Professional Documents
Culture Documents
NLE Funda Tips
NLE Funda Tips
PLANNING PHASE
Environmental Theory
14 Basic Needs
Patient Centered Approaches to
Nursing Model / 21 Nursing Problems
Behavioral System Model
Goal Attainment Theory
Transcultural Nursing Model
Four Conservation Principles
Health care System Model
Self-Care and Self-Care Deficit Theory
Interpersonal Model
Science of Unitary Human Beings
Adaptation Model
Care,Core,Cure
Human Caring Model
Human Becoming
INTERVENTION /
IMPLEMENTATION
-
Prioritize problems
Formulate goals
Select actions
Write nursing orders
Determining needs
for assistance
Putting into action
the plan
Supervising delegated
care
Documenting nursing
activities
Data Collection
Organize Data
Validate Data
Document Data
DIAGNOSIS PHASE
Analyze Data
Identify Health
Problem
Formulate Diagnostic
Statements
Diagnostic Statements
Problem (P): statement of
the clients response.
Etiology (E): factors
contributing
Signs and Symptoms (S):
defining characteristics
manifested by the client
EVALUATION PHASE
Types of Planning
Initial planning, admission
assessment.
Ongoing planning
Discharge planning:
M edications
E xercise
T reatment/therapy
H ygiene
O ut-patient follow up
D iet/nutrition
S exual activity/spirituality
Types of Intervention
Independent
Dependent
Collaborative
Cognitive or Intellectual Skills
Such as analyzing the problem,
problem solving, critical thinking
and making judgments regarding
the patient's needs.
Interpersonal Skills
Which includes therapeutic
communication, active listening,
conveying knowledge and
information, developing trust or
rapport-building with the patient
Technical Skills Which includes
knowledge and skills needed to
properly and safely done the
procedure
Collecting data related to
outcome
Comparing data
Drawing conclusion
Continuing, modifying or
terminating the nursing care
plan
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
C. Airborne Transmission
1. Droplet of nuclei
2. Dust particle in the air containing the infectious
agent
3. Organisms shed into environment from skin, hair,
wounds or perineal area.
D. Vector borne Transmission, arthropods such as
flies, mosquitoes, ticks and others.
VII. ISOLATION PRECAUTIONS
Droplet precautions
Put on a standard mask prior to entering the
isolation room.
Hands must be washed with an antiseptic
preparation and must be dried thoroughly with
a disposable paper towel or washed with a
waterless alcohol hand rub/gel:
1. AFTER contact with the patient or
potentially contaminated items,
2. AFTER removing gloves, and
3. BEFORE taking care of another patient.
Contact precautions
Non-sterile, disposable gloves are needed when
there is contact with an infected site, with
dressings, or with secretions.
A mask when performing procedures that may
generate aerosols or when performing
suctioning is recommended.
Hands washing (see droplet precautions)
VIII. NUTRITION
Food Sources
Protein
Carbohydrates
Fats / Lipids
Vit. A
Vit. D
Vit. E
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
BREAST
C. Vital Signs
Vesicular
Bronchovesicular
Bronchial
Lung periphery
Larger airway
blowing
Trachea
Dependent lobes
Rhonchi
Wheezes
Trachea, bronchi
All lung fields
Pleural
Friction Rub
Random, sudden
reinflation of alveoli
fluids
Fluids, mucus
Severely narrowed
bronchus
Inflamed Pleura
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
FIVE RIGHTS
The Right Drug with
The Right Dose through
The Right Route at
The Right Time to
The Right Patient
Standard Order, Carried out until cancelled by another
order.
PRN Order, As needed, or only when necessary.
Stat Order, Carried out immediately and for one time
only.
Always clarify doubtful /unclear order
Do not leave medicine with the client to take by himself
Do not give drug that shows physical changes or
deterioration
Report an error in medication immediately to the nurse
in charge.
Check medication 3 times before taking to the client:
o When taking the medication from the storage area
o Before placing medication into the medicine
rack/glass
o Before placing medicine to the storage area
The nurse who prepares the medication must be
responsible for administering and recording it. Never
endorse it to another nurse.
Always observe asepsis in preparing and administering
drugs.
Ascertain clients identity before administering
medications. Check room or bed or card, call out clients
name, check I.D., wrist band
Care must be taken to prevent instilling medication
directly into cornea.
ORAL: If patient vomits within 20 30 minutes of taking
the drug, notify the physician. Do not re-administer the
drug without doctors orders.
SUBLINGUAL ROUTE drugs that is placed under the
tongue, where it dissolves.
BUCCAL ROUTE a medication is held in the mouth
against the mucous membranes of the cheek until the drugs
dissolves
EYES MEDS: Apply ointment along inside edge of the
lower eyelid from inner to outer canthus.
EAR MEDS:
Infants: draw the auricle gently downward and
backward.
Adults: lift pinna upward and backward
Intradermal: Parallel to the skin, do not massage
Subcutaneous: 45 degree above the skin, if obese 90
degree
Intramuscular: 90 degree above the skin, aspirate to
check if blood vessel was hit.
D. Urinary Catheterization
Use appropriate size of catheter
Male: Fr 16-18
Female: Fr 12-14
Place the client in appropriate position:
Male: Supine, legs abducted and extended
Female: Dorsal recumbent
Locate the urinary meatus properly:
Male: at the tip of the glans penis
Female: between the clitoris and vaginal orifice
Lubricate catheter with water soluble lubricant before
insertion
Male: 6 7 inches
Female: 1 2 inches
Length of catheter insertion:
Male: 6 9 inches
Female: 3 -4 inches
Anchor catheter properly:
Male: laterally or upward over the lower abdomen /
upper thigh
Female: inner aspect of the thigh
Nursing Interventions to Induce Voiding/Urination
Provide privacy
Assist the patient in the anatomical position of voiding
Serve clean, warm and dry bedpan (female) or urinal
(male)
Allow the client to listen to the sound of running water
Dangle fingers in warm water
Pour warm water over the perineum
Promote relaxation
Provide adequate time for voiding
Last resort: URINARY CATHETERIZATION
F. Enema Administration
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
G. Colostomy Care
Ileostomy
Ascending Colostomy
Transverse
Colostomy
Descending
Colostomy
Sigmoidostomy
Type of Discharge
Liquid fecal drainage
Drainage is constant and cannot
be regulated
Contains some digestive enzymes
Odor is minimal bec of fewer
bacteria are present
Liquid fecal drainage
Drainage is constant and cannot
be regulated
Odor is a problem requiring
control
Malodorous, mushy drainage
H. Suctioning
I. Tracheostomy Care
J. Blood Transfusion
A
B
AB
O
Compatible
A/O
B/O
A / B / AB / O
O
Incompatible
AB / B
AB / A
A / B / AB
K. Assistive Device
Canes
COAL (cane opposite affected leg)
Angel is 20-30 degrees
Walkers
Hand bar below the clients waist and the elbow is
slightly flexed.
Crutches
Length of the Crutches: Subtract 40 cm or 16
inches to the height of the client obtain the
approximate crutch length.
20 to 30 degrees of flexion at the elbow.
Four point gait:
* right crutch, the left foot, the left crutch, right
foot.
Two point gait:
* left foot and right crutch, right foot and left
crutch
Three point gait:
* left foot and both crutches, right foot.
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
Postural drainage
Use of gravity to aid in the drainage of secretions.
Patient is placed in various positions to promote
flow of drainage from different lung segments
using gravity.
Areas with secretions are placed higher than lung
segments to promote drainage.
Patient should maintain each position for 5-15
minutes depending on tolerability.
N. Oxygen Therapy
Three-bottle system
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE