fundamentals of nursing 1
TRANSCRIPT
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FUNDAMENTALS OF NURSING
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To assist clients (sick or well) in the performance of activities contributing to health, it recovery or peaceful death that the clients will perform unaided, if they had the necessary will, strength or knowledge
Nursing
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Caregiver Communicator Educator/Teacher Counselor Manager/Coordinator Change Agent Leader Clinician Advocate
Roles and Responsibilities of Nurses
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P- articipation of client in his own care ensured
R- rights of the client protected A- utonomy is safeguarded N- eeds of client communicated I- nformations related to condition is provided
N- urture therapeutic alliance G- iven opinions and choices
ADVOCATE (PRANING)
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P-erson E- nvironment H-ealth N-ursing
Scopea. Health promotionb. Disease preventionc. Health restorationd. Care of the death and suffering individuals
Major concepts
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ID- I want- pleasure principle Ego- reality, arbiter Superego- moral principle
PERSON
ID EGO SUPEREGO
Manic Schizo BulimiaAntisocial OCNarcisistic anorexia
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Foundation of Nursing Profession“DYNAMIC”Systematic and rational
Nursing Process
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Systematic Use of critical Thinking Client Centered Universal (individual, family, community)
Characteristics
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C-ollection of data O- bservation of data V- alidation of data I- dentification of data
Types of dataa. Subjectiveb. Objective
ASSESSMENT
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T- rust R-apport U- nconditional regards S-et limits T-herapeutic communication C-onfidentiality P-roximities A-ctive listening and observation T- ouch S-et limits
Phases of Communication
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Proximities◦0-18 inches (intimate)◦18-36 inches (personal)◦4-12 ft ( social)◦12-40 ft(public)
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Observation (senses) Interview- purposeful conversation
◦Formal- highly structured, questionnaire, limited time, yes or no
◦Informal- rapport building, free flowing, open ended
Methods of data collection
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Physical Assessment (IPPA)La and Dx resultRecords review
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Nursing Care Models
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Total Patient Care- All aspect of one or more patient
care- Continuous care (endorsement)- Shift based focus- Does not necessitate care (same
nurse)
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Functional nursing◦Division of task◦Task focused◦Nurses are more competent for repeated actions
◦Absence of hollistic care
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Team Nursing◦RN’s lead the team and other assistive personnel
◦Charge nurse◦Coordination of client’s care plan◦collaboration
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Limitations of Team Nursing◦Role confusion◦Lack of time of the team leader to client
◦Non-continuity of care
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Case Management◦Coordinates 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◦Case-type-based care
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Primary Nursing◦Aim to place RN at bedside and improves professional relationship between staff
◦Assumes caseload of patients◦Designed to maintain continuity of care
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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.
a. Total patient care c. Team Nursingb. Functional Nursing d. Primary Nursing
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d. Primary Nursing
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Theorists
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Theorist ModelDorothea Orem Self care and self
care deficitFlorence Nightingale
Environmental Theory/Nurturing Environment
Roy Adoptation ModelHildegrad Peplau NPI
Nursing Theories
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Faye Abdellah 21 Nursing Problems/patient care approaches to nursing model
Imogene King Goal Attainment Theory
Martha Roger Humanistic Science Theory/Science of Unitary Human Being
Leininger Transcultural NursingWatson Human Caring Theory
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Ida Jean Orlando Dynamic Nurse Patient Relationship ModelValidation and evaluation of interactionDeliberative Nursing Process Theory
Rosemarie Parse Human Becoming Theory
Dorothy Johnson Behavioral System Model (7 subsystems)
Neuman Stress Adaptation Model
Myra Levine Conservation Model
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Patricia Benner Primacy of Caring Model/novice-expert
Lydia Hall Core-Care-CureMargareth Neuman Health as Expanding
Consciousness Theory
Joyce Travelbee Humanistic Revolution Theory
Ernestine Wiedenbach
Prescriptive theory (Philosophy, Purpose, practice, art)
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Patricia Benner
Florence Nightingale
Abdella WatsonImogene King
Martha Roger
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A. Temperaturea. Core temperature- deep tissueb. Surface temperature- surface tissue
Factors affecting heat lossb. Conduction- from one place to anotherc. Evaporation- insensible heat lossd. Radiation- with contacte. Convection- air current
Cardinal Signs
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◦ Sites A. Rectal- most accurate
- 2-3 mins, CI to quadriplegic client B. Tympanic- quickest C. Oral- most accessible D. Axillary- safest and non invasive Types of fever1. Intermittent- fever with periods of normal
and subnormal temp2. Remittent- fluctuations for about 2 degrees
Celsius but with no area where temp is normal
3. Relapsing- fever for few days 1-2 days normal temperature
4. Constant- constantly high
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B. Respiration- medulla oblongata12-20cpm- eupnea
>20- tachypnea <12- bradypnea
0- apneaRhytym 1. Cheyne-stoke- waxing and waning
- very deep-very shallow-apnea- Irreversible shock
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◦2. Kussmaul’s- DKA, deep labored breathing
◦3. Biot’s respiration- very shallow apnea
3. Pulse- wave of contractions produced by left ventricle
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I. Guidelines a. Psychological preparation b. Physical preparation (empty
the bladder) c. Environment d. equipment e. Positioning
Physical Assessment
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Registered Nursea. Maintain proper body mechanicsb. Widen base of supportc. Bend kneesd. Do no bend your backe. Avoid stretching/reachingf. Maintain Good body alignment
Basic principles in positioning
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F. Abdomen (IAPePa) G. if female (16y/o)+male md+female RN (witness)
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I. Inspection – use of SightII. Palpation- touch
I. Light/superficial- press the area lightly (circles)
II. Deep/bimanual- Direct hand-palpate, NDH-support the organ or mass
Points: a. Light first before deep b. Wilm’s tumor, appendicitis, abdominal aneurysm
III. Percussion- striking or tapping of body parts
Sequence- IPPA
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Direct- frontal sinus, direct Indirect- pleximeter (middle finger of NDH), plexor (middle finger of DH)
Blunt- Use of percussion hammer, Deep tendon reflex
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Listening to body sounds produced by the body
Types◦a. Direct- use of unaided ear◦Indirect- use of stethoscope
Auscultation
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Color◦Yellow◦Bluish◦Redness Note: Asses for burns
Skin
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Strawberry Tongue Red Beefy tongue Black hairy tongue
Ears Weber- equal laterization of sound Rhine
Tongue/Mouth
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A-ortic- 2nd intercostal space @ right sternal boarder
P- ulmonic- 2nd ICS left sternal boarder Erb’s point- 3rd ics left sternal boarder T-ricuspid- 4th ics left sternal boarder M-itral- pmi, 4th-5th ics midclavicular line left
side
Thorax
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GCS Reflexes Superficial- cremasteric reflex
- Babinski (+) 10 months- cerebral palsy
Neuro
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One of the responsibilities of Mr. Cyrile,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?
Auscultation 3. Palpation Percussion 4. Inspection
◦ 1,2,3 c. 1,2◦ 3,4 d. 1,3,4
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d. 1,3,4
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Infection Control
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STANDARD PRECAUTIONS: “All patients at all times” (formerly Universal Precautions)
1. Handwashing2. Gloves3. Goggles4. Gowns5. Patient-care equipment6. Environmental control
Infection Control
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7. Linen8. Occupational health and bloodborne pathogens
9. Patient placement10. Respiratory hygiene11. Safe injection practices
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In Case of Needle Puncture: W-ash with soap and running
water R-eport without delay A-ssess the source P-ost Exposure Prophylaxis
(PEP) in 1 to 2 hours 12. Lumbar puncture practices
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AirBorne Precaution: “Microorganisms that can survive during out”
RI: Respiratory Isolation ROOM: Private SP: Small Particles DOOR: Closed HP: Hepa filter / N95 /
Particulate Respirator
TRANSMISSION BASED PRECAUTIONS: “Used in addition to Standard Precautions”
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DISEASES {CAMPS} C- hickenpox (Disseminated varicella) A- nthrax M- easles P- ulmonary Tuberculosis S- ARS
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ROOM: PrivateC: CohortingDISTANCE: 3 feet separation with privacy curtain
drawn in between, individual use of equipmentGGG: gown, gloves, gogglesDISEASES {MRSA} M- RSA R- otavirus and RSV S- cabies A- bscess or wounds with uncontained
drainage
Contact Precaution: “Microorganisms that are easily spread by contact with hands or object”
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ROOM: PrivateC: CohortingDistance: 3 feet separation with privacy
curtain drawn in betweenLP: Large ParticleSM: Surgical mask
Droplet Precaution: “Microorganisms that are easily spread by contact with hands or object”
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DISEASES: All respiratory infections except RSV {DROPLETISM}
D- iphtheria (pseudomembrane) R- ubella (German measles) O- ral pharyngitis P- ertussis/ Pneumonia L- egionnaire’s disease E- rythema infectiosum (Fifth disease) T- onsillitis I- nfluenza S- carlet fever M- eningitis
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Enteric Precaution: “When the infectious agent is transmitted in feces”
ROOM: PrivateC: CohortingFO: Fecal-oral routeGG: Gloves and GownsDISEASES: GIT infections
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(formerly Compromised Host Precautions, Transplantation Precautions, and Bone Marrow Transplant Precautions)
Avoid the following:§ Crowds: flu and colds§ Fresh flowers, vegetables and fruits: molds
and fungi§ Live immunizations: (OPV, MMR, BCG, Varicella
vaccines)
Frotective Precaution/ Reverse Isolation/ Neutropenic Precaution:“To protect the patient with impaired resistance to infection”
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§ Stagnant water: Legionnaire’s disease/ Pneumonia
§ Pets with ticks: Scabies§ Bird droppings: Histoplasmosis§ Raw meat, potted plants, fish tanks, cat
litter box and gardening: Toxoplasmosis
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Patient’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)
Ethics
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Ethical PrinciplesAutonomy Self determinationNonmaleficence Cause no harmBeneficence Duty to maintain do
good to othersJustice Equitable distribution
of benefits and tasks (according to care)
Veracity truthFidelity Duty to do what one
has promised
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According to the code of ethics, which of the following is the primary responsibility of the nurse?a. Assist towards peaceful deathb. Preservation of health at all costc. Health is a fundamental rightd. Promotion of health prevention of illness,
alleviation of suffering and restoration of health
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c. Health is a fundamental right
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R-escue- remove all clients in the vicinity
A-larm- Activate fire alarm
C- onfine- close all doors and windows
E- xtinguish- fire extinguisher
Fire Safety
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P- pull the pin A- im at the base of fire S-queeze the handles S- weep the fire from
side to side
Fire Extinguisher
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Type Class of FireA Wood,cloth,
upholstery,paper, rubbish,plastic
B Flammable liquids or gases, grease, tar, oil-based paint
C Electrical equipment
Types of Fire Extinguisher
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Nursing Procedures
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Nursing considerations1. No smoking2. Don not use wool blanket/metal objects
Treatment Modalitya. High O2 delivery
a. Venturi mask- COPD/CALb. Incubator, o2 hood-pedia
Oxygen Treatment Modality
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b. Low o2 delivery1. Nasal cannula- 40-60%2. Simple Face mask- 60-80%3. Partial rebreather mask- 80-90%4. Non rebreather mask-90-95%
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Suctioning
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Patients SizesInfants French 5-8Children French 8-10Adults French 12-18
Suctioning
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Conscious with gag reflex-semifowler’s with head on one side (oral),Neck hyperextended (nasal)
Dyspnea, drooling of saliva, low abg and BS
Application (5-10 seconds)Suctioning (10-15 seconds)Interval (20-30 seconds each)
Position
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Ambu BAG (100% oxygen)
Tracheostomy/endotracheal suctioning
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Parts◦ Inner Cannula◦ Outer Cannula◦ Obturator
Position (insertion) Fowler’s
Time: 2-3 minutes each suction◦ 5-10 seconds suction
Tracheostomy Care
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Tube destruction◦DOB◦Noisy◦Dificulty in suctioning (insertion)
◦Thick,dry secretions◦Mech vent (increased peak pressure)
Complications
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Assist in coughing and deep breathing Provide humidification and suctioning Clean inner cannula regularly The physician repositions or replaces the
tube
Prevention
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Secure the tube in place Instructional policy First 72 hours nurse manually ventilates
while the other call resuscitation team After 72 hours extend the neck and open
the tissue of the stoma Grasp retention sutures Use a dilator Prepare to insert Ventilate
Tube Dislodgement
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Note: do not deflateCoughOral HygieneFeeding
Causes of Dislodgement
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NEX High fowler’s neck hyperextended STOP (CYANOTIC and COUGH) PLACEMENT
A-spirate gastric secretionsA-uscultateI-nject airXRAY (the best!!!)
NGT
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Fowlers If 100 ML????
Tube Feeding
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Positioning
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Appendicitis: Any position if unruptured, and semi fowler if ruptured.
Asthma: Sitting position, leaning forward, to promote patient breathing
Autonomic dysreflexia: High fowler. It will prevent patient from hypertension stroke.
Bronchoscopy: Semi Fowler, to prevent aspiration after procedure.
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Cast: elevate extremity to prevent edema. Cataract surgery: Semi fowler to prevent
edema at the operative site. Cerebral aneurysm: Semi fowler to promote
venous drainage and decrease ICP Cleft lip: Supine after operation, prevent
pressure on the suture line. Cleft palate: Prone/side lying position for
drainage of mucus and/or blood.
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Increased Intracranial Pressure (ICP): Elevate head of the bed.
Mastectomy: Elevate the extremity of the affected side (on pillow) to prevent lymphedema.
Radium implant in the cervix: Flat to prevent dislodge of the implant.
Shock: Modified trendelenburg to promote venous return.
Spinal cord injury: Immobilize the patient
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Which of the following is the correct guideline when positioning patients?a. Put pillows above the joint to immobilize itb. Position of the joints should be slightly
extendedc. Joints of the patients are to be supported with
pillowsd. Patients position should be changed at least
three or four times a day
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c. Joints of the patients are to be supported with pillows
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Client’s approval to have his/her body touched by specific individual
Informed Consent
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Admission Agreement Blood transfusion Surgical Consent Research Consent Special Consents (restraints, photographing
the patient, disposal of body parts, donating organs,autopsy)
Types of Consents
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Physical-restrict client movement through the application of a device
Chemical- medications given to inhibit a specific behavior or movement
Behavioral management, medical standard care standard (12 hours with procedure)
Restraints
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jacket- confused and sedated in bed Belt- transporting Mittens or hand- scratch and injure oneself Limb- immobilize the limb for one hour Elbow infants and small children Mummy- blanket around the body, blood
extraction◦ 24 hours, pad bony prominences
Kinds
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Physician’s order Specific time frame Not PRN Give reason Safe knot (quick release) Neurovascular,circulatory (q30mins) Remove (q2hours)
Interventions
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The following can be alternative to restraints, except;a. The nurses places large plants or furniture as
barriers or division on patient’s roomb. Two nurses in pairs act as buddies to watch out
agitated patientsc. Nurse offers warm beverages, soft lights, and
back rubd. Place television set to distract attention
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d. Place television set to distract attention
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Cleansing enemaCarminative Enema- flatusRetension/Emollient enema- oil or antibiotic
Medicated Enema
Enema
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SizesInfant 12 catheterChildren 14 to 18 catheterAdult 22 to 32 catheter
AmountInfant 50-150mlChildren 250-350 mlAdolescent 300-500 mlAdult 750- 1000ml
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Solution 18 inches in height Insertion 3-4 inches in adult, 2-3, 1 Encourgae to hold the solution (5-10 mins
for cleansing, 30 mins for retention) Position: left lateral sims with right knee
flexed NEVER (APPENDICITIS,ABDOMINAL PAIN<
NAUSEA AND VOMITTING)
REMEMBER
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Amputation TorniquetAutonomic dysreflexia
catheter
Chest Tube Drainage Extra bottle/clamp/forcep/vaselinized gauze
CVA Suctioning equipmentCholinergic crisis Tracheostomy/etDVT Tape measure
Bedside Equipment
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Epiglotitis Tracheostmoy/ET
Hydrocephalus Tape measureLTB TracheostmoyMyasthenic Crisis
Et
Parkinson’s disease
Suction apparatus
PIH Padded mouth gage
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Radium implant Lead container, forceps
Sengstaken-blakemore tube
Scissors
Spinal cord injury TracheostomyThyroidectomy TracheostomyTonsillectomy FlashlightTracheostomy tube Obturator,
hemostatWired jaw Wire cutter
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Oral SL SQ-tubercullin-heparin, rotate site IM
◦ Vastus lateralis- 7 months and below◦ Ventrogluteal◦ Dorsogluteal- 3yo below◦ Deltoid-hep b for adult◦ Z track-seal off
Medication
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a. Right patientb. Right medication- label twice, generic name
always, check handbookAnticoagulant
SE: Bleeding (PR)Aspirin (CI), green leafy
Drug Administration
Heparin Warfarin
PTT (40-70 seconds) PT 10-14 seconds
Protamine SO4 Vitamin K
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c. Right frequencyd.Right rate (don’t eat don’t chew don’t swallow- SL,Buccal)
e. Right dosef. Right approachg. Right to refuse h. Right for educationi. Right documentation
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ROUTE SIZE GAUGE
Degrees
VOLUME
ID 3/8- 5/8
26-27 15 1
SQ 5/8- ½ 25-26 45 2
IM 1/2-1/2 C- 24-25A- 23-24
90 2-5
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The nurse prepares an IIM injection for an adult client using Z-track. 4 ml of the medication is to be administered to the client. Which of the following site will you choose?a. Deltoidb. Rectus Femorisc. Ventrogluteald. Vastus Lateralis
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c. Ventrogluteal
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In infants 1 year old and below, which of the following is the site of choice for intramuscular injection.
a. Deltoidb. Rectus Femorisc. Ventrogluteald. Vastus Lateralis
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d. Vastus Lateralis
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The rationale in giving medication via Z track isa. It decreases leakage of discolouring and
irritating medication into the subcutaneous tissue
b. It allows a faster absorption of the medicationc. The Z track technique prevent irritation of the
muscled. It is more convenient
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a. IT decreases leakage of discolouring and irritating medication into the
subcutaneous tissue
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Allen’s Test Ph- 7.35-7.45 PCO2- 35-45 mmHg HCO3- 22-26 meq/L
ABG reading
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In a client in the health care clinic, arterial blood gas analysis gives the following esluts: PH 7.48, PCO2 32mmhg HCO3 24 meq/L. the nurse interprets that the client has:a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis
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b. Respiratory alkalosis
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Urination- micturition,voiding◦ Poyluria◦ Anuria, oliguria
◦ Medications that can cause retention Anticcholinergic,antispamodic
(papaverine,atrophine) Antidepressant, antipsychotic (MAO) Antihypertensive (hydralazine, methyldopa) Beta blockers Opiods hydrocodone (vicodine)
Elimination
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24 hours urine collection (composition)
Nursing considerationa. Early in the morning
a. All voided specimen must be saved except first urine voided
b. Proper labeling date and time startedc. Send specimen immediately to the lab
(Refrigirate)
Urine collection
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Clean catch/mid stream◦Identify causative agent of UTI◦First urine voided◦Midstream urine savedProper labelingSend to lab (30mins)
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Mr. Ai, 35 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. Catheterizationb. Voiding into clean urinal from where sample
urine is to be collectedc. clean catch” urine collectiond. 24 hour urine collection
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c. clean catch” urine collection
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Normal saline Gauge 18 Close monitoring for Bt
reaction Increase circulatory blood
volume Increase o2 capacity of
blood
Blood transfusion
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PRBC, whole blood- blood volume (4 hours) FFP expland blood volume (20 mins) Platelets- bleeding Clotting factor and cryo precipitate
Common blood products
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Proper refrigiration Crossmatching Prepare equipments aseptically KVO Close observation 5 mins, after 15 mines, vs
q30
Principles
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Acute hemolytic reaction- chills,fever,◦ H-emolytic reaction- lower back pain◦ A-llergic reaction- plasma protein◦ P-yrogenic- fever◦ C-irculatory overload-fast blood administration◦ H-yperkalemia- hemolysis,coagultae◦ A-ir embolism◦ S-eptic reaction- contaminated blood
Common BT reaction
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S-top P-ulse check V/S I-nfuse NSS N-otify
Management
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During the blood transfusion, the patient manifest tachycardia, istended neck vein and increase CVP reading, the nurse should;
a. Obtain VSb. Increase the rate of infusionc. Stop the infusiond. Decrease the rate of infusion
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c. Stop the infusion
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Male FemaleSupine Dorsal
recumbment6-9” 3-4”Inject 5-10 ml Inject 5-10mlLower Abdomen Inner thighUrine bag (bed frame)
Bed frame
Catheterization
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After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily 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?
a. Empty a sample of urine from the collecting bag into the specimen container
b. Disconnect the drainage tube from the indwelling catheter and allow the urine to flow from the catheter into the specimen container
c. Remove urine from the drainage tube with sterile needle and empty urine from the syringe into the specimen container
d. Disconnect the drainage from the collecting bag then allow the urine to flow from the catheter into the specimen container
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c. Remove urine from the drainage tube with sterile needle and empty
urine from the syringe into the specimen container
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Position◦M-Left lateral position with legs flexedProstate- standing position, bending on the table
F- Dorsal recumbment position and hips externally rotates
Digital Rectal Exam
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Dependent measure Cupping- (popping sound, 1-2 mins, 3-5
minutes,tenaciuos secretion Vibration- flat against chest wall,exhalation Postural drainage- 10-15 minutes, 3-4x a
day, 2-3 hours after meals Increase OFI Admnister adjunct therapy
Chest Physiotherapy
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◦ mucolytic drug◦ Expectorant◦ Bronchodilators
S-ympathomimetic A- minophylline X- anthine
Contraindicated R-ib fracture A-ctive tb P- regnant
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Postural Drainage◦Position and locationApical- high fowler’s, sittingPosterior- sidelying, pillow under chest wall
Lower trendelenberg
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Prevents lung collapseImproves pulmonary vetilation
Upright,sittingHold breath for 2-6 seconds
Incentive Spirometer
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Closed Continuous irrigation◦To maintain patent urinary catheter and tubing
Open Irrigation- free blockage3-way foley catheter-1st drainage- bloody-pink-removed after 3 days-voids 4-6 days
Cystoclisis
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Clamp for 4 hoursRelease after 30 minutesAssess for pain and bladder distension
Bladder training
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Skin◦ First line of defense
- Inflammatory response- 2nd line of defense- Immune response- 3rd line of defense
TYPES of wounda. According to purposeb. According to depthc. According to contamination
Skin integrity and wound care
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A. Inflammatory phase- immediately after injury 3-6 days
B. Proliferative phase- 3-4 days up to 21 days - collagen deposition
C. Maturation- day 21 up to 1-3 years
Phases of wound healing
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Red- wound in early regeneration◦Gentle wound care◦Alcohol free barrier◦Fill dead space- hyrodgel,tegaderm- liquify necrotic tissue and hydration
Code RYB
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S- ensory- decrease sensation and mental status
M-oisture- fecal and urinary incontinence A-ctivity- excessive heat M-obility- excessive heat N-utrition- decrease
tissues,hyponatremia,edema, low vitamin c and zinc
F-riction
Pressure ulcer
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I. Ampula-redness, non blanchable erythema
II. B-lister III. C-rater- full
thickness involvement
IV. D-ischarges- foul smelling
Stages
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Patient Kulas, 70 years old is bedridden, upon bed bath reveals a 5cm 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 ita. Redb. Yellowc. Blackd. Blue
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b. Yellow
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Sublavian, intrajugular Indications:
◦ Severe malnutrition◦ Severe burns◦ Bowel disease◦ ARF◦ Hepatic failure◦ Infection control
TPN
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Complication◦Insertion- pneumothorax, hemothorax
◦Infusion- air embolism-valsalva maneuver, infection,hyperglycemia
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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. 66 year-old client with extensive burnsb . A 42 year-old client who has had an open
cholecystectomyc. A 27 year-old client with severe exacerbation of
chron’s diseased. A 35 year-old client with persistent nausea and
vomiting from chemotherapy
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b . A 42 year-old client who has had an open cholecystectomy
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A client receiving TPN 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 TPN?a. Sepsisb. Air embolismc. Hypervolemiad. Hyperglycemia
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c. Hypervolemia
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A client with TPN 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 feetb. On the left side, with the head higher than the feetc. On the right side, with the head lower than the feetd. On the right side, with the head higher than the feet
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a. On the left side, with the head lower than the feet
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Temporary Permanent- non functioning rectum or anus,
colon CA, Bowel CA
Colostomy
Colostomy IleostomyColonLarge bowelSemi solid fecal materialWith irrigation
IleumSmall bowelWet fecal materialOstomy applianceMeticulous skin care
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Red to pink Pale- decrease vascularization Purple- impede circulation Normal- red to pink
◦ No burning sensation◦ moist
Stoma
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A- fluidT- MushyD- MucoidS- Solid
Stool form
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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
finishedb. Stopping irrigation for cramps and clamping
the tubing until cramps passc. Filling the irrigation bag with 500 to 1000 ml of
lukewarm waterd. Hanging the irrigation bag 24” to 36” (60-90
cm) above the stoma
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d. Hanging the irrigation bag 24” to 36” (60-90 cm) above the stoma
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The client ask the nurse, when is the best time to perform irrigation, is during
a. Early morning, before mealsb. Early morning, before meals upon arisingc. Early morning, after mealsd. Early morning
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c. Early morning, after meals
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Appliance 7 days Change 1/3-half fullReminders
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3 chambers◦Collection◦Water sealedFlactuation (upon expiration)
Rise and FallIntermittent bubbling (respiration)
Chest Tubes
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Suction Controlled◦20 cm water◦Continuous bubbling
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Pleur-Evac First Best
Disconnected from patient
Cover with any cleanest material possible
Cover opening with sterile gauze/vaselinized gauze
Disconnected from CTT
Insert tip in a glass of sterile NSS
Clamp the tube farthest from the patient
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Upon assessment of patient Julio, the nurse noticed that he is breathing a little more effort and at a faster rate. The client’s pulse is also increased. Which of the following actions should the nurse implement?a. Check the tubing to ensure that there is no kink and
patient is not lying on itb. Increase the suctionc. Lower the drainage bottles 2-3 feet below the level
of the client’s chestd. Ensure that the tube has two clamps in it to prevent
air leaks
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a. Check the tubing to ensure that there is no kink and patient is not lying on it
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You are assigned to patient Julio who has a water seal drainage system and you noted that the fluid in the chest tube and water seal column has stopped fluctuating. Which is the explanation?a. The lung has fully expandedb. The lung has collapsedc. The chest tube is in the pleural spaced. The mediastinal space has decreased
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a. The lung has fully expanded
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NPO for 6 hours and until gag reflex returns
Expect sore throat Observe respiratory
difficulties
Bronchoscopy
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Following a bronchoscopy, which of the following complains by Ryan should be noted?
a. Nausea and vomitingb. Shortness of breath and laryngeal stridorc. Blood tinged sputum while coughingd. Sore throat and hoarseness
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d. Sore throat and hoarseness
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PARACENTESIS
THORACENTESIS
Semi-fowlers Sitting over bedside table
Empty bladder Local Anesthesia
Check VS (BP,RR,Temp)
>1 L at a time within 30 mins
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Right after thoracentesis, which of the following is the most appropriate nursing intervention?a. Instruct the patient not to cough or deep
breath for two hoursb. Observe for symptoms of tightness of chest or
bleedingc. Place an ice pack on puncture sited. Remove dressing to check for bleeding.
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b. Observe for symptoms of tightness of chest or bleeding
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Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is:a. Keep the sterile equipment from contaminationb. Assist the physicianc. Open and close the three way stop cockd. Observe the patient’s vital signs
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d. Observe the patient’s vital signs
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Report abdominal pain
Monitor VS
Monitor Urine output, puncture site
Lie flat on affected side (head elevated 30 deg 30 minutes)
Measure Abdominal girth
Check leak of fluid
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CrutchesA.Initial positionB. 30 degrees flexedC. Weight- crutch paralysisD. Crutch tips
Assistive devices
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Canes- 91 cm, standard, quad cane
Rubber tip Permit elbow to flex Hold cane on the stronger side of the body Side of the foot 15cm and 15 cm in front
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Walkers◦Four legs with rubber tips◦3 point gait, 2 point gait- walker 15 cm ahead
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Crutches◦ Patient supine position and the nurse measures
from the anterior fold of the axilla and adds 2.5 cm
◦ 2.5-5 cm below the axilla or three finger folds◦ Elbow flexion 30 degrees◦ Gaits
Four point Three point Two point Swing to gait Swing through
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Three-point gait
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A client being measured for crutches asks the nurse why the crutches cannot rest underneath the arm for extra support. The nurse’s response is based on the following understanding that this will result it:
a. A fall and injuryb. Injury to the brachial plexus nervesc. Skin breakdown in the area of the axillad. Impaired range of motion while the client
ambulates
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b. Injury to the brachial plexus nerves
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A nurse has given a client instructions about crutch safety. The nurse determines that the client needs reinforcement of information if the client states:a. That he or she will not use someone else’s
crutchesb. The crutch tips will not slip even when wetc. The need to have spare crutches and tips will
be availabled. The crutch tips should be inspected
periodically for wear
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b. The crutch tips will not slip even when wet
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Four- point gait
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Skin test Mantoux Test
Allergy test PPD, TB test
ID, no red ink Determine tb exposure,dormant/active TB5-10 mm iduration>10 mmHIV- 5mm
Evaluate after 30 minutes
Evaluate after 48- 72 hours
Antibiotic- 7 day treatment
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Hypoxemia 95-100%
Sites:1. Fingers <ring,middle, index>2. Nose3. Earlobe4. Forehand5. Toes
Pulse Oximeter
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Partsa. 2 leadsb. Photodetector
Nursing Consideration1. Cover probe with towel from external
sourse2. Remove nail polish
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DABDA
Concept of death and dying
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Operative consentWHO?? Obtains:surgeon
Witness: Nurse Secure Give: patient
a. consciousb. legal agec. sound mindemergency: doctor
Perioperative Nursing
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WHAT??- name/age/sex - diagnosis - procedure - benefits and risks - alternative - signature
WHEN?? Major/minor anesthesia invasive procedure (body cavity) radiologic procedure and dye
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3 zonesa. unrestricted- unsterile, street clothesb. semirestricted- scrub shoes, OR suit, and capc. restricted- + mask
Intraoperative
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a. Gownb. Glovesc. Drapesd. Accidental puncturee. When in doubt throw it outf. Prepare sterile field closest in timeg. Movement-sterile to sterile,unsterile to
unterile
Principles of Sterility
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A. Surgeon- captain
- 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.
OR TEAM
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B. Assistant to the surgeon(intern/MD/surgeon)C. Anesthesiologist (MD/Nurse Anes)- LOC,IO,Blood
loss, O2 Saturation, VSD. Circulatory 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
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Counting◦ Initial- manufacturer◦ Baseline- set up◦ Closing- first closing- peritoneum, final- skin
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Induced state of partial/total loss of sensation, with or without loss of consciousness
Anesthesia
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Sedation Analgesia Mucsle relaxant
Loss of protective reflex
General + + + (RR) +
Local X + Localized X
Regional Epidural Spinal
XX
++
++ (output below l3-l5)
XX
Conscious sedation
X + + +
Techniques
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I. Onset/Induction- time anest is induced, loss of consciousness
II. Delirium/Excitement- loss of consciousness, muscles relaxation,breathing pattern
III. Operative/Surgical- generalized muscle relaxation and dep vs
IV. Danger/Recovery- cardiac and respiratory arrest, pupils fixed and dilated
- Increased loc- wearing out from patient’s body
Stages (GA)
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Safety- side rails Airway patency- suctioning or intubation CPR (danger) Recovery (Safety)
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SIGN IN BEFORE INDUCTION OF ANESTHESIA
P-aitent confirmedA-irway/aspiration riskA-llergyA-nesthesia safety checklistS-ite marked
WHO surgical check list
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TIME OUT- before incisionS-terility observedI-ntroduce OR teamI-maging displayedA-ntibiotics given for the last 60 mins
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SIGN OUT- transferR-ecord name of the procedureI- nstrument, sponge,sharp count completeS-pecimenE-ndorse equipment problem
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PACU/RRa. Name of surgeon/procedure
B. Evalutae with anes,VS, IO,hemodynamic status
C. Evaluate contraption D. Supine with head on the side E. Once conscious orient
Post Operative Phase
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I. VS-Q15-1 hour - q30min- 2 hours -q1hour- 4 hours -4 hours- shift -q5mins- critical
II. Respiratory system- airway patency -rr, pattern and depthrr-12-20cpm
<12cpm- drug induced respiratory depression
> 12 cpm- pain,metabloic rate
System assessment
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III. Cardio- rate, rhythm, grade, pulse Absent- o Weak- +1 Normal- +2 Strong- +3 Bounding- +4
SHOCK- pulse deficit, apical and radial pulse 1. decrease circulating blood volume 2. possible obstruction Complcation-DVT/Thrombophlebitis
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Thrombolytics- destroy clots-KINASE (TPA) Anticougulants heparin (PTT-20 36 secs- effective
40-72 seconds), warfarin PT (9.6-12.1 seconds x 1.5-2)
IV. Neuro-LOC, order of return of sense Touch Pain Warmth Cold Movement
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V. Renal- UO-30-60cc/hour, skin turgor VI. GI- NPO- clear liquid-soft-DAT
◦ 1. positive gag reflex◦ 2. bowel sound- 5-20 seconds◦ 3. passage of flatus
(-2,3, abdominal distension, N/v- paralytic ileus)-bowel resection
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VII. Integumentary- incision site◦Drainage,redness,sweeling pain, purulent
discharge- infection◦Separtion of suture line, drainage-
dehiscence◦Protrusion of Abdominal Contents-
evisceration- sterile water, low fowler’s with knees bend
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A-ctivity 0-1-2 R-espiration- 0-1-2 Circulation 0-1-2 C-onsciousness 0-1-2 O2 saturation
◦ 95-100%- capillary test◦ ABG- 80-100%◦ Allen’s test- collateral circulation-impede ulnar
artery
Adnettes scoring- 15 minute interval
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Drug of Choice
Disease/Condition/Antidote
Drug of Choice
Hypercalcemia PhosphateHypermagnesemia Calcium Gluconate
HyperK KayexelateMetabolic Acidosis Na BicarbonateAngina NTGChole,Pancreatitis Demerol
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MI Morphine SulfateChron’s Disease, U. Collitis
Steroids
Diabetes Insipidus VasopressinHeparin Protamine SulfateWarfarin Vit KLead Toxicity EDTADigoxin Toxicity DigibindICP MannitolCholinergic Crisis Atrophine SulfateHyperthyroidism Synthroid
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Trichomoniasis MetronidazoleSyphilis PenicillinRheumatoid Arthritis AspirinParkinson LevodopaAlcoholism DisulfiramWithdrawal from Alcohol
Librium
Withdrawal from Opiods
Narcan/Naloxone
UTI PyridiumMegaloblastic Anemia Vit
b12/CyanocobalaminAnemia rt ESRD EPOGEN
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Narcotic Overdose NarcanMuscle Spasticity BaclofenAcetaminophen AcetylcysteinMalaria QuininesFilariasis HetrazanDiptheria PenicillinScabies Benzyl BenzoateGonorrhea CeftriaxoneToxoplasmosis SulfanamideInduction of Labor Oxytocin
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Preterm Labor TerbutalineFetal Lung Maturity SteroidsBT reaxtion EpinephrineAnaphylactic Shock EphinephrineAntipsychotic for Elderly
Haldol
Manic Episodes LithiumThyroid Storm Lugol’s Solutionh. Pylori MetronidazoleStatus Asthmaticus EpinephrineMestinon Athropine Sulfate
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Lithium Toxicity MannitolCHF DigoxinChicken Pox Zovirax/Acyclovir