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Nursing Board Review
Outline of review for the boards
History of Nursing- World and Philippines The Nursing theories Concepts of Health and Illness Human Basic Needs Stress and Adaptation
Outline of review for the boards
ASSESSING HEALTH STATUS
VITAL SIGNS PHYSICAL ASSESSMENT
Outline of review for the boards CLIENT CARE ASEPSIS SAFETY HYGIENE MEDICATIONS SKIN INTEGRITY TERMINAL CARE .
Outline of review for the boards HEATH PROMOTION AND DISEASE PREVENTION ACTIVITY and EXERCISE REST and SLEEP PAIN management NUTRITION FECAL ELIMINATION URINARY ELIMINATION OXYGENATION CIRCULATION Fluids and Electrolytes .
History of Nursing Intuitive Nursing Apprentice Nursing Dark Period of Nursing Educated Nursing Contemporary Nursing .
medical standards and need for nurses .Father of Sanitation Hippocrates.History of Nursing Intuitive Nursing Primitive and untaught Code of HAMMURABI Moses.Developed standards for client care.
Thomas School of Nursing in England Teachers are devoted clinical instructors solely for teaching The first nurse to exert political pressure on government . 1820 in Florence ITALY Trained: Germany at Kaiserswerth School Founded the St.born May 12.History of Nursing Educated Nursing Florence Nightingale.
Nursing in the PHILIPPINES First School of Nursing= ILOILO MISSION hospital school of nursing Anastacia Giron-Tupas= Founder of the PNA Rosario Delgado= first PNA president .
Theories in Nursing Four concepts Central to Nursing: P-E-H-N Person Environment Health Nursing .
Nightingale „The act of utilizing the environment of the patient to assist him in his recovery‟ .Theories in Nursing ENVIRONMENTAL THEORY Relate nature with the bird.
Theories in Nursing INTER-PERSONAL RELATIONS Model Remember “ PEP” talk Hildegard PEPLAU Therapeutic relationship: Orientation= assist client to “understand” problem Identification= Client dependence. inde and inter he recognizes his problems in this phase Exploitation/Exploration= Derives “full value” ini-exploit!! Resolution= old and new goals put aside .
autonomous They must work in such a way that they feel a sense of accomplishment .Theories in Nursing Nature of Nursing. remain independent.Definition of Nursing The meaning of Nursing is “VIRGIN” Recall the 14 needs!!!!! Associate 14 virgin HENS Virginia HENDERSON She believes that clients need to express their emotions.
Theories in Nursing 21 nursing problems “Faid 21” Faye Abdellah .
PARTLY compensatory= unable to perform SOME self care 3.EDUCATIVE= who needs to learn and needs assistance . SUPPORTIVE.CARE Associate “Self care “ to “ORAL care” or “per orem” Dorothea OREM 1.Theories in Nursing GENERAL THEORY OF NURSINGSELF. WHOLLY compensatory= unable to control 2.
Theories in Nursing
BEHAVIORAL SYSTEM MODEL Associate behavior with John (in John and Marsha) “kaya JOHN(son) magsumikap ka “ Dorothy Johnson
Theories in Nursing
Conservation Theory “the Divine is Conservative” “Levin” – levine, divine
Theories in Nursing
Recall that the KING of the land has a GOAL to attain for his kingdom
IMOGENE KING! Her theory is applicable to the child bearing women and their families
Roger.Theories in Nursing UNITARY BEING: Man as the CENTRAL Focus “Roger . let us unite our Man in the center of the battlefield” The whole is greater than its parts Martha ROGERS She believes in the use of the principles of NON CONTACT therapeutic touch .
reactions to stress and adaptation to stressors After overcoming the stresses you will become a “NEW.Man” Intrapersonal stressor= illness Extrapersonal stressors= financial concerns.Theories in Nursing HEALTH CARE SYSTEMS model Betty NEUMAN Stresses. community resources Interpersonal stressor= unrealistic role expectations .
Theories in Nursing ADAPTATION MODEL Individual is a BIOPSYCHOSOCIAL ADAPTIVE system with input and output “associate this with a Nun” SISTER ROY= nag a adopt ng mga bata Her theory supports the unity between the client and God .
Theories in Nursing CULTURAL CARE DIVERSITY Transcultural Nursing Madeleine LEININGER .
I core and I cure” Hall of Fame award!!! LYDIA HALL .Theories in Nursing Nursing Process theory and CARE. CORE and CURE The nurse who coined the word nursing process and stated “ I care.
Theories in Nursing DYNAMIC NURSE-PATIENT Relationship Associate dynamic action to the team of ORLANDO Ida Jean ORLANDO!!! Go Orlando. the dynamic team!!!!! .
you must be a bud first!!!!!!!!!!!! Rosemarie Parse Her theory emphasizes that clients are the AUTHORITY figures and decision makers for their personal health .Theories in Nursing HUMAN BECOMING THEORY Remember to become a „rose‟ per se .
Theories in Nursing HUMAN CARING THEORY „What is caring?” Jean WATSON Caring for clients during their end-oflife experiences .
maxims.Patricia Benner’s Stages of nursing expertise (NACPE) Stage 1 = novice Stage 2= advanced beginner Stage 3= competent Stage 4= proficient Stage 5= expert No experience. demonstrates ORGANIZATIONAL and planning abilities Has 3-5 years of experience. perceives situations as whole. inflexible Demonstrates MARGINALLY acceptable performance. recognizes the meaningful aspects of a real situation Has 2-3 years experience. No longer requires rules. flexible and HIGHLY Proficient.Demonstrates HIGHLY skilled intuitive and analytic ability . performance is limited. has HOLISTIC understanding of patient Performance is FLUID.
mental and social well-being and not merely the absence of disease or infirmity WHO. 1948 .Health Definition A state of complete physical.
“seven wishing WELL” Physical= carry out task Social= interact with people Emotional= express feelings Intellectual= learn and use info Spiritual= belief in supernatural Occupational= leisure and work Environmental= standard of living in community .Wellness State of well-being Seven Components.
Health Theories CLINICAL Health is absence of disease ROLE PERFORMANCE Health is ability to fulfill societal functions ADAPTIVE Heath is a creative process of adaptation .
3.Health Theories EUDEMONISTIC Health is a condition of self-actualization Health is interaction of three elements: Agent Host Environment ECOLOGIC 1. . 2.
Health Theories Dunn “doon. dito. dine and dire” Four quadrants HIGH level Wellness is functioning at the BEST possible level .
Illness and Disease DISEASE Alteration in body functions ILLNESS A state of physical. developmental or spiritual functioning is DIMINISHED . social. emotional. intellectual.
Stages of Illness: S-A-M-D-R SYMPTOM experiences Client believe something is wrong ASSUMPTION of the sick role Excuse form work and family role MEDICAL care contact DEPENDENT CLIENT role RECOVERY or REHABILITATION .
oxygen. food Safety and security Love and belonginess Self esteem Self actualization .Abraham Maslow’s Hierarchy of needs Physiologic needs. water.
Abraham Maslow’s Hierarchy of needs Safety and security Physical safety Psychological safety Shelter from harm .
Abraham Maslow’s Hierarchy of needs Love and belonginess Need to love Need to belong Need for affection .
Abraham Maslow’s Hierarchy of needs Self esteem Self-worth Self-identity Self-respect Self-image .
Abraham Maslow’s Hierarchy of needs Self actualization Self-fulfillment Spiritual fulfillment .
Man and His needs SelfActualization Self-Esteem Love and Belongingness Safety and Security Physiologic Needs .
Need is something desirable and useful Needs are UNIVERSAL Needs are MET in different WAYS Needs are influenced by different FACTORS Priorities may be CHANGED Needs may be POSTPONED Needs are INTER-RELATED
Need is something desirable and useful Prioritization of needs mat be dictated by the client‟s perception
Nursing goal is this area is to:
Meet the PHYSIOLOGICAL needs of the patient Assess the patient's perception of his other needs Employ nursing Interventions according to the PERCEIVED NEEDS of the patient NOT of the nurse
Evaluation Parameters of nursing care The nurse checks if the desired criteria dictated by patient’s needs are achieved Check which interventions were helpful Revise the plan as needed .
Man achieves self-actualization (Udan) A self-actualized person is basically a MENTALLY healthy person And self-actualization is the essence of mental Health .
culturally appropriate. and culturally competent .Cultural care nursing It is the provision of nursing care across cultural boundaries and takes into account the context in which the client lives It is professional nursing that is culturally sensitive.
Cultural care nursing The suggested steps for culture care are: 1. Identify client’s preference in health practices. Become aware of one’s own culture heritage 2. These will affect their health practices 4. hygiene. Become aware of the client’s heritage and health tradition 3. Formulate a culture care plan . diet. etc.
Stress and Adaptation STRESS A condition in which the person responds to changes in the normal balanced state Selye: non specific response of the body to any kind of demand made upon it STRESSOR Any event or stimulus that causes an individual to experience stress .
2. 4. SOURCES OF STRESS Internal External Developmental Situational .Stress and Adaptation 1. 3.
Stress and Adaptation Physiological indicators of stress: Sympathetic response Dilated pupils Diaphoresis Tachycardia. decrease peristalsis Hyperglycemia . tachypnea. HYPERTENSION. Sodium retention Oliguria Dry mouth. increased blood flow to the muscles Increased blood clotting Bronchodilation Skin pallor Water retention.
Stress and Adaptation SELYE’S General Adaptation Theory A-R-E ALARM: sympathetic system is mobilized! RESISTANCE: adaptation takes place EXHAUSTION: adaptation cannot be maintained .
ANXIETY CATEGORY MILD MODERATE SEVERE Inability to focus PANIC Distorted perception Perception and attention Increased Narrowed arousal focus Communicati Increased Voice on questioni tremors ng Focus on particular object VS changes NONE Slight Increase Difficult to Trembling understand unpredictab le response Easily distracted Tachycardi Palpitation. choking. Hyperventil chest pain ation . a.
Anxiety versus fear ANXIETY FEAR State of mental uneasiness Emotion of apprehension Source may not be identifiable Related to the future Vague Result of psychologic or emotional conflict Source is identifiable Related to the present Definite Result of discrete physical or psychological entity. definite and concrete events .
VS T P R BP .
TEMPERATURE Reflects the balance between the heat produced and the heat lost from the body CORE TEMPRATURE: deep tissues of body .
Temperature Monitoring Oral.reflects core temperature .preferred for newborns Tympanic.very accurate Axillary.accessible and convenient Rectal.
Body temperature has a diurnal variation POINT of Highest body temperature is BETWEEN 8 pm to 12 midnight POINT of Lowest body temperature is BETWEEN 4 am to 6 am .
then normal for few days 4. minimal fluctuation . Relapsing: Fever for few days.Temperature Alteration FEVER. Intermittent: Periods of fever and normal temp 2. Constant: ALWAYS above normal. PYREXIA. Remittent: Fever fluctuates BUT above normal 3. HYPERTHERMIA 1.
Heat loss Mechanism Conduction Convection Evaporation Description Transfer of heat form one object to another by direct contact Movement of air and heat by air current Loss of heat through evaporation of water/sweat Radiation Transfer of heat from warm objects to cool objects in the form of electromagnetic waves .
Pulse A wave of blood created by contraction of the left ventricle of the heart Normal range: 60-100 BPM .
Pulse Pulse pressure: Systolic pressure MINUS diastolic pressure Apical pulse MINUS peripheral pulse Systolic pressure falls by more than 15 mmHg during INHALATION Alternating strong and weak pulses Pulse deficit Pulsus paradoxus Pulsus alternans .
Liquid Diet Vs Soft diet Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream. butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods .
rice and pasta= 6-11 servings Fruit and vegetables Meat.Food Guide pyramid Bread. yogurt. eggs Milk. cereals. poultry. oils and sweets . fish. dry beans. cheese Fats.
Primary Prevention Health promotion and Specific protection Health maintenance Screening and case finding Early diagnosis Prompt treatment Rehabilitation Secondary Prevention Tertiary Prevention .
DRE Providing medication and treatment Physical therapy. Self-monitoring of DM. Diet and Nutrition. Pap’s smear. BSE.Primary Prevention Secondary Prevention Education. TSE Sputum AFB. Exercise. Immunization Physical Examination. Speech therapy Tertiary Prevention .
ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHECKUPS .Levels of Prevention 1.
Levels of Prevention 1. ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHECK-UPS Secondary Prevention .
Levels of Prevention 2. Assessing growth and development of children for nutritional evaluation .
Assessing growth and development of children for nutritional evaluation Secondary Prevention .Levels of Prevention 2.
Levels of Prevention 3. Family Planning and marriage counseling .
Levels of Prevention 3. Family Planning and marriage counseling primary prevention .
Teaching a client with diabetes selfmonitoring of glucose level .Levels of Prevention 4.
Levels of Prevention 4. Teaching a client with diabetes selfmonitoring of glucose level Tertiary prevention .
RN. MAP RA Gapuz Review Center . Trillanes III.DIAGNOSTIC EXAMINATIONS Duke J.
MUST KNOWS KNOW NORMAL VALUES FIRST DISEASE CONDITIONS AND THE SIGNIFICANCE OF CERTAIN LABORATORY DATA POSITIONING FOR THIS TESTS PURPOSE AND NURSING ALERT SPECIMEN COLLECTION AND PATIENT PREPARATION POST TEST RESPOSIBILITIES .
5-10 ml for culture and sensitivity test 24 Hours urine Specimen discard the first voided urine Soak specimen in a container of ice Add preservative as ordered and indicate in the label the type of preservative added. .SPECIMEN COLLECTION Urine Clean-catch urine specimen For routine urinalysis and culture and sensitivity test Perineal care before collection The best time to collect the specimen is early in the morning (first voided-specimen) Amount needed: 30-50 cc for urinalysis.
ask the client to void again and collect the specimen Catheterize Urine Specimen Clamp the catheter for 45 mins Practice aseptic technique Do not collect specimen from the urine bag Obtain 3-5 ml of specimen for culture and sensitivity test and 10-15 ml for urinalysis .Second voided Urine Specimen Ask the patient to urinate and discard the first urine specimen and offer a glass of water afterwards After few minutes.
Stool Specimen Routine Fecalysis Use to assess gross appearance. and presence of ova or parasite in the stool Sterile specimen container must be secured Instruct the client to defecate in the bedpan and obtain 1tbsp or 1 inch long stool specimen using a sterile tongue depressor Label the specimen and bring immediately to the laboratory Stool Culture and Sensitivity Test This is done to assess for specific microorganisms and etiologic agents causing gastroenteritis. and bacterial sensitivity to various antibiotics Sterile technique must be employed Label the specimen properly and send immediately to the laboratory .
Guiac Stool Exam (Occult Blood) It detects bleeding at the GI tract and cancer of the stomach Meatless diet for 3 days prior to the procedure No to red or dark colored foods tom prevent false positive result No to iron: discontinue temporarily for 3 days prior to the procedure .
Sputum specimen Gross Appearance Collect early morning specimen Sterile container must be used Mouth care before: gargle only with water (no to mouthwash. or toothpaste) Instruct the client to deep breath and hack-up sputum from the lungs. Sputum Culture and Sensitivity test Used to assess the etiologic agent causing Respiratory tract infection and bacterial sensitivity to various antibiotics .
Acid Fast Bacillus (AFB) staining To determine active PTB Sputum specimen is collected in 3 consecutive mornings Papanicolao or Cytologic Examination of the sputum To assess for cancer cells .
glyceride level) Requires Fasting .Blood Specimen Blood Tests that does not require fasting: Complete Blood Count Hemoglobin Hematocrit Level test Clotting studies Enzyme studies Serum electrolyte studies Fasting Blood Sugar Blood Urea Nitrogen Serum Creatinine Serum lipids (cholesterol level.
Body Secretions Culture and sensitivity test To assess causative agent causing infection. and bacterial sensitivity to various antibiotics Practice aseptic technique .
Arterial blood gas analysis PURPOSE: To monitor the patient’s response to oxygen therapy and detects the presence of acidbase balance. NURSING KEYPOINTS: No to Suctioning prior to obtaining 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 metabolic acidosis for patients with diarrhea.
and after the procedure to prevent constipation Report to the doctor if bowel movement does not occur in 2 days Instruct the patient to increase fluids and eat foods rich in fiber The patient should also increase intake of fluids .Barium enema PURPOSE: To assess the large intestines NURSING KEYPOINTS: Provide a Liquid diet before the procedure. Ensure that a laxative is given before the procedure to promote better visualization.
4. . 3. 2.Friends and Enemas What is an ENEMA? A solution introduced into the rectum and large intestine for the purposes of: To relieve constipation To relieve flatulence To administer medication To evacuate feces in diagnostics or surgery 1.
Cleansing Enema= intended to remove feces to prevent escape during surgery.Enema types 1. Prevent escape of feces during surgery 2. Prepare intestines for diagnostics and surgery 3. for visualization procedure and constipation Purposes To 1. Remove feces in constipation/impaction .
Enema types 2. Retention enema= oil or medication is instilled to treat infection 4. Carminative enema= to expel flatus. repeated 6 times . Return flow enema= also to expel flatus. 60-80 mL of fluids instilled 3.
Enema Solutions Hypertonic Draws water into the colon Distends colon. water intoxication Isotonic Distends colon SE: possible sodium retention SE: May damage mucosa Soap suds Irritates colon Oil enema Lubricates feces . softens feces SE: Retention of sodium Hypotonic SE: F and E imbalance.
The Height of the ENEMAS During MOST enemas For HIGH enema No higher than 30 cm above rectum Up to 45 cm above rectum .
The TIME of the ENEMAS Cleansing Enema For Oil retention enema 5-10 minutes 30 minutes .
The Length of the ENEMA tube insertion The rectal tube is inserted 3 to 4 inches .
and some portion of the small intestines.Barium swallow PURPOSE: To assess for the esophagus. NURSING ALERT: NPO for 6-8 hours before the procedure Laxative is administered after the procedure to counteract the constipating effects of the barium Withhold anticholinergics and narcotics for 24 hours before the test Instruct patient to increase fluids and intake of fiber-rich foods . stomach.
NURSING KEYPOINTS: Check for informed consent Assess allergy to iodine NPO for 6-8 hours before the procedure Check for distal pulses after the procedure Check for bleeding at the arterial puncture site and apply pressure Keep a 20 lbs sandbag at the bedside as a pressure instrument if bleeding occurs Keep the patient flat on bed with the lower extremities hyperextended for 4-6 hours Neurovascular assessment must be performed distal to the catheter insertion site and report any abnormal findings . tension and pressure in various chambers of the heart. saturation. To determine a need for cardiac surgery.Cardiac catheterization PURPOSES: To measure oxygen concentration.
NURSING ALERT: Know the necessary facts: Principles Position Length of tube French number or Circumference Length of tube to be inserted Balloon size Male Supine 40 cm.Catheterization. 5-10 ml. urinary PURPOSE: To determine residual urine and obtain sterile specimen.66 in. #18 6-9 in. indwelling catheter. 5-10 ml Place to secure Inner thigh . #14. suprapubic. It can be a straight catheter.75 in./ 8./ 15.16 2-3 in. and external device catheter. (30 ml)Can be used to achieve hemostasis of the prostatic area following prostatectomy lower abdomen Female Dorsal recumbent 22cm.
The procedure is sterile Maintain a close system The draining bag must always be below the bladder The catheter bag should not be allowed to lie on the floor Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it .
Chest X-RAY PURPOSE: To detect abnormalities of the organs in the thoracic area NURSING KEYPOINTS: Remove any metallic object before the procedure Lead shield for women of childbearing age .
May be done with or without intravenous injection of dye for contrast enhancement . Cross-sectional visualization of the brain determined by computer analysis of relative tissue density as an x-ray beam passes through. infarcted areas. also known as computerized axial tomography (CAT) scan 2. atrophy.Computerized Tomography (CT) Definition 1. and vascular lesions 3. Provides valuable information about location and extent of tumors.
Computerized Tomography (CT) .
Computerized Tomography (CT) .
If the facility is small. Evaluate client's response to procedure . arrange transportation to a larger facility that has the required equipment 3. Evaluate for possible allergy to iodine.Computerized Tomography (CT) Nursing care 1. Withhold food for approximately 4 hours prior to testing. Remove wigs. inform the client that it will be necessary to lie still and that the equipment is complex but will cause no pain or discomfort. clips. infants and cognitively impaired or anxious clients may need to be sedated 2. and pins prior to the test 6. dye may cause nausea in sensitive patients 5. Explain procedure. a component of the contrast material 4.
assess for any allergy to iodine and instruct the patient to be on NPO for 4 hours prior to the procedure Assess for any fear of close spaces (claustrophobia) This procedure is contraindicated to patients who are pregnant and obese (>300 lbs) Let the patient lye still during the whole course of the procedure . NURSING ALERT: If contrast medium will be used.
CVP (Central Venous Pressure) monitoring PURPOSE: It measures the pressure of the Right Atrium NURSING KEYPOINTS: The nurse should place the zero level of the manometer at the level of the Right atrium at the 4th intercostals space to get an accurate reading Instruct the client to avoid coughing and straining as it alters the readings Normal CVP reading is 2-12 mm Hg ( when the tube is at the superior vena cava) .
If general anesthesia will be used have the client on NPO. Pink-tinged or tea-colored urine is expected.Cystoscopy PURPOSE: To assess the bladder and urethra NURSING KEYPOINTS: Check for the informed consent. Monitor intake and output. . Notify the doctor if bright red urine or clots occur. liquid diet if local anesthesia will be used. Administer sitz bath for abdominal pain. After: Force fluids as prescribed.
Doppler ultrasound PURPOSE: Evaluates patency of veins and arteries in the lower extremities. NURSING KEYPOINT: Inform the patient that it is painless. .
Doppler UTZ .
NURSING KEYPOINTS: Instruct the patient to lie still. ST segment elevation or T wave inversion. breathe normally during the procedure Let the patient refrain from talking during the test. ECG (Electrocardiogram) PURPOSE: Records electrical waves of the heart. indicates MI .
and anticonvulsants for 24-48 hours prior to the test . detects intracranial hemorrhage and tumors NURSING KEYPOINTS: Advise the client to shampoo hair before and after the procedure If the electrode gel is non removed by shampooing. the patient may use acetone Withhold stimulants. tranquilizers. EEG (Electroencephalogram) PURPOSES: Records the electrical activity of the brain. antidepressants.
/dl confirms diabetes. Fasting Blood Sugar level PURPOSE: Detects diabetes mellitus NURSING KEYPOINTS: Normal blood sugar level is 80-120 mg/dl A blood sugar level of more than 140 mg. .
and to rule-out pernicious anemia. It may also be done to analyze acidity. . Gastric analysis PURPOSES: This test is used to detect ulcers. Refrigerate gastric samples if NOT tested within 4 hours. In duodenal ulcer. appearance and volume of gastric secretions NURSING KEYPOINTS: In gastric ulcer. HCL is normal. HCL is elevated.
Check for allergy to iodine. IVP requires the use of a contrast medium while KUB does not. Inform the patient about the possible salty taste that may be experienced during the test. IVP (Intravenous pyelography) PURPOSE: Visualization of the urinary tract NURSING KEYPOINTS: Check for the consent. Increase fluid intake after the procedure to facilitate excretion of the dye. . Keep epinephrine at the bedside to counteract possible allergic reaction. NPO for 8-10 hours before the procedure Administer laxative to clear bowels before the procedure. seafoods or shellfish before the procedure since the procedure requires the use of iodine based dye.
. shape and position of kidneys. KUB PURPOSE: Determines the size. ureters and bladder. NURSING KEYPOINT: No special preparation needed.
exhale and hold breath during the insertion of to stabilize position of the liver and prevent accidental puncture of the diaphragm Position the patient on the Right side after liver biopsy with pillows underneath to prevent bleeding Bedrest for 24 hours after the procedure . NURSING KEYPOINTS: Check for the consent. Obtain the result of blood tests before biopsy since bleeding may occur Let the patient assume left side or supine during biopsy Instruct the patient to inhale. Liver biopsy PURPOSE: To determine liver disorders.
Increase fluid intake. . (fetal posistion) During the procedure: needle is inserted between L3 L4 or L4-L5 to prevent accidental puncture to the spinal cord since the spinal cord ends at L2. NURSING KEYPOINTS: Before the procedure: empty bladder and bowel. Position: C-position. Lumbar Puncture PURPOSE: To withdraw CSF to determine abnormalities. After: Position the patient flat for 6-12 hours to prevent spinal headache.
. lotion. talcum powder. Mammography PURPOSE: Detects the presence of breast tumor. NURSING KEYPOINTS: Instruct the patient not to use deodorant. perfume or any ointment on the day of exam as these may give false-positive result Let the patient know that her breasts will be compressed between 2 x-ray plates Provide teachings related to Self-breast examination Done 7 days after menstruation Position: lying down with pillow under the shoulder of the breast being examined or sitting in front of a mirror while raising the hands of the side of the breast being examined.
with treated TB. Mantoux test PURPOSE: A test to determine exposure to TB NURSING KEYPOINTS: A positive test yields an induration of 10 mm. Assess for previous history of PTB and report immediately to the doctor Result is read after 48-72 hours . or more for foreign born children below 4 years old An induration of 5 mm or more is considered positive in patients with HIV. BCG may cause false positive reaction. and if he has had a direct exposure TB Patients.
). . obesity (more than 300 lbs. MRI (Magnetic Resonance Imaging) PURPOSE: Provides cross-sectional images of brain tissues. NURSING KEYPOINTS: Contraindications: pregnant women. patients with unstable vital signs patients with metal implants like pacemaker. claustrophobic patients. hip replacements and jewelries. more detailed than a CT scan.
the globe of the eye. the spinal cord. This procedure utilizes magnetism and radio waves to produce images of cross-sections of the body 2. the heart. bone marrow. MRI can produce accurate images of blood vessels.Magnetic Resonance Imaging (MRI) Definition 1. and can monitor blood velocity . yielding data about the chemical makeup of the tissues 3. and breast tissue. abdominal structures. gray and white brain matter. The MRI machine registers the existence of oddnumbered atoms in the cross sections of the body.
Magnetic Resonance Imaging (MRI)
Nursing care 1. Assess ability to withstand confining surroundings because client must remain in the tunnel-like machine for up to 90 minutes; open MRI may be an option for clients who cannot tolerate closed spaces 2. Instruct client to toilet prior to test, since this will be impossible during the procedure 3. Advise client to remove jewelry, clothing with metal fasteners, dentures, hearing aids, and glasses prior to entering scanner
Magnetic Resonance Imaging (MRI)
4. Since this procedure is contraindicated for certain clients, before the test assess for: a. Metal prostheses, such as orthopedic screws, since the magnetic force can dislodge the devices b. Pacemakers, since the scanner deactivates pacemaker c. Dysrhythmias, because the magnetic field can affect the conduction system of the heart d. Unstable medical conditions, since monitoring of the client is limited during the test 5. Evaluate client's response to procedure
Stool analysis PURPOSE: Assessment of bacteria, virus, malabsorption and blood. NURSING KEYPOINT: Avoid aspirin, red meat and vitamin C three days before the test as these may give a false positive result.
Tonometry PURPOSE: Measures intraocular pressure. . NURSING KEYPOPINTS: Normal reading is 12-21 mm Hg A reading of 25 mm Hg indicates glaucoma.
(+) Glucose: Diabetes mellitus. Infection . SIADH (+) Protein: PIH. Use clean container Decreased specific gravity: diabetes insipidus Increased specific gravity: diabetes mellitus.Urinalysis PURPOSE: To assess characteristics of urine. dehydration. NURSING KEYPOINTS: First voided morning sample preferred: 15 ml. nephrotic syndrome.
but for most purposes doesn’t make much difference .Urine Collection As fresh as possible Mid stream clean catch First morning specimen best.
Hematuria Even small amounts of blood are visible 1 part per 1000 is easily seen .
adrenal glands and the stomach. Discard the first voided urine Place urine output in a clean container preserved in ice chest .Urine collection. NURSING KEYPOINT: Required for ACTH test and schilling‟s test (B12 absorption). 24 hour PURPOSE: Determines the excretion of substances from the kidneys.
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