Fundamentals of Nursing

NCLEX NURSING Review GUIDE

Outline of review for the boards

History of Nursing- World and Philippines The Nursing theories Concepts of Health and Illness Human Basic Needs Stress and Adaptation

Outline of review for the boards

ASSESSING HEALTH STATUS
VITAL SIGNS PHYSICAL ASSESSMENT

Outline of review for the boards

CLIENT CARE
ASEPSIS SAFETY HYGIENE MEDICATIONS SKIN INTEGRITY TERMINAL CARE

Outline of review for the boards

HEATH PROMOTION AND DISEASE PREVENTION
ACTIVITY and EXERCISE REST and SLEEP PAIN management NUTRITION FECAL ELIMINATION URINARY ELIMINATION OXYGENATION CIRCULATION Fluids and Electrolytes

History of Nursing

Intuitive Nursing Apprentice Nursing Dark Period of Nursing Educated Nursing Contemporary Nursing

History of Nursing
Intuitive Nursing Primitive and untaught Code of HAMMURABI Moses- Father of Sanitation Hippocrates- Developed standards for client care, medical standards and need for nurses

History of Nursing
Educated Nursing Florence Nightingale- born May 12, 1820 in Florence ITALY Trained: Germany at Kaiserswerth School Founded the St. Thomas School of Nursing in England

Teachers are devoted clinical instructors solely for teaching The first nurse to exert political pressure on government

Nursing in the PHILIPPINES

First School of Nursing= ILOILO MISSION hospital school of nursing Anastacia Giron-Tupas= Founder of the PNA Rosario Delgado= first PNA president

Theories in Nursing
Four concepts Central to Nursing: P-E-H-N Person Environment Health Nursing

Theories in Nursing

ENVIRONMENTAL THEORY

Relate nature with the bird- Nightingale The act of utilizing the environment of the patient to assist him in his recovery

Theories in Nursing

INTER-PERSONAL RELATIONS Model Remember PEP talk

Hildegard PEPLAU Therapeutic relationship: Orientation= assist client to understand problem Identification= Client dependence, inde and inter he recognizes his problems in this phase Exploitation/Exploration= Derives full value ini-exploit!! Resolution= old and new goals put aside

Theories in Nursing

Nature of Nursing- Definition of Nursing The meaning of Nursing is VIRGIN Recall the 14 needs!!!!! Associate 14 virgin HENS Virginia HENDERSON She believes that clients need to express their emotions, remain independent, autonomous They must work in such a way that they feel a sense of accomplishment

Theories in Nursing

21 nursing problems Faid 21 Faye Abdellah

Theories in Nursing

GENERAL THEORY OF NURSINGSELF- CARE

Associate Self care to ORAL care or per orem Dorothea OREM 1. WHOLLY compensatory= unable to control 2. PARTLY compensatory= unable to perform SOME self care 3. SUPPORTIVE- EDUCATIVE= who needs to learn and needs assistance

Theories in Nursing

BEHAVIORAL SYSTEM MODEL Associate behavior with John (in John and Marsha) kaya JOHN(son) magsumikap ka Dorothy Johnson

Theories in Nursing

Conservation Theory the Divine is Conservative Levin levine, divine

Theories in Nursing

GOAL ATTAINMENT
Recall that the KING of the land has a GOAL to attain for his kingdom

IMOGENE KING! Her theory is applicable to the child bearing women and their families

Theories in Nursing

UNITARY BEING: Man as the CENTRAL Focus Roger , Roger, let us unite our Man in the center of the battlefield The whole is greater than its parts Martha ROGERS She believes in the use of the principles of NON CONTACT therapeutic touch

Theories in Nursing
HEALTH CARE SYSTEMS model Betty NEUMAN Stresses, reactions to stress and adaptation to stressors After overcoming the stresses you will become a NEW- Man Intrapersonal stressor= illness Extrapersonal stressors= financial concerns, community resources Interpersonal stressor= unrealistic role expectations

Theories in Nursing

ADAPTATION MODEL Individual is a BIOPSYCHOSOCIAL ADAPTIVE system with input and output associate this with a Nun SISTER ROY= nag a adopt ng mga bata Her theory supports the unity between the client and God

Theories in Nursing

CULTURAL CARE DIVERSITY Transcultural Nursing Madeleine LEININGER

Theories in Nursing

Nursing Process theory and CARE, CORE and CURE The nurse who coined the word nursing process and stated I care, I core and I cure Hall of Fame award!!! LYDIA HALL

Theories in Nursing

DYNAMIC NURSE-PATIENT Relationship Associate dynamic action to the team of ORLANDO Ida Jean ORLANDO!!! Go Orlando, the dynamic team!!!!!

Theories in Nursing

HUMAN BECOMING THEORY

Remember to become a rose per se , you must be a bud first!!!!!!!!!!!! Rosemarie Parse Her theory emphasizes that clients are the AUTHORITY figures and decision makers for their personal health

Theories in Nursing
HUMAN CARING THEORY What is caring? Jean WATSON Caring for clients during their end-oflife experiences

Patricia Benners Stages of nursing expertise (NACPE)

Stage 1 = novice Stage 2= advanced beginner Stage 3= competent Stage 4= proficient Stage 5= expert
No experience, performance is limited, inflexible Demonstrates MARGINALLY acceptable performance, recognizes the meaningful aspects of a real situation Has 2-3 years experience, demonstrates ORGANIZATIONAL and planning abilities Has 3-5 years of experience, perceives situations as whole, has HOLISTIC understanding of patient Performance is FLUID, flexible and HIGHLY Proficient, No longer requires rules, maxims.Demonstrates HIGHLY skilled intuitive and analytic ability

Health Definition
A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity WHO, 1948

Wellness
State of well-being Seven Components- seven wishing WELL Physical= carry out task Social= interact with people Emotional= express feelings Intellectual= learn and use info Spiritual= belief in supernatural Occupational= leisure and work Environmental= standard of living in community

Health Theories

CLINICAL Health is absence of disease ROLE PERFORMANCE Health is ability to fulfill societal functions ADAPTIVE Heath is a creative process of adaptation

Health Theories

EUDEMONISTIC

Health is a condition of self-actualization

Health is interaction of three elements: Agent Host Environment

ECOLOGIC
1. 2. 3.

Health Theories

Dunn

doon, dito, dine and dire Four quadrants HIGH level Wellness is functioning at the BEST possible level

Illness and Disease

DISEASE Alteration in body functions ILLNESS A state of physical, social, emotional, intellectual, developmental or spiritual functioning is DIMINISHED

Stages of Illness: S-A-M-D-R

SYMPTOM experiences

Client believe something is wrong

ASSUMPTION of the sick role

Excuse form work and family role

MEDICAL care contact DEPENDENT CLIENT role RECOVERY or REHABILITATION

Abraham Maslows Hierarchy of needs

Physiologic needs- oxygen, water, food Safety and security Love and belonginess Self esteem Self actualization

Abraham Maslows Hierarchy of needs

Safety and security

Physical safety Psychological safety Shelter from harm

Abraham Maslows Hierarchy of needs

Love and belonginess

Need to love Need to belong Need for affection

Abraham Maslows Hierarchy of needs

Self esteem

Self-worth Self-identity Self-respect Self-image

Abraham Maslows Hierarchy of needs

Self actualization

Self-fulfillment Spiritual fulfillment

Man and His needs

SelfActualization Self-Esteem

Love and Belongingness

Safety and Security

Physiologic Needs

Mans Need

Need is something desirable and useful Needs are UNIVERSAL Needs are MET in different WAYS Needs are influenced by different FACTORS Priorities may be CHANGED Needs may be POSTPONED Needs are INTER-RELATED

Mans Need

Need is something desirable and useful Prioritization of needs mat be dictated by the clients perception

Mans Need

Nursing goal is this area is to:

Meet the PHYSIOLOGICAL needs of the patient Assess the patient's perception of his other needs Employ nursing Interventions according to the PERCEIVED NEEDS of the patient NOT of the nurse

Evaluation Parameters of nursing care

The nurse checks if the desired criteria dictated by patients needs are achieved Check which interventions were helpful Revise the plan as needed

Man achieves self-actualization

(Udan)

A self-actualized person is basically a MENTALLY healthy person And self-actualization is the essence of mental Health

Cultural care nursing

It is the provision of nursing care across cultural boundaries and takes into account the context in which the client lives

It is professional nursing that is culturally sensitive, culturally appropriate, and culturally competent

Cultural care nursing

The suggested steps for culture care are: 1. Become aware of ones own culture heritage 2. Become aware of the clients heritage and health tradition 3. Identify clients preference in health practices, diet, hygiene, etc. These will affect their health practices 4. Formulate a culture care plan

Stress and Adaptation

STRESS

A condition in which the person responds to changes in the normal balanced state Selye: non specific response of the body to any kind of demand made upon it

STRESSOR

Any event or stimulus that causes an individual to experience stress

Stress and Adaptation

1.
2. 3. 4.

SOURCES OF STRESS Internal External Developmental Situational

Stress and Adaptation

Physiological indicators of stress: Sympathetic response Dilated pupils Diaphoresis Tachycardia, tachypnea, HYPERTENSION, increased blood flow to the muscles Increased blood clotting Bronchodilation Skin pallor Water retention, Sodium retention Oliguria Dry mouth, decrease peristalsis Hyperglycemia

Stress and Adaptation

SELYES General Adaptation Theory

A-R-E
ALARM: sympathetic system is mobilized! RESISTANCE: adaptation takes place EXHAUSTION: adaptation cannot be maintained

ANXIETY
CATEGORY

MILD

MODERATE SEVERE Inability to focus

PANIC
Distorted perception

Perception and attention

Increased Narrowed arousal focus

Communicati Increased Voice on questioni tremors ng Focus on

particular object VS changes NONE Slight Increase

Difficult to Trembling understand unpredictab le response Easily distracted Tachycardi Palpitation, a, choking, Hyperventil chest pain ation

Anxiety versus fear

ANXIETY FEAR State of mental uneasiness Emotion of apprehension Source may not be identifiable Related to the future Vague Result of psychologic or emotional conflict Source is identifiable Related to the present Definite Result of discrete physical or psychological entity, definite and concrete events

VS

T P R BP

TEMPERATURE

Reflects the balance between the heat produced and the heat lost from the body CORE TEMPRATURE: deep tissues of body

Temperature Monitoring
Oral- accessible and convenient Rectal- very accurate Axillary- preferred for newborns Tympanic- reflects core temperature

Body temperature has a diurnal variation

POINT of Highest body temperature is BETWEEN 8 pm to 12 midnight POINT of Lowest body temperature is BETWEEN 4 am to 6 am

Temperature Alteration
FEVER, PYREXIA, HYPERTHERMIA 1. Intermittent: Periods of fever and normal temp 2. Remittent: Fever fluctuates BUT above normal 3. Relapsing: Fever for few days, then normal for few days 4. Constant: ALWAYS above normal, minimal fluctuation

Heat loss
Mechanism Conduction Convection Evaporation Description Transfer of heat form one object to another by direct contact Movement of air and heat by air current Loss of heat through evaporation of water/sweat

Radiation

Transfer of heat from warm objects to cool objects in the form of electromagnetic waves

Pulse

A wave of blood created by contraction of the left ventricle of the heart Normal range: 60-100 BPM

Pulse

Pulse pressure:

Systolic pressure MINUS diastolic pressure

Apical pulse MINUS peripheral pulse Systolic pressure falls by more than 15 mmHg during INHALATION Alternating strong and weak pulses

Pulse deficit

Pulsus paradoxus

Pulsus alternans

Liquid Diet Vs Soft diet

Clear liquid Coffee Tea Carbonated drink Bouillon Clear fruit juice Popsicle Gelatin Hard candy Full liquid Clear liquid PLUS: Milk/Milk prod Vegetable juices Cream, butter Yogurt Puddings Custard Ice cream and sherbet Soft diet All CL and FL plus: Meat Vegetables Fruits Breads and cereals Pureed foods

Food Guide pyramid

Bread, cereals, rice and pasta= 6-11 servings Fruit and vegetables Meat, poultry, fish, dry beans, eggs Milk, yogurt, cheese Fats, oils and sweets

Primary Prevention

Health promotion and Specific protection Health maintenance Screening and case finding Early diagnosis Prompt treatment Rehabilitation

Secondary Prevention

Tertiary Prevention

Primary Prevention Secondary Prevention

Education, Exercise, Diet and Nutrition, Immunization Physical Examination, Paps smear, BSE, TSE Sputum AFB, DRE Providing medication and treatment Physical therapy, Self-monitoring of DM, Speech therapy

Tertiary Prevention

Levels of Prevention
1. ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHECKUPS

Levels of Prevention
1.

ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHECK-UPS

Secondary Prevention

Levels of Prevention
2. Assessing growth and development of children for nutritional evaluation

Levels of Prevention
2. Assessing growth and development of children for nutritional evaluation

Secondary Prevention

Levels of Prevention
3. Family Planning and marriage counseling

Levels of Prevention
3. Family Planning and marriage counseling

primary prevention

Levels of Prevention
4. Teaching a client with diabetes selfmonitoring of glucose level

Levels of Prevention
4. Teaching a client with diabetes selfmonitoring of glucose level Tertiary prevention

DIAGNOSTIC EXAMINATIONS

MUST KNOWS

KNOW NORMAL VALUES FIRST DISEASE CONDITIONS AND THE SIGNIFICANCE OF CERTAIN LABORATORY DATA POSITIONING FOR THIS TESTS PURPOSE AND NURSING ALERT SPECIMEN COLLECTION AND PATIENT PREPARATION POST TEST RESPOSIBILITIES

SPECIMEN COLLECTION
Urine Clean-catch urine specimen For routine urinalysis and culture and sensitivity test Perineal care before collection The best time to collect the specimen is early in the morning (first voided-specimen) Amount needed: 30-50 cc for urinalysis; 5-10 ml for culture and sensitivity test 24 Hours urine Specimen discard the first voided urine Soak specimen in a container of ice Add preservative as ordered and indicate in the label the type of preservative added.

Second voided Urine Specimen Ask the patient to urinate and discard the first urine specimen and offer a glass of water afterwards After few minutes, ask the client to void again and collect the specimen Catheterize Urine Specimen Clamp the catheter for 45 mins Practice aseptic technique Do not collect specimen from the urine bag Obtain 3-5 ml of specimen for culture and sensitivity test and 10-15 ml for urinalysis

Stool Specimen

Routine Fecalysis Use to assess gross appearance, and presence of ova or parasite in the stool Sterile specimen container must be secured Instruct the client to defecate in the bedpan and obtain 1tbsp or 1 inch long stool specimen using a sterile tongue depressor Label the specimen and bring immediately to the laboratory Stool Culture and Sensitivity Test This is done to assess for specific microorganisms and etiologic agents causing gastroenteritis, and bacterial sensitivity to various antibiotics Sterile technique must be employed Label the specimen properly and send immediately to the laboratory

Guiac Stool Exam (Occult Blood) It detects bleeding at the GI tract and cancer of the stomach Meatless diet for 3 days prior to the procedure No to red or dark colored foods tom prevent false positive result No to iron: discontinue temporarily for 3 days prior to the procedure

Sputum specimen Gross Appearance

Collect early morning specimen Sterile container must be used Mouth care before: gargle only with water (no to mouthwash, or toothpaste) Instruct the client to deep breath and hack-up sputum from the lungs.

Sputum Culture and Sensitivity test Used to assess the etiologic agent causing Respiratory tract infection and bacterial sensitivity to various antibiotics

Acid Fast Bacillus (AFB) staining To determine active PTB Sputum specimen is collected in 3 consecutive mornings
Papanicolao or Cytologic Examination of the sputum To assess for cancer cells

Blood Specimen Blood Tests that does not require fasting:

Complete Blood Count Hemoglobin Hematocrit Level test Clotting studies Enzyme studies Serum electrolyte studies Fasting Blood Sugar Blood Urea Nitrogen Serum Creatinine Serum lipids (cholesterol level, glyceride level)

Requires Fasting

Body Secretions Culture and sensitivity test

To assess causative agent causing infection, and bacterial sensitivity to various antibiotics Practice aseptic technique

Arterial blood gas analysis PURPOSE: To monitor the patients response to oxygen therapy and detects the presence of acidbase balance. NURSING KEYPOINTS: No to Suctioning prior to obtaining blood specimen Assess for bleeding and hematoma at the puncture site Apply firm pressure at the puncture site for 5-10 minutes Specimen should be placed in iced-container Assess for metabolic alkalosis for patient with vomiting, and on the other hand, observe for signs and symptoms of metabolic acidosis for patients with diarrhea.

Barium enema PURPOSE: To assess the large intestines NURSING KEYPOINTS: Provide a Liquid diet before the procedure. Ensure that a laxative is given before the procedure to promote better visualization, and after the procedure to prevent constipation Report to the doctor if bowel movement does not occur in 2 days Instruct the patient to increase fluids and eat foods rich in fiber The patient should also increase intake of fluids

Friends and Enemas

What is an ENEMA?
A solution introduced into the rectum and large intestine for the purposes of: To relieve constipation To relieve flatulence To administer medication To evacuate feces in diagnostics or surgery

1.

2.
3. 4.

Enema types
1.

Cleansing Enema= intended to remove feces to prevent escape during surgery, for visualization procedure and constipation Purposes To 1. Prevent escape of feces during surgery 2. Prepare intestines for diagnostics and surgery 3. Remove feces in constipation/impaction

Enema types
2. Carminative enema= to expel flatus, 60-80 mL of fluids instilled 3. Retention enema= oil or medication is instilled to treat infection 4. Return flow enema= also to expel flatus, repeated 6 times

Enema Solutions
Hypertonic Draws water into the colon Distends colon, softens feces SE: Retention of sodium Hypotonic SE: F and E imbalance, water intoxication

Isotonic

Distends colon

SE: possible sodium retention SE: May damage mucosa

Soap suds

Irritates colon

Oil enema

Lubricates feces

The Height of the ENEMAS

During MOST enemas For HIGH enema

No higher than 30 cm above rectum

Up to 45 cm above rectum

The TIME of the ENEMAS

Cleansing Enema For Oil retention enema

5-10 minutes

30 minutes

The Length of the ENEMA tube insertion

The rectal tube is inserted 3 to 4 inches

Barium swallow PURPOSE: To assess for the esophagus, stomach, and some portion of the small intestines. NURSING ALERT: NPO for 6-8 hours before the procedure Laxative is administered after the procedure to counteract the constipating effects of the barium Withhold anticholinergics and narcotics for 24 hours before the test Instruct patient to increase fluids and intake of fiber-rich foods

Cardiac catheterization PURPOSES: To measure oxygen concentration, saturation, tension and pressure in various chambers of the heart. To determine a need for cardiac surgery. NURSING KEYPOINTS: Check for informed consent Assess allergy to iodine NPO for 6-8 hours before the procedure Check for distal pulses after the procedure Check for bleeding at the arterial puncture site and apply pressure Keep a 20 lbs sandbag at the bedside as a pressure instrument if bleeding occurs Keep the patient flat on bed with the lower extremities hyperextended for 4-6 hours Neurovascular assessment must be performed distal to the catheter insertion site and report any abnormal findings

Catheterization, urinary

PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter. NURSING ALERT: Know the necessary facts:
Principles Position Length of tube French number or Circumference Length of tube to be inserted Balloon size Male Supine 40 cm./ 15.75 in. #14- 16 2-3 in. 5-10 ml. (30 ml)Can be used to achieve hemostasis of the prostatic area following prostatectomy lower abdomen Female Dorsal recumbent 22cm./ 8.66 in. #18 6-9 in. 5-10 ml

Place to secure

Inner thigh

The procedure is sterile Maintain a close system The draining bag must always be below the bladder The catheter bag should not be allowed to lie on the floor Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it

Chest X-RAY PURPOSE: To detect abnormalities of the organs in the thoracic area NURSING KEYPOINTS: Remove any metallic object before the procedure Lead shield for women of childbearing age

Computerized Tomography (CT)

Definition 1. Cross-sectional visualization of the brain determined by computer analysis of relative tissue density as an x-ray beam passes through; also known as computerized axial tomography (CAT) scan 2. Provides valuable information about location and extent of tumors, infarcted areas, atrophy, and vascular lesions 3. May be done with or without intravenous injection of dye for contrast enhancement

Computerized Tomography (CT)

Computerized Tomography (CT)

Computerized Tomography (CT)

Nursing care
1. Explain procedure; inform the client that it will be necessary to lie still and that the equipment is complex but will cause no pain or discomfort; infants and cognitively impaired or anxious clients may need to be sedated 2. If the facility is small, arrange transportation to a larger facility that has the required equipment 3. Evaluate for possible allergy to iodine, a component of the contrast material 4. Withhold food for approximately 4 hours prior to testing; dye may cause nausea in sensitive patients 5. Remove wigs, clips, and pins prior to the test 6. Evaluate client's response to procedure

NURSING ALERT: If contrast medium will be used, assess for any allergy to iodine and instruct the patient to be on NPO for 4 hours prior to the procedure Assess for any fear of close spaces (claustrophobia) This procedure is contraindicated to patients who are pregnant and obese (>300 lbs) Let the patient lye still during the whole course of the procedure

CVP (Central Venous Pressure) monitoring PURPOSE: It measures the pressure of the Right Atrium NURSING KEYPOINTS: The nurse should place the zero level of the manometer at the level of the Right atrium at the 4th intercostals space to get an accurate reading Instruct the client to avoid coughing and straining as it alters the readings Normal CVP reading is 2-12 mm Hg ( when the tube is at the superior vena cava)

Cystoscopy PURPOSE: To assess the bladder and urethra NURSING KEYPOINTS: Check for the informed consent. If general anesthesia will be used have the client on NPO; liquid diet if local anesthesia will be used. Monitor intake and output. After: Force fluids as prescribed. Administer sitz bath for abdominal pain. Pink-tinged or tea-colored urine is expected. Notify the doctor if bright red urine or clots occur.

Doppler ultrasound PURPOSE: Evaluates patency of veins and arteries in the lower extremities. NURSING KEYPOINT: Inform the patient that it is painless.

Doppler UTZ

ECG (Electrocardiogram) PURPOSE: Records electrical waves of the heart. NURSING KEYPOINTS: Instruct the patient to lie still, breathe normally during the procedure Let the patient refrain from talking during the test. ST segment elevation or T wave inversion, indicates MI

EEG (Electroencephalogram) PURPOSES: Records the electrical activity of the brain, detects intracranial hemorrhage and tumors NURSING KEYPOINTS: Advise the client to shampoo hair before and after the procedure If the electrode gel is non removed by shampooing, the patient may use acetone Withhold stimulants, antidepressants, tranquilizers, and anticonvulsants for 24-48 hours prior to the test

Fasting Blood Sugar level PURPOSE: Detects diabetes mellitus NURSING KEYPOINTS: Normal blood sugar level is 80-120 mg/dl A blood sugar level of more than 140 mg./dl confirms diabetes.

Gastric analysis PURPOSES: This test is used to detect ulcers, and to rule-out pernicious anemia. It may also be done to analyze acidity, appearance and volume of gastric secretions NURSING KEYPOINTS: In gastric ulcer, HCL is normal, In duodenal ulcer, HCL is elevated. Refrigerate gastric samples if NOT tested within 4 hours.

IVP (Intravenous pyelography) PURPOSE: Visualization of the urinary tract NURSING KEYPOINTS: Check for the consent. NPO for 8-10 hours before the procedure Administer laxative to clear bowels before the procedure. Check for allergy to iodine, seafoods or shellfish before the procedure since the procedure requires the use of iodine based dye. Keep epinephrine at the bedside to counteract possible allergic reaction. IVP requires the use of a contrast medium while KUB does not. Inform the patient about the possible salty taste that may be experienced during the test. Increase fluid intake after the procedure to facilitate excretion of the dye.

KUB PURPOSE: Determines the size, shape and position of kidneys, ureters and bladder. NURSING KEYPOINT: No special preparation needed.

Liver biopsy PURPOSE: To determine liver disorders. NURSING KEYPOINTS: Check for the consent. Obtain the result of blood tests before biopsy since bleeding may occur Let the patient assume left side or supine during biopsy Instruct the patient to inhale, exhale and hold breath during the insertion of to stabilize position of the liver and prevent accidental puncture of the diaphragm Position the patient on the Right side after liver biopsy with pillows underneath to prevent bleeding Bedrest for 24 hours after the procedure

Lumbar Puncture PURPOSE: To withdraw CSF to determine abnormalities. NURSING KEYPOINTS: Before the procedure: empty bladder and bowel. Position: C-position. (fetal posistion) During the procedure: needle is inserted between L3 L4 or L4-L5 to prevent accidental puncture to the spinal cord since the spinal cord ends at L2. After: Position the patient flat for 6-12 hours to prevent spinal headache. Increase fluid intake.

Mammography PURPOSE: Detects the presence of breast tumor. NURSING KEYPOINTS: Instruct the patient not to use deodorant, talcum powder, lotion, perfume or any ointment on the day of exam as these may give false-positive result Let the patient know that her breasts will be compressed between 2 x-ray plates Provide teachings related to Self-breast examination Done 7 days after menstruation Position: lying down with pillow under the shoulder of the breast being examined or sitting in front of a mirror while raising the hands of the side of the breast being examined.

Mantoux test PURPOSE: A test to determine exposure to TB NURSING KEYPOINTS: A positive test yields an induration of 10 mm. or more for foreign born children below 4 years old An induration of 5 mm or more is considered positive in patients with HIV, with treated TB, and if he has had a direct exposure TB Patients. BCG may cause false positive reaction. Assess for previous history of PTB and report immediately to the doctor Result is read after 48-72 hours

MRI (Magnetic Resonance Imaging) PURPOSE: Provides cross-sectional images of brain tissues, more detailed than a CT scan. NURSING KEYPOINTS: Contraindications:

pregnant women, obesity (more than 300 lbs.), claustrophobic patients, patients with unstable vital signs patients with metal implants like pacemaker, hip replacements and jewelries.

Magnetic Resonance Imaging (MRI)

Definition 1. This procedure utilizes magnetism and radio waves to produce images of cross-sections of the body 2. The MRI machine registers the existence of oddnumbered atoms in the cross sections of the body, yielding data about the chemical makeup of the tissues 3. MRI can produce accurate images of blood vessels, bone marrow, gray and white brain matter, the spinal cord, the globe of the eye, the heart, abdominal structures, and breast tissue, and can monitor blood velocity

Magnetic Resonance Imaging (MRI)

Nursing care 1. Assess ability to withstand confining surroundings because client must remain in the tunnel-like machine for up to 90 minutes; open MRI may be an option for clients who cannot tolerate closed spaces 2. Instruct client to toilet prior to test, since this will be impossible during the procedure 3. Advise client to remove jewelry, clothing with metal fasteners, dentures, hearing aids, and glasses prior to entering scanner

Magnetic Resonance Imaging (MRI)

4. Since this procedure is contraindicated for certain clients, before the test assess for: a. Metal prostheses, such as orthopedic screws, since the magnetic force can dislodge the devices b. Pacemakers, since the scanner deactivates pacemaker c. Dysrhythmias, because the magnetic field can affect the conduction system of the heart d. Unstable medical conditions, since monitoring of the client is limited during the test 5. Evaluate client's response to procedure

Stool analysis PURPOSE: Assessment of bacteria, virus, malabsorption and blood. NURSING KEYPOINT: Avoid aspirin, red meat and vitamin C three days before the test as these may give a false positive result.

Tonometry PURPOSE: Measures intraocular pressure. NURSING KEYPOPINTS: Normal reading is 12-21 mm Hg A reading of 25 mm Hg indicates glaucoma.

Urinalysis PURPOSE: To assess characteristics of urine. NURSING KEYPOINTS: First voided morning sample preferred: 15 ml. Use clean container Decreased specific gravity: diabetes insipidus Increased specific gravity: diabetes mellitus, dehydration, SIADH (+) Protein: PIH, nephrotic syndrome. (+) Glucose: Diabetes mellitus, Infection

Urine Collection

As fresh as possible Mid stream clean catch First morning specimen best, but for most purposes doesnt make much difference

Hematuria
Even small amounts of blood are visible 1 part per 1000 is easily seen

Urine collection, 24 hour PURPOSE: Determines the excretion of substances from the kidneys, adrenal glands and the stomach. NURSING KEYPOINT: Required for ACTH test and schillings test (B12 absorption), Discard the first voided urine Place urine output in a clean container preserved in ice chest