SUPPLEMENTS FOR

THEORETICAL
FOUNDATIONS
SAFE AND EFFECTIVE CARE ENVIRONMENT
HEALTH PROMOTION AND MAINTENANCE
FUNDAMENTAL CONCEPTS
REDUCTION OF RISK POTENTIAL
THERAPIES AND PROCEDURES
 MANAGEMENT OF CARE
 COMPETENCE,CONFIDENTIALITY AND
PRIVACY
 ADVOCACY AND ACCOUNTABILITY
 RESPECTFUL CARE AND
RESPONSIBILITY
 PROTECTED ELATIONSHIP AND
PROMOTION OF PUBLIC HEALTH
 ETHICAL STANDARDS OF CARE
 INFORMED CONSENT
 CAPACITY AND COMPETENCE
 INCLUDES EXPLANATION OF
 BENEFITS, EXPECTED
RESULTS,ALTERNATIVES AND RISK
 VOLUNTARY
 INFORMATION UNDERSTOOD
 CANNOT SIGN IF UNDER ALCOHOL
OR PREMEDICATED
 Which statement about
consent is not accurate:
 It includes explanation of benefits
and disadvantages
 It states that consent cannot be
withdrawn anytime
 It requires a competent adult who
can make voluntary choices
 Married minors and pregnant minors
can sign own consent for treatment
 MANAGED CARE
 WORK ALLOCATION
 PATIENT NEEDS AND CONDITIONS
 ABILITIES OF STAFF
 CONTINUITY OF CARE
 KNOWLEDGE OF STAFF AND QUALIFICATIONS\
 RIGHT TASK- FUNCTION , ACTIVITY ,
DECISION…….INFORMATION ,
SUPERVISION , FOLLOW-UP
 DON’T DELEGATE ASSESSMENT,TEACHING
EVALUATION,PLANNING
 DELEGATION
 BUILDS TRUST
 EMPOWERS OTHERS
 TEACHES AN MOTIVATES
 TEAMWORK DEVELOPS
 ENHANCE COMMUNICATION
 RAPID PRODUCTIVITY AND RAISED
SKILL
WHICH OF THE FOLLOWING
IS NOT TRUE ABOUT
MANAGED CARE?
 In delegation , responsibility is transferred,
accountability is shared
 Responsibility is determined by Nurse
practice acts, standards of care, job
description and policy statement
 In delegating identify variables
nevertheless this would not change
authority and responsibility
 Delegate to the lowest person on
heirarchy that has the required skills and
abilities who is allowed to do the task
 Example: “ feed client if
coherent and awake, if
confused do not feed and
notify me asap.
SCOPE
 R.N.-
 PLANNING AND HEALTH TEACHING
 LICENSURE REQUIREMENTS
 ASSESSMENT AND EVALUATION
 NEED FOR KNOWLEDGE AND SKILL
 LPN/LVN-
 STABLE PATIENTS
 STANDARD UNCHANGING PROCEDURES
 SIMPLE MONITORING AND IMPLEMENTATION
 SEQUENCED/PREDICTABLE OUTCOMES
 STATE PRACTICE ACT INCLUSION
 UAP-DIRECT PATIENT CARE ACTIVITY AND
STANDARD OPERATING UNCHANGING
PROCEDURES
 INCIDENT REPORTS
 SEQUENCE-UNEXPECTED OR UNPLANNED
OCCURENCE
 RISK MANAGER
 SITUATIONS-STATEMENT OF FACTS AND
PATIENT PHYSICAL RESPONSE

 ACTUAL AND POTENTIAL-REPORT WITHIN

24 HOURS-INVESTIGATION OF REFERRING
TEAM MANAGEMENT(RISK MANAGER)
In writing an incident report
the nurse manager should
state the following
guidelines on charting
 Don’t include except
words such as error or
inappropriate
 Don’t include judgemental
statements
 Only actual risks should be reported
within 24 hours to the risk manager
 Documentation of clients status
should be continuous
 RESTRAINTS
 LIABLE FOR FALSE IMPRISONMENT

 LAST RESORT
 INFORMED CONSENT(PROXY)
 ALTERNATIVE MEASURES FIRST
 BENEFITS> RISKS
 LENGTH OF TIME AND CIRCUMSTANCES
SPECIFIED
 ENSURE SAFETY – CIRCULATION
CHECKS,SKIN CARE, ROM AND REMOVE
Q2H
 RESTRAINTS IS USED
FOR:
 THE PURPOSE OF DISCIPLINE
 COMFORT AND CONVENIENCE OF
PROVIDER
 REQUIRED TO TREAT MEDICAL SYMPTOMS
 ENSURE USED TO CONTROL BEHAVIOR
 PREVENT BREACH IN SAFE AND EFFECTIVE
DELIVERY OF MEDICAL THERAPY.
 ENSURE SAFETY OF OTHER PATIENTS
 MEDIUM OF LIMIT SETTING AND
PROVISION OF EXTERNAL CONTROLS
 COMPLAINTS
 COMPROMISE / COLLABORATIVE
AGREEMENT
 LISTEN ATTENTIVELY
 EXPLAIN SCOPES AND LIMITATIONS
 ASK AND RELAY EXPECTED
SOLUTIONS AND TERMS
 NON-DEFENSIVE
 A CLIENT WHO IS ABOUT TO BE BATHED BY A
NURSE STATES;”You are too young to know
how to do this, get me someone who knows
what they are doing”.the nurse best response
is:
 We do this procedure daily, I have
done this several times, tell me what
are you afraid of?
 I can see you are upset , can we talk
about it?
 You’re concerns show you are upset,
we will talk about this after I have
demonstrated the procedure.
 Can you be more specific about
you’re concerns?
 Health teaching
 C-CONSIDER SUPPORT SYSTEMS /
COMPLIANCE
 H- olds MOTIVATION AND INSIGHT
 A- ALLOW FEEDBACK
 N-NEEDS MET AND ASSURED
 G- GOALS AND PRIORITIES SET w/
pnt.
 E- EMPATHETIC AND ENSURES
COLLABORATION
 Patient Education
Type of learning:
Cognitive
Psychomotor
Affective

Patients motivation –PRIORITY

FACTORS – DURATION , COMPLEXITY AND SIDE EFFECTS

Discharge planning
 Begins with first encounter
 Functional level considered
Referrals and preferrences
 Compromised plan
 WHAT IS THE BEST GAUGE
THAT THE CLIENT
UNDERSTANDS DISCHARGE

TEACHING?
PATIENT VERBALIZES INTEREST
 PATIENT ASKS QUESTIONS RELATED TO
ADAPTATION TO NEEDED CHANGE IN
BEHAVIOR
 ACCURATE DEMONSTRATION OF
PROCEDURE
 PLANS FOR PRACTICE SESSIONS RELATED
TO HEALTH CARE SUGGESTIONS TAUGHT
BY THE R.N.
 SAFETY AND INFECTION
CONTROL pg.27-49
 UNIVERSAL PRECAUTIONS
 STANDARD PRECAUTIONS – BARRIER

 COMMUNICABLE DISEASE CONCEPTS

 CLINICAL MANIFESTATIONS-
INITIAL,PATHOGNOMONIC/OUTSTANDING
 DIAGNOSTIC TESTS AND ETIOLOGY
 CARE ESSENTIALS AND IMPLICATIONS
 MANAGEMENT
 SEQUELAE
 POISONING

 CHILD PROOF
 REFER - POISON CONTROL CENTER
 IDENTIFY AND BRING AGENT
 SECURE SAFETY AND ABC’S
 INDUCE VOMITING W/ IPECAC
 STOP/DELAY ABSORPTION W/
WATER/MILK/ACTIVATED CHARCOAL
THE NURSE SHOULD INTERVENE IF
A MOTHER OF A VICTIM OF
POISONING VERBALIZES TO DO
THE FOLLOWING:
 PLANS TO INDUCE VOMITING FOR PATIENT
WITH ASPIRIN POISONING
 PLANS TO INDUCE VOMITING WHEN SHE IS
CERTAIN THAT HER CHILD’S GAG REFLEX
AND LOC ARE INTACT
 WILL NOT GIVE IPECAC IF CHILD IS
EXHIBITING NARROWED PULSE PRESSURE
 WILL WAIT FOR THE SEIZURE TO END
BEFORE ADMINISTERING IPECAC
 CONTRAINDICATIONS OF
IPECAC / INDUCTION OF
VOMITING
 SEIZURE
 SUBNORMAL LOC AND GAG REFLEX
 SUBSTANCE CORROSIVE/PETROLEUM
DISTILATE
 SHOCK-SEVERE
 DISASTER PLANNING
 TRIAGE-GREATEST GOOD FOR THE
GREATEST NUMBER OF PEOPLE
 PRINCIPLES- ABCD , MASLOWS

 RED-UNSTABLE – IMMEDIATE CARE

 YELLOW- STABLE – CAN WAIT 30-60 MIN
 GREEN –STABLE- CAN WAIT LONGER
 BLACK- UNSTABLE – FATAL, LAST SEEN
 DOA – SUPPORTIVE COMFORT MEASURES
DURING FIRE WHICH SET OF
PATIENTS WILL THE NURSE
MOBILIZE FIRST
 AMBULATORY
 BEDRIDDEN
 CRITICAL
 TERMINAL
 WHICH STEP IN FIRE
MANAGEMENT COMES
LAST?
 ALARM
 CONTAIN
 MOBILIZE
 EXTINGUISH
PREVENTION AND EARLY
DETECTION OF DISEASE
 GROWTH AND
DEVELOPMENT
 DEVELOPMENTAL TASKS---MILESTONES ----
DELAYS(FIXATIONS/LAG)

 IQ = MA / CA X 100
 JUDGEMENT , COMPREHENSION AND
LISTENING

 DDST – BIRTH TO 6 YEARS

 PERSONAL SOCIAL, FINE , GROSS MOTOR AND
LANGUAGE SKILL AREAS
 HEALTH SCREENING
 OB – GYNE / REPRODUCTIVE TESTS
 UTZ-5 WKS CONFIRM PREGNANCY AND AOG
 AMNIOCENTESIS – 16 WKS-DETECT GENETIC DISORDERS
– 30 WEEKS – L/S RATIO ( 2-4 WKS RESULT)(EMPTY
Bladder)
 OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-
20 MIN----3 CONTRACTIONS OBTAINED WITHIN 10
MINUTES- REACTIVE
 NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR
ACCELERATION OF 15BPM/MORE LASTING 15 SECS -20
MINS. AND RETURN OF FHR TO NORMAL/BASELINE –
REACTIVE
 DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION)
 AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE
DEFECTS – 16-18 WKS
 CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-
12 WKS
NEWBORN/INFANT HEALTH
SCREENING
 PKU – GUTHRINE BLOOD TEST-EAT
CHON FOR 2 DAYS
MIN.(PHEONISTICS – DIAPER)
 SICKLE CELL DISEASE –ABNORMALLY
SHAPED Hg ,
 ELISA AND WESTERN BLOT
 CARRIER SCREENING FOR CYSTIC
FIBROSIS AND SWEAT CHLORIDE
TEST
 SCHOOL AGE
 HEARING AND VISION TESTS
 ALLEN PICTURE CARDS
 SNELLEN CHART-20/40 AT TODDLER
AND 20/20 AT SCHOOL AGE
 WEBER’S-SENSORINEURAL AND
CONDUCTIVE
 RINNE’S- CONDUCTIVE

 DENTAL EXAM – STARTS AT 2 YEARS

 ADOLESCENT
 PPD – INDURATION – 72 HOURS
 BSE – (18-20 YRS.) POST
MENSTRATION/MONTHLY
 TSE – MONTHLY (18-20 YRS)
 PELVIC EXAM WITH PAP SMEAR – IF
SEXUALLY ACTIVE OR 18 Y.O.
ANNUALLY
 ADULT/ELDERLY
 HPN , DM, HEARING AND VISION
 PROSTATE –ANNUALLY@40
 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO
 SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS
 FECAL OCCULT BLOOD TEST- > 50 =
ANNUALLY
 DIGITAL RECTAL EXAM - > 40 Y.O. =
YEARLY
 PELVIC EXAM – 18-40 Y.O. =PERFORMED Q
1 – 3 YEARS WITH PAP TEST
 MAMMOGRAM – 35-39 = BASELINE
40-49 = Q2Y
50 AND OLDER = QYEAR
 BP SCREENING(mmHg)
SYSTOLIC DIASTOLIC FOLLOW-UP

< 130 <85 2 YEARS

130-139 85-89 1 YEAR

140-159 90-99 2 MOS.

160-179 100-109 EVALUATE AND

REFER 1 MOS.

180-209 110-119 1 WEEK

>210 120 IMMEDIATELY
 IMMUNITY pg 127-130
 CONTRAINDICATIONS:
 SEVERE FEBRILE ILLNESS
 LIVE VIRUSES C/I FOR IMMUNOCOMPROMISED
 ALLERGIES
 RECENTLY ACQUIRED PASSIVE
IMMUNITY(BLOOD TRANSFUSION AND
IMMUNOGLOBULINS)
 if child –no evidence of immunization <7
y.o.
 Give DPT,TOPV,TINE
 4-6 WKS LATER MMR
 1 MONTH AFTER DPT AND TOPV
 REPEATED IN ANOTHER MONTH
 AGAIN IN 10-16 MOS.
 CAN GIVE DPT,MMR,TOPV, AND TINE
 TD- 2 DOSES 4-8 WKS APART;3RD DOSE 6-
12 MOS;BOOSTER AT 10 YRS FO LIFE
 OPV/IPV – 2 DOSES AT 4-8 WKS APART ;
3RD DOSE 2 -12 MOS AFTER 2ND(OPV NOT
USED IN US)
 MMR-ONE DOSE – 12 MOS
 VARICELLA – TWO DOSES 4-8 WEEKS
APART STARTS AT 12 MOS.
 HEPA B – 3 DOSES;2ND 1-2 MOS AFTER;3RD
4-6 MS AFTER
 PPV- ONE DOSE ;IF 65 AND RECEIVED >
5YEARS – ADMINISTER
 INFLUENZA –ANNUALLY EACH FALL
 ALLERGY
CONTRAINDICATIONS
 EGGS – INFLUENZA , MMR
 NEOMYCIN – VARICELLA,IPV,MMR
 YEAST – HEPA-B
 GELATIN – VARICELLA

 PREGNANCY C/I: MMR AND VARICELLA

 IMMUNOSUPPRESSED; VARICELLA
 WITH Ig or BT PREVIOUS 3-11 MOS – MMR
AND VARICELLA
 CONSIDERATIONS-
IMMUNIZATION
 DPT - IM – ANTERIOR OR LATERAL THIGH
 FEVER AND SWELLING 24-48 H POTENTIAL
 SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC
AND SCREAMING
 MMR – SC – ANTERIOR OR LATERAL THIGH
 RASH, FEVER ARTHRITIS-10DAYS-2 WKS
 TRIVALENT OPV – PO

 PPD-ID- 4-6/11-16YRS.OLD IN HIGH

PREVALENCE AREAS – EVALUATED 48-72
HOURS
 PHYSICAL ASSESSMENT
 TEACHING OPPURTUNITY
 INSPECTION –VISUALLY
 PALPATION-WARM HANDS
 DORSUM OF FINGERS FOR TEMP
 PERCUSSION-DIRECT,INDIRECT,BLUNT
 RESONANCE-MODERATE LOW PITCHED CLEAR
HOLLOW(LUNG)
 HYPERRESONANCE-OVERINFLATED(EMPHYSEMA)
 TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL)
 DULL-SOFT MUFFLED,DENSE FLUID FILLED
TISSUE(LIVER)
 FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-
(MUSCLE/BONE)
 AUSCULTATION-
 DIAPHRAGM-HIGH
PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW
 VITAL SIGNS
 TEMPERATURE:
 ORAL – 98.6 ‘F / 37 ‘C
 RECTAL – 99.6 ‘F / 37.6’C

 AXILLARY – 97.6’F / 36.5’C


 NORMAL VITAL SIGNS
NEWBORN=30 – 50 / MIN; 120 – 140 / MIN;
60/40 – 80/50 mmHg

 1 – 4 YEARS=20 – 40 / MIN; 80 – 140

/MIN; 90/60 – 99/65 mmHg

 5 – 12 YEARS=15 – 25 / MIN; 70 – 115 /

MIN; 100/56 – 110/60 mmHg

 ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90

60 –140 / 90 mmHg
 BREATHING PATTERNS
 CHEYNE STOKES – PERIODIC BREATHING
CHARACTERIZED BY RHYTMIC WAXING AND
WANING
 DYSPNEA - LABORED PAINFUL BREATHING
 HYPERVENTILATION – ABNORMALLY RAPID DEEP
PROLONGED BREATHING
 KUSSMAULS – AIR HUNGER , MARKED INCREASE
IN DEPTH AND RATE
 TACHYPNEA – FAST SHALLOW BREATHING
 PARADOXICAL – FLAIL CHEST , DEFLATES DURING
INHALATION
 BIOT’S – SHALLOW BREATHS INTERRUPTED BY
APNEA
 NORMAL FINDINGS
 PULSE PRESSURE – 30-40 mmHg
 Intracranial pressure – 10 mmHg
 PULSE DEFICIT – MINIMAL(3-5
ACCEPTABLE)

 IDEAL BODY WEIGHT –

 MALES -106 LBS FOR 1ST 5FT THEN ADD
6LBS/INCH
 FEMALE – 100LBS FOR 1ST 5 FT THEN ADD
5LBS/INCH
 ADD OR SUBTRACT 10% DEPENDING ON BODY
FRAME.
 OBESE AND UNDERWEIGHT IF DEVIATION IS >
20%
 SKIN
 SCARS,BRUISES AND LESIONS
 CHECK COLOR
 EDEMA – GRADING
 0-NO EDEMA
 1-BARELY DETECTABLE
 2-INDENTATION<5MM
 3-INDENTATION 5-10MM
 4-INDENTATION >10MM
 PRESSURE SORE –GRADING
 1-NONBLANCHABLE ERYTHEMA
 2-EPIDERMIS,PARTIAL THICKNESS
 3-FULL DERMIS AND SQ
 4- SUPPORTING TISSUES AND BONES
 TURGOR-PINCH SKIN TENTED 3 SECS
NORMAL(ELDERLY-OVER STERNUM)
 HAIR AND NAILS
 HIRSUTISM-EXCESS
 ALOPECIA-THINNING

 SHAPE – NORMALANGLE OF NAIL

BED-160’; CLUBBING ANGLE > 180
DUE TO PROLONGED DECREASED
OXYGENATION
 BLANCHING =< 3 SECS-NORMAL
 HEAD
 SYMMETRY, SIZE AND SHAPE
 CRANIAL NERVE ASSESSMENTS
 OPTIC-SNELLEN
 OCULOMOTOR- PERRLA
 TRIGEMINAL – BITE DOWN AND STROKES WITH
COTTON
 FACIAL – FACIAL MOVEMENT AND TASTE
 ACCOUSTIC – HEARING AND BALANCE(WATCH
TICK TEST,OTOSCOPIC EXAMS AND POSTURE
TESTS)
 GLOSSOPHARYGEAL-GAG AND SWALLOW
 VAGUS- SWALLOWING AND SPEAKING
 EYES
 PTOSIS-DROOPING OF THE UPPER EYELID
 ASTIGMATISM – UNEVEN CURVATURE OF CORNEA
LEADING TO REFRACTION ERRORS
 NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE
MOVEMENTS
 STRABISMUS-ASSYMETRICAL LIGHT EFLECTION
ON EACH CORNEA
 RED REFLEX FROM RETINA-NORMAL
 COVER UNCOVER TEST – DET.EYE ALIGNMENT
 SNELLEN – FAR DISTANCE VISION/VISUAL ACUITY
 IOP-TONOMETRY TESTS INDENTATION(6-12)
 EARS
 PINNA BACK-UP-ADULT;DOWN-BACK-CHILD
 RINNE TEST – COMPARES AIR
CONDUCTION WITH BONE
CONDUCTION,VIBRATING FORK PLACED
ON THE MASTOID IF SOUND NO LONGER
HEARD POSITIONED IN FRONT OF EAR
CANNAL. SHOULD HEAR A SOUND= 2:1 ;
AIR CONDUCTION > THAN BONE
CONDUCTION ;= POSITIVE RINNE
 ASSESS CONDUCTIVE HEARING LOSS
 EARS
 WEBER – SENSORINEURAL AND
CONDUCTIVE HEARING LOSS
 FORK PLACED MIDDLE OF FORE HEAD,SHOULD
BE HEARD EQUALLY=WEBER NEGATIVE
 IF NOT EQUAL=SENSORINEURAL HEARING
LOSS.
 SOUND HEARD BETTER IN THE IMPAIRED
EAR=BONE CONDUCTIVE HEARING LOSS, IF
VICE VERSA = SENSORINEURAL DISTURBANCE
 NECK,MOUTH AND
PHARYNX
 TEETH-32
 TONSILS – NO TPC , + GAG REFLEX
 CERVICAL LYMPH NODES=<1CM
 CAROTID – PALPATE THRILL,LISTEN
BRUIT
 JUGULAR VEINS – NOT DISTENDED
 TRACHEA-MIDLINE
 THORAX AND LUNGS
 APL DIAMETER-1:2 – 5:7
 1:1 = BARREL CHEST
 TACTILE FREMITUS NORMAL-
BRONCHOPHONY,EGOPHONY AND WHISPERED
PECTORILOQUY-CONSOLIDATION OF LUNGS
 BREATH SOUNDS
 VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –
PERIPHERAL LUNG SURFACES
 BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM
BRONCHI
 BRONCHIAL- LOUD COARSE - TRACHEA
 ADVENTITIOUS BREATH SOUNDS
 RALES-FINE SHORT,CRACKLING OR HIGH PITCHED
SOUNDS-INSPIRATION
 RHONCHI-CONTINOUS LOW PITCHED COARSEGURGLING
HARSH SNORING BEST HEARD ON EXHALATION
 WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION
 STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON
INHALATION
 FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ LIKE
VIBRATIONS – BOTH INHALATION AND EXHALATION
 HEART SOUNDS
 AORTIC AND PULMONIC VALVE AREAS- 2ND
ICS, R AND L RESPECTIVEY
 ERBS POINT 3RD ICS
 TRICUSPID AREA-4TH / 5TH ICS
 MITRAL AREA – 5TH ICS , LEFT MCL
 PMI-5TH ICS MCL –(INFANTS-LATERAL TO
LEFT NIPPLE-4TH ICS)
 S1LUBB-CLOSURE OFAV VALVES
 S2DUBB-CLOSURE OF SEMILUNAR VALVES
 MURMURS , GALLOP-ABNORMAL HEART
SOUNDS
 PERIPHERAL VASCULAR
SYSTEM
 ASSESS
PAIN,PALLOR,PARALYSIS,PARESTHESI
ASAND PULSES.
 ASSESS HOMAN’S SIGN
 PULSE DEFICIT
 BREASTS
 START – UPPER OUTER CLOCKWISE
 ASSESS FOR SIZE,SHAPE,SYMMETRY
AND NODES
 ABDOMEN
 DORSAL RECUMBENT
 INSPECT,AUSCULTATE,PERCUSS AND
PALPATE
 BOWEL SOUNDS-HIGH PITCHED GURGLES
HEARD AT 5 – 20 SECOND INTERVALS( 5-
25/MIN NORMAL)
 IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5
MINS. MORE. SEQUENCE IS CLOCKWISE
FROM RLQ
 HYPOACTIVE < 3
 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT
 TINKLING SOUND – BOWEL OBSTRUCTION
 ABDOMEN
 REBOUND TENDERNESS-
INFLAMMATION OF PERITONEUM

 KIDNEYS- DORSAL LUMBAR AREA –

COSTOVERTEBRAL ANGLE

 KIDNEY PUNCH TEST

 MUSCULOSKELETAL
 SYSTEM
MUSCLE TONE AND STRENGTH
 0=COMPLETE PARALYSIS
 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE
PALPABLE/VISIBLE
 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH
SUPPORT
 3=50% - NORMAL MOVEMENT AGAINST GRAVITY
 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH
MINIMAL RESISTANCE
 5=100%-NORMAL FULL MOVEMENT WITH FULL
RESISTANCE

 JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS

ARE ABNORMAL
 FASCICULATION ABNORMAL CONTRACTIONS AND
SHORTENING OF MUSCLE FIBERS
 TREMOR-INVOLUNTARY TREMBLING
 TEST FOR ROM AND ASSESS FOR
 NEUROLOGIC TESTS
 MENTAL STATUS-
 LANGUAGE-CEREBRAL CORTEX-APHASIA
 ORIENTATION(TIME,PLACE,PERSON)(CONFUSION)
 MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND
REMOTE MEMORY
 ATTENTION SPAN AND CALCULATION
 JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL VIEWS
 PERCEPTION – SENSORY ANALYSIS AND INTEGRATION
 CEREBELLAR FUNCTION- COORDINATION , POINT
TO POINT TOUCHING,ALTERNATING
MOVEMENTS,GAIT
 CRANIAL NERVE FUNCTIONS
 SENSORY FUNCTION(e.g. PROPRIOCEPTION-
POSITION SENSE- RHOMBERG’S TEST)
 NEUROLOGIC TESTS
 DEEP TENDON REFLEX
 0-NO REFLEX
 +1 – MINIMAL ACTIVITY(HYPOACTIVE)
 +2 – NORMAL RESPONSE
 +3 – MORE ACTIVE THAN NORMAL
 +4 – MAXIMUM ACTIVITY
( HYPERACTIVE)
 PRESENCE OF INFANTILE
REFLEXES(BABINSKI) IN AN ADULT
SIGNIFIES CNS PATHOLOGY
 LEVEL OF
 CONSCIOUSNESS
GLASGOW COMA SCALE=15 POINTS, 7 COMA
 EYE OPENING
 SPONTANEOUS=4
 TO VERBAL COMMAND=3
 TO PAIN=2
 NO RESPONSE=1
 MOTOR RESPONSE
 TO VERBAL COMMAND=6
 TO PAINFUL STIMULI/LOCALIZES PAIN=5
 FLEXES AND WITHDRAWS=4
 DECORTICATE=3
 DECEREBRATE=2
 NO RESPONSE=1
 VERBAL RESPONSE
 ORIENTED,CONVERSES=5
 DISORIENTED,CONVERSES=4
 USES INAPPROPRIATE WORDS=3
 USES INCOMPREHENSIBLE SOUNDS=2
 NO RESPONSE=1
 ASSESSING MOTOR
 FUNCTION
WALKING GAITS
 ROMBERGS TEST- STAND FEET TOGETHER
ARMS RESTING AT THE SIDES,EYES OPEN THEN
CLOSED. NEG. ROMBERG – MAY SWAY BUT
KEEPS BALANCE.
 SENSORY ATAXIA-CANNOT BALANCE EYES SHUT
 CEREBELLAR ATAXIA-CANNOT BALANCE EYES SHUT
OR EPON
 HEEL-TOE WALKING AND VICE VERSA
 FINGER TO NOSE TEST AND OTHER SENSORY
FUNCTION TEST (ONE AND TWO POINT
DISCRIMINATION)
 EXTINCTION PHENOMENON-SYMMETRICAL
AREAS ARE TOUCHED BUT SENSATION ON ONE
SIDE CANNOT BE FELT INDICATES LESIONS OF
SENSORY CORTEX
 GENITALIA , ANUS AND
RECTUM
 ASSESS APPEARANCE AND ORIFICES AND
INGUINAL LYMPH NODES
 INSPECT CERVICAL OS AND VAGINA-SPECULUM
 DEVIATIONS
 CYSTOCELE, RECTOCELE,ENTEROCELE
 HYPO AND EPISPADIAS-URETHRAL OPENING DISPLACED
 HERNIAS-DIRECT,INDIRECT , FEMORAL
 INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE
 DIGITAL RECTAL EXAM –INSPECTION AND
PALPATION –POSITION BOTH=SIM’S , FEMALES –
LITHOTOMY;MALES =STAND AND BEND
FORWARD
 PROSTATE GLAND-4 CM ;CERVIX = 2-3 CM
 HEMORRHOIDS =DILATED VEINS
MOBILITY AND IMMOBILITY
 POSTURE AND BODY ALIGNMENT-ERECT
 JOINT MOVEMENTS=RANGE OF MOTION
 CONNECTIVE TISSUE
 BONE TO BONE-LIGAMENT
 BONE TO MUSCLE – TENDON
 COVERS BONES/JOINTS - CARTILAGE
 TYPES OF JOINT
 SYNARTHROSES(CARTILAGENOUS)
 DIARTHROSES( SYNOVIAL)
 AMPIARTHROSES(FIBROUS)
ERGONOMICS-BODY POSITIONING
AND MECHANICS
 PRIORITY-ASSESS PERSONAL CAPACITY 1ST
 USE PROTECTIVE DEVICES/ TRANSFER AIDS
 CHANGE POSITION SLOWLY-ORTHOSTATIC
HYPOTENSION(DANGLE LEGS FIRST)
 PIVOT ON THE STRONGER SIDE,MOVE PNT
TOWARDS STRONGER SIDE
 USE LARGER MUSCLES OF THE BODY AND FACE
THE DIRECTION OF THE MOVEMENT
 PULL SHEETS ARE BETTER METHOD THAN
SLIDING
 ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE
AN ASSISTANT STANDING BY.
 ROCK FROM FRONT TO BACK/VICE VERSA.WIDE
BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF
THE BODY.USE APPROPRIATE TRANSFER AND
AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE
BOARD, DRAW SHEET AND TRANSFER BELT
THERAPEUTIC EXERCISES
 PASSIVE ROM-RETENTION OF ROM AND
MAINTENANCE OF CIRCULATION
 ASSISTIVE- INCREASES MOTION ,
MAINTAINS MUSCLE TONE
 ACTIVE – MAINTAINS MOBILITY OF THE
JOINT AND MAINTAINS MUSCLE STRENGTH
 RESISTIVE – INCREASES MUSCLE POWER
 ISOMETRICS- MAINTENANCE OF STRENGTH
AND PREVENTS MUSCULAR ATROPHY
 DANGERS OF
IMMOBILITY
 DECUBITUS ULCER-OSTEOMYELITIS
 OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND
RENAL CALCULI
 INCREASED CARDIAC WORKLOAD- TACHYCARDIA
 CONTRACTURES- DEFORMITIES
 THROMBUS FORMATION-PULMONARY EMBOLISM
 ORTHOSTATIC HYPOTENSION-
WEAKNESS,FAINTNESS AND DIZZINESS
 RESPIRATORY STASIS – HYPOSTATIC PNEUMONIA
 CONSTIPATION – FECAL IMPACTION
 URINARY STASIS-URINARY RETENTION
 NEGATIVE NITROGEN BALANCE-WEIGHT
LOSS/DEBILITATION
 SPECIFIC THERAPEUTIC
POSITION
 HIGH FOWLERS-60-90’
 FOWLER-45-60’
 SEMI-FOWLERS-30-45’
 LOW-FOWLERS-15-30’
 SUPINE
 DORSAL RECUMBENT
 LITHOTOMY
 TRENDELENBURG
 SIMS LATERAL
 MODIFIED TRENDELENBURG
 PRONE
 KNEE-CHEST
 SIDE-LATERAL
 ORTHOPNEIC
 ASSISTIVE DEVICES
 CRUTCHES
 CRUTCH HEIGHT-
 STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA
OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF
THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5
CM
 TEACH MUSCLE STRENGTHENING EXERCISES
PRIOR TO AMBULATION.WEIGHT ON THE HAND
GRIP (TO AVOID CRUTCH PALSY)
 ELBOWS SHOULD BE FLEXED 20-30’ AND
CRUTCHES SHOULD BE KEPT 6 INCHES
LATERALLY AND 6 INCHES TO THE
FRONT=TRIPOD POSITION(8-10 INCHES-OK)
 INSTRUCT CLIENT TO MAINTAIN AN ERECT
POSTURE
 CRUTCH WALKING GAITS
 FOUR POINT-SLOW SAFE-WEIGHT BEARING
ALLOWED FOR BOTH LEGS
 TWO POINT- FASTER SAFE-WEIGHT BEARING
ALLOWED FOR BOTH LEGS
 THREE-POINT-NON WEIGHT BEARING OF ONE
LEG
 SWINGTO/SWINGTHROUGH-PARTIAL WEIGHT
BEARING ALLOWED FOR BOTH LEGS
 GETTING INTO A CHAIR –BOTH CRUCHES TO
THE WEAK SIDE , STRONGER ARM HOLDS THE
ARMREST
 GOING UP AND DOWN THE STAIRS- GOOD
GOES UP 1ST AND BAD GOES DOWN 1ST.
 WALKER-
 PROVIDES STABILITY AND BALANCE
 MOVE WALKER AHEAD 15 CM
(6INCHES-8-10 INCHES)WHILE
WEIGHT IS BORNE BY BOTH
LEGS.THEN ALTERNATE WEIGHT
BEARING ASSISTED BY THE ARMS
 ELBOWS SHOULD BE FLEXED-20-30’
 IF ONE LEG IS WEAKER MOVE THAT
LEG TOGETHER WITH THE WALKER
 CANE
 HOLD CANE ON THE STRONGER SIDE
 FLEX ELBOW 30’ AND TIP OF CANE 15 CM
LATERAL TO THE SIDE OF THE 5TH TOE.
 ADVANCE CANE AND AFFECTED LEG
,WEIGHT ON CANE WHEN MOVING THE
GOOD LEG
 BUT FOR MAXIMUM SUPPORT ADVANCE
CANE 1 FEET ,MOVE AFFECTED LEG THEN
THE STRONGER LEG
 GOING UP AND DOWN THE STAIRS –SAME
WITH CRUTCHES
 NUTRITION
 PREMATURE INFANTS-LESS
THAN37WKS/2,500G-100-200
CAL/KG/DAY AND HIGHER Na,Ca AND
CHON
 FULL TERM-120 CAL/KG/DAY
 PREGNANCY + 300CAL/DAY
 LACTATION+ 500CAL/DAY
 ENTERAL FEEDINGS
 CONDITIONS
 PREOPERATIVE NEED FOR NUTRITIONAL SUPPORT
 GI PROBLEMS
 ONCOLOGY THERAPY
 ALCOHOLISM,CHRONIC DEPRESSION AND EATING
DISORDERS
 HEAD,NECK DISORDERS OR SURGERY
 COMPLICATIONS
 ASPIRATIONTUBE DISPLACEMENT
 CRAMPING,VOMITING,DIARRHEA
 HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE
INTOLERANCE
 TOTAL PARENTERAL
NUTRITION
 TYPES OF SOLUTIONS
 TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE
BACTERIAL FILTER USED
 TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID,
DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTER

 PERIPHERAL=NO >10% DEXTROSE AND 2 WKS

ONLY
 CENTRAL – INCOMPATIBLE WITH MEDS AND
BLOOD IF SINGLE LUMEN USED
 ATRIAL-HICKMAN/BIOVAC AND GROSHONG-
HUBBER NEEDLE USED TO ACCESS PORT
THROUGH SKIN
 TPN
 INITIAL RATE OF INFUSION 50 ML/HR THEN 100-
125/HR.
 COMPLICATIONS-HYPEROSMOLAR COMA, SEPSIS,
PNEUMOTHORAX
 FAST RATE=HYPEROSMOLAR
STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS)
 SLOWED RATE=REBOUND HYPOGLYCEMIA
 X-RAY CONFIRMS PLACEMENT ATTACH TO PUMP
 IV TUBING AND FILTER CHANGED Q24 HOURS
 ALLOW SOLUTION TO WARM IMMEDIATELY
BEFORE USE
 IF NO SOLUTION USE DEXTROSE 10% W
SOLUTION
 CHECK DAILY CBG,WEIGHT,TEMP. I AND O ,
 CHECK 3X A WEEK BUN, ELECT,
 ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND
 OSTOMIES
 PERMANENT/TEMPORARY
 STOMA RED AND SLIGHT BLEEDING WHEN
TOUCHEDBURNING SENSATION UNDER
FACEPLATE INDICATES SKIN BREAKDOWN,REFER
ABDL DISTENTION/DISCOMFORT,
 KARAYA POWDER(DEC.IRRITATION),
CHARCOAL/BISMUTH CARBONATE-DEODORIZER
 APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-
72H AND 24-48H IFPERIOSTOMAL SKIN
ERYTHEMATOUS, ERODED
 ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO
THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODOR
 COLOSTOMY-FORMED , CAN BE IRRIGATED 300-
500ML AND REGULATED,MAY NOT HAVE TO
WEAR AN APPLIANCE
 URINARY ELIMINATION
 BUN – 10-20 MG/DL
 CREA – 0.7 – 1.4 MG/DL
 24 HOUR URINE PRODUCTION-1000-
1500CC

 ANURIA<100ML/24H
 OLIGURIA< 400 ML/24H
 POLYURIA > 2000 ML/24H
 KEGELS –STRENGTHEN MUSCLES OF THE PELVIC
FLOOR-TIGHTEN FOR 3 SECS THEN RELAX FOR 3
SECS PERFORM LYING DOWN, SITTING AND
STANDING FOR TOTAL OF 45
 BLADDER RETRAINING
 INTERMITTENT CATHETERIZATION AFTER ATTEMPTING
TO VOID Q 2-3H, TIME INCREASES GRADUALLY BUT NO
MORE THAN 8 HOURS
 BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H
THEN ATTEMP TO VOID 30 MINS LATER-TIME
GRADUALLY INCREASED
 TRIGGERING TECHNIQUES-CREDES MANEUVER AND
VALSALVA
 CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE
TO VOID 3-4 HOURS AFETR REMOVAL
 HEMODIALYSIS
 DONE 3-5 HOURS – 2-3 TIMES A WEEK
 AV FISTULA-NO BP,VENIPUNCTURE OR
CONSTRICTIONS
 PALPATE FOR A THRILL AND LISTEN FOR
BRUIT Q8H
 MONITOR FOR HEMORRHAGE
 DISEQUILIBRIUM
SYNDROME,HEPATITIS,HEMORRHAGE,MUS
CLE CRAMPS,AIR EMBOLISM AND SEPSIS-
COMPLICATIONS
 PERITONEAL DIALYSIS
 TENCKOFF,GORE-TEX CATHETER
 WEIGH BEFORE AND AFTER, WARM DIALYSATE
 CHON LOSS, INFECTION, -PERITONITIS(CLOUDY
OUTFLOW,BLEEDING) , FEVER , ABDL
TENDERNESS AND N & V
 PREVENT CONSTIPATION BY INCREASING FIBER IN
DIET,MAINTAIN STERILE PROCEDURE,FOR
PROBLEMS WITH OUT FLOW –REPOSITION
 TYPES: CAPD(4-6H INDWELLING),AUTOMATED
30MINS EXCHANGES, INTERMITTENT- 4X A WEEK
– 10H/DAY, CONTINOUS – 1 DAY INDWELLING
 PREOP CARE
 INFANT-DISTRACT
 TODDLER-ALLOW REGRESSION AND
INVOLVE PARENTS,CONSISTENT
CAREGIVER
 PRE-SCHOOL-LET CHILD HANDLE
EQUIPMENT,EXPRESSION OF FEELINGS
THROUGH PLAY DEMOFAMILIAR
SORROUNDINGS
 SCHOOL AGE- EXPLAIN SIMPLY AND
ALLOW CHOICES
 ADOLESCENTS- INVOLVE AND POINT OUT
STRENGTHS AND BENEFITS,EXPECT
RESISTANCE
 PREOP CHECKLIST
 CONSENT
 HEALTH TEACHING (SPEC. POST OP
PROCEDURES)
 LAB TESTS,ECG,X-RAY
 SKIN PREP
 BOWEL PREP
 IV’S
 NPO
 PREOP MEDS,SEDATION AND ANTIBIOTICS
 REMOVAL OF DENTURES,NAILPOLISH AND
JEWELRY
 NUTRITION-TPN OR ENTERAL FEEDINGS PREOP
 INTRAOP- MAINTAIN SURGICAL ASEPSIS,
MONITOR CLIENT STATUS,, APPROPRIATE
GROUNDING DEVICES, FLUID BALANCE
AND SPONGE/INSTRUMENT COUNT
 POST OP- MONITOR VS
 Q15X4;Q30X2;Q1HX2 THEN PRN
 MONITOR I AND O , K LEVEL , CVP, BOWEL
SOUNDS, BREATH SOUNDS AND LOC
 RESPIRATORY PHYSIOTHERAPY,TCBD
 INCENTIVE SPIROMETRY-20 SECS
INHALATION
 ENCOURAGE AMBUALTION
 REFER IF UNABLE TO VOID IN 8 HOURS
 APPLY TED HOSE AND PNEUMATIC
COMPRESSION DEVICE,CHECK FOR
HOMAN’S SIGN
 WOUNDS
 NOTE DRESSING AND INCISION
 FEVER 1-2 DAYS POST OP-ATELECTASIS/
DEHYDRATION
 3-7 DAYS – INFECTION
 UPPER GI TUBES-GASTRIC DECOMPRESSION
 LOWER GI TUBES – BOWEL DECOMPRESSION
 WOUND HEALING BY 1ST INTENTION-SUTURED
AND APPROXIMATED ; 3RD INTENTION-NOT
CLOSED,W/ PURPOSE EX: DRAINS
 WOUND HEALING BY 2ND INTENTION-INCREASED
INCIDENCE OF INFECTION , INCREASED SCARRING
AND LONGER HEALING TIME
 POST-OP
COMPLICATIONS
 SHOCK
 PARALYTIC ILEUS
 ATELECTASIS AND PNEUMONIA - 2ND DAY
 EMBOLISM- 2ND DAY
 WOUND INFECTION-3-5D
 DEHISCENCE AND EVISCERATION-5-6D
 PSYCHOSIS
 CARDIOVASCULAR COMPROMISE-
 URINARY RETENTION-8-12H
 URINARY INFECTION -5-8 D
 DVT-6-14 DAYS-1 YEAR