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    Fundamentals of Nursing: Jessie Daclis, RN, Usrn, Mbac

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    Allyza Jane Sartiga
    - Open suction canister - Attach suction catheter to tubing - Lubricate catheter tip - Insert catheter gently into airway - Apply suction by pressing control button - Withdraw catheter slowly while suction is applied - Clean, dry and store equipment properly

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    Fundamentals of Nursing: Jessie Daclis, RN, Usrn, Mbac

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    Allyza Jane Sartiga
    502 views110 pages
    - Open suction canister - Attach suction catheter to tubing - Lubricate catheter tip - Insert catheter gently into airway - Apply suction by pressing control button - Withdraw catheter slowly while suction is applied - Clean, dry and store equipment properly

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    - Open suction canister - Attach suction catheter to tubing - Lubricate catheter tip - Insert catheter gently into airway - Apply suction by pressing control button - Withdraw catheter slowly while suction is applied - Clean, dry and store equipment properly

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    502 views110 pages

    Fundamentals of Nursing: Jessie Daclis, RN, Usrn, Mbac

    Uploaded by

    Allyza Jane Sartiga
    - Open suction canister - Attach suction catheter to tubing - Lubricate catheter tip - Insert catheter gently into airway - Apply suction by pressing control button - Withdraw catheter slowly while suction is applied - Clean, dry and store equipment properly

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 110

    FUNDAMENTALS OF NURSING

    JESSIE DACLIS, RN, USRN, MBAc


    TYPES OF NSG INTERVENTION

    1. INDEPENDENT

    2. DEPENDENT

    3. INTERDEPENDENT
    Nursing Care Delivery Systems

    • Functional
    • Total Patient Care
    • Team Nursing
    • Primary Nursing
    • Case Management
    PATRICIA BENNER
    LEAVELL
    Vital Signs Table
    Temperature Conversion
    Diurnal Variations (circadian Rhythm)
    TYPES OF FEVER

    1. Intermittent Fever
    2. Relapsing
    3. Constant
    4. Remittent
    What happens to the BP if there is
    Hyperthermia?
    Management for Hypothermia
    • Warm Environment
    • Dry Clothing
    • Warm Blankets
    • Limbs close to body
    • Cover scalp with cap or turban
    • Warm oral or IV fluids
    • Warming Pads
    Hyperthermia Blanket
    Heart
    Important Pulse Sites
    Pulse Amplitude
    0
    1 faint but detectable
    2 slightly more diminished than normal
    3 normal
    4 bounding
    Respirations
    • Rate
    • Volume
    • Rhythm
    • Breath Sounds (Normal and Adventitious)
    Normal Breath sounds
    • Vesicular Breath Sounds
    • Bronchial Breath sounds
    • Bronchovesicular breath sounds..
    Adventitious sounds
    1. Stridor
    2. Wheezing
    3. Rhonchi
    4. Crackles/Rales
    5. Pleural Friction Rub
    Chest Movements
    • Intercostal retractions
    • Substernal retraction
    • Suprasternal retraction
    Assessing Blood Pressure
    Ensure that client is rested.
    OAllow to pass if the client have smoked or
    ingested caffeine before taking BP.
    O Use appropriate size of BP cuff.
    • O Position the pt in supine or sitting position.
    • O Position the arm at the level of the heart, with the
    palm of the hand facing up.
    • O Apply BP cuff snugly, _ above the antecubital space.
    • O Inflate and deflate BP cuff slowly, at a time.
    • O Wait before making further determinations.
    Pulse Oximeter
    • Finger probe, toe,ear probe,

    • Normal reading is 95% above..if 94% below: assume


    hypoxia.
    • If below 90% seriously hypoxic.

    • Check ABCDE from patient


    • Airway
    • Breathing
    • Circulation
    • Drugs (opioids, sedatives,muscle relaxant)
    • Equipment
    Pulse oximeter
    What is the normal Pulse oximeter
    reading during anesthesia?
    A. 85 - 89%
    B. 90 - 94%
    C. 95 - 99%
    D. 100%
    5 factors that can affect reading
    • • Nail varnish or pigment on finger
    • • Bright light on the probe
    • • Patient movement
    • • Poor perfusion
    • • Carbon monoxide poisoning
    QnA
    The client’s temperature at 8am using an oral
    electornic thermometer is 36.1 degree C (97.2 F). If
    the respiration, pulse and blood pressure were
    within normal range. What would the nurse do
    next?
    A. Wait 15 minutes and retake it
    B. Check what the client’s temperature was the last
    time it was taken.
    C. Retake it using a different thermometer
    D. Chart the temperature; it is normal
    QnA
    When the nurse enters a client’s room to measure
    routine vital signs, the client is on the phone. What
    technique should the nurse use to determine the
    respiratory rate?
    A. Count the respirations during conversational
    pauses.
    B. Ask the client to end the phone call now and
    resume it at a later time.
    C. Wait at the client’s bedside until the phone call is
    completed and then count repsirations.
    D. Since there is no evidence of distress or urgency,
    postpone the measurement until later.
    QnA

    For a client with a previous blood pressureof


    138/74 mmHg and a pulse of 64bpm,
    approximately how long should the nurse take
    to release the blood pressure cuff in order to
    obtain an accurate reading?
    A. 10-20 seconds
    B. 30-45 seconds
    C. 1-1.5 minutes
    D. 3-3.5 mnutes
    An 85 year old client has had a stroke resulting
    in right sided facial drooping, difficulty
    swallowing and the inability to move self or
    maintain position unaided. The nurse
    determines that which site are most
    appropriate for taking the temperature? SATA
    1. Oral
    2. Rectal
    3. Axillary
    4. Tympanic
    5. Temporal Artery
    When auscultating the blood pressure, the nurse
    hears: From 200 to 180 mmhg: silence; then a
    thumping sound continuing down to 150
    mmHg;muffled sounds continuing down to
    130 mmHg; soft thumping sounds continuing
    down to 105 mmHg; muffled sounds
    continuing down to 95mmHg; then silence.
    The nurse recods the blood pressure as :
    E. PAIN
    - A sensation of physical or mental hurt or
    suffering that causes distress or agony to
    the one experiencing it
    CLASSIFICATION OF PAIN
    A. TYPES:
    2. CUTANEOUS
    3. SOMATIC
    4. VISCERAL
    5. REFERRED
    6. INTRACTABLE
    7. PHANTOM
    8. RADIATING
    CHARACTERISTICS OF
    PAIN
    B. LOCATION

    C. DURATION

    D. QUALITY

    E. INTENSITY

    F. FACTORS

    E. EFFECT ON ADL
    Sleep
    4 techniques in PE
    • I
    • P
    • P
    • A
    • Standard: IPPA
    • Abdomen: IAPEPA

    • Palpation:
    A.Light – 1 – 2 cm
    B.Deep – 4 – 5 cm
    >> bimanual palpation
    >> one hand while the other hand supports.
    • In Percussion, we can elicit 5 sounds:
    • Flatness – extremely dull sound by very dense tissue such as
    muscle or bone.
    • Dullness – thudlike(nahulug na bagay sa sahig)sound produced by
    dense tissue. Liver, speen, heart
    • Resonance – hollow sound produced by lungs filled with air.
    • Hyperresonance – not normal; booming sound hear over
    emphysematous lung
    • Tympany – musical or drumlike sound from air filled stomach.

    • Flatness reflects the most dense tissue while tympany is the least
    dense tissue.
    Hair, Scalp, Eyes, Ears

    • PERRLA
    • Normal pupil
    • Shape:
    • Direct response –
    • Consensual
    • Accomodation
    Ears

    • Rinne test Weber’s test


    Romberg’s test
    • Using 512Hz tuning fork.
    • Rinne test – test air conduction.
    • Held perpendicular to external ear.
    • Webers test
    - Place the base of the tuning fork in the
    midline.
    - -
    Eyes

    • visual acuity - snellens chart


    • visual field - glaucoma, macular degeneration.
    Snellen’s chart
    visual acuity testing
    • hold newspaper or magazine 14 inches away
    and ask patient to read.

    • Rosenbaum eye chart- test near vision. it


    consists of paragraphs of text or characters in
    different sizes.

    •
    Ishihara test or Hardy Rand Rittler test

    • color vision testing.


    Amslet Grid
    Ears
    Chest
    GI Assessment

    • Bowel sounds
    • 5 to 30 sounds/minute.
    BSE
    Pap smear
    Diagnostic Examination
    URINE
    URINE

    B. BENEDICT'S TEST

    C. HEAT AND ACETIC ACID TEST


    STOOL

    A. ROUTINE FECALYSIS

    B. CULTURE AND SENSITIVITY

    C. FECAL OCCULT BLOOD TEST


    SPUTUM
    A. GROSS APPEARANCE

    B. CULTURE AND SENSITIVITY

    C. CYTOLOGY

    D. ACID FAST BACILLUS


    BLOOD

    A. WITH FASTING

    B. WITHOUT FASTING
    FOOD PYRAMID
    Progressive Diet
    • Clear Liquid Diet
    • Full Liquid Diet
    • Soft Diet
    • Osterized Feeding
    • Full Diet
    • Low Residue Diet
    • DASH diet
    DIET
    ¾ Acid Ash
    ¾ Alkaline Ash
    ¾ Bland
    ¾ Brat
    ¾ Clear liquid
    ¾ Diabetic
    ¾ Giordano
    ¾ Gluten Free
    ¾ Yin
    DIET
    ¾ Halal
    ¾ High Fiber
    ¾ Kosher
    ¾ Purine Restricted
    ¾ Sodium Restricted
    ¾ Soft
    ¾ Tyramine Free
    ¾ Vegan
    • Which is a normal finding on auscultation of
    the lungs?
    • A. tympany over the right upper lobe.
    • B. Resonance over the left upper lobe.
    • C. hyperresonance over the left lower lobe
    • D. dullness above the left 10th intercostal
    space.
    • After auscultating the abdomen, the nurse
    should report which finding to the primary car
    provider?
    • A. bruit over the aorta
    • B. absence of bowel sounds for 60 seconds.
    • C. continuous bowel sounds over the ileocecal
    valve.
    • D. a completely irregular pattern of bowel
    sounds.
    • If unable to locate the client’s poplitela pulse
    during a routine examination. what should
    the nurse do next?
    • A. check for pedal pulse
    • B. check for femoral pulse
    • C. take the client’s blood prssure on the thigh
    • D. ask another nurse to try to locate the pulse.
    ELIMINATION

    • Urine and Bowel


    • Normal Urine: 60-80ml/hr
    • Normal Bowel: no >3X/day -3x/week

    • PROBLEM: Urinary or Fecal incontinence


    • For urinary incontinence: IMPORTANT
    “KEGEL’s EXERCISE”
    Catheterization
    OSTOMY
    OXYGEN DEVICES AND SYSTEMS

    A. Low-flow Administration

    1. Nasal canula
    2. Simple face mask
    3. Partial Rebreathing mask
    4. Non-breathing mask
    5. Oxygen tent
    B. High-flow Administration

    1. Venturi mask
    2. Face mask
    3. Oxygen hood
    4. Incubator
    FECAL ELIMINATION

    Normal Characteristic of Stool:


    A. Color
    B. Odor
    C. Consistency

    ¾ ACHOLIC STOOL
    ¾ HEMATOCHEZIA
    ¾ MELENA
    ¾ STEATORRHEA
    FECAL ELIMINATION PROBLEMS

    A. DIARRHEA

    B. CONSTIPATION

    C. FECAL IMPACTION

    D. FLATULENCE
    ADMINISTERING ENEMAS
    A. CLEANSING ENEMA
    ¾ High Enema
    ¾ Low-flow Enema

    B. CARMINATIVE ENEMA

    C. RETENTION ENEMA

    D. RETURN FLOW ENEMA

    E. NON RETENTION ENEMA


    URINE ELIMINATION

    Normal Characteristic of Urine:

    A. Color
    B. Odor
    C. PH
    D. Specific gravity
    ALTERATIONS IN URINE COMPOSITION

    A. HEMATURIA

    B. BACTERIURIA

    C. ALBUMINURIA / PROTEINURIA

    D. GLYCOSURIA / KETONURIA
    ALTERED URINE PRODUCTION

    A. POLYURIA

    A. OLIGURIA

    A. ANURIA
    ALTERED URINARY ELIMINATION

    A. FREQUENCY

    B. NOCTURIA

    C. URGENCY

    D. DYSURIA

    E. ENURESIS

    F. INCONTINENCE
    INCENTIVE SPIROMETER
    TRACHEOSTOMY
    CHEST TUBE
    MECHANICAL AIDS

    • 1. Crutches

    • 2. Cane

    • 3. Walker
    SUCTIONING
    Pressure of Suction
    Portable Unit:
    Infant: 2 -5 mmHg
    Child: 5-10 mmHg
    Adult: 10-15 mmHg

    Wall unit:
    Infant: 50-95
    Child: 95-110
    Adult: 100-120 mmHg

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