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 OXIMETER
Critical 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 polish
4. 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 clients hemoglobin level is low and if she needs blood transfusion
B. Check the level of tissue perfusion
C. Check the clients Arterial blood gas
D. Detect oxygen saturation of the arterial blood before symptoms of hypoxemia develops
Answer: 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? clean
6. 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)

THORACENTESIS
POSITION (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
THORACENTESIS
Critical 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 nurses instruction to the client when the physician is inserting the needle and also during the
withdrawal of the needle? EXHALE
5. 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 fowlers 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 SPIROMETRY
Critical 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? TIGHT
5. 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-Fowlers 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 PHYSIOTHERAPY
Critical 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 minutes
6. 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 hands
9. 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 minutes
11. 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 nurses hand should produce the vibration? HEEL
13. When should the nurse start vibrating the hand? During inhalation or exhalation? EXHALATION
14. 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? Clients 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 jelly
Position: Conscious: semi-fowlers 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 naso
4. 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? 95-110
6. 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. 510 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 orifice
10. 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 cartilage
14. 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 COPD
VENTURI 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-fowlers 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 DELIVERY
Critical 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-fowlers 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 down
6. 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-fowlers 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: NSS
TRACHEOSTOMY 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 physicians order
Place in semi-fowlers position spout 12-18 inches away from the clients 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 NUTRITION
ASSESSING 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 NUTRIENTS
Macronutrients 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, Na
Water soluble C- ascorbic acid B1 Thiamine B2 Riboflavin B6 - Pyridoxine B9 Folacin B12 Cyanocobalamine
Nursing 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 (dont 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 toyo
6. 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 = 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
clients 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-FOWLERs 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 clients gown Rationale: to avoid nasal breakdown
In case of nasal breakdown give XYLOCAINE SPRAY
NASOGASTRIC TUBE
Salient 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
o

Aspirate gastric content instil 30mL of air

Check RESIDUAL FEEDING done every 4-6 hours (<100mL)

For new research if RF is up to 400mL continue feeding

Before >100mL STOP FEEDING NOTIFY PHYSICIAN

Height of container 12 above stomach

Temp solution warm to prevent cramping

Duration of solution 30 minutes

Flush tube by using: tap water (30-60 mL)

REMOVING NGT

Handwashing

Position: semi-fowlers 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 clients position during NGT insertion? HIGH-FOWLERs POSITION
3. 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 swallow
9. 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 TUBES
Critical 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 water
9. 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 clients WEIGHT, TRIGLYCERIDE level, SUGAR level.
TOTAL PARENTERAL NUTRITION
Complications:

Hyperglycemi a give insulin - dont catch-up feeding - dont rapidly infuse solution
Pulmonary embolism consider heparin, if tube become OPAQUE place patient in T-position, when
changing dressing place pt in T-position - dont mix drugs or blood with TPN

Infection change tubing q 24hrs and change dressing q 48 hours

ELIMINATION Urinary Fecal
URINARY
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: Schillings test R/o pernicious anemia Creatinine clearance test (creatinn 0.6-1.5)
SPECIMEN THROUGH CATHETER For Urine C/S 3-5mL
CATHETERIZATION
Catheterization
Male Female Position Supine Dorsal Recumbent French (Fr) 16-18 12-14 Length 40 cm 22 cm Insertion 6-9 inches 34 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
Dont 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 voiding

5. To ease insertion of the catheter into a male client, the nurse should hold the penis how many Degrees against the
body? Perpendicular or 90
6. 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 minutes
5. 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 Hirchprungs

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 inches
7. 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 - 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 & ACIDBASE BALANCE
9. OSTOMIES
10. Changing ostomy appliance? CBQ: Critical Pathway 1. When are
pouches emptied? 1/3 to 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 clients appliance?
bathroom 4. What is the preferable position in changing the clients 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 soln: 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 BUCKs
TRACTION lower limbs fractuers 8-10 lbs weight Elevate FOOT of bed
BRYANTs 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 Dont 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 Ps 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 Clients 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 - 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): Ztract 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 clients 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 clients 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 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 soln., 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 physicians order; consent E emergency,
get MDs 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. SCHILLINGs 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 : 1418g/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 - 6070 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