Scope
a. Health promotion
b. Disease prevention
c. Health restoration
d. 2are of the death and suffering individuals
m îD© î want© pleasure principle
m Ego© reality, arbiter
m Superego© moral principle
î
À
Manic Schizo Bulimia
Antisocial O2
Narcisistic anorexia
m Joundation of Nursing
rofession
m ³DYNAMî2
m Systematic and rational
m
m
m
m
m 2©ollection of data
m O© bservation of data
m V© alidation of data
m î© dentification of data
Types of data
a. Subjective
b. Objective
m T© rust
m R©apport
m U© nconditional regards
m S©et limits
m T©herapeutic communication
m 2©onfidentiality
m
©roximities
m A©ctive listening and observation
m T© ouch
m S©et limits
m
roximities
^u© inches (intimate)
^© inches (personal)
^4© ft ( social)
^©4u ft(public)
m Observation (senses)
m înterview© purposeful conversation
^ Jormal© highly structured, questionnaire,
limited time, yes or no
^ înformal© rapport building, free flowing,
open ended
m
hysical Assessment (î
A)
m Laand Dx result
m Records review
Total
atient 2are
© All aspect of one or more patient
care
© 2ontinuous care (endorsement)
© Shift based focus
© Does not necessitate care (same
nurse)
m Junctional nursing
^ Division of task
^ Task focused
^ Nurses are more competent for repeated
actions
^ Absence of hollistic care
m Team Nursing
^ RN¶s lead the team and other assistive
personnel
^ 2harge nurse
^ 2oordination of client¶s care plan
^ collaboration
m Limitations of Team Nursing
^ Role confusion
^ Lack of time of the team leader to
client
^ Non©continuity of care
m 2ase Management
^ 2oordinates and links health care service to
patient and family
^ Rn responsible for care from admission up to
following up of discharge
^ Group of clinicians© collaborative group who
oversees the management of case
^ 2ase©type©based care
m
rimary Nursing
^ Aim to place RN at bedside and
improves professional relationship
between staff
^ Assumes caseload of patients
^ Designed to maintain continuity of care
A nursing care that focuses on the relationship of
the nurse with her client with the same nurse
rendering care all throughout the client¶s
hospitalization.
îmogene King Goal Attainment Theory
Martha Roger Humanistic Science
Theory/Science of
Unitary Human Being
Leininger Transcultural Nursing
Watson Human 2aring Theory
î
×
À
×
6
Rosemarie
arse Human Becoming
Theory
Dorothy Johnson Behavioral System
Model (7 subsystems)
Neuman Stress Adaptation Model
Myra Levine 2onservation Model
Lydia Hall 2ore©2are©2ure
Margareth Neuman Health as Expanding
2onsciousness Theory
Joyce Travelbee Humanistic Revolution
Theory
Ernestine Wiedenbach
rescriptive theory
(
hilosophy,
urpose,
practice, art)
J
×
Abdella Watson
îmogene King Martha Roger
A. Temperature
a. 2ore temperature© deep tissue
b. Surface temperature© surface tissue
.
ulse© wave of contractions
produced by left ventricle
î. Guidelines
a.
sychological preparation
b.
hysical preparation (empty the
bladder)
c. Environment
d. equipment
e.
ositioning
Registered Nurse
a. Maintain proper body mechanics
b. Widen base of support
c. Bend knees
d. Do no bend your back
e. Avoid stretching/reaching
f. Maintain Good body alignment
m J. Abdomen (îA
e
a)
m G. if female (y/o)+male md+female RN
(witness)
î. înspection ± use of Sight
îî.
alpation© touch
î. Light/superficial© press the area lightly (circles)
îî. Deep/bimanual© Direct hand©palpate, NDH©
support the organ or mass
oints: a. Light first before deep
b. Wilm¶s tumor, appendicitis, abdominal
aneurysm
îîî.
ercussion© striking or tapping of body parts
m Direct© frontal sinus, direct
m îndirect© pleximeter (middle finger of
NDH), plexor (middle finger of DH)
m Blunt© Use of percussion hammer, Deep
tendon reflex
m Listening to body sounds produced by the body
m Types
^ a. Direct© use of unaided ear
^ îndirect© use of stethoscope
m 2olor
^Yellow
^Bluish
^Redness
Note: Asses for burns
m Strawberry Tongue
m Red Beefy tongue
m Black hairy tongue
Ears
© Weber© equal laterization of sound
© Rhine
m A©ortic© nd intercostal space @ right sternal
boarder
m
© ulmonic© nd î2S left sternal boarder
m Erb¶s point© rd ics left sternal boarder
m T©ricuspid© 4th ics left sternal boarder
m M©itral© pmi, 4th©th ics midclavicular line left side
m G2S
m Reflexes
m Superficial© cremasteric reflex
© Babinski (+) u months©
cerebral palsy
One of the responsibilities of Mr. 2yrile,RN, an
industrial nurse, is to conduct physical head to
toe assessment, he took the vital signs. Which
of the four assessment techniques did he
utilize?
m Auscultation .
alpation
m
ercussion 4. înspection
^ ,, c. ,
^ ,4 d. ,,4
d. ,,4
m 6i× iÀ
m Àî À
î
m À
m
m À
m
!"
À
î#$# oi
© hickenpox (Disseminated varicella)
i© nthrax
© easles
© ulmonary Tuberculosis
© ARS
À
î$# %
& &
'&
(
)))
&
î#$# oÀi
© RSA
À© otavirus and RSV
© cabies
i© bscess or wounds with uncontained drainage
À
%
&
& '&
* *
î#$# All respiratory infections except
RSV o À
6î
© iphtheria (pseudomembrane)
À© ubella (German measles)
© ral pharyngitis
© ertussis/
neumonia
© egionnaire¶s disease
© rythema infectiosum (Jifth disease)
6© onsillitis
î© nfluenza
© carlet fever
© eningitis
m
$
&
2rowds: flu and colds
Jresh flowers, vegetables and fruits: molds and
fungi
Live immunizations: (O
V, MMR, B2G, Varicella
vaccines)
Stagnant water: Legionnaire¶s disease/
neumonia
ets with ticks: Scabies
Bird droppings: Histoplasmosis
Raw meat, potted plants, fish tanks, cat litter box
and gardening: Toxoplasmosis
m
atient¶s Bill of Rights
^ Reflects acknowledgement of a client¶s
right to participate in her of his health
with an emphasis in client autonomy
^ Morality© behavior (customs, traditions)
^ Values (beliefs and attitudes©decision
making)
Autonomy Self determination
Nonmaleficence 2ause no harm
Beneficence Duty to maintain do
good to others
Justice Equitable distribution of
benefits and tasks
(according to care)
Veracity truth
Jidelity Duty to do what one has
promised
m According to the code of ethics, which of the
following is the primary responsibility of the
nurse?
a. Assist towards peaceful death
b.
reservation of health at all cost
c. Health is a fundamental right
d.
romotion of health prevention of illness, alleviation of
suffering and restoration of health
c. Health is a fundamental right
m R©escue© remove all
clients in the vicinity
m A©larm© Activate fire
alarm
m 2© onfine© close all doors
and windows
m E© xtinguish© fire
extinguisher
m
© pull the pin
m A© im at the base of fire
m S©queeze the handles
m S© weep the fire from side to
side
6
J
A Wood,cloth,
upholstery,paper,
rubbish,plastic
B Jlammable liquids or
gases, grease, tar,
oil©based paint
2 Electrical equipment
Nursing considerations
. No smoking
. Don not use wool blanket/metal objects
Treatment Modality
a. High O delivery
a. Venturi mask© 2O
D/2AL
b. încubator, o hood©pedia
b. Low o delivery
. Nasal cannula© 4u©u
. Simple Jace mask© u©u
.
artial rebreather mask© u©9u
4. Non rebreather mask©9u©9
înfants Jrench ©
2hildren Jrench ©u
Adults Jrench ©
2onscious with gag reflex©semifowler¶s with head
on one side (oral),Neck hyperextended (nasal)
mAmbuBAG (uu
oxygen)
m
arts
^ înner 2annula
^ Outer 2annula
^ Obturator
m
osition (insertion) Jowler¶s
m Time: © minutes each
suction
^ ©u seconds suction
m Tube destruction
^ DOB
^ Noisy
^ Dificulty in suctioning (insertion)
^ Thick,dry secretions
^ Mech vent (increased peak
pressure)
m Assist in coughing and deep breathing
m
rovide humidification and suctioning
m 2lean inner cannula regularly
m The physician repositions or replaces the tube
m Secure the tube in place
m înstructional policy
m Jirst 7 hours nurse manually ventilates while the
other call resuscitation team
m After 7 hours extend the neck and open the
tissue of the stoma
m Grasp retention sutures
m Use a dilator
m
repare to insert
m Ventilate
Note: do not deflate
m2ough
mOral Hygiene
mJeeding
m NEX
m High fowler¶s neck hyperextended
m STO
(2YANOTî2 and 2OUGH)
m
LA2EMENT
A©spirate gastric secretions
! """
m J!
m î
m Appendicitis: Any position if unruptured, and semi
fowler if ruptured.
m Asthma: Sitting position, leaning forward, to
promote patient breathing
m Autonomic dysreflexia: High fowler. ît will prevent
patient from hypertension stroke.
m Bronchoscopy: Semi Jowler, to prevent aspiration
after procedure.
m 2ast: elevate extremity to prevent edema.
m 2ataract surgery: Semi fowler to prevent edema at
the operative site.
m 2erebral aneurysm: Semi fowler to promote
venous drainage and decrease î2
i
înfant u©uml
2hildren u©u ml
Adolescent uu©uu ml
Adult 7u© uuuml
m Solution inches in height
m însertion ©4 inches in adult, ©,
m Encourgae to hold the solution (©u mins for
cleansing, u mins for retention)
m
osition: left lateral sims with right knee flexed
m NEVER (A
ENDî2îTîS,ABDOMîNAL
AîN<
NAUSEA AND VOMîTTîNG)
i
6
"
Autonomic dysreflexia catheter
2hest Tube Drainage Extra
bottle/clamp/forcep/vase
linized gauze
2VA Suctioning equipment
2holinergic crisis Tracheostomy/et
DVT Tape measure
6 6
Hydrocephalus Tape measure
LTB Tracheostmoy
Myasthenic 2risis Et
îH
added mouth
gage
À
#
Sengstaken© Scissors
blakemore tube
Spinal cord injury Tracheostomy
Thyroidectomy Tracheostomy
Tonsillectomy Jlashlight
Tracheostomy tube Obturator, hemostat
Wired jaw Wire cutter
m Oral
m SL
m SQ©tubercullin©heparin, rotate site
m îM
^ Vastus lateralis© 7 months and below
^ Ventrogluteal
^ Dorsogluteal© yo below
^ Deltoid©hep b for adult
^ Z track©seal off
a. Right patient
b. Right medication© label twice, generic name always,
check handbook
Anticoagulant
!
D
TT (4u©7u seconds)
T u©4 seconds
rotamine SO4 Vitamin K
SE: Bleeding (
R)
Aspirin (2î), green leafy
c. Right frequency
d.Right rate (don¶t eat don¶t chew don¶t
swallow© SL,Buccal)
e. Right dose
f. Right approach
g. Right to refuse
h. Right for education
i. Right documentation
À6 î
i
SQ /© © 4
a. Deltoid
b. Rectus Jemoris
c. Ventrogluteal
d. Vastus Lateralis
. 0 *
The rationale in giving medication via Z track is
a. ît decreases leakage of discolouring and irritating
medication into the subcutaneous tissue
b. ît allows a faster absorption of the medication
c. The Z track technique prevent irritation of the muscle
d. ît is more convenient
a. îT decreases leakage of discolouring and
irritating medication into the subcutaneous
tissue
m Allen¶s Test
m
h© 7.©7.4
m
2O© ©4 mmHg
m H2O© © meq/L
m în a client in the health care clinic, arterial blood
gas analysis gives the following esluts:
H 7.4,
2O mmhg H2O 4 meq/L. the nurse
interprets that the client has:
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
'. À
m Urination© micturition,voiding
^
oyluria
^ Anuria, oliguria
Nursing consideration
a. Early in the morning
a. All voided specimen must be saved except
first urine voided
b.
roper labeling date and time started
c. Send specimen immediately to the lab
(Refrigirate)
m 2lean catch/mid stream
^ îdentify causative agent of UTî
^ Jirst urine voided
^ Midstream urine saved
½
roper labeling
½ Send to lab (umins)
m Mr. Ai, y/o, complains of a burning sensation
on urination and a sense of urgency. A urine
specimen is to be collected. Which of the
following is the most appropriate way of
collecting the specimen?
a. 2atheterization
b. Voiding into clean urinal from where sample urine is to
be collected
c. clean catch urine collection
d. 4 hour urine collection
.
1
m Normal saline
m Gauge
m 2lose monitoring for Bt reaction
m încrease circulatory blood
volume
m încrease o capacity of blood
m
RB2, whole blood© blood volume (4 hours)
m JJ
expland blood volume (u mins)
m
latelets© bleeding
m 2lotting factor and cryo precipitate
m
roper refrigiration
m 2rossmatching
m
repare equipments aseptically
m KVO
m 2lose observation mins, after mines, vs qu
m Acute hemolytic reaction© chills,fever,
^ H©emolytic reaction© lower back pain
^ A©llergic reaction© plasma protein
^
©yrogenic© fever
^ 2©irculatory overload©fast blood administration
^ H©yperkalemia© hemolysis,coagultae
^ A©ir embolism
^ S©eptic reaction© contaminated blood
m S©top
m
©ulse check V/S
m î©nfuse NSS
m N©otify
m During the blood transfusion, the patient
manifest tachycardia, istended neck vein and
increase 2V
reading, the nurse should;
a. Obtain VS
b. încrease the rate of infusion
c. Stop the infusion
d. Decrease the rate of infusion
.
J
Supine Dorsal
recumbment
©9 ©4
înject ©u ml înject ©uml
Lower Abdomen înner thigh
Urine bag (bed Bed frame
frame)
m After îV
a renal stone was confirmed, a left
nephrectomy was done. Her post operative order
includes ³daily urine specimen to be sent to the
laboratory . Mark has a foley catheter attached to a
urinary drainage system. How will you collect the urine
specimen?
½ 2ontraindicated
½ R©ib fracture
½ A©ctive tb
½
© regnant
m
osturalDrainage
^
osition and location
½Apical© high fowler¶s, sitting
½
osterior© sidelying, pillow
under chest wall
½Lower trendelenberg
m
revents lung collapse
m împroves pulmonary vetilation
m Upright,sitting
m Hold breath for © seconds
2losed 2ontinuous irrigation
^ To maintain patent urinary catheter and
tubing
Open îrrigation© free blockage
©way foley catheter©
st drainage© bloody©pink©removed after
days©voids 4© days
m 2lamp for 4 hours
m Release after u minutes
m Assess for pain and bladder
distension
m Skin
^ Jirst line of defense
TY
ES of wound
a. According to purpose
b. According to depth
c. According to contamination
m A. înflammatory phase© immediately
after injury © days
m B.
roliferative phase© ©4 days up to
days
½ © collagen deposition
m 2. Maturation© day up to © years
m Red© wound in early regeneration
^Gentle wound care
^Alcohol free barrier
^Jill dead space©
hyrodgel,tegaderm© liquify
necrotic tissue and hydration
m S© ensory© decrease sensation and mental status
m M©oisture© fecal and urinary incontinence
m A©ctivity© excessive heat
m M©obility© excessive heat
m N©utrition© decrease tissues,hyponatremia,edema,
low vitamin c and zinc
m J©riction
m î. Ampula©redness,
non blanchable
erythema
m îî. B©lister
m îîî. 2©rater© full
thickness
involvement
m îV. D©ischarges© foul
smelling
m
atient Kulas, 7u years old is bedridden, upon
bed bath reveals a cm pressure ulcer that is
characterized by a liquid to semi liquid slough
with purulent discharge. According to the RYB
color code, a guide for wound care. What color
classification is it
a. Red
b. Yellow
c. Black
d. Blue
'. 2
&
m Sublavian, intrajugular
m îndications:
^ Severe malnutrition
^ Severe burns
^ Bowel disease
^ ARJ
^ Hepatic failure
^ înfection control
m 2omplication
^însertion© pneumothorax,
hemothorax
^înfusion© air embolism©valsalva
maneuver,
infection,hyperglycemia
A nurse is caring for a group of adult clients on an
acute crae in the unit. As a nurse you
understand that which of the following clients
would be the least likely candidate for parenteral
nutrition?
a. year©old client with extensive burns
b . A 4 year©old client who has had an open
cholecystectomy
c. A 7 year©old client with severe exacerbation of
chron¶s disease
d. A year©old client with persistent nausea and
vomiting from chemotherapy
' . $ 34 ,
&
m A client receiving T
N complains of headache. A
nurse notes that the client has an increased
blood pressure, bounding pulse, jugular vein
distension, and crackles bilaterally. The nurse
interprets that the client is experiencing which
complication of T
N?
a. Sepsis
b. Air embolism
c. Hypervolemia
d. Hyperglycemia
c. Hypervolemia
m A client with T
N infusing has disconnected the
tubing from the central line catheter. A nurse
assesses the client and suspects air embolism. The
nurse should immediately place the client
a. On the left side, with the head lower than the feet
b. On the left side, with the head higher than the feet
c. On the right side, with the head lower than the feet
d. On the right side, with the head higher than the feet
.
&
&
m Temporary
m
ermanent© non functioning rectum or anus, colon
2A, Bowel 2A
î
2olon îleum
Large bowel Small bowel
Semi solid fecal Wet fecal material
material Ostomy appliance
With irrigation Meticulous skin
care
m Red to pink
m
ale© decrease vascularization
m
urple© impede circulation
m Normal© red to pink
^ No burning sensation
^ moist
m A© fluid
m T© Mushy
m D© Mucoid
m S© Solid
m The nurse is teaching a client how to irrigate his
stoma, which indicates that the client needs
more teaching?
a. Washing hands with soap and water when finished
b. Stopping irrigation for cramps and clamping the tubing
until cramps pass
c. Jilling the irrigation bag with uu to uuu ml of
lukewarm water
d. Hanging the irrigation bag 4 to (u©9u cm)
above the stoma
.
' 431
%51 56,!6
'
m The client ask the nurse, when is the best time
to perform irrigation, is during
D, TB test
îD, no red ink Determine tb
exposure,dormant/active TB
©u mm iduration
>u mm
HîV© mm
Sites:
. Jingers <ring,middle, index>
. Nose
. Earlobe
4. Jorehand
. Toes
arts
a. leads
b.
hotodetector
Nursing 2onsideration
. 2over probe with towel from external sourse
. Remove nail polish
m i i
mOperative consent
WHO?? Obtains:surgeon
Witness: Nurse
Secure
Give: patient
a. conscious
b. legal age
c. sound mind
emergency: doctor
WHAT??© name/age/sex
© diagnosis
© procedure
© benefits and risks
© alternative
© signature
WHEN?? Major/minor
anesthesia
invasive procedure (body cavity)
radiologic procedure and dye
zones
a. unrestricted© unsterile, street clothes
b. semirestricted© scrub shoes, OR suit, and cap
c. restricted© + mask
a. Gown
b. Gloves
c. Drapes
d. Accidental puncture
e. When in doubt throw it out
f.
repare sterile field closest in time
g. Movement©sterile to sterile,unsterile to unterile
i
© responsible for
decisions to make
©Respondeat superior© let
the master answer the
situation
© res ipsa liquitor© let the
damage speak for itself
© extension doctrine©
consent from s.o.
B. Assistant to the surgeon(intern/MD/surgeon)
2. Anesthesiologist (MD/Nurse Anes)© LO2,îO,Blood
loss, O Saturation, VS
D. 2irculatory Nurse© Setup or
© Skin prep
© Ensures sterility of the team
E. Scrub Nurse© sets up the field
© Assist in draping the patient
© Handles sterile equipments
© sponge count
© after care
m 2ounting
^ înitial© manufacturer
^ Baseline© set up
^ 2losing© first closing© peritoneum, final© skin
m înduced state of
partial/total loss of
sensation, with or
without loss of
consciousness
i
General + + + (RR) +
Local X + Localized X
Regional
Epidural X + + X
Spinal X + + (output X
below l©l)
2onscious X + + +
sedation
î. Onset/înduction© time anest is induced, loss of
consciousness
îî. Delirium/Excitement© loss of consciousness,
muscles relaxation,breathing pattern
îîî. Operative/Surgical© generalized muscle
relaxation and dep vs
îV. Danger/Recovery© cardiac and respiratory
arrest, pupils fixed and dilated
© încreased loc© wearing out from patient¶s body
m Safety© side rails
m Airway patency© suctioning or intubation
m 2
R (danger)
m Recovery (Safety)
m SîGN îN BEJORE îNDU2TîON OJ ANESTHESîA
©aitent confirmed
A©irway/aspiration risk
A©llergy
A©nesthesia safety checklist
S©ite marked
m TîME OUT© before incision
S©terility observed
î©ntroduce OR team
î©maging displayed
A©ntibiotics given for the last u mins
m SîGN OUT© transfer
R©ecord name of the procedure
î© nstrument, sponge,sharp count complete
S©pecimen
E©ndorse equipment problem
m
A2U/RR
a. Name of surgeon/procedure
m B. Evalutae with anes,VS, îO,hemodynamic status
m 2. Evaluate contraption
m D. Supine with head on the side
m E. Once conscious orient
m î. VS©Q© hour
½ © qumin© hours
½ ©qhour© 4 hours
½ ©4 hours© shift
½ ©qmins© critical
HyperK Kayexelate
Metabolic Acidosis Na Bicarbonate
Angina NTG
2hole,
ancreatitis Demerol
î
2hron¶s Disease, U. Steroids
2ollitis
Diabetes însipidus Vasopressin
Heparin
rotamine Sulfate
Warfarin Vit K
Lead Toxicity EDTA
Digoxin Toxicity Digibind
î2
Mannitol
2holinergic 2risis Atrophine Sulfate
Hyperthyroidism Synthroid
6
Syphilis
enicillin
Rheumatoid Arthritis Aspirin
arkinson Levodopa
Alcoholism Disulfiram
Withdrawal from Alcohol Librium
Withdrawal from Opiods Narcan/Naloxone
UTî
yridium
Megaloblastic Anemia Vit b/2yanocobalamin
Anemia rt ESRD E
OGEN
×
×
Muscle Spasticity Baclofen
Acetaminophen Acetylcystein
Malaria Quinines
Jilariasis Hetrazan
Diptheria
enicillin
Scabies Benzyl Benzoate
Gonorrhea 2eftriaxone
Toxoplasmosis Sulfanamide
înduction of Labor Oxytocin
6
Jetal Lung Maturity Steroids
BT reaxtion Epinephrine
Anaphylactic Shock Ephinephrine
Antipsychotic for Elderly Haldol
Manic Episodes Lithium
Thyroid Storm Lugol¶s Solution
h.
ylori Metronidazole
Status Asthmaticus Epinephrine
Mestinon Athropine Sulfate
6
2HJ Digoxin
2hicken
ox Zovirax/Acyclovir