BOOSTER 3

NURSING KEY POINTS WITH FULL /DETAILED RATIONALES

COMPILED AND SCREENED BY: MR. GICAR C. MAGBANUA

POSITIONS

*** REMEMBER POSITIONS ARE ASKED IN THE NCLEX-RN /DHA/HAAD/PROMETRIC EITHER TO PROMOTE OR TO
PREVENT SOMETHING***

- AFTER BIOPSY- TURN THE CLIENT TOWARD AFFECTED SIDE . TO APPLY PRESSURE IN THE AREA AND
PREVENT BLEEDING.

- DURING THORACENTESIS – PLACE THE CLIENT IN UPRIGHT OR SITTING POSITION AT THE EDGE OF THE
BED , ARMS ON AN OVERBED TABLE , LEANING FORWARD , FEET SUPPORTED ON A FOOT STOOL. THIS
POSITION PERMITS EASY ACCESS TO THE SITE OF INSRTION OF ASPIRATION NEEDLE. IN ADDITION , THIS
WILL PROMOTE COMFORT OF THE CLIENT .

- AFTER THORACENTESIS – POSITION THE CLIENT TOWARD UNAFFECTED SIDE FOR AT LEAST AN HOUR , TO
PREVENT LEAKAGE OF FLUID INTO THE THORACIC CAVITY.

- THE CLIENT ON OXYGEN THERAPY IS BEST PLACED IN SEMI – FOWLER’S POSITION . TO ENHANCE LUNG
EXPANSION AND VENTILATION.

- DURING TRACHEOSTOMY OR ENDOTRACHEAL TUBE SUCTIONING , THE CLIENT IS PREFERABLY PLACED IN

SEMI – FOWLER’S POSITION. TO FACILITATE INSERTION OF SUCTION CATHETER AND ENHANCE REMOVAL
OF MUCUS SECRETIONS.

- DURING POSTURAL DRAINAGE , POSITION THE CLIENT SO THAT THE AREA OF ACCUMULATION OF
MUCOUS SECRETIONS IS IN VERTICAL POSITION WITH THE BRONCHUS. TO FACILITATE DRAINAGE OF
SECRECTIONS BY GRAVITY. E.G. IF THE AFFECTED IF THE AFFECTED AREA IS A LOWER LOBE, THE HEAD
PART SHOULD BE LOWER THAN THE BODY ( TRENDELENBURG POSITION)

- AFTER BRONCHOGRAPHY AND BRONCHOSCOPY , THE CLIENT SHOULD BE PLACED IN SIDE – LYING /
LATERAL POSITION OR SEMI – FOWLER’S POSITION. THIS IS TO PROMOTE DRAINAGE OF SECRETIONS
FROM THE MOUTH AND PREVENT ASPIRATIONS .

- THE CLIENT WITH COPD/CHRONIC AIRFLOW LIMITATION IS BEST PLACED IN SITTING UPRIGHT,LEANING
FORWARD POSITION , WITH ARMS ON OVERBED TABLE AT SHOULDER LEVEL ( ORTHOPNEIC POSITION) .
UPRIGHT POSITION MOVES THE DIAPHRAGM DOWN BY GRAVITY. THIS ALLOWS ADEQUATE LUNG
EXPANSION . LEANING FORWARD POSITION ALLOWS ADEQUATE EXHALATION OF RETAINED CARBON
DIOXIDE . ELEVATION OF THE ARMS AT SHOULDER LEVEL ALLOWS ADEQUATE MOVEMENT OF
RESPIRATORY MUSCLES.

- THE CLIENT WITH EPISTAXIS ( NOSEBLEEDING) IS BEST PLACED IN SITTING/ UPRIGHT POSITION ,
LEANING FORWARD WITH HEAD TIPPED. THIS POSITION PREVENTS ASPIRATION OF BLOOD.

- AFTER TONSILLECTOMY – THE CLIENT IS PLACED EITHER IN SIDE – LYING / LATERAL POSITION OR IN
PRONE POSITION WITH PILLOW UNDER THE CHEST. THIS IS TO PROMOTE DRAINAGE OF SECRETIONS
FROM THE MOUTH AND THEREFORE , PREVENT ASPIRATION. ONCE THE CLIENT IS AWAKE , HE MAY BE
PLACED IN SEMI- FOWLER’S POSITION.

- THE CLIENT WITH PULMONARY EDEMA IS BEST PLACED IN HIGH- FOWLER’S POSITION WITH LEGS
SLIGHTLY DEPENDENT ( LOWERED) . HIGH FOWLER’S POSITION IS EFFECTIVE IN RELIEVING DYSPNEA .
LOWERING THE CLIENT’S LEGS WILL REDUCE VENOUS RETURN TO THE HEART (PRELOAD) THEREBY
REDUCING CARDIAC WORKLOAD.
 - THE CLIENT WHO HAS UNDERGONE PNEUMONECTOMY SHOULD BE TURNED SLIGHTLY TOWARDS
AFFECTED SIDE ( ONE QUARTER OF A FULL TURN), WITH HEAD ELEVATED OR BE PLACED IN SEMI-
FOWLER’S POSITION. TURNING THE CLIENT TOWARDS THE AFFECTED SIDE PREVENTS FLOODING OF THE
REMAINING LUNG WITH BLOOD FROM THE OPERATED SIDE. SLIGHT TURNING (NOT FULL SIDE LYING
POSITION , TOWARDS AFFECTED SIDE ) IS DONE TO PREVENT MEDIASTINAL SHIFT . SEMI – FOWLER’S
POSITION PERMITS MAXIMUM LUNG EXPANSION

- AFTER LOBECTOMY , SEGMENTECTOMY , WEDGE RESECTION, DECORTICATIONS, THORACOPLASTY ,

PLACE THE CLIENT IN SEMI – FOWLER’S POSITION OR TURN TO THE UNAFFECTED SIDE WITH HEAD
ELEVATED. SEMI- FOWLER’S POSITION PERMITS MAXIMUM LUNG EXPANSION . TURNING THE CLIENT TO
THE UNOPERATED SIDE ALLOWS ADEQUATE VENTILATION OF THE INVOLVED LUNG OR REMAINING
PORTION OF THE LUNG.

- THE CLIENT WITH FLAIL CHEST IS BEST PLACED IN SEMI – FOWLER’S POSITION , TURNED TOWARDS THE
AFFECTED SIDE OR THE AFFECTED SIDE BE SUPPORTED . THIS IS TO CONTROL PARADOXICAL BREATHING
THEREBY , PREVENT HYPERCAPNEA ( RETENTION OF CARBON DIOXIDE)

- THE CHILD WITH EPIGLOTTITIS, LARYNGOTRACHEOBRONCHITIS , BRONCHIOLITIS USUALLY ASSUMES

THE TRIPOD POSITION ( SITTING UPRIGHT , LEANING FORWARD WITH HANDS ON THE BED / FLOOR).
THIS POSITION FACILITATES BREATHING.

- TO PREVENT SIDS( SUDDEN INFANT DEATH SYNDROME) , PLACE THE INFANT DURING SLEEP IN SUPINE OR
SIDE – LYING POSITION IN A FIRM BED. REFRAIN FROM PLACING THE INFANT IN PRONE POSITION
DURING SLEEP . THIS POSITION HAD BEEN ASSOCIATED WITH SIDS . IN ADDITION , DO NOT PLACE THE
INFANT IN SOFT BED OR OVER A PILLOW OR OVER A COMFORTER. SLEEPING ON SOFT SURFACE HAD ALSO
BEEN ASSOCIATED WITH SIDS.

CARE OF CLIENTS WITH CARDIOVASCULAR AND HEMATOLOGIC DISORDERS

- THE MOST COMFORTABLE POSITION FOR THE CLIENT WITH MYOCARDIAL INFARCTION (MI) IS SEMI-
FOWLER’S. THIS POSITION PROMOTES MAXIMUM LUNG EXPANSION AND IMPROVES MYOCARDIAL
OXYGENATION.

- THE CLIENT WITH CONGESTIVE HEART FAILURE IS BEST PLACED IN HIGH FOWLER’S POSITION. THIS
POSITION RELIEVES DYSPNEA AND REDUCES CARDIAC WORKLOAD.

- DURING CENTRAL VENOUS PRESSURE (CVP) MONITORING , THE CLIENT IS BEST PLACED IN SUPINE
POSITION . HOWEVER IF THE CLIENT IS DYSPNEIC AND IS UNABLE TO TOLERATE SUPINE POSITION , THE
CVP READING IS TAKEN WITH HEAD OF BED (HOB) ELEVATED. RECORD THE DEGREE OF ELEVATION OF
HOB DURING THE INITIAL READING , AND PLACE THE CLIENT IN THE SAME POSITION DURING THE
SUBSEQUENT READINGS . THIS IS TO ENSURE ACCURACY OF CVP READINGS.

- IF THE CLIENT HAD UNDERGONE CARDIAC CATHETERIZATION THAT INVOLVES THE FEMORAL ARTERY ,
THE CLIENT SHOULD BE ON BED REST FOR 24 HOURS , WITH THE LOWER EXTREMITIES IN EXTENSION.
THE HOB MAY BE ELEVATED AT A MAXIMUM OF 30 – DEGREE ANGLE FOR THE FIRST 24 HOURS . ACUTE
FLEXION OF THE AREA MAY CAUSE CIRCULATORY IMPAIRMENT.

- WHEN TAKING NITROGLYCERINE, ASSUME SITTING OR SUPINE POSITION FOR SEVERAL MINUTES. TO
PREVENT ORTHOSTATIC HYPOTENSION.

- DURING CARDIOVERSION , DEFIBRILLATION, CPR, THE CLIENT IS BEST PLACED IN SUPINE POSITION ON A
FLAT , FIRM SURFACE.

- THE CLIENT WITH ARTERIAL INSUFFICIENCY (E.G. ARTERIOSCLEROSIS OBLITERANS, RAYNUADS

DISEASE, BUERGER’S DISEASE ) SHOULD BE POSITIONED WITH THE LOWER EXTREMITIES SLIGHTLY
 LOWER THAN THE LEVEL OF THE HEART ( DEPENDENT POSITION) . THIS POSITION PROMOTED ARTERIAL
FLOW.

- THE CLIENT WITH VENOUS INSUFFICIENCY (E.G. VARICOSE VEINS IN THE LEGS, THROMBOPHLEBITIS )
SHOULD BE POSITIONED WITH THE LOWER EXTREMITIES ELEVATED. THIS POSITION PROMOTES VENOUS
RETURN AND RELIEVES EDEMA OF THE LEGS.

- THE CHILD WITH TETRALOGY OF FALLOT IN “TET SPELL” ( HYPOXIDE EPISODE ) SHOULD BE PLACED IN
KNEE- TO – CHEST POSITION (SQUATTING IS USUALLY ASSUMED BY OLDER CHILDREN) . THIS POSITION
IMPROVES VENOUS RETURN TO THE HEART , INCREASES CARDIAC OUTPUT AND IMPROVES TISSUE
OXYGENATION.

- IF THE CLIENT RECEIVING IV FLUID INFUSION EXPERIENCES SIGNS AND SYMPTOMS OF AIR EMBOLISM ,
HE SHOULD BE PLACED ON THE LEFT SIDE- LYING , TRENDELENBURG POSITION ( LEFT SIDE LYING
POSITION WITH HOB LOWER THAN THE FOOT PART). THIS POSITION ALLOWS THE AIR TO BE ABSORBED
IN THE RIGHT SIDE OF THE HEART AND PREVENTS PULMONARY EMBOLISM.

CARE OF CLIENTS WITH GASTROINTESTINAL, HEPATO-BILIARY AND PANCREATIC DISORDERS

- DURING EXAMINATION OF THE ABDOMEN , THE CLIENT IS PLACED IN DORSAL RECUMBENT POSITION (
SUPINE WITH KNEES FLEXED) . THIS IS TO RELAX THE ABDOMINAL MUSCLES AND FACILITATE
EXAMINATION OF ABDOMINAL ORGANS.

- DURING RECTAL EXAMINATION , THE CLIENT IS PLACED IN LATERAL / SIDE LYING POSITION . TO
FACILITATE EXAMINATION OF THE AREA.

- AFTER UPPER GASTROINTESTINAL ENDOSCOPY (ESOPHAGOSCOPY,GASTROSCOPY, DUODENOSCOPY), THE

CLIENT SHOULD BE PLACED IN LATERAL/ SIDE –LYING POSITION . THIS PROMOTES DRAINAGE FROM THE
MOUTH AND PREVENTS ASPIRATION. ( THE GAG REFLEX WAS DEPRESSED BY ANESTHETIC SPRAY INTO
THE THROAT DURING THE PROCEDURE TO FACILITATE INSERTION OF ENDOSCOPE)

- AFTER ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP), THE CLIENT IS PLACED IN

SIDE- LYING POSITION. ( THIS PROCEDURE INVOLVES UPPER GI ENDOSCOPY)

- DURING NASOGASTRIC TUBE(NGT) INSERTION, THE CLIENT SHOULD BE PLACED IN HIGH – FOWLER’S
POSITION, WITH THE NECK HYPEREXTENDED ,INITIALLY. ONCE THE TUBE IS ADVANCED AS THE CLIENT
SWALLOWS SIPS OF WATER , IT PERMISSIBLE. THESE ACTIONS FACILITATE INSERTION OF THE NGT.

- DURING AND AFTER NGT FEEDING (GASTRIC GAVAGE) AND GASTROSTOMY FEEDING, THE CLIENT IS BEST
PLACED IN SEMI- FOWLER’S POSITION. THIS POSITION PREVENTS REFLUX AND ASPIRATION OF FEEDING.

- AFTER INSERTION OF INTESTINAL / NASOENTERIC TUBE (E.G. CANTOR TUBE, MILLER- ABBOT TUBE) , THE
CLIENT SHOULD BE PLACED IN RIGHT SIDE- LYING POSITION, TO HELP ADVANCE THE TUBE INTO THE
DUODENUM.

- DURING INSERTION OF TOTAL PARENTERAL NUTRITION (TPN) CATHETER, THROUGH THE SUBCLAVIAN
VEIN, THE CLIENT SHOULD BE PLACED IN TRENDELENBURG POSITION. THIS IS TO ENGORGE THE VEIN TO
FACILITATE INSERTION OF THE CATHETER. THIS WILL ALSO PREVENT AIR EMBOLISM.

- DURING ENEMA ADMINISTRATION , THE ADULT CLIENT SHOULD BE PLACED IN LEFT- LATERAL . THIS IS TO
FACILITATE THE FLOW OF SOLUTION BY GRAVITY.

- DURING ENEMA ADMINISTRATION IN AN INFANT OR SMALL CHILD. THE CHILD SHOULD BE PLACED IN
DORSAL RECUMBENT POSITION.

- THE CLIENT WITH HIATAL HERNIA SHOULD ASSUME UPRIGHT/ SITTING POSITION DURING AND AFTER
EATING. THIS IS TO PREVENT GERD.
 - AFTER GASTRIC AND BILIARY SURGERY ( DURING IMMEDIATE POST – OPERATIVE PERIOD) THE CLIENT
SHOULD BE PLACED IN SEMI – FOWLER’S POSITION. THIS IS TO PROMOTE LUNG EXPANSIONAND
VENTILATION AND TO PREVENT ATELECTASIS.( GASTRIC AND BILIARY SURGERY INVOLVE HIGH
ABDOMINAL INCISION/ NEAR THE DIAPHRAGM). THEREFORE , THERE IS HIGH RISK FOR ESPIRATORY
COMPLICATIONS TO OCCUR.

- TO PREVENT DUMPING SYNDROME AFTER GASTRIC SURGERY , THE CLIENT SHOULD LIE DOWN IN LEFT
SIDE- LYING POSITION. THIS IS TO SLOW DOWN EMPTYING OF GASTRIC CONTENT INTO THE DUODENUM.

- IF THE CLIENT HAS PERITONITIS , HE IS PREFERABLY PLACED IN SEMI – FOWLER’S POSITION. THIS IS TO
LOCALIZE THE INFLAMMATORY PROCESS IN THE PELVIC AREA .

- COLOSTOMY IRRIGATION IS DONE WITH THE CLIENT IN SEMI – FOWLER’S POSITION, THEN SITTING ON A
TOILET BOWL ONCE HE/SHE IS AMBULATORY.

- AFTER HEMORRHOIDECTOMY , THE CLIENT SHOULD BE PLACED IN SIDE – LYING POSITION. TO PREVENT
PRESSURE IN THE OPERATED AREA AND TO PROMOTE COMFORT.

- AFTER FEEDING AN INFANT , PLACE HIM/HER IN RIGHT SIDE – LYING POSITION. TO PREVENT GERD AND
ASPIRATION.

- AFTER CLEFT LIP REPAIR, THE CLIENT IS PLACED IN SIDE – LYING POSITION. THIS IS TO PROMOTE
DRAINAGE FROM THE MOUTH AND TO PREVENT ASPIRATION. DO NOT PLACE THE CLIENT IN PRONE
POSITION TO PREVENT TENSION OF THE SUTURE LINE. ELBOW RESTRAINTS SHOULD ALSO BE APPLIED TO
PREVENT TRAUMA OF THE SUTURE LINE.

- AFTER CLEFT PALATE REPAIR , THE CLIENT MAY BE PLACED IN SIDE – LYING AND PRONE POSITIONS.
THESE POSITIONS PROMOTE DRAINAGE FROM THE MOUTH AND PREVENT ASPIRATION.

- AFTER REPAIR OF IMPERFORATE ANUS, THE CHILD IS PLACED IN SIDE- LYING POSITION OR SUPINE WITH
TH ELEGS SUSPENDED AT RIGHT ANGLE. THIS IS TO PREVENT PRESSURE IN THE OPERATED AREA
THEREBY , MINIMIZE DISCOMFORT.

- DURING LIVER BIOPSY, THE CLIENT IS PLACED ON THE LEFT SIDE. TO FACILITATE APPROACH TO THE
LIVER WHICH IS LOCATED IN THE RIGHT SIDE OF THE ABDOMEN( RIGHT UPPER QUADRANT).

- AFTER LIVER BIOPSY , THE CLIENT IS TURNED TO THE RIGHT SIDE WITH ROLLED TOWEL UNDER THE
PUNCTURE SITE . THIS IS TO APPLY PRESSURE AT THE PUNCTURE SITE AND PREVENT BLEEDING.

- DURING PARACENTESIS , THE CLIENT IS PLACED IN SITTING / UPRIGHT POSITION. TO FACILITATE

ASPIRATION OF ABDOMINAL (PERITONEAL) FLUID.

CARE OF CLIENTS WITH ENDOCRINE DISORDERS

- AFTER TRANSPHENOIDAL HYPOPHYSECTOMY , THE CLIENT IS PLACED IN SEMI – FOWLER’S POSITION(

HOB ELEVATED FOR 2 WEEKS). TO PROMOTE VENOUS DRAINAGE AND DRAINAGE OF FLUIDS FROM THE
SURGICAL SITE .

- AFTER THYROIDECTOMY , THE CLIENT SHOULD BE PLACED IN SEMI – FOWLER’S POSITION WITH THE
HEAD , NECK , AND SHOULDER ERECT. AVOID HYPEREXTENSION AND FLEXION OF THE NECK TO PREVENT
TENSION ON THE SUTURE LINE . TENSION ON THE SUTURE LINE MAY CAUSE BLEEDING.

- DURING EPISODE OF HYPERTENSION IN A CLIENT WITH PHEOCHROMOCYTOMA , THE CLIENT SHOULD BE

POSITIONED WITH HOB ELEVATED ( FOWLER’S POSITION) TO PROVIDE ORTHOSTATIC DECREASE IN
BLOOD PRESSURE.
CARE OF CLIENTS WITH FLUID – ELECTROLYTE , ACID – BASE IMBALANCES, GENITO- URINARY
DISORDERS , SHOCK, BURNS

- DURING INSERTION OF URINARY CATHETER , POSITION THE CLIENT AS FOLLOWS:

 MALE : SUPINE WITH LEGS EXTENDED AND ABDUCTED.
 FEMALE : DORSAL RECUMBENT ( SUPINE WITH KNEES FLEXED).

- DURING CYSTOSCOPY , THE CLIENT IS PLACED IN LITHOTOMY POSITION . THIS POSITION PROMOTES
EASY INSERTION OF CYSTOSCOPE.

- DURING RENAL BIOPSY , THE CLIENT SHOULD BE PLACED IN PRONE POSITION , BECAUSE THE KIDNEYS
ARE LOCATED RETROPERITONEALLY.

- AFTER RENAL BIOPSY , THE CLIENT SHOULD BE PLACED IN SUPINE POSITION WITH SMALL PILLOW OR
ROLLED TOWEL UNDER THE POSTERIOR LUMBAR AREA TO APPLY PRESSURE AND PREVENT BLEEDING.

- DURING INSERTION OF PERITONEAL CATHETER FOR PERITONEAL DIALYSIS , THE CLIENT SHOULD BE
PLACED IN DORSAL RECUMBENT POSITION OR SEMI – FOWLER’S POSITION WITH THE KNEES FLEXED.
THIS IS TO RELAX ABDOMINAL MUSCLES AND FACILITATE INSERTION OF THE PERITONEAL CATHETER.

- DURING VAGINAL EXAMINATION , THE CLIENT SHOULD BE PLACED IN DORSAL RECUMBENT POSITION , IF
SHE IS IN BED . IF THE PROCEDURE IS DONE ON AN EXAMINATION TABLE , THE CLIENT IS PLACED IN
LITHOTOMY POSITION . THIS IS TO FACILITATE VISUALIZATION AND EXAMINATION OF THE AREA.

- THE CLIENT IN SHOCK SHOULD BE PLACED IN MODIFIED TRENDELENBURG POSITION ( SUPINE WITH
SMALL HEAD PILLOW TO PREVENT CEREBRAL VENOUS CONGESTION ; LEGS ELEVATED AT 20 – 30 DEGREE
ANGLE, HIPS HIGHER THAN THE TRUNK TO PROMOTE VENOUS RETURN ). INCREASED VENOUS RETURN
CAUSES INCREASED FORCE OF CARDIAC CONTRACTILITY AND THEREFORE , INCREASED CARDIAC OUTPUT
AND TISSUE PERFUSION.

- THE CLIENT WITH BURNS ( ESPECIALLY ON THE FACE , NECK, CHEST , ARMS AND BODY ) SHOULD BE
POSITIONED SUPINE TO PROMOTE POSITION OF EXTENSION . THIS IS TO PREVENT CONTRACTURES.

CARE OF CLIENTS WITH NEUROLOGIC DISORDERS

- DURING LUMBAR PUNCTURE , THE CLIENT SHOULD BE PLACED IN LATERAL , KNEE- CHEST POSITION
(FETAL POSITION / FLEXED POSITION/C POSITION /SHRIMP POSITION) TO WIDEN INTERVERTEBRAL
SPACES AND FACILITATE INSERTION OF SPINAL NEEDLE.

- AFTER LUMBAR PUNCTURE , THE CLIENT SHOULD LIE FLAT FOR 6 TO 8 HOURS TO PREVENT HEADACHE
DUE TO LEAKAGE OF CSF FROM THE PUNCTURE HOLE. THE CLIENT IS ALLOWED TO TURN TO SIDES.

- AFTER CEREBRAL ANGIOGRAPHY THAT INVOLVES FEMORAL PUNCTURE , KEEP THE AFFECTED LEG
EXTENDED AND IMMOBILE FOR FEW HOURS – THIS IS TO PROMOTE CIRCULATION AND PREVENT
DISLODGEMENT OF BLOOD CLOT . THE CLIENT SHOULD BE ON BED REST FOR 24 HOURS.

- AFTER PANTOPAQUE- OIL – BASED DYE – MYELOGRAM , THE CLIENT SHOULD LIE FLAT FOR 6 TO 24 HOURS
TO PREVENT SPINAL HEADACHE . ALL OF THE OIL BASED DYE CAN BE REMOVED AFTER THE PROCEDURE
BECAUSE IT DOES NOT MIX WITH CSF.

- AFTER METRIMAZIDE ( WATER BASED DYE- MYELOGRAM- HOB IS ELEVATED AT 30 DEGREE ANGLE ( SEMI –
FOWLER’S) FOR AT LEAST 8 HOURS TO PREVENT MENINGEAL IRRITATION . THE WATER – BASED DYE
COMBINES WELL WITH CSF , THEREFORE , NOT ALL OF IT IS REMOVED AFTER THE PROCEDURE .

- THE CLIENT WITH INCREASED ICP SHOULD BE PLACED IN LATERAL , SEMI FOWLER’S POSITION ( HOB
ELEVATED AT – 15 – TO 30 DEGREE ANGLE UP TO 45 DEGREE ANGLE . THIS IS TO DRAIN CSF FROM
SUBARACHNOID SPACE OF THE BRAIN TO THE SUBARACHNOID SPACE OF THE SPINAL CORD. THIS WILL
REDUCE THE ICP . THIS POSITION WILL ALSO PROMOTE ADEQUATE LUNG EXPANSION AND IMPROVE
 CEREBRAL TISSUE OXYGENATION . THE HEAD OF THE CLIENT SHOULD BE IN NEUTRAL POSITION .
FLEXION OF THE NECK WILL RESULT TO CEREBRAL VENOUS CONGESTION CAUSING FURTHER INCREASE
IN ICP . ELEVATION OF HOB MORE THAN 45 DEGREE ANGLE MAY CAUSE BRAIN HERNIATION.

- THE CLIENT WITH SPINAL CORD INJURY SHOULD BE PLACED IN FLAT/SUPINE POSITION ON A FIRM
SURFACE ( SPINAL BOARD) – THIS IS TO MAINTAIN ALIGNMENT OF THE SPINE.

- THE CLIENT ON ASPIRATION PRECAUTION – SHOULD BE PLACED IN AN UPRIGHT POSITION DURING

FEEDING OR DRINKING.

CARE OF THE CLIENTS WITH MUSCULOSKELETAL DISORDERS

- THE CLIENT IN BRYANT’S TRACTION SHOULD BE PLACED IN SUPINE POSITION WITH BOTH LEGS
SUSPENDED AT 90 – DEGREE ANGLE. BOTH LEGS ARE ELEVATED EVEN IF ONLY ONE HIP IS AFFECTED
BECAUSE THE WEIGHT OF THE CHILD IS NOT ADEQUATE TO PROVIDE COUNTERTRACTION.

THE KNEES SHOULD BE SLIGHTLY FLEXED TO PREVENT TO PREVENT HYPEREXTENSION DEFORMITY OF

THE KNEES . HYPEREXTENSION DEFORMITY OF THE KNEES WILL CAUSE INABILITY OF THE CHILD TO FLEX
THE KNEES. THE BUTTOCKS SHOULD BE OFF FROM THE MATTRESS BY ONE INCH. THIS IS TO IMPROVE THE
EFFICIENCY OF THE WEIGHT OF THE BODY AS COUNTERTRACTION .

- THE CLIENT IN BUCK’S TRACTION SHOULD BE PLACED IN SUPINE POSITION , WITH THE FOOTPART OF THE
BED ELEVATED. THIS IS TO IMPROVE THE EFFICIENCY OF THE WEIGHT OF THE BODY AS
COUNTERTRACTION . ELEVATE THE AFFECTED LEG WITH A PILLOW TO PREVENT PRESSURE SORE AT THE
HEEL OF THE FOOT.

- THE CLIENT IN RUSSEL TRACTION SHOULD BE PLACED IN SUPINE POSITION WITH KNEES FLEXED AT 20 TO
30 DEGREE ANGLE, SUPPORTED WITH SLING . CHECK THE BACK OF THE KNEE FOR PRESSURE SORE.

- IN 90- 90 TRACTION , THE CLIENT’S THIGH IS POSITIONED AT 90- DEGREE ANGLE( PERPENDICULAR) WITH
THE BODY AND HIS LEG IS AT 90 – DEGREE ANGLE WITH THE THIGH.

- THE CLIENT IN BALANCED SUSPENSION TRACTION IS PLACED IN SUPINE POSITION, WITH THE AFFECTED
LEG SUPPORTED WITH THOMAS SPLINT AND THE KNEE FLEXED AT 20 – 30 DEGREE ANGLE . IF THE CLIENT
IS IN THOMAS SPLINT , CHECK THE GROIN FOR PRESSURE SORE. THE FOOT SHOULD BE SUPPORTED WITH
FOOTPLATE TO PREVENT FOOTDROP.

- THE CLIENT USING CRUTCHES SHOULD ASSUME TRIPOD POSITION ( PLACE CRUTCHES FORWARD AND TO
THE SIDE ) FOR BALANCE AND STABILITY.

- AFTER LUMBAR LAMINECTOMY , THE CLIENT SHOULD PLACED IN FLAT POSITION AND TURNED AS A UNIT
(LOGROLLING TECHNIQUE) . THIS IS TO MAINTAIN ALIGNMENT OF THE OPERATED AREA.

- AFTER CERVICAL LAMINECTOMY , THE CLIENT SHOULD BE PLACED IN SEMI- FOWLER’S POSITION TO
FACILITATE BREATHING AND RELIEVE PRESSURE FROM THE OPERATED AREA.

- THE CLIENT ON CRUTCHFIELD TRACTION TONGS SHOULD BE PLACED FLAT ON BED AND TURNED AS A
UNIT.

MASSAGE BACK OF THE HEAD TO PREVENT PRESSURE SORE.

- AFTER TOTAL HIP REPLACEMENT (HIP ARTHROPLASTY) THE CLIENT IS PLACED IN SUPINE POSITION,
WITH THE AFFECTED EXTREMITY EXTENDED AND ABDUCTED WITH ABDUCTOR PILLOW. THIS IS TO KEEP
THE PROSTHESIS IN PLACE. THE HOB MAYBE ELEVATED AT A MAXIMUM OF 30 DEGREE ANGLE DURING
EATING. ONCE THE CLIENT IS ALLOWED TO SIT – UP , HIP FLEXION SHOULD BE UP TO 90 – DEGREE ANGLE
ONLY. ACUTE HIP FLEXION MAY CAUSE DISLODGEMENT OF THE PROSTHESIS.
 - AFTER AMPUTATION OF LOWER EXTREMITY , THE STUMP SHOULD BE POSITIONED IN ADDUCTION WITH
THE UNAFFECTED EXTREMITY. THIS IS TO PREVENT CONTRACTURE DEFORMITY OF THE HIP.

CARE OF THE CLIENT WITH EYE AND EAR DISORDERS

- AFTER EYE SURGERY ( E.G. CATARACT EXTRACTION ) , THE CLIENT SHOULD BE PLACED IN SUPINE
POSITION AND HE MAY BE TURNED TO THE UNOPERATED SIDE. THIS IS TO PREVENT TRAUMA OF THE
OPERATED EYE. ONCE THE CLIENT IS FULLY AWAKE , HE MAY BE PLACED IN SEMI- FOWLER’S POSITION.

- THE CLIENT WITH RETINAL DETACHMENT SHOULD BE POSITIONED AS FOLLOWS:

A. PREOPERATIVELY , THE AREA OF DETACHMENT SHOULD BE ON DEPENDENT POSITION(LOWER), TO
ALLOW THE VITREOUS HUMOR TO APPLY PRESSURE IN THE AREA . THIS WILL PREVENT FURTHER
DETACHMENT OF THE RETINA.
B. POSTOPERATIVELY, THE AREA AFFECTED SHOULD BE IN UPPER POSITION. THIS IS TO LOWER THE
SCLERA AND CHOROID BY GRAVITY AND ALLOW ATTACHEMENT OF THE AREA OF DETACHMENT.

- AFTER EAR SURGERY – THE CLIENT SHOULD BE TURNED TO THE UNOPERATED SIDE TO PREVENT TRAUMA
IN THE OPERATED EAR.

CARE OF THE CLIENTS AFTER BREAST SURGERY

- AFTER MASTECTOMY , THE CLIENT SHOULD BE PLACED IN SEMI – FOWLER’S POSITION WITH THE ARM ON
THE AFFECTED SIDE ABDUCTED AND ELEVATED WITH PILLOW. THIS IS TO PROMOTE VENOUS RETURN
AND TO PREVENT LYMPHEDEMA.

*** REMEMBER POSITIONS ARE ASKED IN THE NCLEX-RN EITHER TO PROMOTE OR TO PREVENT
SOMETHING***

DIAGNOSTIC TESTS

GENERAL PRINCIPLES IN THE CARE OF CLIENTS UNDERGOING DIAGNOSTIC TESTS

1. PREPARE THE CLIENT PHYSICALLY AND PSYCHOLOGICALLY TO ALLAY ANXIETY.

2. PROVIDE PRIVACY TO PREVENT FEELINGS OF EMBARASSMENT .
3. PROVIDE ADEQUATE INFORMATION ABOUT THE PROCEDURE : PURPOSE OF THE PROCEDURE , WHAT
TO EXPECT DURING THE PROCEDURE , AND WHAT IS EXPECTED OF THE CLIENT , TO GAIN HIS
COOPERATION.
4. NPO ( NOTHING PER OREM) IS REQUIRED FOR PROCEDURES THAT INVOLVE THE EXAMINATION OF
THE FOLLOWING:
A. UPPERT GIT E.G UPPER GI SERIES, UPPER GI ENDOSCOPY
B. LOWER GIT , E.G. BARIUM ENEMA , LOWER GI ENDOSCOPY
C. BODY CAVITIES THAT INVOLVE INSERTION OF INSTRUMENTS THROUGH THE NOSE OR MOUTH
E.G. BRONCHOSCOPY , BRONCHOGRAPHY, UPPER GI ENDOSCOPY , ERCP.
5. WRITTEN CONSENT IS REQUIRED FOR PROCEDURES THAT INVOLVE THE FOLLOWING:
A. INVASION OF BODY CAVITIES E.G. ENDOSCOPIC EXAMINATIONS: GI ENDOSCOPY, CYSTOSCOPY,
BRONCHOSCOPY.
B. TISSUE INJURY E.G. BIOPSY , LUMBAR PUNCTURE, THORACENTESIS, PARACENTESIS.
C. USE OF ANESTHESIA.
D. USE OF CONTRAST MEDIUM , EITHER RADIOPAQUE DYE OR RADIOISOTOPE E.G. RADIOGRAPHIC
EXAMINATIONS.
6. ASSESS FOR ALLERGY TO SEAFOODS AND IODINE FOR PROCEDURES THAT INVOLVE USE OF
IODINATED CONTRAST MEDIUM E.G. BRONCHOGRAPHY , CARDIAC CATHETERIZATION ,
ANGIOGRAPHY, INTRAVENOUS PYELOGRAPHY (IVP). IODINATED CONTRAST MEDIUM NORMALLY
CAUSES WARM OR FLUSHING SENSATION.
7. ASSESS FOR HISTORY OF CLAUSTROPHOBIA IF THE PROCEDURE INVOLVES PLACING THE CLIENT IN A
TUNNEL – LIKE DEVICE. E.G. CAT SCAN, MRI, PET SCAN.
8. INCREASE FLUID INTAKE AFTER PROCEDURES THAT INVOLVE USE OF CONTRAST MEDIUM . THIS IS TO
PROMOTE EXCRETION OF THE DYE . E.G. IVP,MYELOGRAPHY, ANGIOGRAPHY.
9. THE SEQUENCE OF METHODS FOR EXAMINATION OF THE ABDOMEN IS AS FOLLOWS: INSPECTION,
AUSCULTATION, PERCUSSION, AND PALPATION.
10. NO ABDOMINAL PALPATION AMONG CLIENTS WITH TUMOR OF THE LIVER AND TUMOR OF THE
KIDNEYS .
11. DURING EXAMINATION OF THE ABDOMEN , IT IS IMPORTANT TO FLEX THE KNEES TO RELAX THE
ABDOMINAL MUSCLES AND FACILITATE THE EXAMINATION OF ABDOMINAL ORGANS .
12. THE SEQUENCE OF EXAMINING THE QUADRANTS OF THE ABDOMEN IS AS FOLLOWS:
RLQ,RUQ,LUQ,LLQ.
13. THE BEST POSITION WHEN EXAMINING THE CHEST IS SITTING /UPRIGHT POSITION. THIS PERMITS
EXAMINATION OF BOTH THE ANTERIOR AND THE POSTERIOR CHEST.
14. TO PALPATE THE NECK FOR LYMPHADENOPATHY AND ENLARGEMENT OF THE THYROID GLAND , THE
NURSE SHOULD STAND BEHIND THE CLIENT.
15. IF OPHTHALMOLOGY IS DONE , DARKEN THE ROOM FOR BETTER ILLUMINATION.
16. FOR CULTURE AND SENSITIVITY TEST OF VARIOUS SPECIMEN ( URINE, STOOL , SPUTUM , BLOOD ,
BODY SECRETIONS) OBTAIN SPECIMEN BEFORE THE FIRST DOSE OF ANTIMICROBIALS AND USE
STRICTLY STERILE SPECIMEN CONTAINER.
17. IF A FEMALE CLIENT IS TO BE EXAMINED BY A MALE PHYSICIAN , A FEMALE NURSE MUST BE IN
ATTENDANCE . THIS ENSURES THAT THE PROCEDURE IS DONE IN AN ETHICAL MANNER.