FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

FUNDAMENTALS OF NURSING |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MADAM TONI NOTARIO
I. CONCEPT OF OXYGENATION 4. SUCTIONING- remove pulmonary secretions
O2 THERAPY (phlegm)
1. PURPOSE: Reverse Hypoxia (low oxygen in • Priority: prevent hypoxia
tissues/cells); Hypoxemia (low oxygen in blood); • Management: Hyper oxygenate before and
Anoxia (absence of oxygen) after to prevent hypoxia
2. GOAL: Increase Oxygen Levels • Position: conscious – semi-fowler’s;
3. POSITION: Fowler’s (90 degrees upright) to unconscious – side lying (to prevent
increase lung expansion aspiration)
• DOB 5. TECHNIQUE- sterile
o If pregnant woman, position is left side- • Dominant Hand- sterile
lying position (maternal position of • Non-Dominant Hand- clean
comfort). * apply suction upon withdrawal to prevent
o For OB Cases, in any problem, left-side trauma
lying pos. is the answer because if the 6. SUCTION CATHETER SIZE (in French)
position of comfort for pregnant women • Adult 12-18
• SOB • Child 8-10
• Orthopnea • Infant 5-8
4. CONTRAINDICATED SUBSTANCES 7. SUCTION PRESSURE (mmHg)
No Alcohol & Oil- it is directly flammable PORTABLE WALL-TYPE
5. CONTRAINDICATED TOYS (for pedia concept) ADULT 10-15 100-120
Battery-operated toys – ignites unexpectedly CHILD 5-10 95-110
6. CLOTHING INFANT 3-5 50-95
Cotton-based ONLY; prevents static friction * 120- for thick and tenacious secretion
7. DEVICES 8. SUCTION TYPES
• Pulse Oximeter- measures oxygen ORAL NASAL TRACHEAL
saturation (finger – highly vascularized) DURATION 10-15 seconds 5-10
o Don’t allow the sensor to be exposed to REST
20-30 seconds 2-3 minutes
PERIOD
direct sunlight; it will give inaccurate
LENGTH 3-5 inches 2-3 inches
results.
Clean NSS Water;
o Other: earlobe, forehead, nose bridge LUBRICANT
Water
KY Jelly
sterile water
• Incentive Spirometer- increase alveolar * Shorter suction the better to prevent hypoxia
expansion (or lung expansion) * Regardless, 2-3 minutes is the best answer
• Humidifier- Dry Gas to produce moisture CHEST PHYSIOTHERAPY
O2 PRECAUTION 1. DONE: before meals to prevent aspiration; 2-3
• No Smoking- put near the bed, O2 Tank, Door hours if after meals
O2 DELIVERY SYSTEM 2. CONTRAINDICATIONS
1. LOW FLOW • (+) PTB
• Nasal Cannula (2-6L/min; Entry level) • History of Myocardial Infarction/Angina
• Face Mask (simple up to 8L/min, partial • Bony Prominence
rebreather 10-12L/min, non-rebreather • Breast Tissue of women
15L/min) 3. COMPONENTS
• Incentive Spirometer- increase alveolar a) PERCUSSION- cupping & tapping technique
expansion (or lung expansion) (hollow sound)
2. HIGH FLOW b) VIBRATION- fine & shaking motion (during
• Venturi Mask exhalation phase)
COPD- preferable for precise delivery (blue c) POSTURAL DRAINAGE-
for exact 3L/min) APEX: Upright leaning forward
• CPAP, CPEP, BiPAP BASE: Modified Trendelenburg
3. WALL-OUTLET SUPPLEMENTAL THERAPY RL: Left-side lying
GREEN oxygen LL: Right-side lying
BLUE nitrous oxide; laughing gas
YELLOW medical air; compressed air
WHITE suction / vacuum

ALVAERA, M.E., EDILLON, A.M., NOVAL, K.L. 1

FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW
FUNDAMENTALS OF NURSING |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MADAM TONI NOTARIO
II. INFUSION PROCEDURE • LENGTH: Nose, Ear Lobe, Xiphoid (NEX);
TPN Approx. 50cm
1. aka IV Hyperalimentation Feeding • LUBRICANT: KY Jelly; R: prevent lipid
2. INDICATIONS pneumonia (aspiration pneumonia)
• Severe malnutrition • INSTRUCTION:
o Nursing Responsibilities: Hyperextension
§ Check for albumin levels (<2.5 Flexion= swallow
g/dL) • CHECK PLACEMENT:
§ Check for daily weight pH level- must be <5
• Post-surgery 10-15 mL of air- gurgling/whooshing sound
3. COMPONENTS x-ray- confirmatory test
• CHO (carbohydrates)- glucose (60-70%) • SECURE THE TUBE:
• CHON (proteins)- amino acid (30-40%) o Nasal Bridge
• Fat- lipid (10-20%) o Cheek
• Vitamins & Minerals * perform oral and nasal care
• Electrolytes FEEDING PHASE (clean)
• Fluids • POSITION: Fowler’s Position
4. ACCESS POINT • HEIGHT: Hang Tube 12-18 inches
• Sub-clavian vein- more common and safer • SOLUTION: Osteurized Feeding Solution
• Internal Jugular Vein • BEFORE FEEDING: check the patency
5. COMPLICATION • AFTER FEEDING: flush with 30-60mL of clean
• Hyperglycemia- regular insulin (only insulin water
can be given through IV; short acting; clear; WITHDRAWAL PHASE (clean)
ex: Humulin-R) • POSITION: Fowler’s Position
• Sepsis- broad spectrum antibiotic • ACTIVITIES: fold or coil the tube around your
6. NURSING CONSIDERATIONS hand; remove it slowly and gently
• V/S- Q4; temp (for sepsis) III. BOWEL ELIMINATION
• BGM- Q6 (hyperglycemia) COLOSTOMY/ILEOSTOMY
• Don’t stop TPN abruptly- to prevent rebound 1. STOMA- pinkish, moist, shiny
hypoglycemia 2. ABNORMAL
• Technique- sterile • Pallor- anemia
• Solution- up to 24 hours only • Bluish- cyanosis
7. Doctor will order and insert; Pharmacist will mix; • Blackish- necrosis
Nurse will monitor & regulate 3. CONTRAINDICATED FOODS
NGT • Gas Forming Food- to prevent abdominal
1. 3 CONCEPTS distention (root crops, cruciferous)
o GAVAGE: IN- Feeding • Colostomy- low fiber
o LAVAGE: OUT- Irrigation/ Sample • Ileostomy- no seeds; continuous drainage
o DECOMPRESSION: OUT- connected to 4. CONTROLLING ODOR
suction (prone to metabolic alkalosis) • Charcoal
2. 5 TYPES OF TUBES • Yoghurt-based- best choice (prebiotics)
TYPE DESCRIPTION NUMBER OF • A green leafy vegetable
LUMEN
• Milk
LEVIN intended for NGT Single lumen
5. CHANGING OF BAG
Salem-sump intended for NGT Double Lumen
Cantor intended for NIT Single lumen • 1/3 to ½ full
Miller-Abbott intended for NIT Double Lumen • 1/3 is the best answer
Sengstaken- special; given to px Triple Lumen 6. SKIN PROTECTION
Blakemore with esophageal • Stomahesives
tube varices • Karaya
3. PRINCIPLES 7. ACTIVITIES
INSERTION PHASE (sterile) • Basic household chores allowed.
• POSITION: Fowler’s Position

ALVAERA, M.E., EDILLON, A.M., NOVAL, K.L. 2

 FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW
FUNDAMENTALS OF NURSING |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MADAM TONI NOTARIO
• Not allowed to lift heavy objects as it can add o FEMALE- front-to-back, figure of 7, firm
more pressure to abdominal pressure. o MALE- tip-to-base, if uncircumcised,
• Allowed to go swimming. (Picture framing retract foreskin/ center to outer, circular
technique is applied – sealing of stoma; Placing form; firm stroke
tape around the stoma) 7. CLINICAL ALERT:
• Maintain cleanest to dirtiest pathway
8. DOUBLE-BARREL COLOSTOMY technique (R: to prevent cross
• Also called as Transverse loop colostomy infection/contamination)
• Clean Technique • Secure the catheter
• Proximal (Right) – Feces (Not formed) o FEMALE: inner thigh
• Distal (Left) – Mucus (Formed) o MALE: lower abdomen
• Descending to Sigmoid is formed stool 8. SPECIAL CONSIDERATION: urine collection
• Smell of stool is strong pungent (aromatic). STERILE SPECIMEN: aspirate urine from the
IV. URINARY ELIMINATION port with sterile syringe
CYSTOCLYSIS/BLADDER IRRIGATION
CATHETERIZATION 1. Performed after bladder or prostate surgery
• A process of removing urine out from the bladder expelling clots (first color to see is red)
with the use of catheter made of rubber 2. TURP (transurethral resection of the prostate)-
(commonly used in the Philippines) or silicon performed in patients with BPH (Benign Prostatic
(expensive). Hypertrophy)
• Dependent nursing action that needs doctor’s 3. PRINCIPLES:
order. • Lumen: Triple lumen
Straight Indwelling/ Foley Drainage: outflow
catheterization Irrigating solution: inflow
Short term Long term Balloon: anchor
Without balloon With balloon • Check the lines periodically for kinks
Single lumen Double lumen R: for solutions to flow freely
INDWELLING/FOLEY/RETENTION For fast infusion: check lines frequently
Remains into the bladder for continuous urine • Outflow (drainage) vs Inflow (NSS
drainage solution or sterile water)
1. POSITION o NORMAL Outflow=Inflow
• Female: Dorsal recumbent o NORMAL O > I
• Male: Supine o ABNORMAL O <I ABNORMAL (refer
2. TECHNIQUE immediately, patient is experiencing
• Sterile internal bleeding)
3. FRENCH SIZE *low BP, high RR and PR
• FEMALE: 14-16 • Color of drainage
• MALE: 16-18 o Bright red (open drip) - fast infusion (R: to
clean/ irrigate)
• COMMON SIZE: 16
o Clear (slow drip) - slow-down infusion,
*Never force the catheter upon insertion (R: prevent
40-50ml/hr
trauma)
*If uncircumcised, retract the prepuce. • Technique: Sterile Procedure
Length: V. ASSISTIVE DEVICES
• FEMALE: 3-4 inches (more prone to UTI) 1. CANE (Tungkod)
• MALE: 6-9 inches (may have UTI due to • Quad cane (quadcept)- most stable and
holding of urine) expensive
4. CHECK THE BALLOON • Tripod offset
• Inflate 5-10cc of sterile water • Standard offset
*Never inflate balloon unless urine flows. • Principles
5. LUBRICANT: KY Jelly, water based a. Position- placed on unaffected leg
6. CLEANSING OF EXTERNAL GENITALIA o Cane
• Cleanest to dirtiest (R: prevent cross- o Opposite
contamination) o Affected

ALVAERA, M.E., EDILLON, A.M., NOVAL, K.L. 3

FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW
FUNDAMENTALS OF NURSING |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MADAM TONI NOTARIO
o Leg • Handle: 20-30 degree angle of FLEXION
b. Handle • Nurse: Stand and assist on affected side just
o Level of greater trochanter (hip bone) behind the weak leg
R: to form angle of flexion (20-30 • Gait
degree angle) o One leg is weak
Angle is measured through o One leg is paralyzed
Goniometer o Weak- Walker-bad leg- good leg
c. Gaits o Paralyzed- Walker-swing onto it
o UP- good leg-cane-bad leg (GL-C- Plegia- paralyzed
BL) Right brain controls right face, left
o DOWN- cane-bad leg-good leg (C- body
BL-GL) Left brain controls left face, right body
2. CRUTCHES (Saklay)
• Axillary Crutch VI. ADMINISTRATION OF MEDICATION
o Axillary bar- 2-3 inches or 2-3 finger PER OREM
breath below axillary • Safest- because it is not invasive
Don’t bear weight in crutch the • Most accessible
pressure of the crutch can • Slowest absorption- synthesized and
damage the brachial plexus metabolized in liver
nerves and cause irreversible • Most comfortable- without pain
crutch paralysis (CRUTCH PALSY) 1. Position: Fowler’s Upright position (R: prevent
o Hand bar- weight with supporting aspiration)
palms 2. Types of oral medications:
o Rubber tip- most important part to o Liquid
ensure safety - Syrup
• Basic crutch stance - Suspension
o 6 inches to the side and front from - Solution
smallest toe (TRIPOD POSITION) - Elixir
3. GAITS - Decoction (Boiling herbals plants)
• 4 PT GAIT - Used with barrel cup, dropper, syringe
o left crutch - right bad leg-right crutch - left o Nursing considerations
good leg weight bearing gait - Consider calibration (R: to get exact
o freshly injured amount of drug)
o slowest pace - Consider the lower meniscus (R: it would
• 3 PT GAIT be the accurate measurement)
o 2 crutches + bad leg - good leg o Solid
o partial or non-weight bearing gait - Tablet
• 2 PT GAIT - Capsules
o left crutch + right bad leg - right crutch + - Lozenges
left good leg - Lozenges
o non-weight bearing gait Enteric coated- don’t crush and chew (R: to prevent
• SWING TO GI upset)
o maintain tripod position upon landing OTIC (EARS)
o freshly injured Position: side lying
• SWING THROUGH Age Consideration:
o extended of the back of the patient upon Pulling of pina: (R: to straighten the ear canal)
landing • 3 y.o and above – Up and backward
o nearly cured • 3 y.o below – down and backward
o requires more energy OPTIC (EYES)
• STAIRS: 3 pt gait • OS (Left); OD (Right); OU (Both)
o Up: good leg – 2 crutches + bad leg Position: Neck hyperextension
o Down: 2 crutches + bad leg – good leg Forms:
4. Walker (Andador) • Drops
• Position: Center in front of patient o Liquid type

ALVAERA, M.E., EDILLON, A.M., NOVAL, K.L. 4

FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW
FUNDAMENTALS OF NURSING |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MADAM TONI NOTARIO
o Pinch the lower outer third of conjunctiva
sac and form a canal
o 2-3 drops on the lower outer third of
conjunctiva
o tip of canister will not touch the eye to
prevent cross contamination
• Ointment
o Inner to outer cantus (eye)
o Solid
PARENTERAL (INVASIVE)
• Fastest in absorption
• Most dangerous; Most Invasive
• Used needles and gauges
• Uses universal precaution
o Handwashing before and after
o Never recap needles after use
o Dispose to sharps container
• Needles and gauges
ID SC IM
Length 3/8-5/8 5/8-1/2 ½-1 1/2
Child-
24-25
Gauge 26-27 25-26
Adult-
23 to 24
Angle 15 45 90
PRINCIPLES
1. Intradermal
o Bevel up
o No red ink
o No massaging
2. Subcutaneous
o Rotate the site of injection
(R: to prevent lipodystrophy)
3. Intramuscular
o Aspirate before releasing the medication
(R: to determine if you hit a vein)

ALVAERA, M.E., EDILLON, A.M., NOVAL, K.L. 5