefruits and orange.
Deficiency: megaloblastic anemia, poor growth, birth defects
7. Vitamin B12 (Cyanocobalamine) requires intrinsic factor for
absorption in the stomach. This is not absorbed in Pernicious
Anemia.
- Folate metabolism, nerve function.
Sources: liver, kidney meat, oyster, cheese, eggs, shrimp,
milk
Deficiency: megaloblastic anemia, poor nerve function
MINERALS
1. Potassium (K) major intracellular cation. - given with
furosemide - fluid balance, nerve and muscle function
Sources: bananas, avocado, strawberries, cantaloupe, oranges,
mushrooms, carrots, spinach, tomatoes, potatoes, raisins (other
dried fruits), fish, beef, veal, pork
Deficiency: muscular weakness, fatigue, confusion
Toxicity: muscular weakness, cardiac arrest
2. Iron (Fe) components of hemoglobin and enzymes
Sources: liver, meat, dark-green vegetables, green and red beans
(dried beans), egg yolk, breads, cereals, clams
Deficiency: anemia, weakness, infections, fatigue, pale eye
membranes
Toxicity: Acute: shock, death. Chronic: liver damage, cardiac
failure
Nursing Considerations for Iron
Must be given between meals
If given per orem: black stool
If liquid: use straw
If injectible: dont massage3. Calcium (Ca)
- 99% of calcium is in the bone - Major component of renal
calculi - if increased, calcitonin is given - Bone and tooth
formation; blood clotting; muscle function; nerve transmission;
blood pressure
Sources: yogurt, low fat milk and dairy products, green leafy
vegetables, broccoli, carrots, seafood, nuts, legumes, whole
grains, rhubarb
Deficiency: stunted growth in children; bone loss (osteoporosis)
in adults
Toxicity: extra calcium usually excreted; possible depressed
absorption of some other minerals and kidney damage
4. Sodium (Na)
- Water goes to where Na is ! - given with lithium carbonate -
fluid balance, nerve impulse transmission
Sources: table salt, soy sauce, cured pork, milk, butter,
ketchup, canned food, processed foods, white and whole wheat bread,
cheese, mustard, snack foods
Deficiency: muscle cramps, reduced appetite, weakness
Toxicity: high blood pressure in some people
IX. THERAPEUTIC DIETS
Acid-ash diet
retards the formation of alkalinic renal stones
indicated to patients with renal calculi (Alkaline stones)
e.g. cheese, cranberries, eggs, meat, plums, prunes, whole
grains
Alkaline ash diet
retards the formation of acid renal stones
indicated to patients with renal stones (Acidic stones)
e.g. fruits (except cranberries, plums, prunes), milk,
vegetables
Bland diet
low fiber, mechanical irritants, chemical stimulants
indicated for patients with gastritis, diarrhea, biliary
indigestion, and hiatal hernia
BRAT diet
banana, rice, apple, toast
indicated for patients with diarrhea
Butterball diet
spare protein but high in carbohydrates
indicated for patients with liver disorders
Clear liquid diet
to relieve thirst and help maintain fluid balance
indicated for post-operative patients and following vomiting and
gastroenteritis
Diabetic diet
well balance diet
the purpose is to maintain near to normal blood glucose
level
indicated to patients with diabetes mellitus
Full Liquid diet
it serves to provide nutrition to patients who cannot chew or
tolerate solid foods
indicated to patients with stomach upsets, post-surgical
patients, after progression from clear liquid diet
Giordano diet
spare protein
indicated to patients who suffers from Chronic Renal Failure
Gluten free diet
no to BROW - Barley, Rye, Oat, Wheat
this is the diet of a patient who suffers from Celiac's
disease
Halal diet
no pork diet
diet of the Moslems
High fiber diet
fruits and vegetable
it speeds up the passage of food to the digestive tract, softens
the stool
indicated to patients who are constipated, with diverticulitis,
with hyperlipedemia (to initiate removal of fats)
High Protein diet
lean-meat, cheese, eggs
indicated to patients with nephrotic syndrome
Kosher diet
meat and milk cannot be served simultaneously
diet of the Orthodox Jews
Low carbohydrate diet
indicated to patients with Dumping Syndrome
Low fat/cholesterol diet
it serve the purpose of reducing hyperlipidemia, and to patients
with intolerance to fats
indicated to patients with cardiovascular diseases, patients who
underwent resection of the small intestines, hypertension,
cholecystitis and cholelithiasis
Low residue diet
reduces the bulk of stools indicated to patients with ulcerative
colitis, diverticulitis. Patients who will undergo surgery of the
GI tract
Low sodium diet
indicated to patients with cardiovascular and renal disorder
Purine restricted diet
to reduce uric acid
indicated to patients with gouty arthritis, renal calculi, and
hyperuricemia
Sodium-restricted diet
indicated to patients with heart failure, hypertension, renal
diseases, PIH, and steroid therapy
Soft diet
used to provide nutrition for those patients having problems in
chewing
for patients with ill-fitting dentures; transition from
full-liquid to general diet, patients with gastrointestinal
disturbances such as gastric ulcers and cholelithiasis
Tyramine-free diet
use to prevent hypertensive crisis for patients who are taking
in MAOI antidepressant
no to ABC's - Avocado, Banana, Canned and Processed Foods, and
also, no to fermented foods
Vegan diet
diet of the Seventh Day Adventists
vegetarian diet
Yin diet
Cold deserts after a surgery. It is a Chinese belief
X. POSITIONS
I. Positions for clients with Respiratory Disorders
After lung Biopsy: Affected Side - To apply pressure in the site
and prevent bleeding
During Thoracentesis: Upright or Sitting Position at the edge of
the bed, arms on overbed table, leaning forward, and feet supported
on a foot stool - For easy access to the site of insertion of
aspiration needle. It also promotes comfort.
After Thoracentesis: Unaffected side for 1 hour to prevent
leakage of fluid into the thoracic cavity.
Client on Oxygen Therapy: Semi-Fowlers position - For lung
expansion and ventilation.
During Tracheostomy or Endotracheal Tube Suctioning:
Semi-Fowlers position - To facilitate suction catheter insertion
and enhance removal of mucous membrane. After Bronchosgraphy and
Bronchoscopy: Side-lying/lateral or semi-fowlers position - To
promote drainage of secretions from the mouth and prevent
aspiration.
COPD: Sitting Upright, leaning forward position, with arms on
overbed table at shoulder level (orthopneic position) - To allow
lung expansion.
Epistaxis: Sitting/Upright position, leaning forward with head
tipped - To prevent aspiration of blood.
After Tonsillectomy: Side lying/lateral or prone position with
pillow under the chest - To promote drainage of mouth secretions
and prevent aspiration. If client is awake, maybe placed in
semi-fowlers position.
Pulmonary Edema: High-Fowlers position with legs slightly
dependent (lowered) - To relieve dyspnea. Lowering the legs reduces
venous return thereby reduces cardiac workload.
Pneumonectomy: Slightly towards affected side, with head
elevated or Semi-Fowlers position for lung expansion - To prevent
flooding of blood coming from the affected side to the remaining
lung. Slight turning prevents mediastinal shift.
Flail Chest: Semi-fowlers position, turned towards the affected
side or the affected side be supported - To control paradoxical
breathing and prevent hypercapnea.
Child with Epiglottitis, laryngotracheobronchitis,
bronchiolitis: Tripod position (sitting upright, leaning forward
with hands on the bed or floor) to facilitate breathing.
SIDS (Sudden Infant Death Syndrome): Supine or Side-lying
position in a firm bed during sleep. Do not place the infant in
prone position during sleep. Do not place infant in soft bed or
over a pillow or comforter. II. Positions for clients with
Cardiovascular and Hematologic Disorders
Myocardial Infarction (MI): Semifowlers position for maximum
lung expansion and improves myocardial oxygenation.
Congestive Heart Failure (CHF): High-fowlers position it
relieves dyspnea and reduces cardiac workload.
When taking Nitroglycerin: Sitting or Supine position to prevent
orthostatic hypotension
Arterial Insufficiency: Lower extremities slightly lower than
the level of the heart (dependent position) it promotes arterial
flow
Venous Insufficiency: Lower extremities elevated it promotes
venous return and relieves edema of the legs.
Tetralogy of Fallot in tet spell (hypoxic episode):
Knee-to-Chest position or
Squatting position to improve venous return, increases cardiac
output and improve tissue oxygenation.
Air Embolism: Left Side-lying position, Trendelenburg position
it allows the air to be absorbed in the right side of the heart
thus prevents pulmonary embolism.
III. Positions for clients with Gastrointenstinal,
hepato-Biliary and Pancreatic Disorders
During Abdominal Examination: Dorsal recumbent position to relax
the abdominal muscles and facilitate abdominal examination.
During Rectal Examination: Lateral/Side-lying position to
facilitate examination of the area.
During Nasogastric tube (NGT) insertion: High-fowlers position,
with the neck hyperextended, initially. Flex the neck slightly once
the tube reaches the oropharynx.
During and after NGT feeding (gastric gavage) and Gastrostomy
feeding: Semi-fowlers position to prevent reflux and aspiration of
feeding.
After insertion of Intestinal/Nasogastric Tube: Right Side-lying
position it helps advance the tube into the duodenum.
During insertion of Parenteral Nutrition (TPN) Catheter:
Trendelenburg position to engorge the vein and facilitate insertion
of the catheter to the subclavian vein. It also prevent air
embolism.
During Enema Administration: Left lateral position for adult.
Dorsal Recumbent position for infant and children. Hiatal Hernia:
Upright/Sitting position during and after eating To prevent
gastroesophageal reflux.
After Gastric and Biliary Surgery: Semi-fowlers position To
promote lung expansion and ventilation and also prevents
atelectasis.
Dumping Syndrome: Left side-lying position To slow down emptying
of gastric content into the jejunum.
Peritonitis: Semi-fowlers position To localize the inflammatory
process in the pelvic area. Colostomy Irrigation: Semi-fowlers
position, then sitting on a bowl once ambulatory.
After Hemorrhoidectomy: Side-lying position It prevents pressure
in the operated area and promote comfort.
After Infant Feeding: Right side-lying position It prevents
gastroesophageal reflux and aspiration.
After Cleft Lip Repair: Side-lying position To promote drainage
and prevent aspiration. No to Prone position to prevent tension on
the suture line. Restraint the elbow to prevent trauma in the
suture line.
After Cleft Palate Repair: Side-lying and Prone position to
promote drainage and prevents aspiration.
After repair of Imperforate Anus: Side-lying position or Supine
with the legs suspended at the right angle To prevent pressure in
the area and minimize discomfort.
During Liver Biopsy: Left Side to facilitate approach to the
liver After Liver Biopsy: Right Side with rolled towel under the
puncture site it helps apply pressure at the puncture site and
prevent bleeding.
During Paracentesis: Sitting/Upright position it facilitates
aspiration of abdominal fluid. IV. Positions for clients with
Fluid-Electrolyte, Acid-Base Imbalances, Genito-Urinary Disorders,
Shock, Burns
During insertion of Urinary Catheter: Supine with legs extended
and abducted for male. Dorsal Recumbent for female.
During Cyctoscopy: Lithotomy position to promote easy insertion
of cystoscope.
During Renal Biopsy: Prone position it is because the kidneys
location is retroperitoneally.
After Renal Biopsy: Supine position with small pillow or rolled
towel under the posterior lumbar area to apply pressure and prevent
bleeding.
During insertion of Peritoneal Catheter: Dorsal Recumbent or
Semi-fowlers position with the knees flexed To relax abdominal
muscles and facilitates the insertion of the catheter.
During Vaginal Examination: Dorsal Recumbent if she is in bed.
Lithotomy position if the examination is done in the table.
Shock: Modified Trendelenburg position to increase venous return
and increased force of cardiac contractility thus increases cardiac
output and tissue perfusion.
Burns: Supine position To promote position of extension and
prevent contractures.
V. Positions for clients with Neurologic Disorder
During Lumbar Puncture: Lateral, Knee-chest position
(fetal/flexed/C-position/shrimp position) to widen intervetebral
spaces and facilitate insertion of spinal needle.
After Pantopaque (oil-based dye) myelogram: Lie Flat for 6 to 8
hours to prevent spinal headache.
After Metrizamide (water-based dye) myelogram: Semi-fowlers
position for 8 hours to prevent meningeal irritation.
Intracranial Pressure: Lateral, Semi-fowlers position to reduce
the pressure, promote adequate lung expansion and improve cerebral
tissue perfusion.
Spinal Cord Injury: Flat/Supine position on a firm space to
maintain alignment of spine.
VI. Positions for clients with Eye and Ear Disorders
After Eye Surgery: Supine position turned to the Unoperated Side
to prevent trauma to the affected eye. If the client is fully
awake: Semi-fowlers position.
Retinal Detachment
Preoperative: Dependent position (lower) to prevent further
detachment of the retina.
Postoperative: Dependent position (upper) to lower the sclera
and choroids by gravity and allow attachment of the area of retinal
detachment.
After Ear Surgery: Unoperated Side to prevent trauma to operated
side.
XI. PROCEDURES
ABDOMINAL ASSESSMENT
Purpose - determine the presence of mass, abnormal bowel sounds,
lesions, and other abnormalities in the abdominal region.
Nursing Keypoints: Position: Dorsal Recumbent Sequence: (IAPP)
Inspection, Auscultation, Percussion, Palpation. Start palpating
from RLQ, RUQ to LUQ, to LLQ
palpation is done last because it can possibly alter the bowel
rhythms and may therefore give rise to abnormal sounds
No to palpation to patients with Wilhm's tumor and abdominal
Aortic Aneurysm
ARTERIAL BLOOD GAS ANALYSIS
Purpose - to monitor the patient's response to oxygen therapy
and detects the presence of acid-base imbalance.
Nursing Keypoints: no to suctioning prior to obtain blood
specimen
assess for bleeding and hematoma at the puncture site
apply firm pressure at the puncture site for 5-10 minutes
specimen should be placed in iced-container
Assess for metabolic alkalosis for patient with vomiting, and on
the other hand, observe for signs and symptoms of metaboli