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ABDOMINAL ASSESSMENT • Procedure: I-A-Pe-Pa Regular assessment: I-Pa-Pe-A
Sequence: RLQ RUQ LUQ LLQ Position: dorsal recumbent AVOID: A – ppendicitis P – heochromocytoma A – bdominal Aortic Aneurysm W – ilm’s tumor
ABSENT MECONIUM PASSAGE • Cystic fibrosis • Hirschprung’s disease • Imperforate anus ARTERIAL BLOOD GAS (ABG) • Serum pH 7.35 – 7.45 CO2 35 – 45 HCO3 22 – 26 PaO2 85 – 95 mmHg Increased: Polycythemia Decrease: Anemia • BEFORE: Allen Test to assess patency of the RADIAL artery*** Avoid suctioning at least 20-30 minutes BEFORE procedure AFTER: Apply pressure on puncture site for 5 minutes
ABDOMINAL PARACENTESIS • Purpose: Obtain fluid specimen To relieve pressure on the abdominal organs d/t the excess fluid • • BEFORE: Ask client to void DURING: Position: Sitting position Common site: midway between the umbilicus and symphysis pubis Strict sterile technique Measure abdominal girth at the umbilical level Maximum amount drained is 1500 mL Instruction:
ACROMEGALY • Increase growth hormone AFTER puberty • Increase glucose level • S/Sx: Broad and bulbous nose Enlarged hands and feet Continuous grow of soft tissues (ear, nose) • Complications Enlarged heart Diabetes mellitus Heart failure • Reason of seeking for medical care: change in appearance
Octreotide (Sandostatin) give SQ if given 3x a week
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) • “shock lung” • Pathophysiology: o Decreased surfactants o Decreased surface tension o Damage to alveolar-capillary membrane o Leakage of fluid into the ITS o Resulting to pulmonary edema • S/Sx: o Dyspnea, retractions
ADDISON’s and CUSHINGS DISEASE ADDISON’s “All STEROIDS (S.S.S.) are DOWN except for Potassium” MAIN DOWN: SUGAR (HYPOGLYCEMIA) PROBLEM AND its DOWN: SALT (HYPONATREMIA) symptoms HYPOVOLEMIA DHN, weight loss HYPOTENSION 7. DOWN: SEX HORMONES Decrease sexual urge or libido
CUSHING’s “All STEROIDS (S.S.S.) are UP except for Potassium” UP: SUGAR (HYPERGLYCEMIA) UP: SALT (HYPERNATREMIA)
HYPERVOLEMIA Edema (Moonface, Weight gain) HYPERTENSION
UP: SEX HORMONES Decrease sexual urge or libido
UP: Potassium HYPERKALEMIA Weakness, fatigue Tachycardia, Arrhythmia Diarrhea Metabolic acidosis Tall/ Tented T wave
Virilization (mascularity in female) Amenorrhea, Hirsutism, Enlargement of clitoris Osteoporosis Gynecomastia (males)
YES steroids (pro-Na, anti-K) Monitor VS, I&O, weight DIET: high calorie, high CHO (glucose), high NA, low K
DOWN: Potassium HYPOKALEMIA Weakness, fatigue Bradycardia Constipation Metabolic alkalosis Flat T wave NO steroids Monitor VS, I&O, weight DIET: low calorie, low CHO, low Na, high K, high CHON Reverse isolation* BILATERAL ADRENOLECTOMY GIVE Calcium (for osteoporosis)
S.S.S (Sugar, Salt, Sex hormone) steroids Cushing’s disease prone to infection
ANEMIA – Decrease oxygen carrying capacity of RBC • Common Nursing diagnosis: Activity intolerance • TYPES Pernicious anemia – immature RBC due to lack of vitamin B12
Aplastic Anemia – decrease RBC, platelet, WBC Sickle cell anemia – sickled RBC Management: • H - ydration • O - oxygeantion • P – ain management
ANGINA • 2 GOALS IN ANGINAL MANAGEMENT: o Goal # 1: Increase oxygen supply to the myocardium (vasodilation) o Goal # 2: Decrease oxygen demand
Nitrates – Goal # 1 Example: Nitroglycerin, Isosorbide mononitrate (Imdur), Isosorbide dinitrate (Isordil) Side effects: flushing, throbbing headache, hypotension, dizziness Keep drug only for 6 months, cool, dry and dark environment Carry all times DO NOT administer with Sildenafil (Viagra)
AVOID: hot baths (vasodilation)
Beta Blockers – Goal # 2 Example: Propranolol (inderal), Metropolol (Lopressor) Calcium Channel Blockers – Goal # 1 and 2 Examples: Amlodipine (Norvasc), Verapamil, Nifedipine, Diltiazem (Cardizem),
ANEURYSM – is ballooning of the blood vessel • TYPES o Saccular o Fusiform
Dissecting - a TEAR in the intima of the blood vessel*** Type A – affects the ascending aorta Type B – affects the descending aorta
Complication: rupture/ internal hemorrhage/ shock
11. APPENDICITIS • Inflammation of the appendix • LOCATION: RLQ/ right iliac/ Mc Burney’s point • CAUSE: due to obstruction from fecalith low fiber diet
12. APPENDICITIS, manifestations • increase WBC, fever • PECULIAR SIGNS:
Rovsing’s sign Mc Burney’s sign Psoas sign Obturator sign Blumberg sign (+) cough sign
pressure on the LLQ causes pain in the RLQ pain at RLQ upon palpation pain on passive extension of right hip (lateral position with right hip flexion) pain with passive flexion and internal rotation of the right hip rebound tenderness (peritonitis) RLQ pain on coughing
With pain – inflammation Without pain – rupture • Tachycardia – late sign • Abdominal distention and paralytic ileus/ decreased or absent bowels sounds 13. APPENDICITIS, management • NPO • POSITION: (acute phase) most comfortable position; Semi fowler’s to relieve pain and discomfort (rupture) upright • Sx: Appendectomy Position: flat on bed • ALLOW: cold application • AVOID: warm compress analgesics – will mask the pain* Laxatives, enema, palpation (increase peristalsis) 14. ARNOLD-CHAIRI MALFORMATION • Related to neural tube defect • S/Sx: o Swallowing difficulty
Weakening of the extremities Stridor
RHEUMATOID ARTHRITIS Autoimmune/ Systemic BODY PART AFFECTED S/Sx Small joints (wrist, elbow) Bilateral • Ulnar drift • Boutenniere deformity • Swan neck deformity • Sjogren’s syndrome – excessive dryness of eyes, mouth and vagina • Felty’s syndrome – leukopenia, spleenomegaly Gold therapy Aspirin regularly -w/o for tinnitus-toxicity Steroids Hot and cold compress
OSTEOARTHRITIS Degenerative disease (“wear and tear”) Common aggravating factor: obesity Weight bearing joints (hips, spine, knee, ankle) Unilateral/ progressive • Heberdend’s – distal • Bouchard’s – proximal
GOUTY ARTHRITIS Metabolic Altered purine metabolism Big toe
• Tophi/ podagra – uric acid crystallization • Elevated uric acid
W-weight control (decrease calorie) H-hot compress or ice packs A- aspirin use T- trunk assistive devices- cane
• AVOID: organ meats, alcohol legumes, sardines • Increase fluid intake
• • •
P-probenecid - excretion of uric acid A-allopurinol - decrease production of uric acid C-colchicine - analgesic, antiinflammatory
HPN. Clear liquid diet (1 – 3 days) Laxatives. Blood Components Blood Component Whole blood PRBC Cryoprecipitate Platelets Fresh frozen plasma Infusion rate 2 to 4 hours 2 to 4 hours 30 minutes Rapid Rapid of bleeding. Reaction C – irculatory overload too rapid dyspnea. shock HA A – llergic antigen/ antibody transfusion urticaria. Cryoprecipitate 21. 1 to 2 hours Volume 500 ml 250 ml 10 ml 35 to 50 ml 250 ml 22. PRBC o Rapid: Plasma. increased PR H – emolytic incompatibility jaundice. Laxative Stool color: chalky white 1 – 3 days 19.reduces uric acid in the blood SURGICAL ASEPSIS To destroy microorganism including spores Procedure involving sterile areas Sterilization (sterile) 17. AVPU SCALE A – Alert and Awake V – Verbal response to stimuli P – Pain response to stimuli U – Unresponsive 18. management • (in sequence) B – T stop L – et the tubings be changed O –pen NSS . chills 23.• 16. ASEPSIS Purpose Indication Technique MEDICAL ASEPSIS To reduce microorganism Routine nursing care Disinfection (clean) S-sulfinpyrazone. BLOOD TRANSFUSION. Platelets. Cleansing enema Constipation: Increase fluids. BLOOD TRANSFUSION RECTION. BLOOD TRANSFUSION. BARIUM SWALLOW AND BARIUM ENEMA BARRIUM SWALLOW USE Examination of UGT BEFORE NPO 6 – 8 hours AFTER BARIUM ENEMA Examination of LGT NPO at midnight (6 – 8 hrs) DIET: Low residue diet. wheezing P – yrogenic bacterial fever. BLOOD TRANSFUSION • BEFORE Check order – 2 RN’s o Client name and identification number o Unit number o Blood type matching o Expiration date Informed consent Blood matching Obtain baseline VS warm blood at room temperature NOT more than 30 minutes • DURING • STAY with the patient and Check every 15 minutes – 1st hour Check every hour – succeeding hours OTHERS: Gauge: 18 or 19*** Y set filter IV transfusion set*** IV fluid: NSS only (other solution causes hemolysis) Time o 4 hours: WBC. BLEEDING PRECAUTION (OPEN WOUND) P – ressure over the injury E – levate above the heart C – old compress A – rterial pressure T – orniquet 20.
Stoma • Color brick red May turn to pink after several months and years • Sensation normally no sensation • Protrusion ½ to ¾ inches • Drain 1/3 to ½ full • Appliance size (pouch opening) 1/16 to 1/8 inches 27. site is iliac crest Prone • AFTER: PREVENT BLEEDING Bed rest for 30 minutes Ice bag on punctured site Pressure on the puncture site Position: Lie on operative/biopsied side for 10 to 15 minutes 25. where are you! S – cold the bank 24. iliac spines. or proximal tibia (children) DURING Position: site is sternum Supine About 1 to 2 mL of bone marrow is obtained. BOWEL DIVERSIONS. Types of Ostomy • COLOSTOMY IRRIGATIONS – needed by Descending and sigmoid colostomy 1st – stimulate 2nd – evacuate Position: sitting 28. A – lways check the VS D – octor. BOWEL DIVERSIONS. iliac crest. Foods Causes odor Beans Asparagus Garlic Eggs Spices Celery Cabbage Corn Camote Cauliflower Champagne Cucumbers Carbonated drinks Tapioca Rice Yogurt Apple and apple sauce Banana Cheese Causes gas: Thicken stool: • • 29. Permanent colostomy – Descending and sigmoid colostomy Colon cancer – sigmoid colostomy BREASTFEEDING. Types of Ostomy • Ileostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) • Cecostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) • Ascending colostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) • Transverse colostomy mushy/ semi-formed • Descending colostomy formed • Sigmoid colostomy formed 26. BOWEL DIVERSIONS. BONE MARROW BIOPSY/ ASPIRATION • • Bones commonly used: sternum. Assessment of proper latching • C – hin to breast O – pen mouth widely L – ips turned outward A – reola is visible above only • • Nipple – touches the posterior tongue 9to promote swallowing reflex) Nipple (bottle) – always filled with milk 9to prevent colic) Color of stools: . BOWEL DIVERSIONS.
Dermis. no edema Very painful. BURNS. BRONCHOSCOPY • BEFORE: NPO for 6-12 hours prior to procedure. Flash – explosion d. blistered. blanches with pressure Painless Red to Gray/ waxy white color Wet surface (broken blisters) Edema painless. bone and muscles • HEALING PROCESS 1st degree – 3 to 7 days 2nd degree – average of 21 days 3rd degree – skin grafting compartment syndrome 4th degree – amputation. 33. BURNS. causes/ types • CAUSES/ TYPES: Thermal burns Scald burns – hot fluids b. NPO till gag returns then start with ice chips then followed by sips of water soft diet regular diet ice bags to throat minimize talking. classification Fist degree Superficial burn PARTIA L Second degree Third degree Superficial Partial thickness burn Deep Partial thickness burn Full thickness burn Epidermis Epidermis and dermis Skin to SQ pain. dry. • B – ronchoconstriction caused by leukotrienes I – nflammation caused by IgE M – ucus production caused by GOBLET CELLS Give BRONCHODILATOR first. 2 Parameters to meaasure 1) Extent – percentage Rule of 9 – quick way Palm method – use for scattered burn 2) Severity – 1st to 4th degree (Depth) 34. edema. very red. followed by STEROIDS 31. Breast fed: golden yellow Formula fed: pale yellow 30. maintain good oral hygiene • DURING: uses local anesthetic spray to minimize gagging while inserting the bronchoscope supine with head hyperextended • AFTER: POSITION: semi fowler's 32. reddened (erythematosus). assess for respiratory distress BURNS. SQ tissue. white or charred sunburn Scalds (contact with hot liquids) Fire • Electricity or lightning • Prolonged exposure to hot liquids/ objects FULL Fourth degree Epidermis. contact with hot objects Chemical burns – acids. stages of burn injury 1st stage Fluid Accumulation IV to IT Hypovolemia/ shock Oliguria Decrease Blood volume Decrease BP Increase HR. skin grafting 35. warm saline gargles. pale. coughing. BRONCHIAL ASTHMA • • Most common triggering factor: dust TRIAD symptoms. no dentures. Flame – ignition/ fire c. alkali Electrical burns – electrical wires Radiation a. Increase RR Increase HCT Increase potassium 2nd stage Fluid remobilization IT to IV (Hypervolemia) Diuresis Increase Blood volume Increased BP Fluid overload CHF 3rd stage Recovery/ Convalescnce Healing process Decreased calcium (calcium is used in wound healing) . laughing. BURNS.
LPG) Patient with burns with diarrhea. RSIK FACTORS • Breast Cancer o Early menarche o Late menopause o Nulliparity o • 1st pregnancy at 35 years old Bladder Cancer . first to be done:*** o Turn OFF the electric soource Components of FIRE:*** o Oxygen (open window. neck. electric spark. Begins 48 to 72 hours after the time of injury REHABILITATIVE Begins when the client is hemodynamically stable. Type B – for Fuel fire oil. wound closure. friction producing equipment) o Combustible material (kerosene. oxygen tank) o Friction (drapes.Confine the fire o 4. kerosene (contains carbon dioxide) Type C – for Electric Fire appliances. first thing to do is: o flush the eyes with water continuously for 20 minutes SKIN GRAFT o Heterograft (xenograft) – is a graft of skin obtained from another species. woods.Protect patient o 2. BURNS. “must-to-know” • • Burns to the chest. capillary permeability is restored. leaves (contain water under pressure) • o o o 38. suspected organism: o Clostridium Deficile Chemical burn to the eyes. and diuresis has begun begins with wound closure until the burn is healed Amount of fluid: based on the client’s weight extent of injury infection control wound care. gasoline. o Autograft – is a graft of skin obtained from the patient itself o Homograft – is a graft of skin obtained from same species like a cadaver 6 to 24 hours after dead • • • • • • • FIRE management. pain management.Extinguish the fire FIRE EXTINGUISHER. BURNS. phases of burn management EMERGENT. PRIORITY nursing diagnosis: o Ineffective airway clearance*** IV fluid used in FLUID RESUSCIATION: Lactated Ringers (LR) Patient is burning: o “DROP and ROLL”*** o AVOID: Standing – to prevent inhalation Running – to prevent fanning of fire Electric burn. back.Decrease sodium and water Myoglobinuria Decrease HCT Decrease potassium Decrease sodium and water 36. usually 24 to 48 hours following injury BEGINS Begins at the time of injury ENDS ends with the retoration of capillary permeability (fluid resuscitation) GOAL/ FOCUS • Fluid resuscitation • Fluid replacement are calculated from the TIME of INJURY and not from the TIME OF ARRIVAL at the hospital and • • • • • ACUTE. and physical therapy until the patient has reached the highest level of functioning Designed so that the client can gain independence and achieve maximal function 37. types*** o Type A – for Trash fire paper. sequence*** o 1.Activate alarm o 3. and face. wire (contains dry chemicals) Type D – any kind (contains graphite) CANCER. such as a pig. nutritional support.
cotton-tip applicator for viscous xylocaine over lesions Neutropenic precaution o Handwashing o Neutropenic diet/ low-bacteria diet: cooked foods o AVOID: fresh flowers. vaccinations o Reverse isolation/ private room o Assess vital signs every 4hours Thrombocytopenic precaution o AVOID: aspirin. fruits. CHEST TUBE a. IM. contact sports o Use soft bristled toothbrush. 3 to 5 days after the onset of menstruation Monthly. raw foods.o o • Smoking Hair dye Gastric Cancer o Smoked foods o Peptic Ulcer Disease: gastric ulcer o Raw foods 39. WATER SEAL BOTTLE NURSING CONSIDERATIONS: • Immerse tip of the tube in 2. DRAINAGE BOTTLE NURSING CONSIDERATIONS: • Keep at least 2 to 3 feet below the chest (to allow drainage by gravity) NEVER raise the bottle above the level of the heart (to prevent reflux of air or fluid) • NOTE: COLOR: bloody drainage during the first 24 hours • OUPUT: 500 – 1000 ml during the first 24 hours*** FLUID DRAINAGE: the tube is inserted at 8th or 9th ICS AIR DRAINAGE: the tube is inserted 2nd or 3rd ICS COMMON OBSERVATIONS • NO DRAINAGE Resolution Obstruction b. CANCER SCREENING PROCEDURE Breast Self Exam (BSE) Testicular Self Exam (TSE) Mammogram Paps smear Digital rectal Exam (DRE) SCHEDULE Monthly. hot o SFF o Diet: soft bland o Ensure adequate fluid hydration o Frequent oral hygiene o Rinse mouth with ½ strength peroxide and NSS o Brush teeth with soft toothbrush and baking soda o USE: unwaxed dental floss. electric razor. after a warm bath 35 to 40 years – 1x (baseline) 41 to 50 years – every 2 years 51 and above – yearly Onset – 40 – every 3 years 41 and above – yearly 50 and above – yearly 40 and above – yearly (if high risk) 40. CHEMOTHERAPY SIDE EFFECTS Side effects Nausea and vomiting Anorexia Interventions o Provide antiemetics 30 – 60 minutes before chemotherapy o AVOID: unpleasant odors. spicy foods. fall during expiration) • NO FLUCTUATIONS Obstruction – check and milk the tubing with CAUTION Low suction . vegetables.3 cm of sterile NSS to create water seal COMMON OBSERVATION: • INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration. stool softener Blood transfusion Bed rest o Discuss potential TEMPORARY hair loss o Use of wigs o If hair grows back – color and texture changes o AVOID: excessive shampooing o Increase fluids o Temporary GATRO-INTESTINAL Oral thrush Neutropenia (WBC) HEMATOPOEITIC (Bone marrow suppression) Thrombocytopenia (Platelets) Anemia (RBC) Alopecia INTEGUMENTARY Cystitis Sterility/ infertility GENITO-URINARY 41. punctures. invasive procedures.
CHEST TUBE REMOVAL • Give analgesics 30 minutes before removal • Clamp on bedside • DURING removal: let the patient EXHALE and hold breath while doing VALSALVA MANEUVER • Maintain dry. calcium: may cause obstruction. high progesterone) MANIFESTATIONS: TRIAD symptoms: o RUQ pain – that radiates to midsternum.• c. CHOLECYSTITIS CHOLELITHIASIS: stones in the gall bladder (occurs due to hypercholesterolemia) CHOLECYSTITIS: inflammation of the gall bladder Stone: cholesterol*. bile pigments. Clamping the chest tubes IF a client with an air in the pleural space will cause increased pressure buildup and possible TENSION PHEUMOTHORAX e. scapular area or right shoulder*** o Fever o Jaundice/ pruritus Increased bilirubin*** Increased alkaline phosphatase if with obstruction*** (+) Murphy’s sign – pain during inhalation when the physician’s hand is placed on the patient’s RUQ abdomen Decrease ADEK – bleeding (low Vitamin K) Acholic stools (pale/ gray stools/ clay-colored) Steatorrhea (no bile to emulsify the fats) DIAG AND LAB ERCP (endoscopic retrograde cholangiopancreatography) Oral cholecystography – PROCEDURE OF CHOICE!*** UTZ .5 cells/mm Glucose: 40 to 80 mg/dl (40 to 80 mg/100ml) Protein: 15 to 45 mg/dl (15 to 45 mg/100 ml) Diagnostic test for meningitis. result Increase protein content Decrease glucose content Increase WBC content Cloudy (bacterial meningitis) Clear (viral meningitis) • 43. sterile.ray for confirmation CONTINUOUS BUBBLING Air leakage (except during suctioning) SUCTION CHAMBER NURSING CONSIDERATIONS: • Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS (to stabilize the normal negative pressure in the lungs and protects the pleura from trauma if the suction pressure is inadvertently increased) COMMON OBSERVATIONS • CONTINUOUS GENTLE BUBBLING (indicates adequate suction control) NORMAL d. f. CEREBROSPINAL • • • FLUID (CSF) ANALYSIS Protects from mechanical trauma Function of CSF: Carries nutrients to brain Characteristics Normal pressure: 5 to 15 mmHg/ 70 to 180 mmH2O Normal volume: 100 to 200 ml WBC: 0 . infection stones may spread to: o common bile duct (choledocholithiasis) o pancreatic duct (pancreatitis) 6F’s: o Female (contraceptives) o Fat (obesity) o Forty (low estrogen levels) o Flatulence o Fair o Fertile (decrease estrogen. 42. occlusive dressing EMERGENCY SITUATION • DISLODGE (chest tube removal FROM THE CLIENT) AT BEDSIDE: vaselinized gauze Palm pressure (for splinting) • DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage) • ATBEDSIDE: Extra bottle immersed in sterile water Clamp (Hemostat) ALERT! Never clamp the test tubes over an expanded period of time. Re expand lungs – do chest X.
DIABETES INSIPIDUS and SIADH DIABETES INSIPIDUS MAIN PROBLEM Decrease ADH secretion NURSING Fluid Volume Deficit DIAGNOSIS Decrease urine specific gravity – DILUTED Dehydration. low fat give Vitamin K as ordered SURGICAL INTERVENTIONS: Cholecystostomy: incision into the GB for the purpose of drainage Abdominal cholecystectomy: removal of the GB for the purpose of drainage Laparoscopic cholecystectomy: removal of GB thru an endoscope inserted thru the abdominal wall Choledochotomy: incision into the CBD for removal of stones 44.Force fluids (2 – 3 L/ day) DIET AVOID foods that exert diuretic effect (coffee. moderate CHON. CYSTOSCOPY • Direct visualization of the LOWER urinary tract (bladder and urethra) • PURPOSE: specimen collection treatment of the interior of the bladder and urethra Prostate surgery • Local anesthesia – commonly used • POSITION: dorsal recumbent • CONTRAINDICATIONS: acute cystitis. tea) Vasopressin DRUGS SIADH Increase ADH secretion Fluid Volume Excess Increase urine specific gravity CONCENTRATED Edema Oliguria Weight gain Hypertension Hypervolemia Hyponatremia (DILUTIONAL) Hemodilution (decrease HCT) Water intoxication Restrict fluid ALLOW foods that exert diuretic effect (coffee. CVP MONITORING • Measure the pressure of the right atrium • Place the zero level of the manometer at the level if the right atrium (4th ICS) • AVOID: coughing and straining • NORMAL: 2 -12 mmHg 47. Polydipsia Weight loss S/SX Hypotension Hypovolemia Hypernatremia (CONCENTRATIONAL) Hemoconcentration (increase HCT) COMPLICATION Shock Hydration . CT SCAN • • • • • X-ray Contrast medium – warm sensation AVOID: pregnant women Before: NPO After: increase fluid 46. Constipation Polyuria.INTERVENTION Pain control o Narcotics o antipasmodics and anticholinergics (to reduce spasms and contractions of the GB) NGT insertion – for gastric decompression DIET: high CHO. tea) Diuretics (Loop and Osmotic) Demeclocycline (Declomycin) 49. DUMPING SYNDROME • S/sx: . pain in suprapubic region 48. CORONARY ARTERY BYPASS GRAFT Used for multiple vessel affection Sources of Grafts: o Saphaneous vein o Internal mammary artery o Radial artery 45. dysuria. bleeding disorders • AFTER: Assess VS urine characteristic (NORMAL: pink tinged or tea-colored urine) I&O Encourage fluids Sitz bath Observe for fever.
ECG • NORMAL o o o PR 0.40 seconds QRS 0.12 – 0. Diarrhea Shock-like symptoms: diaphoresis. insert in rotating motion • Infant Child Adult 1 – 1. Bisacodyl/ Fleet oil • • Hypotonic Isotonic Irritants Lubricants Position: left-sidelying/ dorsal recumbent Enema tube – lubricate first.10 seconds • • • • • HYPERKALEMIA Tall T wave HYPOKALEMIA Flat T wave HYPERCALCEMIA Short ST segment and QT interval HYPOCALCEMIA Lengthened ST segment and QT interval Atrial flutter o With P wave (saw tooth) o Regular rhythm o Normal QRS Atrial fibrillation*** o No P wave o Irregular rhythm o Normal QRS Atrial tachycardia o With P wave (different shape) o Regular rhythm o Normal QRS Ventricular fibrillation o No P wave o Chaotic rhythm o No QRS Ventricular tachycardia o No P wave o Regular rhythm o Wide and bizarre QRS • • • • 52. ENEMA • TYPES: Cleansing enema Carminative enema Return flow/ Harris flush/ Colonel irrigation Retention cleansing (3x) flatus flatus (5 – 6x) soften. cold and clammy • • 50.04 – 0. lubricate (1 – 3 hours) • SOLUTIONS: Hypertonic sodium biphosphate tap water NSS soapsuds.5 inches 2 – 3 inches 3 – 4 inches Cramping: Lower the solution . EAR • Position after feeding: LEFT SIDE LYING (to delay drainage to stomach) Common complication of gastrectomy Ear bones (Ossicles) M – alleus A – nvil S – tapes Stirrups Hammer Incus • Position during drug administration: Below 3 years old – down and back Above 3 years old – up and back 51.32 – 0.20 seconds QT 0.
EPIGLOTTITIS • Tripod position*** • Always an emergency situation • Essential equipment for epiglottitis: tracheostomy 54. EYES: OTITIS MEDIA (ear problem) • Causes: Propping the bottle Passive smoking *** Frequent tonsillitis • S/Sx: Otalgia – ear pain Otorrhrea • Management: Myringotomy with tympanostomy tube First line of drug: Ampicillin Second line of drug: Cotrimoxazole 57. POSITION of the Nurse: Nurse walk one step ahead of the patient Never rearrange things (familiarization of environment)*** EYES: GLAUCOMA • S/sx: Tunnel vision/ PERMANENT peripheral vision loss (“I can’t see the person besides me.R.S. EYES: CATARACT • S/sx: • 58. Absent red eye reflex Blurring of vision Clouding of lens – from inner to outer Management: SURGERY ONLY*** EYES: BLIND PATIENT 20/ 200 59.”)*** Eye pain Halo lights*** Eye meds for life NO need for water restriction AVOID: Midriatics (dilation) • • • 60. Increase tone Increase mass Joint flexibility Use of trapeze Walking Swimming Cycling Running Increase endurance Increase heart rate and cardiac output Quadricep setting Squeezing on stress ball Kegel’s EXAMPLES 56.7oC) 53. E. types CHARACTERISTICS OTHER NAME JOINT MOVEMENT CONTRACTION BENEFITS on MUSCLES ISOTONIC Dynamic Increase strength ISOMETRIC Static/Setting x Increase strength ISOKINETIC Resistive Increase strength Increase size Increase blood pressure and blood flow to muscles May be isometric or isotonic with resistance Weight-lifting 55. Clamp and wait for 30 seconds*** Restart • Temperature: 100oF (37.S. EYES: POST-SURGERY . feeding method of patients with cleft lip and cleft palate • E – nlarge the nipple hole • S – timulate the sucking • S – wallow • R – est EXERCISES.
shrimps • Oyster. Polyneuritis MANIFESTATIONS: o Clumsiness . poor vision • Blind patient: 20/ 200 • Stimulating color: red.1st sign o ASCENDING PARALYSIS: progressive. Dyspnea Sensory findings: paresthesia. numbness COMPLICATION: respiratory failure MANAGEMENT: o Symptomatic o Steroid o SAFETY: Side rails o Self-limiting 67. FOODS rich in IRON • Liver • Green leafy vegetables • Dried fruits • Scallops. burning pain.• • • • • • Patch AFFECTED eye Night shield at NIGHT AVOID: o Coughing o sneezing. o lifting more than 5 5lbs o bending (from waist). clams • molasses 63. GUILLIAN BARRE SYNDROME • acquired inflammatory disease (12 cranial and 31peripheral nerves) • • Bilateral. Geriatric client. HEARING LOSS • Severity of hearing loss LOSS IN DECIBELS 0–15 >15–25 >25–40 INTERPRETATION Normal hearing Slight hearing loss Mild hearing loss . o prolonged watching or reading after surgery ALLOW: o bending (from knees) o sneezing (mouth open) NORMAL: mild to moderate eye pain ABNORMAL: Severe eye pain – infection/ hemorrhage 61. GTPALM • • G – Gravida P – Para refers to the number of pregnancies regardless of outcome refers to the number of deliveries that reached viability (20 weeks gestation) born dead or alive. multiple births count as 1 delivery regardless of the number of newborns delivered • • • • • T – Term deliveries number of TERM births (infants born after 37 weeks and above) P – Preterm deliveries number of PRETERM births (infants born between 20 to 37 weeks) A – Abortions number of pregnancies that end in spontaneous or therapeutic abortion prior to age of viability (20 weeks) L – Live number of children currently alive M – Multiple gestations and births (not the number of neonates delivered) 66. bilateral o o • • Dysphagia. Symmetrical. Dysarthria. Geriatric client. orange and yellow • Nurse walk one step ahead of the patient 65. FECAL C-olor -----------brown/yellow – stercobilin O-dor------------aromatic C-onsistensy-----------solid-semi-formed moist A-mount ----------------100-400g/day S-hape------------------cylindrical 62. hearing impairment • Speak infront • Talk slowly • AVOID mounting (lip exaggeration) • AVOID: high pitched voice (shouting) 64.
edema) Increase menstruation (menorrhagia) DIET: • Low calorie. HOSPITAL TANKS COLOR CODING • • • • Nitrous oxide (laughing gas) Oxygen Cyclospropane Nitrogen Carbon dioxide Helium Medical air Blue Green Orange Black Grey Brown Yellow • • • 72. Gain Decrease T4 – decrease body heat production. tremors insomnia) Increase MEtabolic rate Increase SKIN moist (diaphoresis) Decrease weight (tissue wasting) Decrease menstruation (amenorrhea) Exopthalmus DIET: • High calorie. hypoactive) Decrease MEtabolic rate Decrease SKIN moist (dry. increase VS Increase T4 – increased body heat production Increase Thyrocalcitonin – decreased serum calcium Increase GI motility (diarrhea) Increase Appetite Increase VS (Heat intolerance. Basedow’s disorder. High FATS • Skin care Cool environment 73. High CHO. cretinism: children) HYPERTHYROIDISM (Grave’s disease. bradycardia. hypothermia most fatal) Decrease Energy (fatigue. Low fiber • Increase fluids • High CHON. MAIN PROBLEM S/SX Decrease T3 – decrease BMR. High fiber • Increase fluid intake/ IVF (constipation) or decrease fluids (edema) • High CHON. HEPATITIS • Hepatitis A and E – fecal-oral (contaminated food and drink) • Hepatitis B. Low CHO. Low FATS Skin care Warm environment MNGT . brittle/ coarse hair/ skin) Increase weight (fluid retention. HOSPITAL EMERGENCY COLOR CODING • Code blue – cardiac arrest. nervousness. catabolism Decrease Thyrocalcitonin – increased serum calcium Decrease GI motility (constipation) Decrease Appetite increased lypolysis atherosclerosis MI Decrease VS (Cold intolerance. confusion to coma ASTERIXIS – flapping tremor • • DRUGS: lactulose (NH3 binding effect) neomycin sulfate (Mycifradin) – inhibits action of intestinal bacteria (that produces ammonia) Diet: decrease protein (to reduce ammonia) 69. HEPATIC ENCEPHALOPATHY • S/Sx: Moderate hearing loss Moderate to severe hearing loss Severe hearing loss Profound hearing loss Altered LOC changes: memory loss. C and D – blood (needle stick. management • G – lucose (D50) • I – nsulin • C – calcium replacement (to force potassium back in the IC compartment) • K – ayexalate (retain the enema for 30 minutes to allow for sodium exchange. medical emergency • Code pink – infant abduction • Code red – hospital fire • Code yellow – bomb threat • Code silver – person with weapon (combative) 71. Thyrotoxicosois) Increase T3 – increase BMR. HYPERKALEMIA. tachycardia) Increase Energy (Restlessness. afterward. the client should have diarrhea. Parry’s disease. wt.) • S – odium bicarbonate + • DIALYSIS • DIURETICS HYPOTHYROIDISM AND HYPERTHYROIDISM HYPOTHYROIDISM (myxedema. Hashimoto.>40–55 >55–70 >70–90 >90 68. sex) 70. lethargy. Toxic diffuse goiter.
urgical procedure using scalpel. given in HYPERparathyroidism Diuretic that eliminates calcium as well as sodium and potassium in urine 75. nausea and vomiting Low calcium diet High phosphate diet Calcitonin Furosemide Vitamin D Renal stones MAIN PROBLEM S/SX DIET DRUGS COMPLICATI ON FOODS high in CALCIUM: • Orange • Spinach • Milk • Yogurt Aluminum hydroxide (Amphogel). given in HYPOparathyroidism Antacid but the side effect is phosphate binder Furosemide (Lasix). Methimazole (Tapazole) SE: agranulocytosis Beta blockers: Propranolol (Inderal) IODIDES: KISS: Potassium Iodide Saturated solution (lugols solution) Steroids: Dexamethasone COMPLICATI ON MYXEDEMA COMA Hypothermia Altered LOC leading to coma Bradycardia THYROTOXIC CRISIS (THYROID STORM) Fever Agitation Tachycardia 74. suture (Invasive procedures) 77. isopreterenol (bradycardia) Diuretics (edema) Stool softeners/ laxatives (constipation) NOTE: never give SEDATIVES. other CNS depressants Radioactive iodine ( I) therapy Anti-thyroid agents (Thionamides): 131 Propylthiouracil (PTU). INFORMED CONSENT. HYPOPARATHYROIDISM AND HYPERPARATHYROIDISM HYPOPARATHYROIDIS M Decrease Calcium Increased Phosphate Tetany (Chvostek and Trousseau) Laryngospasm Paresthesia High calcium diet Low phosphate diet Calcium gluconate AlOH (Amphogel) Seizure HYPERPARATHYROI DISM Increase Calcium Decreased Phosphate Bone pain/ fracture Renal colic Anorexia. scissors. 78. purpose • To ensure the client’s understanding of the nature of the surgery • To indicate the client’s decision • To protect the client against unauthorized procedure • To protect the surgeon and hospital against legal action INFORMED CONSENT. circumstances requiring an informed consent • R – adiation or cobalt therapy • A – nesthesia use • B – lood administration • I – nvasive procedure E – ntrance into a body cavity S . narcotics.Sx: SUBTOTAL THYROIDECTOMY DRUGS Lifetime thyroid hormone (Levothyroxine (Synthroid)) SE: insomnia Atrophine SO4. INFORMED CONSENT • Requisites for validity of informed consent Legal age Mentally capacitated Secured within 24 hours before the surgery Secured before pre-op medication administration . steroids • AVOID: Straining/ constipation Lifting heavy objects 76. INCREASED INTRACRANIAL PRESSURE • Cushing’s symptoms: Increased BP and MAP Decreased RR and PR Wide pulse pressure • Position: high-fowlers position • DRUGS: mannitol.
increased BP SOB. psychologically incapacitated permission from responsible family member For emancipated minors (married. complications Circulatory overload Air embolism Phlebitis Dyspnea. mumos Pertussis. clients at risk of 3rd space fluid shift • Avoid D5W if the client is at risk of increased intracranial pressure (ICP) • Use LR for BURNS • EXAMPLES: D5W/ D10W/ D50W – red NSS – green D5NSS – yellow D5LR – pink Plain LR – blue 0.last IV THERAPY. unconscious. physician • • • For minors (under 18). crackles Dyspnea. any pregnant female or any who has given birth) 4 Criteria are needed to be met if consent is not needed anymore: There is an immediate threat to life Experts agree that it is an emergency Client is unable to consent A legally authorized person cannot be reached Surgery without consent-. Written permission Signature Witness – nurse.45% D5LR TPN Dialysate contraindicated for clients with increased intracranial pressure. IV THERAPY.5% dextrose ISOTONIC Solute = solvent O pressure of solution No movement expand the intravascular compartment Hypovolemia Burns (resuscitative stage) D5W LR NSS D5 0.45% NSS 0. in military service. college student living away from home. GABHS (Scarlet fever.33% NSS 2.45 NSS – sky blue D5NM – orange 81. pharyngitis) Diptheria MRSA (Staph) Impetigo Scabies Herpes Simplex Hepatitis A Diarrhea Contact Skin Gloves gown • • 80. decreased BP Swelling + Heat slow down Discontinue Left sidelying and trendelenburg Discontinue . Immunocompromised – first Infectious .BATTERY! • 79. pneumonia German measles.225% NSS HYPERTONIC Solute > solvent From Intracellular TO Intravascular shrink/ crenation Edema D10W D50W D5NSS 5% dextrose in 0. ISOLATION PRECAUTION • Tier 1: Standard Precaution to all blood and body fluids except for sweat to all clients regardless of diagnosis hand washing and PPE (clean) • Tier 2: Transmission-based precaution Airborne > 3 feet Droplet nuclei < 5 microns Droplet < 3 feet Droplet nuclei > 5 microns N95 Mask Measles TB Varicella (chickenpox) Meningitis. types Characteristics Fluid movement Effect to the cell Indications Examples HYPOTONIC Solute < solvent from Intravascular TO cells Swell Dehydrated patients Distilled water 0.
converses 4 – Disoriented. LEUKEMIA • Increased immature WBC • • Decrease matured WBC risk for infection Decrease RBC activity intolerance . LATEX ALLERGY • FOODS: o Avocado o Potatoes o Bananas o Passion fruits o Chestnuts o Tropical fruits (mango) o Kiwi fruits o Strawberry o Grapes o Soy beans o Pineapple • Catheters.Pyrogenic reaction Infiltration Fever.V. high pitch sound caused by air passing through constricted air passages o Urticaria o Wheezing o Watery eyes • Non latex gloves vinyl gloves • Non latex balloon mylar 84. HAZARDS Eyes goggles Skin gown and gloves Lungs mask 83.E. confused Level III (stuporous) – responds to strong stimuli only Level IV (coma) – unresponsive. L.S. absent protective reflexes c. LEVEL OF CONSCIOUSNESS a.A.U. TYPES • • • Carbon dioxide – gas (clear goggles) ND:YAG – Neodymium: Yttrium Alluminum garnet) – bright lamp (green goggles) Argon – gas (orange goggles) c. condom.P. coherent Level II (lethargic) – drowsy. rubbers. L – ight A – mplification by S – timulated E – mission of R – adiation b. GLASGOW COMA SCALE EYE OPENING 4 – Spontaneous 3 – To verbal command 2 – To pain 1 – No response GLASGOW COMA SCALE VERBAL RESPONSE 5 – Oriented. sleepy.R. 85. (for Pediatric client) A – Alert and Awake V – Verbal response to stimuli P – Pain response in stimuli U – Unresponsive Level I (conscious) – 3 C’s: conscious. A. a.in a comatose state 3 – lowest score 15 – highest score b. converses 3 – Uses inappropriate words 2 – Makes incomprehensible sounds 1 – No response MOTOR RESPONSE 6 – To verbal command 5 – To localized pain 4 – Withdraws 3 – Flexes abnormally (Decorticate) 2 – Extends abnormally (Decerebrate) 1 – No response 7 and below . cognitive. balloons • Contraindicated with spina bifida patients • Assess for signs and symptoms: o STRIDOR (best option) – harsh. chills Swelling + Cool Cold Elevate Restart Discontinue Retain IV equipment for C&S Discontinue Warm/ Moist heat (due to edema) Elevate Restart (another site) 82. obtunded.
• DURING remain still while completely enclosed in scanner throughout the procedure. • AVOID: patients with orthopedic hardware intrauterine devices pacemaker internal surgical clips or other fixed metallic objects in the body (braces. glasses. 0. Spleenomegaly Hemorrhoids Ascites and edema (unable to metabolize protein) Spider angioma/ telangiectasia (dilated vein/capillaries over the face and trunk) Esophageal varices. cytology. sugar [normally present]. with history of TB. which lasts 45-60 minutes.1 mL of PPD is injected INTRADERMALLY. 90. or drugs (anesthesia) into the spinal canal AREA: Insert needle between L3 – L4 or L4 – L5 (spinal cord ends in L2) BEFORE PROCEDURE: Obtain consent Empty bladder DURING PROCEDURE: Position of the patient: C-position (flex the shoulders. and platelet count • DURING: exhale and hold breath • AFTER: Right side-lying position 87. GI bleeding Leg varicositites 88. MAGNETIC RESONANCE IMAGING (MRI)/ NUCLEAR MAGNETIC RESONANCE (NMR) • Uses radio waves • BEFORE: remove metals: jewelry. retainers) • BEFORE: Have client void before test. • Teach relaxation techniques to assist client to remain still and to help prevent claustrophobia] NORMAL: audible humming and thumping noises from the scanner during test. not the head) Position of the nurse: infront of the patient Position of the doctor: at the back of the patient AFTER PROCEDURE: prevent spinal headache Position: flat for 6-12 hours (to prevent spinal headache) Force fluids (to maintain pressure and prevent spinal headache) Blood patching label specimen • • • • 89. and other metallic objects. pedia. prothrombin time.• Decreases platelets risk for bleeding 86. MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) Test • • • Route: Read: Result: ID. Sedate client if ordered. C&S) Check color of CSF (normally clear) and check for blood Inject air. dye. LIVER BIOPSY • BEFORE: Note blood clotting defects. wigs (with metal clips). hairpins. LIVER CIRRHOSIS • Most common type: Laennec (due to alcohol) PORTAL HYPERTENSION Portal HPN. geriatric clients) 0 . LUMBAR PUNCTURE (LUMBAR TAP) • PURPOSE: To withdraw CSF to determine abnormalities Measures CSF pressure (normal opening pressure 60-150 mm H2O) Obtain specimens for lab analysis (protein [normally not present]. creating a wheal or bleb 48 to 72 hours (+) to exposure 10 mm and above not immunocompromised 5 mm and above immunocompromised (HIV. Increase collateral circulation Caput medusa (dilated veins over the abdomen) Hepatomegaly.4 mm= NOT SIGNIFICANT Erythema without induration is NOT considered significant .
Drug effects • Therapeutic – desired • • • Side effects – 2nd effect. use the formula: o . use the formula: o + 09 + 07 (MM. NAEGELE’s RULE • If LMP is from APRIL TO DECEMBER. such as athletes involved in football and wrestling.91. unexpected Allergic reaction – immunologic response 92. YY) • If LMP is from JANUARY TO MARCH. razors. Coumadin + Vitamin K increase or decrease metabolism/ excretion eg. THROMBOCYTOPENIA Petechiae ANEMIA Fatigue NEUTROPENIA Fever and sore throat MYOCARDIAL INFARCTION • Cardiac enzymes o after 1 hour o after 2 hour o after 4 hour o after 24 hour • ECG changes o Pathologic Q wave o ST elevation o T wave inversion Myoglobin Troponin CPK-MB LDH 96. Drug interaction • Additive effect • • • b. codeine + aspirin = intense pain relief OHA + NSAIDs = hypoglycemia*** 1+1=0 eg. such as towels. Community-associated MRSA – happens to people who have close skin-to-skin contact with others. antibiotics no specific time of administration/ as needed eg. Synergism/ potentiation Antagonist Interference 1+1=2 eg. diazepam + alcohol = increase sedation 1+1=3 eg. Anxiolytic (pre-surgery) carried out indefinitely eg. MRSA (methicillin-resistant Staphylococcus aureus) • 2 types of infection: Hospital-associated MRSA – happens to people in healthcare settings. MEDICATION ORDER. components • Clients name • Date and time of order • Name of drugs • Dose and route • Time of frequency • Signature 93. Practice good hygiene Keep cuts and scrapes clean and covered with a bandage until healed Avoid: o contact with other people’s wounds or bandages o sharing personal items. or clothes Wash soiled sheets. DD. towels and clothes in hot water with bleach and dry in a hot dryer • • • • 94. Pain relievers within 24 hours Signed Indicate as Telephone Order Put decimal number Medication order • STAT (“statim”) • • • • Single order/ one time Standing / routine PRN (“Pro Re Nata”) Telephone order c.03 + 07 + 01 (MM. MYELOSUPPRESSION • • • 95. DD) . washcloths. Probenecid decrease excretion of Penicillin immediate/ once eg. Magnesium sulfate (preeclampsia) once eg. expected Adverse effects – severe side effect. MEDICATION a.
NASOGASTRIC TUBE (NGT) • TYPES • Levin .2 NEPHRITIS (NEPHRITIC SYNDROME) Inflammation of the kidneys GABHS Hematuria (gross) Edema (periorbital) HPN Proteinuria Oliguria/ Anuria Increase BUN/ creatinine DIET: low sodium. Edema (anasarca) DIET: high protein.) Position: high-fowlers and neck hyperextended Instruction: ask to swallow Placement: 1.M. Hypoalbuminemia 2.Aspirate and pH test normal gastric pH = 1 to 4 (acidic) 3. OBSTRUCTIVE SLEEP APNEA (OSA) • OSA – is the most common type of sleep apnea syndrome • Cause: o Obesity .). Hyperlipidemia 4. NEPHRITIS and NEPHROSIS (NEPHROTIC SYNDROME) NEPHROSIS (NEPHROTIC SYNDROME) Increase glomerular membrane permeability Autoimmune 1.X.Listen/ auscultate – after introduction of 10 – 30 ml of air (20 ml) REMOVAL Instil 50 ml of air • • Take deep breath and hold pinch catheter withdraw Mouth care and blow nose FEEDING Check placement Position: sitting/ upright/ fowlers Check for RESIDUAL CONTENT dont discard. above 100ml – STOP Hang: 12 inches from point of insertion Flush : 50 to 100 ml of water Remain upright – 30 minutes 98. NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST) Variables Results NST FM andFHR NORMAL (Reactive/ Positive) Increase FM Increase FHR (acceleration) Decrease FM Decrease FHR (deceleration) ABNORMAL (Nonreactive/ Negative) Increase FM Decrease FHR (deceleration) Decrease FM Increase FHR (acceleration) 2 FHR acceleration/ 10 minutes Each acceleration increase to 15 bpm/ 15 sec. low sodium.U.single lumen Salem sump – double lumen INSERTION Measurement: adult (N. decrease OFI Bed rest 99.E. pedia (N.X.4 – 1.E.X-ray 2.97. Proteinemia 3. decrease OFI Ambulate Normal BUN = 10 – 20 Normal creatinine 0. CST (OCT) UC and FHR NORMAL (Non-reactive/ Negative) Increase UC Decrease FHR (deceleration) Decrease UC Increase FHR (acceleration) ABNORMAL (Reactive/ Positive) Increase UC Increase FHR (acceleration) Decrease UC Decrease FHR (deceleration) 3 contraction/ 10 minutes Each contraction = 40 to 60 seconds EARLY LATE VARIABLE FETAL HEART RATE DECELERATIONS CAUSE MANAGEMENT Head compression Observation Uteroplacental insufficiency Side-lying position Oxygenation Increased IV fluids Stop Oxytocin (Pitocin) Call the MD Caesarean if not corrected Cord compression Trendelenburg/ Knee-chest/ Side-lying position Oxygenation Increased IV fluids Stop Oxytocin (Pitocin) Call the MD Caesarean section if not corrected 100.
o o • • Old men Smoking • Pathophysiology: decrease diameter of the upper airway S/Sx: o Insomnia o Snoring o Morning headaches o Hypertension o Enuresis • Complications: o CAD. PACEMAKER: CONTRAINDICATIONS o Strong magnetic fields – MRI o o Electrical fields – high powered instruments (microwave oven. HPN o CVA o Premature death o MI. OR TEAM MEMBERS SCRUB Surgeon Surgical assistant Scrub nurse SCRUB NURSE Performs complete scrub Prepares and hands out instruments Hands instruments while maintaining sterile technique Ensures everybody in the scrub team practices sterile technique Partner in OS and instrument counting Anticipates the needs of the team Patient advocate (act in behalf of the patient). total parenteral nutrition) o o o NG tube anticholinergics H2-receptor antagonists 104. GUARDIAN OF THE PATIENT. dysrhythmias Management: o AVOID: sleeping in supine. radio. PARKINSON’s DISEASE • Tremors (resting and pillrolling) • Rigidity (cogwheel) • Akinesia/ Bradykinesia • Mask like face 105. alcohol o Lose weight 101. vacuum cleaners) Cellular phones – do not place near chest. TV. doing something that patient can’t do NON SCRUB Anesthesiologist Biomed Circulating nurse CIRCULATING NURSE Greets the client upon arrival – 1st primary responsibility of circulating nurse Checks client identification Sponge counting together with scrub nurse Monitors the urine output and blood loss together with anesthesiologist Ensures the consent form is signed Documents the entire procedure o o o o o o o o o o o o o 102. PANCREATITIS • Acute pancreatitis can become chronic • AVOID: Morphine sulfate is not used to treat pain since it can cause the sphincter of Oddi to spasm Stimulation of the pancreas: DO NOT USE enteral feedings • MANAGEMENT: Position: Side-lying to lessen the pain Meperidine (Demerol) Pancreatic enzymes and bile salts with meals*** IV fluids (to prevent shock) insulin for hyperglycemia calcium replacement decrease stimulation of pancreas o NPO-TPN (nothing by mouth. place in the ear farthest in the pacemaker implant 103. pylori o NSAIDS o Iron o Steroids . PEPTIC ULCER DISEASE • Risk factors: o H.
chew gum or suck on hard candy Urinary frequency Kegel’s exercise. place moist towel on the sinuses Ptyalism Use mouthwash as needed. (morning sickness) eat dry crackers on arising. report signs of infection. cyclophosphamide to effect myelosuppression AVOID: iron rich foods will enhance the production of RBC*** 109. CVA) o Heart failure o Bleeding due to congestion and overdistention of capillaries and venules o Peptic ulcer due to increased gastric secretions o • Gout due to increased uric acid released by nucleoprotein Management o Increase fluids o o Phlebotomy removal of excess blood then DISCARD*** Drugs: o Radioactive phosphorus (32P) reduces RBC production Nitrogen mustard. POLYCYTHEMIA VERA • S/Sx:*** o o o o o o o Ruddy complexion capillary congestion in the skin and mucous membranes Splenomegaly Erythromelalgia Generalized pruritus (due to basophils)*** HPN Increased hematocrit Increased bilirubin Increased liver enzymes Increased RBC Increased WBC Increased platelets (immature) • Complication: o Thrombus formation (MI. PHEOCHROMOCYTOMA • Tumor of adrenal MEDULLA • • Main problem: increased production of catecholamines (epinephrine and norepinephrine) S/Sx: o HPN o Hyperhydrosis o High PR 108. avoid caffeine Constipation Increase fiber and fluids have a regular bowel movement Leg Cramps Increase calcium intake avoid pointing your toes. dorsiflex feet. increase fluid intake. decrease caffeinated and carbonated drinks Nasal stuffiness Use cool air vaporizer. PREGNANCY: DISCOMFORTS OF PREGNANCY ASSESSMENT NURSING MANAGEMENT Nausea and vomiting Eat small frequent meals. turning Characteristic of breathing pattern: o shallow Position to relieve pain: o sitting and leaning forward (orthopnic) o o Cough*** • • 107. may occur any time of day Breast soreness Well-fitting bra.o o Smoking and alcohol Stress 106. careful lifting. PERICARDITIS*** • Pain is aggravated by: Deep inspiration (so the patient do shallow inspiration)*** o Swallowing o Lying down. chlorambucil. local heat application Backache Emphasize posture. busulfan. decrease fluids before bed. stoop to pick up objects . good shoes (low heeled).
PULSE OXIMETRY/ O2 SATURATION/ CONCENTRATION • Measures the oxygen concentration and pulse • Site: finger. more frequently felt after 28 weeks. the uterus can be felt through the abdominal wall. rupture and atrophy of deep connective tissues of the skin o Linea nigra • Amenorrhea – cessation of menses • Breast changes – enlarge and become tender 111. support stockings.softening of the cervix. PREGNANCY: Effects of smoking • Congenital heart defects • SGA • Respiratory distress • Premature death • SIDS 114.painless. spicy and fatty foods Slow. avoid restrictive garments on the lower half of the body Schedule a rest period daily.occurs between the 16th and 20th week after the onset of the last menses.bluish or purplish discoloration of cervix and vaginal wall Goodell's sign . They usually disappear with walking or exercise • Leukorrhea .at about 12 weeks' gestation.lower uterine segment softens 6 to 8 weeks after the onset of the last menstrual period Chadwick's sign . tissue necrosis 115.sinking and rebounding of the fetus Braxton Hicks contractions . frequent meals avoid overeating. STAGES OF PRESSURE ULCERS Stage 1 – non-blanchable. PREGNANCY: Positive signs and symptoms – definite signs of pregnancy • Fetal heart tones (FHTs) . take a sitz bath. deliberate movements.usually heard between 16th and 20th week of gestation with a fetoscope or the 10th and 12th week of gestation with a Doppler stethoscope • Fetal movement felt by the examiner (after about 20 weeks gestation) • Fetal body outline through the maternal abdomen in the second half of pregnancy • Fetal sonographical evidence (after 4 weeks' gestation) using vaginal ultrasound.sensations of fetal movement in the abdomen) . palpable contractions occurring at irregular intervals. may occur as early as 4 weeks 112. Fetal cardiac motion can be detected by 6 weeks' gestation 113. • Pigmentation of the skin o Melasma gravidarum (Chloasma) – mask of pregnancy o Abdominal striae (striae gravidarum) – due to stretching. shallow water blister 3 – subcutaneous involvement. PRURITUS • Bathe in tepid water and apply emollient lotion . erythema 2 – epidermis and dermis involvement. nose. toes. apply witch hazel compress Walk regularly rest with feet elevated avoid long periods of standing and sitting do not cross your legs 110. deeper crater 4 – muscles and bone involvement.increase in vaginal discharge • Uterine changes – from pear shape to spherical around 8 weeks gestation and becomes ovoid from 16 weeks until term • Enlargement of abdomen . use extra pillow for comfort Avoid constipation and straining with bowel movement. PREGNANCY: Probable signs and symptoms • • • Positive Pregnancy test/ HCG in urine or serum Ballottement . earlobe or forehead • Normal: 95 to 100% 70% life threatening • AVOID: Movement Nail polish Light 116. just above the symphysis pubis • • • Hegar's sign . lie on left side when at rest Rest with your feet elevated. PREGNANCY: Presumptive signs and symptoms • Fatigue – response to increased hormonal levels • Urinary frequency – caused by pressure of expanding uterus in the bladder • Nausea and vomiting (morning sickness) • Quickening .Heartburn Dizziness Ankle edema Fatigue Hemorrhoids Varicose veins Small.
• • tends to be PROACTIVE instead of reactive. o o o improvement opportunities are developed by focusing upon the work process the improvement of the quality of services is an ongoing (continuous) process 119. nonrestrictive clothing Keep nails short Apply cool and moist compress • 117. light. cosmetics Adhesive tape Tight clothing 120. Quality Assurance (QA) – focus upon “doing it right” • A systematic process of organization-wide participation and partnership in planning and implementing improvement methods to understand and meet customer needs and expectations • emphasis is on maintaining minimum standards of care • • tended to be REACTIVE rather than proactive involves such methods as: o chart audits o reviewing incident reports o determining whether performance conforms to standards. mineral oil Calamine Antihistamine oatmeal bath Cocoa-butter Menthol/ camphor Cornstarch Cool environment o o o o o o o • • Provide cool. SEIZURES • • • Priority DURING: safety Priority AFTER: airway Seizure Precaution . RADIATION THERAPY TELETHERAPY External Not radioactive Cobalt therapy. Linear Accelerated Radiation SOURCE PATIENT EXAMPLE S BRACHYTHERAPY internal Radioactive 1. Vitamin B12 Sealed – implant (seeds) cesium. TOTAL QUALITY MANAGEMENT (TQM) – focuses on “doing the right thing” • aka Quality Improvement (QI)/ Process Improvement (PI) • QI’s emphasis is upon identifying real and potential problems • participation and partnership in planning and implementing improvement methods to understand and meet customer needs and expectations. General Principles of TQM: o quality is achieved through the participation of everyone in the organization • • decisions to change or improve a system or process are made based on data (not majority rule) uses such methods as o building quality performance into the work process o meeting the needs of the customer proactively. principle benefits o viewing every problem as a possible opportunity for improvement o involving staff in how the work is designed and delivered (improves staff satisfaction) o empowering staff to identify and implement improvement resulting in increased patient outcomes o increasing the customer’s perception that you care by designing health care processes to meet customer needs. powder. 2. iridium S – hield: lead + Dosimeter badge T – ime: 5 min/visit. • • • Structure Evaluation – evaluating the “physical setting” Process Evaluation – evaluating “how the nursing care is rendered” Outcome Evaluation – evaluating the demonstrable changes brought by the nursing process 118.• • AVOID o o ALLOW soaps and detergents petroleum. Unsealed – oral. IV radioactive iodine 131. 1 pt/ day D – istance: 3 feet away At bedside: forceps and lead container AVOID: pregnant and children Aratula: “Caution” ALLOW • Leave markings • Vitamin A and D • Soap and water and pat dry • • • • • AVOID Sunlight Alcohol Lotion. 30 min/ shift. as opposed to the health care provider’s needs.
SHOCK . liver. Label Avoid specified foods and vitamin C 3 days prior to collection and specified medication 7 days prior to FALSE NEGATIVE VITAMIN C • collection.Reduction of arterial pressure leading to decrease blood flow • Types: (1) (2) Cardiogenic – loss of cardiac pumping action (MI. and processed meats) • RAW VEGETABLES or FRUITS (Particularly radishes. metabolic acidosis (due to accumulation of lactic acid) IRREVERSIBLE severe organ damage • Common Symptom:*** Decrease BP. turnips. P – osition: side-lying L – oose the clothings A – VOID: resrictions N – ote: duration and characteristics of the seizure O – xygenate: jaw-thrust D – rugs: diazepam. drugs and chemical Septic Septic – massive infection PROGRESSIVE Decreased BP Increased RR and PR Altered LOC Oliguria increased BUN and Creatinine stress ulcers and increased risk for GI bleeding. MAP (Mean Arterial Pressure) Increase RR. Void before the specimen collection (to prevent urine contamination) QUANTITY: LIQUID STOOL: 15 to 30 mL Refrigerate and label FECAL OCCULT BLOOD TESTING (Guaiac Test) • Occult = hidden SOLID STOOL: About a pea-size or 1 inch (2. drug depressants) Vasogenic – massive vasodilation • • • Stages: COMPENSATORY Normal BP Increased RR and PR cold clammy skin oliguria hypoactive bowel sounds Anaphylactic – massive reaction to food.5cm) a. Major cause of septic shock gram-negative bacteria First drug to be given for SHOCK Epinephrine 123. • • Uses a chemical reagent which detects the presence of the enzyme peroxidase in the hemoglobin molecule. the patient is also at an increased risk for deep vein thrombosis. Specimen collection: STOOL Defecate in a clean bed pan or bedside commode. horseradish. Avoid contaminating the specimen with urine or toilet tissue. noise) 121. PR Narrow Pulse Pressure Position: modified trendelenburg*** • • • • In neurogenic shock. SCHILLING’s TEST PART 1 (CONFIRMATORY) Vitamin B12 (+) vitamin B12 in urine normal (-) vitamin B12 in urine (+) Pernicious Anemia PART 2 (IDENTIFICATION OF CAUSE) Vitamin B12 and Intrinsic factor (+) vitamin B12 in urine Pernicious Anemia is stomach in origin (-) vitamin B12 in urine Pernicious Anemia is small intestine in origin 122. carbamazepine R – emove harmful objects at the bedside A – t the bedside: suction machine P – ad and raise the side rails E – liminate environmental stimuli (bright lights.phenytoin. RESULTS: • • Changes in color like blue indicates a guaiac positive result No change or any other color than blue indicates a negative result. FALSE POSITIVE • RED MEAT (Beef. dehydration) most common (3) Distributive/ Circulatory Neurogenic (SCI. bleeding/ hemorrhagic shock. CHF) Hypovolemic – decrease blood volume (burns. and melon) .
or drug use during pregnancy poor prenatal care prematurity or low birth-weight mothers younger than 20 . SPONGE COUNTING • 1. drinking. and ANTICOAGULANTS) 124. touch. QUANTITY: 30 to 50 ml – routine urinalysis 5 to 10 ml – C&S Nurse aspirates from the lumen of a latex catheter or from a self-sealing port Collection of all urine produced in 24 hours The first voided urine is discarded. the parents often never face reality and stuck in the grieving process. SUCTIONING • Endotracheal • Position: semi-fowlers • Time: 5 to 10 seconds/ 5 minutes • Interval: 20 to 30 seconds • DURING Lubricate the catheter with water-soluble lubricant (2 to 3 inches) Insert during INHALATION in circular motion DO NOT insert during swallowing (it may enter the esophagus) o But in NGT let the patient swallow to promote entrance in stomach Apply suction: during withdrawal • Hyperoxygenate BEFORE and AFTER suctioning Conscious: DBE Unconscious: ambubag. If they don’t see their baby. STILLBORN CHILD • Management: Parents need to see. Again. o o o Wear gloves when collection. last urine voided included Either refrigerated or preservative is added CLEAN-CATCH or MIDSTREAM URINE For urine cultures Done when a woman has menstrual period CATHETER 24-HOUR Collection of sterile specimen usually done when client’s are catheterized for other reasons To determine the ability of the kidneys to concentrate urine To determine disorders of glucose metabolism To determine levels of specific constituents 126.before closure of a body cavity (depends on the surgery done) 3. Allow and encourage them to take photos of their angel. rock. IRON preparations. wash. Specimen collection: URINE SPECIMEN PURPOSE CLEAN VOIDED For routine examination CONSIDERATIONS WHEN COLLECTING Usually collected by the client with minimal assistance Preferably done on the first voided specimen in the morning but it can be collected anytime if needed At least 10 to 30 mL Clean container is used BEST TIME: early morning – concentrated urine Sterile specimen container Place specimen during midstream flow. Specimen collection: SPUTUM Sputum – arises from the tissue of the respiratory tract Saliva – excreted by the salivary and mucus glands BEST TIME: early morning BEFORE: Mouth care DURING: o Deep breaths then cough up 15 to 30 mL (1 to 2 tablespoons). and dress baby Get footprints. 128. ID band. SUDDEN INFANT DEATH SYNDROME (SIDS) • Causes: smoking. not spit Should be cough directly into the specimen container 125. pictures.before opening 2. encourage to hold.• MEDICATIONS (NSAIDs. 3 to 5 times (12 – 15 LPM) 129. lock of hair. Ask the client to expectorate. and cuddle their baby. name the child and use the name often.before skin closure • The SCRUB and the CIRCULATING nurses should count audibly and concurrently 127.
deep breathing AFTER: Unaffected side with head elevation of 30o for at least 30 minutes • • • 136. not more than 1000 mL should be removed AVOID: coughing . THYROIDECTOMY: Complications Bleeding – Feeling of fullness at incision site o Check soiled dressing at nape area. tobacco smoke exposure following birth overheating from excessive sleepwear and bedding stomach sleeping 130. SUTURES (catgut) – a thread. or other material used in the operation of stitching parts of the body together TYPES OF SUTURES: • Absorbable – digested by body enzyme/ use in internal organs*** plain gut (yellow) chromic gut (brown) • Non-absorbable – become encapsulated by tissue and remains unless removed (removed 7 days after) silk (light blue) nylon (green) cotton (pink) Prolene (royal blue) Mersilenne (Turquoise) Vicryl (purple) Dacron (orange) 131. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) • Autoimmune • S/SX: Fatigue Arthritis Sensitivity to sunlight Butterfly rash • Management: NO CURE GOAL: controlling symptoms steroids 132. sandbag Accidental removal of parathyroid – Hypocalcemia – classic sign tetany . TELEPHONE ORDER • Only RN’s may receive telephone orders • The order should be countersigned by the physician within 24 hours 133. wire. TETRALOGY OF FALLOT • 4 Defects: o Pulmonic Stenosis o Right Ventricular Hypertrophy o Ventricular Septal Defect o Overridding of the Aorta • Tet spells – severe acute cyanosis • Position: Knee-chest/ Squatting*** • Sign o Machine-like murmurs o Clubbing of fingers o Cyanosis • Management: o Surgery: Blalock Taussig procedure shunting of the subclavian artery and pulmonary artery 135. TENSILON TEST • edrophonium chloride (Tensilon) IV • evaluation of muscle strength • USE: To diagnose myasthenia gravis • At bedside: resuscitation equipment atropine sulfate on bedside for possible CHOLINERGIC CRISIS neostigmine for possible MYASTHENIC CRISIS • Results: (+) diagnosis = improvement on muscle function after administration of drug (-) diagnosis = muscle fasciculations occur as a result of the drug 134. THORACENTESIS • Purpose: To remove excess fluid or air to ease breathing • POSITION: sitting while leaning forward over a pillow • Chest X-ray identifies best insertion site • • Within the first 30 minutes.
T-TUBE • PURPOSE: To maintain patency*** To drain To prevent bile leakage to the peritoneum • DRAINAGE Amount: 1st 24 hours – 500 to 1000 ml Normal color of stool after removal – “brown” Draining – does not need doctors order Color: 1st 24 hours – reddish brown • • 139.o Calcium gluconate. Irritability. Agitation.R. TRACTIONS • TYPES Skin traction – impaired skin integrity Skeletal traction – risk for infection • Counter traction – weight of the patient • Bucks – not more than 8 to 10 lbs of weight should be applied • Crutchfield tongs (skull tongs) – used to immobilize the cervical spine (indicated for unstable fractures or dislocation of the cervical spine) • Crutchfield tongs/ Gardner-Wells skull tongs • POSITION: supine 140. TOTAL PARENTERAL NUTRITION (TPN)/ PN/ IV HYPERALIMENTATION • • • • Dextrose content 10 to 50% Change the solution after 24 hours Site: central veins (SVC) subclavian vein (an x-ray is done to confirm its placement) Position during insertion: trendelenburg Complication: Thrombophlebitis due to hypertonicity of the solution Hyperglycemia rapid infusion change access site regulate Hypoglycemia Infection Fluid overload Air embolism Allergy D10W pedia abrupt discontinuation hyperinsulinismdon’t stop abruptly unsterile procedure sterile technique rapid infusion regulate • • If TPN is emptied and no doctors follow up order give hypertonic solution • D50W adult BEFORE: check label of solution and rate of infusion with medical order inspect TPN bottle for precipitates or turbidity administer via an infusion pump DURING: Initially administered at 50 ml/hr*** for the FIRST hour Monitor glucose Monitor vital signs every 4 hours AFTER: Monitor WBC • PRIORITY NURSING DIAGNOSIS: High risk for infection • Do not overcorrect flow rate if too slow or fast • STERILE technique*** • Transparent air-occlusive dressing*** • 138. TRIAGE • “trier”. restlessness. Tachycardia o beta blockers 137.to sort • To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be addressed 3 CATEGORIES IN TRIAGE in E. eye threatening Needs treatment in 20 minutes EMERGENT NON-URGENT Green Can wait hours or days Color Urgency . URGENT Red Yellow Life.to prevent arrhythmia • • • Laryngospasm – DOB. suction Accidental damage of the laryngeal nerve – Hoarseness of voice o Encourage patient to talk post op asap to determine laryngeal nerve damage Thyroid storm – Fever. limb. slowly administer. SOB o tracheostomy at bedside.
rash. weak pumping – BP decreases) Peripheral vascular resistance (increased vasoconstriction – BP increases) Blood volume (BV decreases – BP decreases. simple fracture. Systolic – contraction – depolarization Diastolic – relaxation – repolarization b. chemicals in the eye. BLOOD PRESSURE a. Results: loss. asthma with no respiratory distress sprain. Use the bell of the stethoscope low pitched sounds Pump about 30 mmHg more from the point the pulse has disappeared. Deflate the cuff at a rate of 2 to 3 mmHg per second. sore throat IMMEDIATE Number Color Examples 1 Red Chest wounds. VENOUS DISORDERS • Management: o Elevate legs o Exercise legs o Early ambulation o Elastic stockings VITAL SIGNS 143. Weber negative – if sound is heard on both sides or localized at the center of the ear.5 cm above the antecubital space. – sound heard on the normal ear – sensorineural disturbance RINNE TEST –To compare air conduction from bone conduction. shock. newborns may become silent or open their eyes wide. TUNNING FORK TEST a. severe hemorrhage to 2 hours Fever >40oC. Hold and place the base of the tunning fork on top of the client’s head. by 3 or 4 months. open fractures. 142. Rest the arms for 1 to 2 minutes before taking the blood pressure again. ask the client where he/she hears the noise. high spinal cord injury 141. BV increases – BP increases) Blood viscosity (blood highly viscous – BP increases) ASSESSING BLOOD PRESSURE The cuff should wrap (A) 40% of the arm length and (B) 80% should encircle the adult’s arm (arm circumference)/ 100% of the child’s arm The lower border of the cuff should be 2. eye Minor burns. abdominal pain. smoking or ingested caffeine Read lower meniscus of the mercury to prevent error of parallax o error of parallax – if the eye level is higher than the level of lower meniscus . Pumping action of the heart (strong pumping – BP increases. minor laceration. Ask client to block one ear intermittently (move a fingertip in and out of the ear) Hold the handle of the activated tuning fork against the mastoid process (until vibrations can no longer be felt/heard by the client). child will turn his/her head toward the sound. Weber positive – sound heard better on the impaired ear – bone-conductive hearing loss. DETERMINANTS OF BLOOD PRESSURE • • • • c. and CNS injuries minor bleeding EXPECTANT 4 Black Unresponsive. 2-3 burns 4 CATEGORIES IN TRIAGE in DISASTER DELAYED MINIMAL 2 3 Yellow Green Stable abdominal wound. Positive Rinne – Air conduction (AC) is greater than bone conducted (BC). Toothache. Negative Rinne – BC is equal to or longer than air conduction – indicating a conductive hearing Infants: ring a bell or have the parent call the child’s name (to assess gross hearing). severe respiratory distress. Calibrate the sphygmomanometer every 6 months Allow 30 minutes for resting if the client has exercise. penetrating trauma. minor fractures. in cases reading is not certain. Immediately hold the vibrating fork with the prongs in front of the client’s ear canal.Examples Needs immediate attention Chest pain. simple headache. cardiac arrest. limb amputation. Results: b. WEBER’S TEST – To test for bone conduction by examining lateralization of sound.
caffeine and exercise for the last 30 minutes 144. • • • • • Wait for 10 to 15 minutes if he client has been physically active.Position the patient (prone/ supine with knees flexed) • 2. 146. very fast 9 Risk of injuring the membrane) E – Evident cerumen A – An ear infection is present R – Reading may vary between left and right measurement c. Doppler ultrasound stethoscope (DUS): transducer probe (gel may be applied) and stethoscope headset. d. Apical pulse below 7 years old – located at the 4th ICS LMCL PULSE SITES Infants. when using a DUS.A 40% B 80% d.palpate the pulse • 4. reflects the core temperature. hold the probe lightly over the pulse site. Common mistakes FALSE-LOW Bladder of cuff too wide Arm above heart level FALSE-HIGH Bladder of cuff narrow Arm below heart level Deflating cuff too slowly Inflating too slowly Smoking. Use 2 or 3 middle fingertips lightly over the pulse site. palpable: brachial and femoral 7 years old and above – located at the 5th ICS LMCL . AXILLARY – Safe and non-invasive A – Axillary injury X – eXercise/activity I – Inadequate circulation L – Laging basa (moist pits) A – After bathing RECTAL – Reliable measurement (Inconvenient and more unpleasant) R – Rectal disease/diarrhea I – Immunosuppressed C – Clotting disorders T – Turning to the side is difficult H – Hemorrhoids U – Undergone rectal surgery M – Myocardial infarction TYMPANIC – Readily accessible. BP in THIGH*** • 1. ORAL – accessible and convenient S – Smoking* N – Newborn O – Oral surgery U – Ulceration/injury to the mouth T – Tremors/convulsions H – Hot/cold foods & fluids just ingested wait for 15 to 30 minutes before taking temperature b. TEMPERATURE a. intense tapping (loud tapping) Phase 4 – a softer blowing sound that fades (muffled sound) Phase 5 – Silence determines the diastole BP – 104/100/90 (Phases I/ IV/ V) • eg 145. PULSE – the wave of blood created by the contraction of the left ventricle. KOROTKOFF PHASES • • • • Phase 1 – a sharp thump determines the systole Phase 2 – a blowing or whooshing sound (increasing sound) Phase 3 – a crisp.Expose the thigh • 3.wrap the BP cuff e.
bradypnea (abnormally slow). c. transplant • Order – aromatic • pH – 4. and Kussmaul’s breathing (hyperventilation associated with metabolic acidosis). get new catheter and insert to urethra then remove the catheter from vagina Increases susceptibility to infection 149. URINARY CATHETERIZATION: TYPES TYPES Straight Catheter NO.upper thigh or abdomen Female . 148. HYPERVENTILAT ION HYPOVENTILATI ON CHEYNE-STOKES BIOT’S RHYTHM – Cheyne-Stokes breathing (regular rhythm from very deep to very shallow respirations then temporary apnea) and Biot’s respiration (shallow breaths interrupted by apnea). adults: radial brachial carotid 147.inner thigh NO TUB BATHS. EUPNEA TACHYPNEA F E I H DEPTH – Hyperventilation (rapid and deep breaths).5 to 8 • Amount – 1200-1500 ml/day (30-60 ml/hr) • Sp. . and apnea (absence of breathing). APNEA BRADYPNEA b. PREVENTING UTI W – ash before and after sex O – n time voiding M – ake us of cotton undergarment A – lways wipe from anterior to posterior N – o sprays. Allens test: CPR. RATE – Eupnea (breathing that is normal in rate and depth). • 2 Types of breathing Costal – thoracic Diaphragmatic – Abdominal • • First to take BEFORE invasive procedures Physiologic apnea C D a. OF SINGLE: only for drainage LUMENS PURPOSE SPECIAL CONISDERATIONS Inserted only as much times as it takes to drain the bladder or obtain a urine specimen Coude catheter is a variation of straight catheter which has a curved and tapered tip.25 150. usually used for male patients with prostatic hypertrophy Indwelling Catheter (Foley or Retention catheter) DOUBLE: • urine drainage • for inflation of balloon (serves as an anchor) OR TRIPLE: • urine drainage • for inflation of balloon (serves as an anchor) • for continuous irrigation Inserted and stays connected to the bladder for a long time Secure catheter tubing: male . URINE ELIMINATION • Color – amber/straw.gr – 1. powder. RESPIRATIONS – The act of breathing. harsh soaps. infants: CPR. shower is preferable Collection bag should always be below bladder Position during procedure: FEMALE – Dorsal Recumbent MALE – Supine Lubricate catheter Catheter accidentally slips into vagina: leave the catheter in vagina. tachypnea (abnormally fast).010-10. hypoventilation (very shallow respirations).