NURSING PROCEDURES

NURSING SKILLS (OXYGENATION) o Pulse Oximeter o Sputum Specimen Collection o Thoracentesis o Incentive Spirometer o CPT (Chest Physiotherapy) o Suctioning CTT: 3-way bottle system o O2 delivery o DBE (Deep breathing Exercises)

PULSE OXIMETERCritical Pathway 1. If the client is allergic to adhesive, what type of Pulse Oximeter shouldthe nurse use? Use a clip sensor instead of an adhesive sensor 2. What is the best site for Pulse Oximeter? Good circulation, capillary refill… if not, nasal sensor or forehead sensor. 3. How should the nurse prepare the site? Clean with alcohol, remove nail polish4. What is the rationale why the nurse should immobilize the monitoring site? Movement may be misinterpreted as an arterial pulsation 5. How frequent should the nurse change the monitoring site? 4 hours for adhesive, 2 hours for spring / clip tension sensor 6. If the nurse notices that the window is open and sunlight is coming in from the outside, what should he do? Cover sensor with a sheet or towel to block large amount of lights alter sa02

A pulse oximeter is attached to Ms. Dizon to: A. Determine if the client’s hemoglobin level is low and if she needs blood transfusion B. Check the level of tissue perfusion C. Check the client’s Arterial blood gas D. Detect oxygen saturation of the arterial blood before symptoms of hypoxemia developsAnswer: D

SPUTUM EXAMINATION Purpose for collecting sputum specimen

1. For C/S specific organism and drug sensitivity 2. Cytology identify the structure and pathology of cells, cancer.. 3. AFB use to identify TB 4. Evaluation effectiveness of therapy

SPUTUM EXAM COMMON FINDINGS: White & frohy color - Asthma Gelatinous - Bronchitis Blood Streak - PTB Pinkish - Pulmonary Edema Yellow - Bacterial Pneumonia Green rusty - Viral Pneumonia

SPUTUM EXAMINATION Critical pathway 1. When is the best time to collect a specimen? morning 2. In rinsing the mouth, what should the nurse use? water 3. Clean or Sterile specimen container? sterile 4. How much sputum will the nurse collect? 1-2 tbsp / 15-30 ml 5. Clean or Sterile gloves? clean6. What should I instruct the client? 3 breaths cough 7. Priority after collection? Oral hygiene

SPUTUM COLLECTION BEFORE: TIME of COLLECTION: early in the morning no mouthwash only water 3 deep cough 1-2 tbsp / 15-30 mL AFTER: Yes to mouthwash (oral care)

THORACENTESISPOSITION (BEFORE): Orthopneic position (sitting head over the table) POSITION (AFTER): UNAFFECTED SIDE Note: In case of hypovolemic shock, position client in TRENDELENBURG POSITION SECURE CONSENT. Who? Physician ANESTHESIA: LOCAL Inhale or Exhale (during insertion )? INHALE during insertion but EXHALE during withdrawal

THORACENTESISCritical Pathway 1. What is the position of the client for Thoracentesis? LEAN FORWARD 2. Who will secure the consent for Thoracentesis? PHYSICIAN 3. What kind of anesthesia is used in this procedure? LOCAL ANESTHESIA 4. What should be the nurse’s instruction to the client when the physician is inserting the needle and also during the withdrawal of the needle? EXHALE5. After Thoracentesis, what should be the position of the client? UNAFFECTED SIDE 6. If expectoration of blood is noted, what should the nurse do? NOTIFY PHYSICIAN 7. To evaluate the effectiveness of the procedure and to rule out the development of pneumothorax, the nurse will expect what procedure that will be done to the patient? CHEST X-RAY

CRITICAL PATHWAY A client is to undergo Thoracentesis, the nurse knows that a preprocedural timeout is performed to:

A. Ascertain that the client is ready to undergo the procedure B. Make sure that the client has signed the consent C. Make sure that the members of the healthcare team will verify the client, the procedure and other aspects of the procedure D. Provide rest and comfort to all hospital personnel

CRITICAL PATHWAY After Thoracentesis, the patient is put on what position? A. Supine position B. Side lying , affected side C. Side lying, unaffected side D. Semi fowler’s position

INCENTIVE SPIROMETER Have the client seal her lips around the mouthpiece. Inhale slowly and deeply for at least three seconds.POSITION: UPRIGHT/SITTING SEAL lips around the mouthpiece Inhale SLOWLY and DEEPLY TIME: HOLD for 6 seconds FREQUENCY: 4 times hourly (every 15 minutes)

INCENTIVE SPIROMETRYCritical Pathway 1. What should be the optimum position of the client? Upright , sitting HF 2. How should the client hold the device? UPRIGHT 3. What should you tell the client before putting the mouthpiece around the mouth? EXHALE NORMALLY 4. How should the client seal the mouthpiece with her mouth? TIGHT5. What kind of instruction will you give to elevate the spirometer ball? SLOW & DEEP in 6 seconds 7 . After using the incentive spirometer, what is the best thing the client should do? COUGH 8. How frequent should the client use the device ? Q 15 mins , 4 times hourly during waking time 9. If the client is using a disposable mouthpiece, how frequent will the nurse change it? Every 24 hours

CRITICAL PATHWAY In preparing the client before incentive spirometry, The nurse should position the client: A. Semi-fowlers B. fowlers C. High fowlers D. Orthopneic

CHEST PHYSIOTHERAPY Includes: postural drainage, chest percussion, vibration, breathing exercises POSTURAL DRAINAGE - It uses specific positions that allow the force of gravity to assist in the removal of bronchial secretions Notes: before meals and at bedtime ; remain in each position for 10 to 15 minutes the entire procedure should not be more than 30 minutes usually performed 3-4 times

Location of secretions 1. Apical section of the UL – High-Fowler’s position 2. Posterior section of the UL – Side-lying position 3. RL – Left side with pillow under the chest wall 4. LL – Trendelenburg position

PERCUSSION - is carried out by cupping the hands and lightly striking the chest wall Note: Done 1-2 minutes 3-5 minutes for pt with tenacious secretions  

VIBRATION - is the technique of applying manual compression and tremor to the chest wall. Note: Done during the exhalation phase of respiration Done during 5 exhalations

PERCUSSION: done 1-2 mins and 3-5 mins in pt with tenacious secretions VIBRATION: done during 5 exhalations POSTURAL DRAINAGE : done 10-15 minutes NOTE: The entire procedure should not be more than 30 minutes Frequency: 3-4 times a day

CHEST PHYSIOTHERAPYCritical Pathway 1. Is chest physiotherapy dependent or independent nursing action? Dependent action 2. What is the correct sequence in performing chest physiotherapy? Positioning, percussion, vibration 3.The secretion from various lung segments are drained by postural drainage using what force? GRAVITATIONAL FORCE 4. If the client has a pooling of secretion in the lower lobe of both lungs at the posterior segments, what is the best position that the nurse should utilize? Trendelenburg position lying flat on the abdomen 5. Positions in PD is usually assumed for how many minutes? 10-15 minutes6. The entire procedure of Chest physiotherapy will normally take howmany minutes? 30 minutes 7. When is the best time in performing PD? At bedtime, before meals, 2 hours after meals 8. How should the nurse position his hands when percussing the chest? Percussion is forceful striking of the skin with cupper hands9. To help prevent skin reddening after percussion, what should the nurse do initially before starting the procedure ? Cover with towel or gown to reduce discomfort 10. How long should the nurse percuss each lung segment? 1-2 minutes11. How will you know that you are performing the procedure correctly? Vigorous quivering of the hand produced by the hand placed flat against the clients skin 12. What part of the nurse’s hand should produce the vibration? HEEL 13. When should the nurse start vibrating the hand? During inhalation or exhalation? EXHALATION14. After each session of PVD, what should the nurse instruct the client? cough 15. What is the MAIN reason why CPT is contraindicated to some patients? Client’s tolerance of positioning 16. How long should the nurse perform vibration? 5 vibration/exhalation per lung segment

CRITICAL PATHWAY Mario listens to Richard's bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segment of the lungs when Mario does percussion would be: A. Client lying on his back then flat on his abdomen on Trendelenburg position B. Client seated upright in bed or on chair then leaning forward in sitting position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position

CRITICAL PATHWAY Mario prepares Richard for postural drainage and percussion, Which of the following is a special consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute

B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client

SUCTIONING Purpose: to remove the obstruction (phlegm) When to suction? NOISY BREATHING suggest OBSTRUCTION When to apply pressure? Withdrawal How to apply pressure? occluding the vent or port with non-dominant hand Duration: 5-10 seconds (max of 15 sec) Interval: 20-30 sec Lubricant: Oropharyngeal: Use NSS/tap water Nasopharyngeal: Use KY jellyPosition: Conscious: semi-fowler’s pos. Unconscious: lateral pos Depth of Insertion: 3-5” Gloves: Sterile (dominant hand: tip of suction), clean (non-dominant: port or vent) Suction pressure: ADULT: 10-15 CHILD: 5-10 INFANT: 3-5

SUCTIONING Critical Pathway 1. How frequent should the nurse suction a client? Depends on the assessment, breath sound… rattling or bubbling breath sound that signals accumlation of secretion. Unable to expectorate, unable to swallow. 2. What technique should the nurse use throughout the procedure? Sterile or Clean? Medical or Surgical asepsis? Medical Asepsis 3. What are the possible lubricants that the nurse could use? NSS or sterile water for oro, Water soluble lubricant for the naso4. How should the nurse position a client before suctioning? Conscious : semi fowlers oral: head turned to one side, naso- neckhyperextend unconscious : lateral position facing you – prevent aspiration, let the tongue fall to prevent obstruction 5. How should the nurse instruct the client during tube insertion? 95-1106. How long is the depth of insertion? 7. When to apply suction? Insertion or withdrawal? How much is the pressure applied? Withdrawal. 10-15 if Adult. 5-10 if child. 8. In suctioning using the mouth as the portal of entry, how will the nurse prevent gagging? Allow patient to swallow 9. What should the nurse do in case of any obstruction or difficulty inserting the tube? Never force an obstruction, try another orifice10. How long should a suction last? 5-10 sec, allow 30 sec interval between suction 11. If suction is to be repeated, how long should the nurse wait? 20-30seconds 12. If the left bronchus is to be suctioned using the endotracheal approach, what instruction should you tell the client to facilitate the entry of the catheter into the left bronchus? POSITION SEMI FOWLERS RIGHT SIDE 13. In endotracheal suctioning, if a resistance is met at the recommended distance, what should the nurse do? Mouth to midsternum, nose earlobe side of the neck – thyroid cartilage14. After suctioning, what is the primordial instruction that the nurse should tell the client? MOUTHCARE

CRITICAL PATHWAY How long should you insert the catheter used in nasopharyngeal suctioning? A. From the mouth to the midsternum B. From the tip of the nose, to the earlobe and to the xyphoid process C. From the tip of the nose to the earlobe D. From the tip of the nose, to the earlobe and to the side of the neck

OXYGEN DELIVERY Low flow 1. Nasal Cannula or prong 20-40% / 2-6L 2. Simple face mask 40-60 5-8L – assess claustrophobia 3. Partial rebreathing 60-90 6-10L – avoid twist or kinks 4. Non rebreathing 90-100 6-15L – note if flaps are functioning properly

High flow 1. VENTURI MASK – low concentration , preferred for clients with COPDVENTURI MASK - is the most reliable and accurate method. Use primarily in COPD patient. It provide ACCURATE low O2 rate.

HYPERBARIC MASK - is administered through cylinder chamber. Is used to treat conditions such as air embolism, carbon monoxide poisoning, gangrene, tissue necrosis, and hemorrhage.

OXYGEN DELIVERY POSITION: Semi-fowler’s pos. “ NO SMOKING” sign: at tank, or wall HUMIDIFY OXYGEN : use distilled water LUBRICANT: water soluble lubricant (KY Jelly) Do not use OIL cause it ignites when exposed to compressed oxygen OXYGEN is colorless, odorless, tasteless and dry gas that supports combustion

CRITICAL PATHWAY Mang Ruben has emphysema and was rushed to the hospital because of sever dyspnea. The doctor ordered oxygen and a venturi mask was not available. Which is the best alternative that the nurse could use for Mang Ruben? A. Face mask C. Nasal Cannula B. Non rebreather mask D. Venturi mask

OXYGEN DELIVERYCritical Pathway 1. What is the best oxygen delivery device to use in clients with COPD? Venturi Mask 2. What should the nurse do first, put the device [ face mask, cannula ] first or turn on the oxygen first? Turn the oxygen first 3. What is the most non threatening method of oxygen delivery for most clients? Nasal cannula 4. What is the preferable position when giving oxygen therapy? Semi-fowler’s position 5. What is the best lubricant to use when inserting the cannula to the nares? Water-soluble lubricant 6. How many percent of oxygen is present in the normal air the we breathe? 21 %

CHEST TUBE THERAPY PURPOSE: To drain air or fluid from lungs AIR 2 nd ICS FLUID 8 th ICS Indication: Pleural Effusion Pneumothorax Common signs: SHORTNESS OF BREATH

CHEST TUBE THERAPY (D – W – S) Drainage Bottle: Normal: Intermittent bubbling Abnormal: Continuous bubbling Water – sealed Bottle: Normal: Intermittent bubbling Abnormal: Continuous bubbling Suction Bottle: Normal: Continuous bubbling Abnormal: Intermittent bubbling

CHEST TUBE THERAPY CONSIDERATIONS: 1. Bubbles in the second bottle? clamp <10seconds (to prevent TENSION PNEUMOTHORAX) 2. Broken bottle? extra bottle with NSS 3. Dislodged chest tube? cover with vaselinized gauze 4. Transporting with CT ? keep bottle below chest 5. Removal of CT? bear down6. Sign of CT removal? full lung expansion as per chest x-ray 7. Equipment needed at bedside? 2 rubber-tipped clamps (used when changing the drainage system)

CRITICAL PATHWAY LM has chest tube attached to a pleural drainage system. When caring for LM you should: A. change the dressing daily using aseptic technique B. empty the drainage system at the end of the shift C. palpate the surrounding areas for crepitus D. clamp the chest tube when suctioning

TRACHEOSTOMY 1. Position: semi-fowler’s pos (if unconscious: lateral pos facing nurse) 2. Communication: picture board or magic slate 3. Safety: strict asepsis is a must and slip 2 fingers to check tightness 4. TUBES: Inner Cannula: remove once in a while to remove crust

5. Soaking agent: Hydrogen Peroxide 6. Rinsing agent: NSSTRACHEOSTOMY Equipment at bedside: suction apparatus, ambu bag, tracheo set NOTE: CBQ 2011 Secure first the new tie before removing the old tie (to prevent dislodgement of the outer cannula) NOTE: CBQ 2011 (Use the square-knot technique)

TRACHEOSTOMY Notes (Mind-mapping): Sterile! longer than 10-14d SOAK: Hydrogen Peroxide RINSE: Normal Saline Solution Check tightness: slip two fingers Bedside: AMBU BAG and TRACHEOSTOMY SET

STEAM INHALATION NOTE: it is a dependent nursing function but HEAT APPLICATION requires physician’s order Place in semi-fowler’s position spout 12-18 inches away from the client’s nose or adjust the distance as necessary TIME DURATION: 15-20 minutes

BRONCHOSCOPY BEFORE: Obtain consent – Physician Empty bladder

AFTER Monitor v/s q15 mins NPO until gag/swallow reflex give ice chips before giving foods

NURSING SKILLS NUTRITIONASSESSING NUTRITIONAL STATUS (ABCD Approach) 1. A anthropometric measurement 2. B biochemical data 3. C clinical signs of nutritional status 4. D dietary history

Anthropometric Measurements 1. Height 2. Weight 3. Skin fold measurements 4. Mid upper arm circumference 30 ang average, measure from the acromion to olecranon 5. BMI [ 20 to 25 ]

QUESTION : Compute for the BMI of Gardo, weighing 248 lbs and with a vertical length of 6 feet and 11 inches.

BIOCHEMICAL DATA Biochemical Data use to detect malnutrition before anthropometric changes occurs 1. Hemoglobin low = IDA , normal should be not below 12 mg/dl (12-16 mg/dL) 2. Hematocrit percentage of RBC in found in a whole blood 40-50 , (35-45% )Increase Hct = DHN 3. Serum Albumin protein , produced by the liver .. Changes slowly, good indicator of long term protein deficiency 3.5 to 5.5 g/dl 4. Transferrin more sensitive indicator of protein malnutrition because it responds quickly to changes. Synth by liver. High when low iron, low when high iron .5. Lymphocyte decreases as protein decreases 15-40% of rbc Decrease protein = decrease lymphocytes = risk to infection 6. Nitrogen Balance BUN 10-20 mg/dl elevated : starvation or excessive fluid intake, decrease cause by low protein diet. 7. Creatinine depends on the skeletal muscle mass, decrease / sm atrophy… body builders .

CRITICAL PATHWAY 1. The nurse knows that if a client has a Hematocrit level of 60%, the client is probably experiencing: A. Delusions C. Too little fluid B. Too much fluid D. This is a normal value

PARADIGM OF NUTRIENTSMacronutrients CHON (grow), CHO(go), HCHO (glow) Micronutrients Vitamins and minerals Vitamins water soluble and fat soluble

Fat soluble: A - retinol D – Ergocalciferol E – Tocopherol K – Menadione MINERALS K, Fe, Ca, NaWater soluble C- ascorbic acid B1 – Thiamine B2 Riboflavin B6 - Pyridoxine B9 – Folacin B12 – CyanocobalamineNursing considerations 1. C – give with IRON to increase absorption 2. B1 – give in pt with beri beri and alcoholic 3. B2- for skin problems such scabies 4. B3 – pellagra 5. B6 – for pt receiving INH (Izoniazid) 6. B9 – receive during the first trimester of pregnancy to prevent NTD 7. B12 – pernicious anemia (lifetime)8. D – with Ca supplement 9. E – given to client with dementia and for good looking skin 10. K – prevent bleeding 11. Potassium – given with furosemide 12. Fe – give with meals, if per orem (black stool) , if liquid (use straw) , if injectable (don’t massage) 13. Ca – for bone formation Na – give with lithium carbonate

DIETS A. Clear Liquid Diet B. Full Liquid Diet C. Soft Diet D. Diabetic Diet E. Low salt Diet F. Acid/Alkaline Ash Diet G. Bland Diet H. Regular Diet High Fiber Diet

DIETS 1. Coffee, Tea, Gelatin and Yogurt 2. Pudding, Custards, Margarine and Peanut Butter 3. Hard candy, clear apple juice and Bouillon 4. Whole wheat bread, raisins and corn 5. teaspoon of salt with no patis and toyo6. Mashed potatos, Tender meat and fish with Avocado 7. Milk, Vegetable, Fruits except cranberries and plums 8. 50% CHO, 30% FATS, 20% CHON 9. Eggnog with Ginger Ale 10. 1500 mg of salt 11. Meat, Eggs, Cheese, Whole grains, Cranberies and Plums 12. 250 grams of carbohydrates, 67 grams of fats and 100 grams of protein in a 2,000 calorie daily intake without adding simple sugars.

79. DIETS I cup = 1/2 hamburger 1 egg = ¼ cup cottage cheese 1 tsp = 2 tsp mayonnaise Clear liquid Apple juice grape juice geleatin Popsicle Hard candy

Full liquid = Milk custard Ice cream Yogurt Butter Orange juice

DIET – COMMON BOARD QUESTION Yogurt aids in lactose intolerance Tofu is high in protein Raw carrots is rich in CHO

FEEDING CONSIDERING THE IMCI PROTOCOL 6 months BF 8x/24 12months 3x if BF 2 yo 5x if not breastfeeding Older 3+2 snacks

CRITICAL PATHWAY. After an operation, Gerard has been given a clear liquid diet. The nurse will eliminate which of the following on the client’s tray? A. Coffee C. Butterball candy B. Gelatin D. Sarsi

Halal - no PORK - no gelatin - no alcohol Kosher - MILK and MEAT are not eaten together Vegan - fully vegetarian diet (Vit B12 def)

Notes: 1. apple juice good source of vit. C 2. raw carrots are a source of carbohydrates 9 calories in CHO, 4 calories in CHON and HCOH 3. Prudent diet contains LESS FATS, COMPLEX CHO and MODERATE CHON

CRITICAL PATHWAY Assuming a cup of rice provides 50 grams of carbohydrates. How many calories are there in that cup of rice? A. 150 calories C. 200 calories B. 250 calories D. 400 calories

NUTRITION in AGES Infant Breastmilk or formula with iron Cereals veg fruits protein rich foods (table foods) egg yolk, Toodler --> avoid using foodas rewards enjoy self-feeding with finger foods develop food jags Preschooler finger food is still common Schooler eat fast food and junk foods but to peers Adolescent diet (struggle for ideal body weight) Adult dining-out (improve financial status) Older adult constipation is common and poor appetite

NASOGASTRIC TUBES Purpose: Lavage – to irrigate/remove toxins Gavage – to nourish Position: HIGH-FOWLER’s position

90. NASOGASTRIC TUBES LOC Patency nares ( insert tube in patent nostril)Length of tube: Approximately 50cm (NEX) Landmark: ADULT NEX PEDIATRIC ENX Special concern: NASOINTESTINAL TUBE measure NEX + 8-10” then position Right side lying position

NASOGASTRIC TUBES Landmarks: ADULT – NEX (Nose to Earlobe to Xiphoid process) PEDIA – ENX (Ear lobe to Nose to Xiphoid process) Lubricant: water soluble (at least 2-4”)Insertion: Position of the head:1 st – hyperextend 2 nd Flex the neck closer to the chest Instruct pt to SWALLOW or SIP WATER through straw (to close the glottis)

Checking placement of tube: Aspirate (note the pH level 0-4 normal) and color (green or off white) auscultate for WHOOSHING SOUND after introducing 20CC of air bubbles after placing the port to water CXR

Secure the tube: 1 st – bridge of nose 2 nd client’s gown Rationale: to avoid nasal breakdown In case of nasal breakdown give XYLOCAINE SPRAY

NASOGASTRIC TUBESalient points: For Nasointestinal tube measure NEX then add 8-10 inches then position client on his right side

NASOGASTRIC TUBE Tube is measured in French size Handwashing is a must before and after the procedure Check allergy to KIWI FRUIT or latex Discontinue if cyanosis is noted Flush/Irrigate tube feeding with 30-60ml of water q4h A residual volume of >100-150 ml indicates delayed gastric emptying. Notify MD. Feeding set changed q24h. Bag rinsed q4h.

NASOGASTRIC TUBES Single lumen LEVINE CANTOR (balloon is inflated before insertion) Double lumen Salem sump Miller Abbot (Balloon is inflated after insertion) “abot hanggang intestine Triple lumen Uses mercury to inflate the balloon SENGSTAKEN BLAKEMORE Four lumen anderson tube (Gastric) MINNESOTA (Intestinal)

NGT FEEDING

o Position: Low or semi (30-45) o Aspirate gastric content instil 30mL of air o Check RESIDUAL FEEDING done every 4-6 hours (<100mL) o For new research if RF is up to 400mL continue feeding o Before >100mL STOP FEEDING NOTIFY PHYSICIANo Height of container 12 “ above stomach o Temp solution warm to prevent cramping o Duration of solution 30 minutes o Flush tube by using: tap water (30-60 mL)

REMOVING NGT Handwashing Position: semi-fowler’s with towel on chest Before: HFP Flush tube with 10 mL tap water or 30 mL of air Inhale deeply hold remove Pinch tube as withdrawn - to prevent drainange into the trachea If nosebleed occlude til subsides

NASOGASTRIC TUBE 1. What are the purposes of having an NGT? To administer feedings to a client who cannot eat or have high risk for aspiration, to suction stomach contents to prevent distention, remove stomach content for analysis, wash the stomach in case of poisoning and to administer medication 2. What is the client’s position during NGT insertion? HIGH-FOWLER’s POSITION3. How should the nurse select the best nostril before NGT insertion? Use penlight to observe for intactness of the nostril, ask the client to breath and then listen on which nares is more patent 4. How can the nurse stiffen a rubber tube? Rubber is soft, place on ice… 5. How can the nurse make the plastic tube more flexible? Plastic tube is harder, place on warm water.6. How long will the nurse insert the NGT? In Infant – midway bet umblicus and the xyphoid process 7. What is the best lubricant that a nurse could use in inserting the NGT? WATER-SOLUBLE LUBRICANT 8. During the insertion of the NGT, What instructions are necessary to facilitate the entry of the NGT? Hyperextend the clients neck and advance the tube, when you observe gag reflex, tilt head forward and swallow9. If the nurse notices that the client is teary, what should the nurse do? Withdraw 10. If for the first time, the nurse meets a resistance, what should he do? Withdraw

NASOGASTRIC TUBESCritical Pathway 1.What are the possible positions in giving NGT Feedings? Sitting position, fowlers, right side lying position. 2. Before feeding the client, what is the most important thing a nurse should assess? Placement of the tube – aspirate check for ph should be 1 to 5. pleural ph is 7.4 3. If the nurse notices that there is 30 ml of undigested formula, what should she do? >50 cc or more ask the nurse in charge or the doctor.4. What should the nurse do with aspirated undigested formula? Discard or return to the client? Return 5. If the client experience discomfort during feeding, what should the nurse do? Stop temporarily by clamping or pinching the tubing.6. If the nurse raises the syringe, what will happen to the speed of flow? Increase speed 7. How high should the nurse hold the syringe or the prefilled formula when administering the tube feedings? 12 inches above the insertion point. 8. At the near end of the tube feeding, what should the nurse add to the feeding solution to ensure that the lumen of the tube remains patent? Instill 60 cc of water9. Before all the water runs down to the tube, what should the nurse do to prevent unnecessary distention? CLAMP 10. How long should the client maintain the sitting/fowlers position after feeding? 30 minutes

CRITICAL PATHWAY How could the nurse best assess the patency of the tube after NGT insertion? A. X ray B. Aspirate the gastric content and check for the PH C. Instill 30 cc of air and listen for gurgling sounds D. Observe the client for coughing and choking or ask the client to hum

TOTAL PARENTERAL NUTRITION Indication: If the client cannot masticate food, inadequate protein intake Sites: Internal jugular vein Subclavian vein

Nursing considerations: Assess allergy to EGGS because there is lipid to be administered Refrigerate solution but warm before admin Give D10 W Normal weight gain 2lbs/week

TOTAL PARENTERAL NUTRITION Salient points:

o Check BP every 6 hours/24 hrs o Meds administration through TPN:

1. Stop S aline flush (20mL) 2. A dminister S aline flush (20mL) 3. H eparin

o Monitor the client’s WEIGHT, TRIGLYCERIDE level, SUGAR level.

TOTAL PARENTERAL NUTRITION Complications:

Hyperglycemi a give insulin - don’t “catch-up” feeding - don’t rapidly infuse solution Pulmonary embolism consider heparin, if tube become OPAQUE place patient in T-position, when

changing dressing place pt in T-position - don’t mix drugs or blood with TPN Infection change tubing q 24hrs and change dressing q 48 hours

ELIMINATION Urinary FecalURINARY Assessing the normal urine:

o Amount per hour: 30 – 50 mL o Color: amber o Consistency: clear o Odor: aromatic o Sterility: no bacteria o Acidity: 4.5 – 8 normally acidic o Specific Gravity: 1.01 – 1.025

URINE: COMMON FINDINGS Pink urine dilantin Brown Flagyl Black Bactrim Cloudy Infection Red Orange Rifampicin

URINARY COLLECTION OF SPECIMEN 1. Clean-catch mid-stream 2. Second-voided 24-hour urine specimen/creatinine clearance test 3. Specimen through and indwelling catheter

CLEAN-CATCH MID-STREAM Purpose: Urinalysis Amount: 30-50mL Instructoin: female clean meatus front to back male glans penis to shaft to base

SECOND-VOIDED URINE Indication: Acetic and benidect test Amount: Acetic 1/3 of test tube Benedicts 5mL

24-hour urine specimen Indications: Schilling’s test R/o pernicious anemia Creatinine clearance test (creatinn 0.6-1.5)

SPECIMEN THROUGH CATHETER For Urine C/S 3-5mL

CATHETERIZATIONCatheterization Male Female Position Supine Dorsal Recumbent French (Fr) 16-18 12-14 Length 40 cm 22 cm Insertion 6-9 inches 3-4 inches Attachment Symphysis pubis or lower abdomen Inner thigh

If during insertion, you observed a backflow of urine, advance further the catheter by 1-2 “ then gently tug the cord to check it secured. If resistance is felt allow pt to BREATH

Mastery Drill: you answer Male: Length: _________ French: _________ Attachment: _____ Position: ________

Female: Length: _________ French: _________ Attachment: _____ Position: ________

CBI: CONTINOUS BLADDER IRRIGATION Indication: Post prostatectomy Triple lumen catheter: 1 lumen urine dranage 1 lumen balloon (30 ccNSS) 1 lumen irrigant (sterile NSS) Duration: 2-3 days Sign of an effective CBI urine color change from bright red to pink amber straw Don’t shave hair

CRITICAL PATHWAY 1. What should be the position of a female client during catheterization? Dorsal recumbent position 2. What kind of lubricant is used in urinary catheterization? Water-soluble lubricant 3 . How long should the nurse insert a catheter if the client is male? 8 inches for male and 4 inches for females 4. During the insertion of the urinary catheter, the nurse instructs the client to? Deep breath or strain as if voiding5. To ease insertion of the catheter into a male client, the nurse should hold the penis how many Degrees against the body? Perpendicular or 906. As the urine begins to flow, how many inch should the nurse further insert the tube before Inflating the balloon? 1-2 inches 7. In male clients, where should the nurse tape the catheter? Leg or abdomen to prevent penoscrotal pressure 8. Where should the nurse secure the urinary drainage bag? Bed frame 9. What type of catheter is preferred for clients with BPH? coude 10. In removing the indwelling catheter, the nurse should instruct the client to INHALE or EXHALE? exhale

CATHETERIZATION 1. What is the only type of catheter that allows sterile specimen collection? Self sealing rubber catheters, not plastic, silicone or silastic catheter 2. Before inserting the syringe into the drainage port, what should the nurse do to prevent contamination of the specimen? Don gloves, wipe the area with a disinfectant swab 3. If there is no urine aspirated from the catheter, what should the nurse do? Clamp the drainage tubing for 30 minutes 4. How many minutes should the clamp be maintained? 30 minutes5. To facilitate the self sealing of the rubber catheter, the nurse should inject the syringe at how many degrees? C/S? 3 cc for c/s and 30 cc for urinalysis 6. How many cc of urine is to be aspirated from the patient for a routine Urinalysis? 7. In case of clamping the catheter, where should the nurse inject the syringe? Below or above the clamp site?

FECAL Assessing the normal stool 1. Color brown, 2. Odor pungent, malansa – blood/infection 3. Amount 100-400g 4. Consistency formed,semiformed,moist,soft constipated, diarrhea 5. Shape cylindrical with thick diameter 6. Frequency 1 to 2 times a day

FECALYSIS Indication : to rule out presence of OVA and parasite Amount: 1 tsp Equipments: Bed pan and sterile tongue depressor

GUAIAC TEST or OCCULT BLLOD TEST Indication : rule out colon cancer Amount: 1 tsp Instruction: No red meat, chocolate, food with colorings for 3 consecutive days

TYPES OF STOOL Ribbon-like Hirchprung’s Fatty stool Pancreatitis Clay-colored Liver and gall-bladder problem Blood & Mucus Bacterial infection Black stool iron supp Red stool colon bleeding

CRITICAL PATHWAY. The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should: A. take the specimen to the laboratory immediately. B. apply a solution to the stool specimen. C. collect the specimen in a sterile container . D. store the specimen on ice.

Enema Types of Enemas Type Solution Indication Cleansing Tap water Soap suds Normal saline Evacuate lower bowel before diagnostic studies or surgery Retention (should be retained for at least 30 min) Emollient (oil) Soften and lubricate stool for easy evacuation Carminative (return flow) Tap water Normal saline Relief of distension due to flatus Medication Normal saline Sterile water mixed with prescribed medication Will depend on what medication is introduced

138. Cleansing Enema Solution: Tap water, Soap suds, NSS Retention Enema Solution: Emollient (oil) retained in 30 minutes to lubricate Carminative enema Solution: Tap water and NSS for FLATULENCE

Enema Position: ______________ left side-lying position, with right knee bent. Height of solution: __________ Hang bag of enema solution 12 to 18 inches above anus. Notes: Lubricate 4 to 5 inches of catheter tip. If client complains of increased pain or cramping, or if fluid is not being retained, STOP procedure, wait a few minutes, then restart

140. Enema Notes: no more than 3 L fluid should be administered in any one series of enemas Repeated enemas produce irritation of bowel mucosa and perianal area, as well as electrolyte loss and exhaustion

141. Mastery Drill: Please answer Position: ___________ Carminative enema: Solution: ___________ Purpose: ___________ Retention enema: Solution: ___________ Purpose: ___________ Cleansing enema: Solution: ___________ Purpose: ___________ Height of solution: ____________ 143. ENEMA Critical Pathway

1. How long does a retention enema is retained to obtain the desired softening effect? 1-3 hours 2. A type of enema used to relieve excessive flatus is? Carminative and harris flush 3. The amount of fluid that is use in a high cleansing enema is? 1 L 4. Mang Roberto is scheduled for a diagnostic examination, fluoroscopy of the urinary tract. He will receive what kind of enema the morning before the procedure? Cleansing enema 5. Cleansing enema are retained for how many minutes? 5-10 minutes 6. For most enemas, the enema can is held how many inches above the rectum? 12 inches

144.

CRITICAL PATHWAY The nurse must administer an enema to an adult client. The appropriate depth for inserting an enema into an average-sized adult is: A. 1&quot; to 2&quot;. C. 3&quot; to 4&quot;. B. 4&quot; to 6&quot;. D. 6&quot; to 8&quot;.

145. ENEMA CBQ: Critical Pathway

1. What is the preferred position in giving an enema? Left sims , left lateral 2. In giving an enema, the nurse uses which technique? Medical or Surgical asepsis? Medical Asespsis 3. How long will the nurse insert the tube? 3-4 inches 4. In any case that the nurse encounter any resistance in inserting the tube, What should the nurse do? Take a deep breath, persist? Report to the nurse in charge 5. During tube insertion, to relax the anal sphincter, the nurse will ask the client to? Inhale or Exhale? EXHALE 6. In a high cleansing enema, how high should the nurse hold the enema can? 12 inches7. If the client experiences cramping and pain, what should the nurse do? Clamp for 30 seconds 8. How will the nurse know that sufficient fluid is already administered to the client? urge to defecate 9. How long will the client retain the fluid if this is a cleansing enema? 5-10 minutes 10. In administering an enema to an incontinent client, what should the nurse do to help the client retain the solution? Press the buttocks together

NURSING PROCEDURES (PART 2 ) 2. REVIEW FORMULA CONCEPT-BASED MASTERY DRILLS CRITICAL

PATHWAY BULLETS/MIND-MAPPING 3. PART 2: NURSING SKILLS 4. OSTOMIES Definition of Terms 1. Gastrostomy to the stomach 2.

Jejunostomy to the jejunum 3. Ileostomy- (Permanent) 4. Colostomy – (Permanent) 5. Ureterostomy 6. Ileal Conduit 7. Stoma – (Permanent) Classification by 1. Permanence 2. Anatomic location

5. Intestinal Ostomies Color: BRIGHT RED Stabilization of stoma: 6-8 weeks Expected functioning: 3-5 days from the creation of stoma Appearance: Protrudes ½ - 1 slightly edematous (Edema subsides after 6 weeks) Position: Sitting or lying position Irrigant: tap water (lukewarm) Amount: 1000 mL (first irrigation 500mL) Height of container: 12 inches Temperature: warm (105-110 F) Duration: 5-6 minutes

6. ILEOSTOMY Concern: Acidic feces Intervention: karaya gum Concern: Unpleasant odor Interventon: deodorizer, small amount of vinegar or charcoal-filtered disc Diet of choice high residue diet like green leafy veg (to minimize odor)

7. CRITICALPATHWAY A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: A . increasing fluid intake to prevent dehydration . B. wearing an appliance pouch only at bedtime. C. consuming a low-protein, high-fiber diet. D. taking only enteric-coated medications.

8. OSTOMIES: Consideration Handwashing before and after Fecal pouch is removed every 3 days to assess for signs of skin breakdown Avoid gas forming foods like EGG & ONION Complication: DEHYDRATION & ACID-BASE BALANCE

9. OSTOMIES 10. Changing ostomy appliance? CBQ: Critical Pathway 1. When are

pouches emptied? 1/3 to ½ full 2. When is the best time to perform ostomy appliance change? Not be close to meal or visiting hours, drainage is least likely to occur 3. Where is the best place to change the client’s appliance? bathroom 4. What is the preferable position in changing the client’s stoma? Lying,sitting,standing facilitate smoother pouch application avoid wrinkles 5. What Aseptic technique is used in this procedure? Sterile

11. Changing ostomy appliance? 6. If the area around the site is hairy, the nurse should clip or shave the hair? shave 7. Before removing the appliance, what should the nurse do first to its content? Empty the content with its bottom opening into the bedpan, prevent spillage into the skin. assess

12. Changing ostomy appliance CBQ: Critical Pathway 8. In cleaning the stoma, the nurse should use what? Use warm water, mild soap (optional), and cotton balls or a washcloth and towel to clean the skin and stoma. 9.

What paste is used as an adhesive to attach the face plate and the appliance properly? Use a special skin cleanser to remove dried, hard stool. 10. What is the normal color of the stoma? BRIGHT RED 11. How frequent should the nurse change the pouch? [Disposable 1 week, reusable, twice a week]

13. COLOSTOMY Normal stoma: red or pink - Bright red Fecal matter should not be allowed to remain on the skin Empty pouch when half to one-third full Avoid gas-forming foods (ex. Cabbage, onions)

14. Colostomy Irrigation Purpose: to empty the colon and establish a regular pattern of defecation Best time to perform: performed at the same time each day, preferably 1hr after a meal Position: lie on side/sit on the toilet itself Irrigation solution: 500 to 1500 mL of lukewarm tapwater/ PNSS Height of sol’n: 18-20 inches in above the stoma (shoulder height when the patient is seated) Insertion of catheter: No more than 3 inches

15. Colostomy Irrigation Insert the catheter no more than 3 in Never force the catheter! Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest before progressing.

16. Colostomy Irrigation CBQ: Critical Pathway 1. What is the main purpose of Colostomy irrigation? TO ESTABLISH REGULAR PATTERN OF DEFECATION 2. How frequent should the patient irrigate? Daily (same time) 4. When is the best time to perform colostomy irrigation? 1 hour after meal 3. How much and what type of fluid is used during colostomy irrigation? 500 to 1500 mL of lukewarm tapwater/ PNSS 4. Where is the irrigation performed? Comfort Room/ toilet room

17. Colostomy Irrigation 5. If cramping is felt during irrigation, ? STOP 6. If the client experience difficulty in inserting the tube, what should you instruct the client? NOTIFY THE PHYSICIAN – sign of obstruction or occlusion of site

18. CRITICAL PATHWAY The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching? A . Hanging the irrigation bag 24&quot; to 36&quot; (60 to 90 cm) above the stoma B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water C. Stopping irrigation for cramps and clamping the tubing until cramps pass D. Washing hands with soap and water when finished

19. BARRIUM ENEMA Purpose: Visualize Lower GI BEFORE: Liquid diet laxative NPO 6-8 hrs no narcotics and anticholinergics for 24 hrs Check allergies to seafoods AFTER: Laxative to counteract the constipation effect of barrium white stool is normal in 3 days Increase fluid intake

20. BARRIUM SWALLOW Purpose: upper Gi Before: NPO 6-8 hrs Assess for allergy After: Laxative White stool is normal Increase fluid intake

21. CRITICAL PATHWAY If the order is to give Barrium swallow and Barrium Enema at the same time, what is the initial action of the nurse? 1 st : Administer Barrium Enema 2 nd: Barrium swallow

22. MODULE 9: NURSING SKILLS MOBILITY 23. ASSISTIVE DEVICE: CRUTCHES Position: Tripod position (6 “ lateral

foot and 6” anterior foot) Handle: level of the greater trochanter Elbow flexion: 20-30 degree angle (to prevent contracture) Distance of the axillla from axillary bar: 1-2 inches (November 2009 NLE question)

24. ASSISTIVE DEVICE: CRUTCHES When climbing stairs: GOOD LEG FIRST, FOLLOWED by BAD Leg & CANE When going down the stairs: BAD LEG & cane first, then GOOD LEG A NONSLID SHOE is required.

25. ASSISTIVE DEVICE: CANE COAL CANE OPPOSITE AFFECTED LEG (meaning hawakan ang Cane sa Unaffected leg ) Advance cane: Cane then Affected leg first Advance first the cane, then the weak leg followed by the good leg Once recovered: advance simultaneously the weak leg and the cane ff by the good leg

26. Cane Notes: flex the elbow at a 30-degree angle level with the greater trochanter tip of the cane 6 inches lateral to the base of the fifth toe tip with its concentric rings provides optimal stability

27. ASSISTIVE DEVICE: Traction ALWAYS : (Notes) Maintain correct body alignment Make certain that ropes are in the wheel grooves of the pulleys, ropes are not frayed, that the weights hang free , and that the

knots in the rope are tied securely Maintain traction with prescribed weight Perform neurovascular checks every hour for the first 24-48 hours Use fracture pan for toileting

28. Traction SKIN TRACTION adhesive tapes, Velcro straps , or a fitted brace RUSSEL TRACTION FEMUR fractures Bed is FLAT always BUCK’s TRACTION lower limbs fractuers 8-10 lbs weight Elevate FOOT of bed BRYANT’s TRACTION for CHILDREN FLEXED at a 90-degree buttocks raised 1-2 in off the mattress Child act as COUNTERTRACTION

29. Traction Notes: SKELETAL traction: use of a metal pin or wire . Tongs use to immobilize cervical fractures. is balanced traction

30. Traction Notes: SKIN TRACTIONS: Cervical traction: cervical injury . Pelvic belt or girdle: lower back . Humerus traction: upper arm fractures

31. Casts Fiberglass Plaster of Paris (Traditional Cast) Dries instantly Delayed drying (24-72 hours) May get wet Softens when wet Dull appearance Shiny appearance Light weight Heavy weight Higher durability Durable (may crack)

32. Casts Notes: HANDLE using PALMS only . (NOT FINGERS) elevate above the heart Don’t scratch under the cast Cushion rough edges of the cast with tape P ______ for wet fiberglass use hair blow dryer on a COOL SETTING REPORT to MD if 6 P’s occur Note odors and WARM SPOTS infection Do not attempt to fix broken cast

33. PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: WATER BED

34. PREVENTION of immobility 35. PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: TRAPEZE 36. PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY:

FOOTBOARD 37. PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: TOWEL 38. PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY:

TROCANTHER ROLL 39. MODULE 9: NURSING SKILLS MEDICATIONS 40. MEDICATION ORDERS STAT Single Order Standing Order PRN

Order Determine the types of order of the following: You answer this Acetaminophen, po q4h X 5 days Demerol, IM qid Valium, 50mg prn Brevital, 100mg hs 1 day before surgery Brevital, 50mg qhs at bedtime Morphine, 20mg IM STAT Oxytocin, 8 mU/min IV at 10:00 A.M

41. RIGHTS in medication Rights of drug administration Right Drug Right Dose Right Time Right Route Right Patient Right Documentation Right Approach Right Evaluation Right to Educate Client’s right to refuse Right Assessment

42. Medicine Administration Route Length Gauge Degree ID 3/8 – 1/2 G 25-27 10-15(bevel up) SC ½ - 5/8 G 25-27 45 degree (90 degrees in INSULIN and Heparin admin IM 1-1.5inches G 20-24 (G 22 children, G24 Infant) 90 degrees

43.   44. MASTERY DRILL: What ROUTE? ChoiceS: IM,ID,SC BCG

___________ Measles _________ Hepa, DPT _______ Heparin: _________ Insulin ___________ Depoprovera ______ Iron (Dextran): Z-tract method (Common board question)

45. SALIENT POINTS: SITE Z-tract method – best route for IRON Dermis – Intradermal (DO NOT MASSAGE) Ventrogluteal – best IM site for adult (1-3 years old) Dorsogluteal – best IM site > 3 years old Vastus lateralis – best IM site for infant (<1 year old)

46. Administering Medication via Z-track Injection 47. Z-tract Medication Use (DOMINANT or NONDOMINANT) to hold the

skin? NONDOMINANT You can (MASSAGE or NOT MASSAGE) the injection site. DO NOT MASSAGE

48. Common Routes of Medication Administration 1. PO 2. Sublingual 3. Topical - skin 4. Subcutaneous 5. Intramuscular 6. Intravenous 7. Rectal 8. Intrathecal – drug is administered through SPINE 9. Intraosseous – drug is administered through BONE

49. MASTERY DRILL (ROUTE) OPV Lumbar Puncture Suppository Visine SUBLINGUAL place medication under the tongue and allow it to dissolve completely. BUCCAL place the medication in the mouth against the cheek until it dissolves completely.

50. CRITICAL PATHWAY Correct or Incorrect Approach? The nurse practiced strict surgical asepsis when administering a rectal suppository. I C The nurse validated a doctors order because it was unclear. C The nurse administered an unfamiliar medication I C Narcotics are placed in a locked cabinet C The nurse administered a drug endorsed by the previous shift C

51. CRITICAL PATHWAY Correct or Incorrect Approach? The nurse, who administered potassium unincorporated prepared an incident report and then report the situation to the nurse in charge. C The client is very uncooperative during medication administration. The nurse hid the drug on the client’s meal observing the bioethical principle of paternalism. C The nurse returned an intermediate NPH insulin because it is cloudy. IC The nurse Relabeled a drug because the label fell. C The Nurse reads to label thrice, upon opening the cabinet, during administration and after administration of the drug. C

52. OTHER NURSING PROCEDURES BLOOD TRANSFUSION INTRAVENOUS INSERTION DIALYSIS MECHANICAL VENTILATION

53. Intravenous therapy Note: In choosing an IV site: - choose DISTAL vein first - Avoid client’s dominant hand and arm. - Avoid an area of skin affected by a rash or infection. TORNIQUET: 6-8 inches above the site Insert: BEVELS UP (5-25 degree) Advance needle 1⁄4–1⁄2 in after successful venipuncture

54. Intravenous therapy Note: Change IV tubing every 24-72 hours Change venipuncture site every 48-72 hours Change IV dressing every 72 hours DO NOT let an IV bag or bottle of solution hang for more than 24 hours DO NOT allow the IV tubing to touch the floor

55. Intravenous therapy Complications 1. Infiltration and Extravasation - coolness at site; - remove IV device stat; elevate extremity and apply warm compresses 2. Phlebitis and Thrombophlebitis - warm at the site - apply cold moist compresses , remove IV, notify, restart

56. Intravenous therapy Complications: 3. Air Embolism - clamp tubing - turn the client on the left side with the head of bed lowered (Trendelenburg) to trap air in the right atrium, - notify

57. IV FLUIDS 58. IVFLUIDS: SALIENT POINTS Isotonic Solution – equal ratio of solute

& solvent – zero pressured solution all plain sol’n., Plain IMB, Plain NSS – there is no change cell structure Hypertonic Solution – more solute than solvent (ispiso) – high gradient pressured solution all D 5 , all D 10 , all D 50 – cell shrinkage / crenation – Ex. given to edema, fluid volume excess  

59. IVFLUIDS: SALIENT POINTS Hypotonic Solution – more solvent than solute (lasaw) – low gradient pressured solution .30, .35, .45 – cell swells; if not regulated, cells will burst – Ex. given to diarrhea, fluid volume deficit * Major electrolyte Potassium (K + ) needed for contraction [affects mobility] Sodium (Na + ) for water regulation / retention because Na + attracts water - is regulated by aldosterone (adrenal cortex)

60. BLOOD DONATION Legal basis RA 7719 Mainn principle: It is a humanitarian act Possible donors: Age: 16-65 yo (if minor parental consent is needed) Hgb: 12.5 Weight: <110 lbs donate 250 mL >110 lbs donate 450 mL BP – Systolic 100-140 mmHg and Diastolic of 60-90 mmHg

61. BLOOD DONATION Contraindications: AIDS KIDNEY d/o CANCER DM Epileptic pt Hepatitis and Malaria pt Recipients: Leukemia, liver d/o, loss of blood from surgery

62. BLOOD DONATION Aftercare: Adhesive tape 3-12 hours No smoking - 2 hours No alcohol – 12 hours Free arm activity – 24 hours

63. Blood Transfusion Note: RBC : 250 ml Whole blood : 500 ml Solution: NSS 1 unit = 4 hours only 20-30 minutes interval from Blood bank to administration DO NOT REFRIGERATE Stay for first 15-30 minutes

64. Blood Transfusion Note: If transfusion reaction occurs: STOP transfusion, (CBQ) change IV tubing down to the IV site, keep IV line open with NS, notify physician and blood bank, return blood bag and tubing to blood bank; Do NOT leave client alone

65. Blood Transfusion Note: Gauge: 18 transfusion: confirming product compatibility and verifying client identity Verify by 2 nurses

66.   67. BLOOD TRANSFUSION Type A – A antigen anti-B antigen Type B B

antigen anti-A antibodies 68. BLOOD TRANSFUSION Type AB Both A and B antigen has no A or B

antibodies universal recipient Type O Has no A or B antigen has both A and B antibodies Universal donor

69. MASTERY DRILL: PLEASE ANSWER ___________has B antigen ___________ has A or B antibodies ________has both A & B anitbodies ___________ has anti-B antibodies ___________ has A antigen ___________ has no A or B anitgen ________has both A and B antigen

70. TYPES OF BLOOD PRODUCTS Blood products: PRBC 1 unit raises Hct by 4% WB for volume expansion FFP Replace coagulation factos (use within 6 hours) Platelets infuse 10 minutes per unit Cyoprecipitate restores factor VII and fibrinogen in tx HEMOPHILIA A

71. Mechanical Ventilation Note: High Pressure Alarm: Indication: Obstruction Cause: Secretions, kinked tubing, bucking Low Pressure Alarm: Indication: A Leak or Disconnection

72. Responding to Accidental Poisoning DRUGS WITH ANTIDOTE Acetaminophen Acetylcysteine Benzodiazepine Flumazenil Coumadin Vitamin K Cyanide Poisoning Methylene Blue Digitalis Digibind Heparin Protamine Sulfate (NLE question July 2010) Iron Deferoxamine Mesylate Lead Edetate Disodium (EDTA) Magnesium Sulfate Calcium Gluconate Morphine Naloxone Hydrochloride Penicillin

73. Mastery Drill: Please answer Digitalis Cyanide Poisoning Lead Iron Heparin Coumadin Magnesium Sulfate Morphine Acetaminophen Penicillin

74. DIALYSIS 2 types: Peritonela dialysis Hemodialysis 75. DIALYSIS * Give 1,000 units of heparin *What do you call that test that

evaluates the therapeutic effect of heparin? Answer: PTT (Partial Thromboplastin Time) *What is the antidote for heparin toxicity? Answer: Protamine sulfate

76. DIALYSIS *What is that test that calls for the therapeutic effectiveness of warfarin? Answer: PT (Prothrombin Time) *What is the antidote for warfarin toxicity? Answer: Vitamin K Heparin prevents coagulation injected in the artery

77. PERITONEAL DIALYSIS 78. HEMODIALYSIS 79. RESTRAINTS R – requires physician’s order; consent E – emergency,

get MD’s order ASAP S- shortest duration (least restrictive) To protect patient and others A- ssess q 15-30 mins & document Individualized supervision (one-on-one) Never used punishment Total documentation Seclusion as last step

80.   81.   82.   83.   84.   85.   86. LUMBAR PUNCTURE Purpose: To withdraw CSF Empty bowel and

bladder C-position (fetal position or shrimp position) Insertion site: L3-L4 or L4-L5 (prevent puncture of the spinal cord since it ends at L2) After: FLAT Position 6-12 hours to prevent spinal headache

87. SCHILLING’s TEST Purpose: Use to detect Vitamin B12 absorption Excretion of Vitmin B12 8-40% is normal >40 % excretion of Vit B12 indicates Pernicious anemia Test: 24-hour urine specimen

88. EYE EXAMINATIONS Snellen chart – to check visual acuity E-Chart – to check visual acuity of illiterate patient Tonemetry – to check IOP . Normal level 12-21 mmHg Perimetry – to check peripheral vision Ishihara plate – to check color bilndness

89. EAR EXAMINATIONS Caloric test – alternate instillation of warm and cold water into the ear of the patient Otoscopy – Visualization of the inner ear

90.   91.   92.   93.   94. COMPLETE BLOOD COUNT Hgb - Female: 12-16g/ml; Male : 14-

18g/ml Hct: Female: 36 - 46 percent Male :41 - 53 percent Platelet count: 150,000 – 400, 000 /mm3 WBC: 5,000-10,000/mm 3 RBC : 4.5-6.2 million/mm 3 Neutrophils : 60-70% (inflammatory response) Lymphocytes : 20-30% (immune system) Eosinophils : 1-4 % (allergic reaction) Basophils : 0 – 0.5% (allergic and parasitic reaction )

95. NORMAL LABORATORY VALUES RED BLOOD CELL: HEMOGLOBIN 4.5-6.2 million/mm 3 male : 14-18g/ml WHITE BLOOD CELL: female: 12-16g/ml 5,000-10,000/mm 3 Neutrophil PLATELET - 60-70 250-000-45000/mm 2 -inflammatory responses BLOOD UREA NITROGEN (BUN) : Eosinophil -detect renal failure -1-4% -10-20 mg/dl -allergic reaction Basophil -0-0.5% -allergic reaction and parasitic reaction Monocyte -2-6% -immune function Lymphocyte -20-30% -vertebrate immune system

96.   97.   98. MODULE 10: HYGIENE Types of bathing: 1. Cleaning Bathing 2.

Therapeutic bathing 99. HYGIENE: BATHING Types of bathing: 1. Cleaning bath COMPLETE

- bedridden PARTIAL – some parts (perineum, groin and axilla) SELF-HELP BATH – parts that cannot be reached by pt 2. Therapeutic bathing COOL BATH – for muscle tension (30 mins) WARM BATH – for muscle spasm (3 mins) COLLOIDAL BATH (oatmeal bath of cornstarch) – for pruritus

100. MODULE 10: HYGIENE DRY SKIN OILY SKIN TEMPERATURE COLD WARM MUST- HAVE Use Moisturizer Use Astringent FREQUENCY Less More INSTRUCTION Avoid scratching the skin Avoid fatty and oily foods

101. HYGIENE: BATHING Shampooing: use circular motion Combing: from root to tip Brushing teeth: hold toothbrush 45 degree angle Clean the eyes: inner to outer canthus Wash the limbs: distal to proximal Cut the nails: straight across Shave the hair: follow the hairline

102. HYGIENE: BATHING Washing the perineum: MALE Position: Supine position Equipment: Clean gloves FEMALE Position: Dorsal recumbent pos (Inner to Outer ) Equipment: Forceps/gloves