December 2012 NLE Tips Funda

WHAT YOU SHOULD KNOW BEFORE THE PNLE

DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 1: FUNDAMENTALS OF NURSING

POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming December 2012 PNLE

I. NURSING THEORIST Florence Nightingale Environmental Theory Virginia Henderson 14 Basic Needs Faye Abdellah Patient – Centered Approaches to

Nursing Model / 21 Nursing Problems Dorothy Johnson Behavioral System Model Imogene King Goal Attainment Theory Madeleine Leininger Transcultural Nursing Model Myra Levin Four Conservation Principles Betty Neuman Health care System Model Dorotheo Orem Self-Care and Self-Care Deficit Theory Hildegard Peplau Interpersonal Model Martha Rogers Science of Unitary Human Beings Sister Callista Roy Adaptation Model Lydia Hall Care,Core,Cure Jean Watson Human Caring Model Rosemarie Rizzo Parse

Human Becoming

II. NURSING HISTORY

Moses – “Father of Sanitation” Hippocrates – “Father of Scientific Medicine” Clara Barton, founded the American Red Cross Caroline Hampton Robb, The first to nurse to wear

gloves while working as an operating room nurse. Dona Hilaria de Aguinaldo, organized Filipino Red

Cross. Anastacia Giron – Tupas, First Filipino nurse to hold

the position of Chief Nurse Superintendent; founder of the Philippine Nurses Association.

III. NURSING PROCESS ASSESSMENT PHASE - Data Collection - Organize Data - Validate Data - Document Data

Subjective Data also referred to as symptoms or covert data Objective Data also referred to as signs or overt data, are detectable by an observer Primary source is the client Secondary source is family or anyone else that is not the client Methods of Data Collection Observing To observe is to gather data by using the sense. Interviewing Is a planned communication or a conversation with purpose Examining Is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.

DIAGNOSIS PHASE - Analyze Data - Identify Health

Problem - Formulate Diagnostic

Statements Diagnostic Statements Problem (P): statement of the client’s response. Etiology (E): factors contributing Signs and Symptoms (S): defining characteristics manifested by the client

Types of Nursing Diagnosis Actual diagnosis is a client problem that is present at the time of the nursing assessment. Risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors Wellness diagnosis Possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses .

PLANNING PHASE - Prioritize problems - Formulate goals - Select actions - Write nursing orders

Types of Planning Initial planning, admission assessment. Ongoing planning Discharge planning: M edications E xercise T reatment/therapy H ygiene O ut-patient follow up D iet/nutrition S exual activity/spirituality

INTERVENTION / IMPLEMENTATION - Determining needs

for assistance - Putting into action

the plan - Supervising delegated

care - Documenting nursing

activities

Types of Intervention Independent Dependent Collaborative

Cognitive or Intellectual Skills Such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient's needs. Interpersonal Skills Which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient Technical Skills Which includes knowledge and skills needed to properly and safely done the procedure

EVALUATION PHASE Collecting data related to outcome Comparing data Drawing conclusion Continuing, modifying or terminating the nursing care plan

IV. ROLES AND FUNCTIONS OF THE PROFESSIONAL NURSE

Direct Care Provider - provides total care using the

nursing process .

Communicator – communicates with clients, support

person and colleagues to facilitate all nursing action.

Teacher – provides health teaching

Counselor – helps the client to recognize and cope with

stressful pyschological or social problem,

Client Advocate – the nurse becomes an activist speaking

up for the client who cannot or will not speak for self.

Change Agent – initiates changes and assists the client

make modifications in the lifestyle to promote health.

Leader – nurse through the process of interpersonal

influence .

Manager – the nurse plans, gives directions, develops staff,

monitors operation.

Case Manager – coordinates the activities of other

member of the health care team.

Researcher – participates in scientific investigation and

uses research findings in practice.

Collaborator – works in a combined effort with all those

involved in care delivery.




V. HEALTH / DISEASE / ILLNESS Health is the complete physical, mental, social (totality)

well-being and not merely the absence of disease or

infirmity.

FOUR MODELS OF HEALTH BY SMITH 1. Clinical Model Man is viewed as a Physiologic Being If there are no signs and symptoms of a disease, then

you are healthy 2. Role Performance Model

As long as you are able to perform SOCIETAL functions and ROLES you are healthy

3. Adaptive Model Health is viewed in terms of capacity to ADAPT Failure to adapt is disease

4. Eudaemonistic Model Because health is viewed in terms of Actualization

Disease is a pathologic change in the structure or function

of the mind and body

Illness is a highly subjective feeling of being sick or ill

STAGES OF ILLNESS AND HEALTH-SEEKING BEHAVIOR BY SUCHMAN

Symptom Experience

Client realizes there is a problem

Client responds emotionally

Sick Role Assumption

Self-medication / Self-treatment

Communication to others

Assuming a Dependent Role

Accepts the diagnosis

Follows prescribed treatment

Achieving recovery and rehabilitation

Gives up the dependent role and assumes

normal activities and responsibilities

VI. CHAIN OF INFECTION

► MODE OF TRANSMISSION it indicates the potential of the

disease; conveyance of the agent to the host; it can be by common source transmission, contact source, air-borne transmission.

There are four main routes of transmission A. By Contact Transmission

1. Direct contact ( person to person ) 2. Indirect contact ( usually an inanimate object) 3. Droplet contact ( from coughing, sneezing, or talking, or talking by an infected person)

B. By Vehicle Route ( through contaminated items) 1. Food – salmonellosis 2. Water – shigellosis, legionellosis 3. Drugs – bacteremia resulting from infusion of a contaminated infusion product 4. Blood – hepatitis B,

C. Airborne Transmission 1. Droplet of nuclei 2. Dust particle in the air containing the infectious agent 3. Organisms shed into environment from skin, hair, wounds or perineal area. D. Vector borne Transmission, arthropods such as

flies, mosquitoes, ticks and others. VII. ISOLATION PRECAUTIONS Standard Precautions / Universal Precautions

Applies to ALL BODY FLUIDS Includes:

1. HAND WASHING 2. Personal Protective Equipment

(sequence of removing PPE’s) gloves-mask-gown-eyewear-cap

3. Safe use of sharps 4. Removing spills of blood and body fluids 5. Cleaning and disinfecting equipment

Transmission Based Precautions

• Airborne precautions A single room under negative pressure

ventilation with a wash hand basin The door must be kept closed at all times except

during necessary entrances and exits. Disposable paper towels A high efficiency mask, if available, should be

worn when entering the room of a patient with known or suspected tuberculosis.

• Droplet precautions Put on a standard mask prior to entering the

isolation room. Hands must be washed with an antiseptic

preparation and must be dried thoroughly with a disposable paper towel or washed with a waterless alcohol hand rub/gel: 1. AFTER contact with the patient or

potentially contaminated items, 2. AFTER removing gloves, and 3. BEFORE taking care of another patient.

• Contact precautions Non-sterile, disposable gloves are needed when

there is contact with an infected site, with dressings, or with secretions.

A mask when performing procedures that may generate aerosols or when performing suctioning is recommended.

Hands washing (see droplet precautions) VIII. NUTRITION Food Sources Protein Meat, fish, eggs, milk, poultry, cheese,

beans, mongo Carbohydrates Grains, Legumes, Potatoes, Cereals,

Breads Fats / Lipids Saturated: coconut oil, and palm kernel

oil, dairy products (especially butter, , cream, and cheese), meat (beef), dark meat of poultry, and poultry skin, chocolate Unsaturated: Avocado, Nuts, Vegetable oils such as soybean, canola, and olive oils

Vit. A Eggs, carrots, squash, all green leafy vegetables

Vit. D Fish, liver, egg, milk, margarine Note: excess vit.D may lead to fetal cardiac problem

Vit. E Green leafy vegetables, fish, corn




Vit.K Leafy green vegetables, particularly the dark green ones such as: Spinach, Broccoli, Malunggay, Avocado

Vit. C Tomatoes, guava, papaya, citrus fruits Folic Acid Asparagus, organ meat, green leafy

vegetables Vit. B ( foods rich in protein ) Calcium and Phosphorus

Milk, cheese, green leafy vegetables, whole grains, seafood, tofu

Iron Pork liver, lean meat, kamote leaves, soybeans, seaweeds, mongo

Iodine Iodized salt, seafood, milk, egg, bread IX. NURSING SKILLS A. Hygiene A complete bed bath consists of washing a dependent

client’s entire body in bed; a complete bed bath with assistance involves helping the client to wash.

A partial bed bath consists of or buttocks that may cause discomfort or odor if le washing only parts of the client’s body such as feet ft unwashed.

A tub bath or shower provides a more thorough cleansing than a bed bath; the amount of nursing assistance is determined by the client’s age and health and safety consideration.

A therapeutic bath is ordered by a physician for a specific purpose. Therapeutic baths include: Sitz bath – to reduce inflammation and clean the

perineal area. Tepid sponge bath – to reduce fever. Medicated tub bath – to relieve skin irritation.

Nursing Consideration

Avoid unnecessary exposure and chilling. Expose, wash, rinse and dry only a part of the

body at one time. Avoid draft Use correct temperature of water.

Observe the patient’s body closely for physical signs such as rashes, swelling, discoloration, sore, burns etc.

Give special attention to the following body areas; behind the ears, axilla, under the breast, umbilicus, pubic region, groin and spaces between the fingers and toes.

Do the bath quickly but unhurriedly, use even, smooth but firm strokes.

Use adequate amount of water and change as frequently as necessary.

If possible, do such procedure as vaginal douche, enema, shampoo, oral care etc. before bath.

B. Physical Assessment Provide privacy. Make sure that all needed instruments are available

before starting the physical assessment Be systematic and organized when assessing the client.

Inspection, Palpation, Percussion, Auscultation. EYES: Visual acuity is tested using a snellen chart. The

room used for this test should be well lighted EARS: Weber’s Test assesses bone conduction, this is a

test of sound lateralization, Rinne Test compares bone conduction with air condition.

NECK: Let the client sit on a chair while the examiner stands behind him.

THORAX: The client should be sitting upright without support and uncovered to the waist.

HEART: Anatomic areas for auscultation of the heart Aortic valve – Right 2nd ICS sternal border. Pulmonic Valve – Left 2nd ICS sternal border. Tricuspid Valve – – Left 5th ICS sternal border. Mitral Valve – Left 5th ICS midclavicular line

BREAST

ABDOMEN: Place the client in a supine position with the knees slightly flexed to relax abdominal muscles. (Inspection,Auscultation,Percussion,Auscultation)

C. Vital Signs Temperature (NV 36 – 37.5 C)

Elderly people are at risk of hypothermia Hard work or strenuous exercise can increase

body temperature Oral: most accessible 2-3 mins. * 15 minutes

interval after ingestion of hot or cold drinks Rectal: most accurate 2-3 mins. Axillary: most safest 6-9 mins.

Pulse (NV 60-100 bpm) Wave of blood created by contraction of the left

ventricle of the heart Radial: best site for adult Brachial: best site for children Apical: best site for 3 years old below

Respiration (NV 12/16-20)

Normal Breath Sound

Vesicular Soft, low pitch Lung periphery Broncho-vesicular

Medium pitch Larger airway blowing

Bronchial Loud, high pitch Trachea

Abnormal Breath Sound

Crackles Dependent lobes Random, sudden reinflation of alveoli fluids

Rhonchi Trachea, bronchi Fluids, mucus Wheezes All lung fields Severely narrowed

bronchus Pleural Friction Rub

Lateral lung field Inflamed Pleura

Blood Pressure (NV 120/80 mm/hg)

This is the force exerted by the blood against a vessel wall

The pressure rises with age. A rest of 30 minutes is indicated before the blood

pressure can be readily assessed after stressful activity.

Interval of 30 minutes is needed after smoking or drinking caffeine.

After menopause, women generally have higher blood pressures than before.

Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening




Common Errors in Blood Pressure Assessment Errors Effect

Bladder cuff too narrow Erroneously high Bladder cuff too wide Erroneously high Arm unsupported Erroneously high Insufficient rest before the assessment

Erroneously high

Repeating assessment too quickly

Erroneously high

Cuff wrapped too loosely or unevenly

Erroneously low

Deflating cuff too quickly Erroneously low systolic and high diastolic reading

Deflating cuff too slowly Erroneously high diastolic reading

Failure to use the same arm consistently

Inconsistent measurements

Arm above level of the heart Erroneously low Assessing immediately after a meal or while client smokes

Erroneously high

Failure to identify auscultatory gap pressure

Erroneously low systolic pressure and erroneously low diastolic

D. Medication Administration FIVE RIGHTS

The Right Drug with The Right Dose through The Right Route at The Right Time to The Right Patient

Standard Order, Carried out until cancelled by another order.

PRN Order, As needed, or only when necessary. Stat Order, Carried out immediately and for one time

only. Always clarify doubtful /unclear order Do not leave medicine with the client to take by himself Do not give drug that shows physical changes or

deterioration Report an error in medication immediately to the nurse

in charge. Check medication 3 times before taking to the client:

o When taking the medication from the storage area o Before placing medication into the medicine

rack/glass o Before placing medicine to the storage area

The nurse who prepares the medication must be responsible for administering and recording it. Never endorse it to another nurse.

Always observe asepsis in preparing and administering drugs.

Ascertain client’s identity before administering medications. Check room or bed or card, call out client’s name, check I.D., wrist band

Care must be taken to prevent instilling medication directly into cornea.

ORAL: If patient vomits within 20 – 30 minutes of taking the drug, notify the physician. Do not re-administer the drug without doctor’s orders. SUBLINGUAL ROUTE – drugs that is placed under the

tongue, where it dissolves.

BUCCAL ROUTE – a medication is held in the mouth

against the mucous membranes of the cheek until the drugs

dissolves

EYES MEDS: Apply ointment along inside edge of the lower eyelid from inner to outer canthus.

EAR MEDS: Infants: draw the auricle gently downward and backward. Adults: lift pinna upward and backward

Intradermal: Parallel to the skin, do not massage Subcutaneous: 45 degree above the skin, if obese 90

degree Intramuscular: 90 degree above the skin, aspirate to

check if blood vessel was hit.

D. Urinary Catheterization Use appropriate size of catheter

Male: Fr 16-18 Female: Fr 12-14

Place the client in appropriate position: Male: Supine, legs abducted and extended Female: Dorsal recumbent

Locate the urinary meatus properly: Male: at the tip of the glans penis Female: between the clitoris and vaginal orifice

Lubricate catheter with water soluble lubricant before insertion

Male: 6 – 7 inches Female: 1 – 2 inches

Length of catheter insertion: Male: 6 – 9 inches Female: 3 -4 inches

Anchor catheter properly: Male: laterally or upward over the lower abdomen / upper thigh Female: inner aspect of the thigh

Nursing Interventions to Induce Voiding/Urination Provide privacy Assist the patient in the anatomical position of voiding Serve clean, warm and dry bedpan (female) or urinal

(male) Allow the client to listen to the sound of running water Dangle fingers in warm water Pour warm water over the perineum Promote relaxation Provide adequate time for voiding Last resort: URINARY CATHETERIZATION E. Nasogastric Tube (NGT) Gavage (feeding) / Lavage (suctioning) Select the nostril that has greater airflow. Assist the client to a high fowler’s position NEX technique (nose-ear-xiphoid) Checking the patency:

Aspirate stomach contents and check the pH, which should be acidic

Introduce 10-30 ml of air into the NGT and auscultate at the epigastric area, gurgling sound is heard

The most accurate method of assessing the placement of NGT is X-ray study

Before feeding assess residual feeding contents. To assess

absorption of the last feeding, if 50 ml or more, verify if the

feeding will be given.

Height of feeding is 12 inches above the point of insertion.

Ask the client to remain in position for at least 30 min Common Problems of Tube Feedings

Vomiting Aspiration Diarrhea Hyperglycemia

F. Enema Administration

Position the client: Adult: Left lateral Infant/small children: Dorsal recumbent

Lubricate the tube about 5 cm ( 2 in ) Insert 7 – 10 cm ( 3 to 4 inches) or rectal tube gently

in rotating motion Raise the solution container and open the clamp to

allow fluid to flow High Enema: 12-18 inches above the rectum Low Enema: 12 inches above the rectum

If the client complains of fullness or pain, use the clamp to stop the flow for 30 sec. and then restart the flow at a slower rate

Encourage the client to retain the enema, ask the client to remain lying down




G. Colostomy Care

Stoma should appear red, similar to the mucosal linin of the inner cheek

Slight bleeding initially when the stoma is touched is normal, but other bleeding should be reported.

Change colostomy appliance if it is 1/3 full. Use warm water, mild soap (optional), and cotton

balls or a washcloth and towel to clean the skin and stoma.

Apply skin barrier over the skin around the stoma to prevent skin breakdown.

Changing is best in the morning before breakfast. Control Odor: (deodorizer, charcoal disk and prevent

odor causing foods)

Type of Discharge Ileostomy Liquid fecal drainage

Drainage is constant and cannot be regulated

Contains some digestive enzymes Odor is minimal bec of fewer

bacteria are present Ascending Colostomy Liquid fecal drainage

Drainage is constant and cannot be regulated

Odor is a problem requiring control

Transverse Colostomy

Malodorous, mushy drainage

Descending Colostomy

Solid fecal drainage

Sigmoidostomy Normal fecal characteristics H. Suctioning

Suction only when necessary not routinely Use the smallest suction catheter if possible Client should be in semi or high Fowler’s position Use sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and

after suctioning Insert catheter with gloved hand (3-5“ length of

catheter insertion) without applying suction. Three passes of the catheter is the maximum, with 10 seconds per pass.

Apply suction only during withdrawal of catheter The suction pressure should be limited to less than

120 mmHg When withdrawing catheter rotate while applying

intermittent suction Suctioning should take only 10 seconds (maximum of

15 seconds) I. Tracheostomy Care

Assist the client to a semi-Fowler’s or Fowlers position.

Hydrogen peroxide moisten and loosens dried secretions

Rinse the inner cannula thoroughly in the sterile normal saline.

When changing the ties: tie one end of the new tie to the eye of the flange while leaving old ties in place.

Put two fingers under the tapes before tying it.

J. Blood Transfusion

Compatible Incompatible A A / O AB / B B B / O AB / A

AB A / B / AB / O O O A / B / AB

Check for cross matching and blood typing. To ensure compatibility

Obtain and record baseline VS, Note: If patient has fever do not transfuse

Practice strict, ASEPSIS At least 2 nurses check the label of the blood

transfusion, Check the following: - Serial Number - Blood component - Blood type - Rh factor - Expiration date - Screening test

Check the blood for gas bubbles and any unusual color or cloudiness. Note: Gas bubbles indicate bacterial growth, Unusual color or cloudiness indicate hemolysis

Warm blood at room temperature before transfusion. Identify client properly, two nurses check the client’s

identification Gauge of needle: #18 Drop Factor: KVO Duration: RBC – 4 hours;

Platelets, FFP – 20 minutes When reactions occurs:

STOP transfusion KVO with PNSS Send remaining blood, a sample of client blood

and urine sample to the laboratory. Notify the physician Monitor VS Monitor I & O

Common BT reactions: Hemolytic: flank /back pain Anaphylactic: rashes, itching, DOB (worst) Febrile: fever and chills Circulatory Overload: DOB, crackles Sepsis: Fever and chills

K. Assistive Device

Canes COAL (cane opposite affected leg) Angel is 20-30 degrees

Walkers Hand bar below the client’s waist and the elbow is

slightly flexed. Crutches

Length of the Crutches: Subtract 40 cm or 16 inches to the height of the client obtain the approximate crutch length.

20 to 30 degrees of flexion at the elbow. Four point gait:

* right crutch, the left foot, the left crutch, right foot.

Two point gait: * left foot and right crutch, right foot and left crutch

Three point gait: * left foot and both crutches, right foot.

Swing Through Gait: . * Advance both crutches, Lift both feet and swing forward, Land the feet in front of crutches.

Going up the stairs: (good goes to heaven, bad goes to hell)

L. Chest Physiotheraphy ( CPT )

Steam Inhalation Place the client in Semi-Fowler’s position Cover the client’s eyes with washcloth to prevent

irritation Place the steam inhalator in a flat, stable surface. Place the spout 12 – 18 inches away from the

client’s nose or adjust distance as necessary To be effective, render steam inhalation therapy

for 15 – 20 minutes




Postural drainage

Use of gravity to aid in the drainage of secretions. Patient is placed in various positions to promote

flow of drainage from different lung segments using gravity.

Areas with secretions are placed higher than lung segments to promote drainage.

Patient should maintain each position for 5-15 minutes depending on tolerability.

M. Closed Chest Drainage ( Thoracostomy Tube ) Types of Bottle Drainage

One-bottle system The bottle serves as drainage and water-seal Immerse tip of the tube in 2-3 cm of sterile NSS

to create water-seal. Keep bottle at least 2-3 feet below the level of

the chest Observe for fluctuation of fluid along the tube.

The fluctuation synchronizes with the respiration.

Observe for intermittent bubbling of fluid; continues bubbling means presence of air-leak

In the absence of fluctuation: Suspect obstruction of the device

Assess the patient first, then if patient is stable Check for kinks along tubing; Milk tubing towards the bottle (If the hospital

allows the nurse to milk the tube) If there is no obstruction, consider lung re-

expansion; (validated by chest x-ray) Air vent should be open to air.

Two-bottle system

If not connected to the suction apparatus The first bottle is drainage bottle; The second bottle is water-seal bottle Observe for fluctuation of fluid along the tube

(water-seal bottle or the second bottle) and intermittent bubbling with each respiration.

Three-bottle system

The first bottle is the drainage bottle; The second bottle is water seal bottle The third bottle is suction control bottle.

Observe for intermittent bubbling and

fluctuation with respiration in the water- seal bottle

Continuous GENTLE bubbling in the suction control bottle.

Suspect a leak if there is continuous bubbling in the WATER seal bottle or if there is VIGOROUS bubbling in the suction control bottle.

The nurse should look for the leak and report the observation at once. Never clamp the tubing unnecessarily.

If there is NO fluctuation in the water seal bottle, it may mean TWO things

Either the lungs have expanded or the system is NOT functioning appropriately.

In this situation, the nurse refers the observation to the physician, who will order for an X-ray to confirm the suspicion.

In the event that the water seal bottle breaks, the nurse temporarily kinks the tube and must obtain a receptacle or container with sterile water and immerse the tubing.

She should obtain another set of sterile bottle as replacement. She should NEVER CLAMP the tube for a longer time to avoid tension pneumothorax.

In the event the tube accidentally is pulled out, the nurse obtains vaselinized gauze and covers the stoma.

She should immediately contact the physician. N. Oxygen Therapy Nasal Cannula (24% - 45% ) at flow rate of 2 – 6 L/min. Simple Face Mask (40% - 60%) at liter flows of 5 - 8

L/min Partial Rebreather Mask (60% - 90%) at liter flows of

6 – 10 L/min. Non-Rebreather Mask (95% - 100%) at liter flows of

10 – 15 L/min. Oxygen is colorless, odorless, tasteless and a dry gas that

support combustion, therefore leakage cannot be detected.

Place cautionary signs reading “ No SMOKING: Oxygen in Use”

Avoid materials that generate static electricity, such as woolen blankets and synthetic fibers.

Set up the oxygen equipment and the humidifier filled with distilled/sterile water.

CANNULA: Put over the client’s face, with the outlet prongs fitting into the nares.

FACE MASK: Fit the mask to the contours of the client’s face, apply it from the nose downward

December 2012 NLE Tips Funda

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