NLE Tips

WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS

PART 1: FUNDAMENTALS OF NURSING

I. NURSING THEORIST PLANNING PHASE Types of Planning

Florence Nightingale Environmental Theory -‐ Prioritize problems Initial planning, admission
Virginia Henderson 14 Basic Needs -‐ Formulate goals assessment.
Faye Abdellah Patient – Centered Approaches to -‐ Select actions Ongoing planning
Nursing Model / 21 Nursing Problems -‐ Write nursing orders Discharge planning:
Dorothy Johnson Behavioral System Model M edications
Imogene King Goal Attainment Theory E xercise
Madeleine Leininger Transcultural Nursing Model T reatment/therapy
Myra Levin Four Conservation Principles H ygiene
Betty Neuman Health care System Model O ut-‐patient follow up
Dorotheo Orem Self-‐Care and Self-‐Care Deficit Theory D iet/nutrition
Hildegard Peplau Interpersonal Model S exual activity/spirituality
INTERVENTION / Types of Intervention
Martha Rogers Science of Unitary Human Beings
IMPLEMENTATION • Independent
Sister Callista Roy Adaptation Model
• Dependent
Lydia Hall Care,Core,Cure
-‐ Determining needs • Collaborative
Jean Watson Human Caring Model
for assistance
Rosemarie Rizzo Human Becoming -‐ Putting into action Cognitive or Intellectual Skills
Parse the plan Such as analyzing the problem,
-‐ Supervising problem solving, critical
II. NURSING PROCESS delegated care thinking and making judgments
-‐ Documenting regarding the patient's needs.
ASSESSMENT PHASE Subjective Data also referred to nursing activities Interpersonal Skills
as symptoms or covert data
Which includes therapeutic
-‐ Data Collection Objective Data also referred to
communication, active listening,
-‐ Organize Data as signs or overt data, are
conveying knowledge and
-‐ Validate Data detectable by an observer information, developing trust or
-‐ Document Data Primary source is the client rapport-‐building with the
Secondary source is family or
patient
anyone else that is not the client
Technical Skills Which includes

knowledge and skills needed to
Methods of Data Collection
properly and safely done the
Observing To observe is to
procedure
gather data by using the sense.

Interviewing Is a planned
EVALUATION PHASE Collecting data related to
communication or a
outcome
conversation with purpose
Comparing data
Examining Is a systematic data-‐
Drawing conclusion
collection method that uses
Continuing, modifying or
observation (i.e., the senses of
terminating the nursing care
sight, hearing, smell, and touch)
plan
to detect health problems.

III. ROLES AND FUNCTIONS OF THE PROFESSIONAL
DIAGNOSIS PHASE Types of Nursing Diagnosis
-‐ Analyze Data NURSE
-‐ Identify Health Actual diagnosis is a client
Problem problem that is present at the • Direct Care Provider -‐ provides total care using the
-‐ Formulate time of the nursing assessment. nursing process .
Diagnostic Risk nursing diagnosis is a • Communicator – communicates with clients, support
Statements clinical judgment that a problem
person and colleagues to facilitate all nursing action.
does not exist, but the presence
Diagnostic Statements of risk factors • Teacher – provides health teaching
Problem (P): statement Wellness diagnosis • Counselor – helps the client to recognize and cope with
of the client’s response. Possible nursing diagnosis is stressful pyschological or social problem,
Etiology (E): factors one in which evidence about a • Client Advocate – the nurse becomes an activist
contributing health problem is incomplete or speaking up for the client who cannot or will not speak
Signs and Symptoms unclear.
for self.
(S): defining Syndrome diagnosis is a
characteristics diagnosis that is associated with • Change Agent – initiates changes and assists the client
manifested by the client a cluster of other diagnoses. make modifications in the lifestyle to promote health.
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE


• Leader – nurse through the process of interpersonal IV. ISOLATION PRECAUTIONS
influence .
• Manager – the nurse plans, gives directions, develops Ø Standard Precautions / Universal Precautions
ü Applies to ALL BODY FLUIDS
staff, monitors operation.
ü Includes:
• Case Manager – coordinates the activities of other 1. HAND WASHING
member of the health care team. 2. Personal Protective Equipment
• Researcher – participates in scientific investigation and (sequence of removing PPE’s)
uses research findings in practice. gloves-‐mask-‐gown-‐eyewear-‐cap
3. Safe use of sharps
• Collaborator – works in a combined effort with all those
4. Removing spills of blood and body fluids
involved in care delivery.
5. Cleaning and disinfecting equipment

Ø Transmission Based Precautions
III. CHAIN OF INFECTION • Airborne precautions
ü A single room under negative pressure
ventilation with a wash hand basin
ü The door must be kept closed at all times
except during necessary entrances and exits.
ü Disposable paper towels
ü A high efficiency mask, if available, should be
worn when entering the room of a patient
with known or suspected tuberculosis.

• Droplet precautions
ü Put on a standard mask prior to entering the
isolation room.
ü Hands must be washed with an antiseptic
preparation and must be dried thoroughly
with a disposable paper towel or washed with
a waterless alcohol hand rub/gel:
► MODE OF TRANSMISSION it indicates the potential of 1. AFTER contact with the patient or
the disease; conveyance of the agent to the host; it can be potentially contaminated items,
by common source transmission, contact source, air-‐ 2. AFTER removing gloves, and
borne transmission. 3. BEFORE taking care of another patient.

There are four main routes of transmission • Contact precautions
A. By Contact Transmission ü Non-‐sterile, disposable gloves are needed
1. Direct contact ( person to person ) when there is contact with an infected site,
2. Indirect contact ( usually an inanimate object) with dressings, or with secretions.
3. Droplet contact ( from coughing, sneezing, or ü A mask when performing procedures that
talking, or talking by an infected person) may generate aerosols or when performing
suctioning is recommended.
B. By Vehicle Route ( through contaminated items) ü Hands washing (see droplet precautions)
1. Food – salmonellosis
2. Water – shigellosis, legionellosis
3. Drugs – bacteremia resulting from infusion of a V. NURSING SKILLS
contaminated infusion product
4. Blood – hepatitis B, A. Physical Assessment
Ø Provide privacy.
C. Airborne Transmission Ø Make sure that all needed instruments are available
1. Droplet of nuclei before starting the physical assessment
2. Dust particle in the air containing the infectious Ø Be systematic and organized when assessing the client.
agent Inspection, Palpation, Percussion, Auscultation.
3. Organisms shed into environment from skin, hair, Ø EYES: Visual acuity is tested using a snellen chart. The
wounds or perineal area. room used for this test should be well lighted
Ø EARS: Weber’s Test assesses bone conduction, this is
D. Vector borne Transmission, arthropods such as a test of sound lateralization, Rinne Test compares
flies, mosquitoes, ticks and others. bone conduction with air condition.
Ø NECK: Let the client sit on a chair while the examiner
stands behind him.



Ø THORAX: The client should be sitting upright without Ø Blood Pressure (NV 120/80 mm/hg)
support and uncovered to the waist. ü This is the force exerted by the blood against a
Ø HEART: Anatomic areas for auscultation of the heart vessel wall
ü Aortic valve – Right 2nd ICS sternal border. ü The pressure rises with age.
ü Pulmonic Valve – Left 2nd ICS sternal border. ü A rest of 30 minutes is indicated before the blood
ü Tricuspid Valve – – Left 5th ICS sternal border. pressure can be readily assessed after stressful
ü Mitral Valve – Left 5th ICS midclavicular line activity.
Ø BREAST ü Interval of 30 minutes is needed after smoking or
drinking caffeine.
ü After menopause, women generally have higher
blood pressures than before.
ü Pressure is usually lowest early in the morning,
when the metabolic rate is lowest, then rises
throughout the day and peaks in the late
afternoon or early evening

Common Errors in Blood Pressure Assessment

Errors Effect

Ø ABDOMEN: Place the client in a supine position with Bladder cuff too narrow Erroneously high
the knees slightly flexed to relax abdominal muscles. Bladder cuff too wide Erroneously low
(Inspection,Auscultation,Percussion,Auscultation) Arm unsupported Erroneously high
Insufficient rest before the Erroneously high
B. Vital Signs assessment
Repeating assessment too Erroneously high
Ø Temperature (NV 36 – 37.5 C) quickly
ü Elderly people are at risk of hypothermia Cuff wrapped too loosely or Erroneously low
ü Hard work or strenuous exercise can increase unevenly
body temperature Deflating cuff too quickly Erroneously low systolic and
ü Oral: most accessible 2-‐3 mins. * 15 minutes high diastolic reading
interval after ingestion of hot or cold drinks Deflating cuff too slowly Erroneously high diastolic
ü Rectal: most accurate 2-‐3 mins. reading
ü Axillary: most safest 6-‐9 mins. Failure to use the same arm Inconsistent measurements
consistently
Ø Pulse (NV 60-‐100 bpm) Arm above level of the heart Erroneously low
ü Wave of blood created by contraction of the left Assessing immediately after Erroneously high
ventricle of the heart a meal or while client
ü Radial: best site for adult smokes
ü Brachial: best site for children Failure to identify Erroneously low systolic
ü Apical: best site for 3 years old below auscultatory gap pressure pressure and erroneously
low diastolic
Ø Respiration (NV 12/16-‐20)

Normal Breath Sound C. Medication Administration

Vesicular Soft, low pitch Lung periphery Ø FIVE RIGHTS
Broncho-‐ Medium pitch Larger airway The Right Drug with
vesicular blowing The Right Dose through
Bronchial Loud, high pitch Trachea The Right Route at
The Right Time to
Abnormal Breath Sound The Right Patient
Ø Standard Order, Carried out until cancelled by
another order.
Crackles Dependent lobes Random, sudden Ø PRN Order, As needed, or only when necessary.
reinflation of alveoli Ø Stat Order, Carried out immediately and for one time
fluids only.
Rhonchi Trachea, bronchi Fluids, mucus Ø Always clarify doubtful /unclear order
Wheezes All lung fields Severely narrowed Ø Do not leave medicine with the client to take by
bronchus himself
Pleural Lateral lung field Inflamed Pleura Ø Do not give drug that shows physical changes or
Friction Rub deterioration


Ø Report an error in medication immediately to the E. Nasogastric Tube (NGT)
nurse in charge.
Ø The nurse who prepares the medication must be Ø Gavage (feeding) / Lavage (suctioning)
responsible for administering and recording it. Never Ø Select the nostril that has greater airflow.
endorse it to another nurse. Ø Assist the client to a high fowler’s position
Ø Always observe asepsis in preparing and Ø NEX technique (nose-‐ear-‐xiphoid)
administering drugs. Ø Checking the patency:
Ø Ascertain client’s identity before administering ü Aspirate stomach contents and check the pH,
medications. Check room or bed or card, call out which should be acidic
client’s name, check I.D., wrist band ü Introduce 10-‐30 ml of air into the NGT and
Ø Care must be taken to prevent instilling medication auscultate at the epigastric area, gurgling sound
directly into cornea. is heard
Ø Apply ointment along inside edge of the lower eyelid ü The most accurate method of assessing the
from inner to outer canthus. placement of NGT is X-‐ray study
Ø EAR MEDS:
Infants: draw the auricle gently downward and Ø Before feeding assess residual feeding contents. To
backward. assess absorption of the last feeding, if 50 ml or
Adults: lift pinna upward and backward more, verify if the feeding will be given.
Ø Intradermal: Parallel to the skin, do not massage Ø Height of feeding is 12 inches above the point of
Ø Subcutaneous: 45 degree above the skin, if obese 90 insertion.
degree Ø Ask the client to remain in position for at least 30
Ø Intramuscular: 90 degree above the skin, aspirate to min
check if blood vessel was hit. Ø Common Problems of Tube Feedings
• Vomiting
D. Urinary Catheterization • Aspiration
Ø Use appropriate size of catheter • Diarrhea
Male: Fr 16-‐18 • Hyperglycemia
Female: Fr 12-‐14
Ø Place the client in appropriate position: F. Enema Administration
Male: Supine, legs abducted and extended
Female: Dorsal recumbent Ø Position the client:
Ø Locate the urinary meatus properly: Adult: Left lateral
Male: at the tip of the glans penis Infant/small children: Dorsal recumbent
Female: between the clitoris and vaginal orifice Ø Lubricate the tube about 5 cm ( 2 in )
Ø Lubricate catheter with water soluble lubricant before Ø Insert 7 – 10 cm ( 3 to 4 inches) or rectal tube gently
insertion in rotating motion
Male: 6 – 7 inches Ø Raise the solution container and open the clamp to
Female: 1 – 2 inches allow fluid to flow
Ø Length of catheter insertion: High Enema: 12-‐18 inches above the rectum
Male: 6 – 9 inches Low Enema: 12 inches above the rectum
Female: 3 -‐4 inches Ø If the client complains of fullness or pain, use the
Ø Anchor catheter properly: clamp to stop the flow for 30 sec. and then restart
Male: laterally or upward over the lower abdomen / the flow at a slower rate
upper thigh Ø Encourage the client to retain the enema, ask the
Female: inner aspect of the thigh client to remain lying down

Nursing Interventions to Induce Voiding/Urination G. Colostomy Care

v Provide privacy Ø Stoma should appear red, similar to the mucosal
v Assist the patient in the anatomical position of voiding linin of the inner cheek
v Serve clean, warm and dry bedpan (female) or urinal Ø Slight bleeding initially when the stoma is touched
(male) is normal, but other bleeding should be reported.
v Allow the client to listen to the sound of running water Ø Change colostomy appliance if it is 1/3 full.
v Dangle fingers in warm water Ø Use warm water, mild soap (optional), and cotton
v Pour warm water over the perineum balls or a washcloth and towel to clean the skin and
v Promote relaxation stoma.
v Provide adequate time for voiding Ø Apply skin barrier over the skin around the stoma
v Last resort: URINARY CATHETERIZATION to prevent skin breakdown.
Ø Changing is best in the morning before breakfast.
Ø Control Odor: (deodorizer, charcoal disk and
prevent odor causing foods)



Type of Discharge
Ileostomy • Liquid fecal drainage Ø Check for cross matching and blood typing. To
• Drainage is constant and cannot ensure compatibility
be regulated Ø Obtain and record baseline VS, Note: If patient has
• Contains some digestive fever do not transfuse
enzymes Ø Practice strict, ASEPSIS
• Odor is minimal bec of fewer Ø At least 2 nurses check the label of the blood
bacteria are present transfusion, Check the following:
Ascending • Liquid fecal drainage -‐ Serial Number
Colostomy -‐ Blood component
• Drainage is constant and cannot
be regulated -‐ Blood type
-‐ Rh factor
• Odor is a problem requiring
-‐ Expiration date
control
-‐ Screening test
Transverse Malodorous, mushy drainage
•
Ø Check the blood for gas bubbles and any unusual
Colostomy
color or cloudiness. Note: Gas bubbles indicate
Descending • Solid fecal drainage bacterial growth, Unusual color or cloudiness
Colostomy
indicate hemolysis
Sigmoidostomy • Normal fecal characteristics Ø Warm blood at room temperature before
transfusion.
Ø Identify client properly, two nurses check the
H. Suctioning client’s identification
Ø Gauge of needle: #18
Ø Suction only when necessary not routinely Ø Drop Factor: KVO
Ø Use the smallest suction catheter if possible Ø Duration: RBC – 4 hours;
Ø Client should be in semi or high Fowler’s position Platelets, FFP – 20 minutes
Ø Use sterile gloves, sterile suction catheter Ø When reactions occurs:
Ø Hyperventilate client with 100% oxygen before ü STOP transfusion
and after suctioning ü KVO with PNSS
Ø Insert catheter with gloved hand (3-‐5“ length of ü Send remaining blood, a sample of client blood
catheter insertion) without applying suction. Three and urine sample to the laboratory.
passes of the catheter is the maximum, with 10 ü Notify the physician
seconds per pass. ü Monitor VS
Ø Apply suction only during withdrawal of catheter ü Monitor I & O
Ø The suction pressure should be limited to less than Ø Common BT reactions:
120 mmHg ü Hemolytic: flank /back pain
Ø When withdrawing catheter rotate while applying ü Anaphylactic: rashes, itching, DOB (worst)
intermittent suction ü Febrile: fever and chills
Ø Suctioning should take only 10 seconds (maximum ü Circulatory Overload: DOB, crackles
of 15 seconds) ü Sepsis: Fever and chills

K. Assistive Device
I. Tracheostomy Care
Ø Canes
Ø Assist the client to a semi-‐Fowler’s or Fowlers ü COAL (cane opposite affected leg)
position. ü Angel is 20-‐30 degrees
Ø Hydrogen peroxide moisten and loosens dried Ø Walkers
secretions ü Hand bar below the client’s waist and the elbow
Ø Rinse the inner cannula thoroughly in the sterile is slightly flexed.
normal saline. Ø Crutches
Ø When changing the ties: tie one end of the new tie to ü Length of the Crutches: Subtract 40 cm or 16
the eye of the flange while leaving old ties in place. inches to the height of the client obtain the
Ø Put two fingers under the tapes before tying it. approximate crutch length.
ü 20 to 30 degrees of flexion at the elbow.
ü Four point gait:
J. Blood Transfusion * right crutch, the left foot, the left crutch, right
foot.
Compatible Incompatible ü Two point gait:
A A / O AB / B * left foot and right crutch, right foot and left
B B / O AB / A crutch
AB A / B / AB / O ü Three point gait:
O O A / B / AB * left foot and both crutches, right foot.


ü Swing Through Gait: . ü Observe for fluctuation of fluid along the tube
* Advance both crutches, Lift both feet and swing (water-‐seal bottle or the second bottle) and
forward, Land the feet in front of crutches. intermittent bubbling with each respiration.

• Three-‐bottle system
ü Going up the stairs: (good goes to heaven,
bad goes to hell)

L. Chest Physiotheraphy ( CPT )
Ø Steam Inhalation
ü Place the client in Semi-‐Fowler’s position
ü Cover the client’s eyes with washcloth to
prevent irritation
ü Place the steam inhalator in a flat, stable
surface.
ü Place the spout 12 – 18 inches away from the
client’s nose or adjust distance as necessary
ü To be effective, render steam inhalation
therapy for 15 – 20 minutes

Ø Postural drainage
ü Use of gravity to aid in the drainage of ü The first bottle is the drainage bottle;
secretions. ü The second bottle is water seal bottle
ü Patient is placed in various positions to ü The third bottle is suction control bottle.
promote flow of drainage from different lung
segments using gravity. ü Observe for intermittent bubbling and
ü Areas with secretions are placed higher than fluctuation with respiration in the water-‐
lung segments to promote drainage. seal bottle
ü Patient should maintain each position for 5-‐15 ü Continuous GENTLE bubbling in the suction
minutes depending on tolerability. control bottle.
ü Suspect a leak if there is continuous bubbling
in the WATER seal bottle or if there is
M. Closed Chest Drainage ( Thoracostomy Tube ) VIGOROUS bubbling in the suction control
bottle.
Types of Bottle Drainage ü The nurse should look for the leak and report
the observation at once. Never clamp the
• One-‐bottle system
tubing unnecessarily.
ü The bottle serves as drainage and water-‐seal
ü If there is NO fluctuation in the water seal
ü Immerse tip of the tube in 2-‐3 cm of sterile
bottle, it may mean TWO things
NSS to create water-‐seal.
ü Either the lungs have expanded or the
ü Keep bottle at least 2-‐3 feet below the level of
system is NOT functioning appropriately.
the chest
ü In this situation, the nurse refers the
ü Observe for fluctuation of fluid along the tube.
observation to the physician, who will order
The fluctuation synchronizes with the
for an X-‐ray to confirm the suspicion.
respiration.
ü In the event that the water seal bottle
ü Observe for intermittent bubbling of fluid;
breaks, the nurse temporarily kinks the tube
continues bubbling means presence of air-‐leak
and must obtain a receptacle or container

with sterile water and immerse the tubing.
In the absence of fluctuation:
ü She should obtain another set of sterile bottle
Suspect obstruction of the device
as replacement. She should NEVER CLAMP
v Assess the patient first, then if patient is stable
the tube for a longer time to avoid tension
v Check for kinks along tubing;
pneumothorax.
v Milk tubing towards the bottle (If the hospital
ü In the event the tube accidentally is pulled
allows the nurse to milk the tube)
out, the nurse obtains vaselinized gauze and
v If there is no obstruction, consider lung re-‐
covers the stoma.
expansion; (validated by chest x-‐ray)
ü She should immediately contact the
v Air vent should be open to air.
physician.

• Two-‐bottle system

ü If not connected to the suction apparatus

ü The first bottle is drainage bottle;

ü The second bottle is water-‐seal bottle



N. Oxygen Therapy

Ø Nasal Cannula (24% -‐ 45% ) at flow rate of 2 – 6
L/min.
Ø Simple Face Mask (40% -‐ 60%) at liter flows of 5 -‐ 8
L/min
Ø Partial Rebreather Mask (60% -‐ 90%) at liter flows
of 6 – 10 L/min.
Ø Non-‐Rebreather Mask (95% -‐ 100%) at liter flows of
10 – 15 L/min.
Ø Oxygen is colorless, odorless, tasteless and a dry gas
that support combustion, therefore leakage cannot be
detected.
Ø Place cautionary signs reading “ No SMOKING:
Oxygen in Use”
Ø Avoid materials that generate static electricity, such as
woolen blankets and synthetic fibers.
Ø Set up the oxygen equipment and the humidifier
filled with distilled/sterile water.

Ø CANNULA: Put over the client’s face, with the outlet
prongs fitting into the nares.
Ø FACE MASK: Fit the mask to the contours of the
client’s face, apply it from the nose downward


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WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

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