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    Nursing

    Uploaded by

    cookiednn

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    © All Rights Reserved
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    CHES Study. eWay ene) ‘Assessment: The process by which 2 nurse investigates the shysical, peyenosocla, and fpirtual needs of a patient trough the collection of Eibjective ard objective data ‘Analysis (ke. diagnosis: The data collected during the assessment phase is evalusted to determine a pian of care 1 dats from the assessment anc analysis phases used to Sevelop mensurable goals and cutcomes (8, nursing interventions. + Implementation: The nursing interventions ae put into practice. * Evaluation: The outcomes ofthe nursing interventions ae assessed Tae hed Rec To ausc i lung sounds, move the diaphragm of your stethoscope according to the numbers on the corresponding figures. There are three normal breath sounds: (@) Bronchial breath sounds: Loud, harsh, and high-pitched heard over tra ‘chea, bronch (betwen clavicles and midsternur), nd main bronchus (BV) Bronchovesicuar breath sounds: Slowing sounds of moderate tensity nd pitch; heard in the posterior chest between the scapulae and in the centor part ofthe anterior chest (W) Vesicular breath sounds: Sot, breezy, and low-pitched: heard over the pe: ripheral lung area and throughout most ofthe lung fields I: Assess general appearance and behavior, posture, gait, Fygtene,spasch, mental status, aight and weight, hearing and via stu vtal signe, and auton. ‘Head and neck: Assess sell size, shape, and symmety, as wall ag tar and scalp. Palpate for masses on scalp, en face toa, and neck. Palpate sinuses for tendemess and masses inspect scars and Cenjunetva. Assess pupil rexponce by using PERRLA (pvpils cia, found, reactive to lght and accommodation. Test convergence (5, tyes shit rom ear object toa near object, pups constc, confront SG ieee of the peer el and comen tht reflex Ispec rd palpate teeth and ura Tet ise of ula and goo ex. Ass Scnee af sma and tas. Chace range of motion (SOK) in neck and Shoulders. Palpate mph nodes for fondernass and swoling,trachos {oceymmetry, and tyre or masses ‘Upper extremities Inspects, test capilry refi palpste periph rf pules rata marle Seength, assess ROM, andchece deep tendon taleces «Posterior thorax: Inspect spine for algnment,asest anteroposterior to stra! meta, asst thoracc expansion, palpate tactle fem, ‘demess, pereuss the liver, and palpate the Kidneys and spleen. “Lower extremities: inspect skin, palpate peripheral pulses, assess for crackles Jon, tus, auscultate breath sounds, and perform blunt percussion over : (ceil sn ea ounde ba neptaion Pogue purer odor, ‘Anterior thorax: Observe respiratory pattem, palpate respiratory monary fibrosis ‘Reurson, uscultats breath sounds ausealtsteheartaouncs mapect | [Rhench Rating sound en expratien Bronchectasis, ranch, jugular veins, and perfarm breast exam: emphysema, preumonia ‘Abdomen: Asscultete for bowel sounds, percuss for masses and ten- | |Wheezes | High-pitched musical sound during both | Anaphylaxis, asthma Piewal ve heat fale, Popping, ercklng, bling, moist Ingpration and expratin Vouden emphysema, reign bodies ry, grating sound on both inspiration Pleural infarc, peur preureria Homans’ sgn, inspect ana palpate its fr weling. auees for pedal | | tnd anil edema’ and aeaase ROM re ‘Inspection is the careful examination ofthe patient as a whole, as wel as of sod ster ang te vay, ary, and okay sense t gor Information Ths prosos: Examines color shape, synmoty, and position of body pars. Should be purpose and aystemate, vat Body pare compare bilaterally {Sunng the entre sxamnation = Reguites good ighting to alow vista inspection of the body without i {orton or shadows +Palpation ' the tecique of using touch to gather infrmetin about tem perature turgor, texture molstur, siz, shape, conssteney, location, and ten= Semness ofan organ or body par. “"Palpaton can be light the application of pressure by depressing the skin nd underying vueturos about a half inch) er deop (pation ung nerd rozero to depres the dan andl undering svete about ame he pationt should be provided wath privacy, and the norse shoud have ‘warm hans an shont fngema Any areas of tendomess should be pal pated lot ~ Buring pslpstion, asese consistency of tasues, alignment and intactnest cof sructres, symmetry of body perts or movements anc ransmsion of ine woratione + Percussion rwsives striking one abject with enother to erate sound as 9 ‘means of assessing the loeston, 83e, and density of underying eaves, The LA, Stn stl change ae you move om one aes to tha newt Pereueion ie lone vitn the tale Anger of the dominant hand tapping on the mela finger of the rondomnant hand wis te nondomnané palm on the body. ~The nondominant hand placed on the area tobe porcussed, wth fingers Slohty separated — The dominant hand is used as the stking force by exerting a sharp down- ward wrist movernent so that the tp of the middle finger 9 te dominant Nand bres the ont of te meddle fnger on the nondominant hand. CSS There ae five types of percussion sounds 1. Tympary: Lous, drurlike sound 2. Resonance: Moderate to lous, low pitched, hollow sound . nance: Very loud, low-pitched booming sound 4 Flatness: Sof high-pitched, ise sounds 5. Dullness: Soft to moderate, big pitched, thuclke sound Hoathy lungs Asthma, COPD, pneumothorax Muscle orbone, severe pneumonia Dunes Liver or hear: |Orgens, purl fusion, pneumonia, turar| + Auscultation involves [stoning to sounds produced by the body using 2 Ststhoscops, Auscultation i performed for'tie purposes of examining the Creuiatory system, respiratory system, and gastrontestinal (2) system: "Sounds must be isolated for proper identification and evaluation = The stethoscope has a diaphragm that detects high-pitched sounds and a ball that detects lonepitched sounds, ~ Four characterises of sounds should be noted 1. Pitch 2: Loudness 3. Quality 4. Duration Sipe acorerr “tien ed oe Roe at “inher ouch Nac She cp cna “Pale sae SS on Tr ss sent «fe at ty emt pty etn pal dep 3 tows Spe dsr nero ‘entail ee acta coal em pen oe il oh rnc en sos 1 cm) accompanied by severe foot and fegsweling [Complex [Normal Length of Time |Whet Represents [ers Depolatn of ati peoees is oncom Prinenal fo12-02 see Time for imps pred tom JS complex [0.0401 see Spann ott bai Jr ineral | 043 sec Becca cle aie | 20 seer Gao | complnen cheats: sa beta com rmave _|.10-25seclnamplue [Replereaion o venrces ae si li Tis ciety Pulses ‘When checking pulses, note sire symmetry. Rate the stongth of 0 (absent) # 1+ (decreased) * 2 normal +32 (Gn + 45 (bounding) Repeat the procedure on the opposite side. rate, and pulse as: Tho Skin ‘The skin provides protection by preventing id loss; regulating body tem- perature: providing sensory perception; excreting impurities, and protecting ‘Sgainst infection, exposure, ond treuma. The skin i the largest organ in the body, and the average adult hes over 20 square feet of akin + Sen consists of three layers: epidermis, dermis, and subcutaneous tissue. + 5kin corres out seven major Functions: ‘Acts as a barre ta loss of water and electrolytes Protects the body from external agents Regulates body heat ‘Acts as a sense organ for touch, temperature, and pain Performs sell-maintenance and wound repair Produces vtamin D Delay hypersensiity reaction to foreign substances Rughness, lesions, pedureuation: ed pigmented lesone may indicate vasculr snges common duesse-indeating lesions ate hemangiomas, elanglectses, petochise, purpur, and eechymos icky retums tots _|Skin is slow to ream to its regular shape regular shape ater prching [or remains inden afer pinching Dry Excessive dhress, redness, fakiness; |otconeve mortars or ponginere ferperature_|Coo! to warm Mot or cold Muscle Strength na F>) Text suena of mor muscle groups sing te jllowing grading sale * Grade 5: Full ROM against gravity and fll resistance (100% of normal) * Grade 4: Full ROM against gravity and some resistance (78% of normal) + Grade 3: Full ROM wath gravity (50% of normal) * Grade 2: Full ROM with gravity eliminated or passive ROM (25% of normal * Grade 1: Sight contraction (10% of nermal) ‘Compare strength bilaterally. Stage Stage! ‘Assessment Findings Nonblanchable erythema; remain red 30 minutes efter pressure hat been relleved cpaderms rrmare tort. Stage It | Epidermis ic broken, lesion is suporcil, and there is partial thickreeesn oes Stage | Theres fl thickness skin oss down though the dermis, ‘hare i fil thickness i Stage Iv structures such as muse, ion ond bone. Stage Stage nee) + Oral: Capsule, tabla, or liquid: absorbed in gastrin ‘intravenous (IV): Injection into bicodstream via vain ‘intradermal: Injection into the dermal layer ofthe skin ‘Intramuscular (IMf Injection into muscle; can use large doses; fast, systemic action + Intrathecal: injection into spinal canal affects spinal fuid + Subeutaneous (subeutl: Injection into tissue below dermis, * Sublingual: Absorbed under the tongue + Rectal or vaginal: Suppositonos or roams; uel fo local distribution + Inhalation: Absorbed in Lungs: gaseous form; rapid absorption Formulas (GO act , Five Rights of Medication ose Oreset — Amount Administer Administration “. Right pationt Doseete Sete seusoncenemnntion 2 Raht dove Vote Soin 3. Rghtrowe 4, Righttme 5. Right mecicaton Medication Dosage Calculations Example ‘Onier amosicilin S00 mg oral ral Medications aug iy guide ‘salable: amoxil oral us Use the following formula Geewnaaeeaes. tofind the dosage for liquide (DesiveaiHave) * Quantity = ‘Tablets and Capsules Use the following formula to find Use (O/H x (300/200) x 5 = x 25x5—125mL Example the dosage for tablet and capsules: Ordo (Desredifiave)= Quanty=r pOdaay Pte” 10009 Parenteral Medications Parenteral medications ae any ‘medications not given trough the Girt nlusing IM, and subeu Use the following formule to find the dosage for lguids: (Desived/Have) » Quantty ~ ‘Aaliabl: oyprofen 200 mg tablets Use (O/H) x @:(1000/200) x 1 = Sx1=Stablets (Order oxacilin sodium (Bacto) 300 mg IM every 8 hours, ‘Ausable: onaclin sochum (Bactocl) : game Fist, make any necessary conversions: 11g= 1000 mg ‘Then use (D/H) x a (20071000) 3-1 = 03x3=09 mL Because the answer it lass than tml, round tothe nearest huredth: 0.90 ml. Injection Sites Invradermeal intradermal injections are normaly done {or alergy testing and for tubereslone sceening. The needle s inserted. at 9 10" to.18-degree angle ita the dermal layer ofthe sin nner Forearm The inner forearm isthe most common ‘aruda fection ste The recon ven onthe fot potion of te inner au Eso the forern. The patent should be tested withthe palm acing upward and the arm braced or supported Subscapular Region {an injection n the subscapular region is iven'on the upper back below the shou jer blades. The patient should be in a prone postion o seated, leaning forward Subcutneous Subcut injection are used to administer medications that need to be absorbed Slowly The noodle snserted st 945-0 S0.segree angle n the fay Heaue just Under the skin am An arm injection is given inthe lateral aspect of the upper arm, 3¢ least one finds wit below the shoulder snd cone hand’ width above the ebow. Thigh 1A igh injection is given anywhere be tween the middle ofthe anterior thigh fnd the middle of the lateral thigh, ot feast one hand’ width Below the hip nd ne hand's width above the knee. Absiomen ‘An abdomen injection is given between the waist and the hip, ftem where the abdomen begins to\ curve t0 approx 2 inches rom he center bs Intramuscular IM injections are used to administer fast Scting medications. The noodle is nso id ata 90-dogree angle into the musce. Mid.Dehoid Ares ‘The recommended boundaries of the injection area form a rectangle bounded by the lower edge of the scromion pro- cues on the top tra! de of the arm opposite the axa point on the Tat- ; {armpit) on the bottom. Avoid the actomion and humerus, a5 well as the brachial vers tnd artenes. Limit the number of injections here, as the area is small and cannot tolerte repeated injections or quantities of meciea tions greater than} mL. Ventrogluteal Ares The ie the ste of cnoice for acts and infants older than 12 months, 2s tis removed fom A Ir enes ar vasa suchen, aipate 1ofind the greater wochanter the anterior su perio iliac spine, andthe lac erst When in Jecting ito the let side of the patent. place the palm of the right hand on the greater tro chenter and the index finger on the anterior {superior lite spine. Spread the middle finger posteriorly away from the index finger as for ' possible along the iliac crest, a: shown in the figure. A "V" space or viangle between the index and middle finger is formed. The injection is made in the center of the tiangh wth the needle directed sightly upward to: ‘hard the crest ofthe lum NOTE: When injecting into the right side of the pation, use your left hand for placement Vastus Laterals Area ‘This is a relatively safe injection sit, free from ma- Jornerves and blood vessels. This injection area ls Bounded by the mc-anteror thigh on the font of the leg, the michlateral thigh on the side, a hand- breath below the greater vocherter ofthe femur at the proximal end, and another handbreadth sbove the fnee atthe distal end j roc Ychnique bi i H [A Lirace technique is usec for adminstering any ‘ritating fluid to seal masication in the muscle Retract the sstue, insert the needle, adminster the medication, remove the need, and release the Sesue. Note in the folowing fgure the teu telatonships ater the angled Each et by te needle. 2.rack Technique | ‘Boke ther fret valves these Ww Regular Semilente NPs Urvaiento 70% NPH & 20% Regular 35h 58h 1216hes 182th 18-26 10-28 hee 28-36 hes 3b hs 1826s 23h 4h 12h 12h no te peal 14-24 bes 1618 be 22h Lspro ‘Common IV Solutions ‘Isotonie: Dextrose 5% in water (O.Wi; 09% eodium chloride INaCh; Lactated Ringer (LR) ‘Hypertonic: D,,W; 3% NaCl; 5% NaCl; D.LR, D,0.45% NaCl 09% Nac ‘+ Hypotonie: DW; 0.45% NaCl; 0.33% NaC! IV Flow Rate Calculations IV flow rate can be measured in drops per minute (gtts/min ‘oF milters per hour (he) Calculating ts/min Total Volume to Be Given (in mL}/Time (in Minutes) » Drop Factor = gtt/mia (Order nicardipine 10 mg in 26 mL over Thou; drop factor ~ 18 Fst, convert hours to minutes: hour = 60 minutes Than calculate rate: 25 mL. x 15 _ 375, 0 0 Round tothe nearest whole number: gt/min Novolog Regular Semiente ‘The fastest. acting insulins are doser tothe phnger NPE Example The slowerecting insulins Lente are doserto the needle Lantus Calculation Uhratente Celevlating mL/hr Total Volume to Be Given (i mLVinfuson Time (e. Hours) = mL/hr ‘Order: IV saline 1000 mL over 4 hours 100m. Ths 2s0 mine Normal Ackit Screning Test | Normal Conditions with Abnormal Findings Increased | Decreased aun Ja20mmg/dl. [Congestive her flare (CHF, excessive protin inthe Liver alu, low protein det, malnution, {Gieser, Cl Bleeding, her stack, hypowtlma, ney |onerhycration ‘lannse edrey fla, shock unary act cbatacton soda Oa) 145 mEajt |CHF, dehydration, isbetes, cloharess, cartes, | Aactesn cardiac fre, bowel sbabuction, burs, hypenensen omen, toxemi, vorting fchoue,darhes, epyacna, Gl maatapton Pores 27-52 meq) |Addoss, screnocontalsuficiecy anemia, ait, |Alccholam, laos, bradycardia, colon cancer, CHF, schma. burs saies,syerythmse, hypoventation | choniccrhoss Cohn eco, darhes, choses cuore 70-100 mg/d. |Disbetes,hypentyoidom pancreatic cancer, eal pops, Wishrte, (astra) |pancresten prodsbotes ntuin overdo, msnarton, caret Pypogicer Crate Jott 3mg/at | Acute tubular necrosis (TN, CHF, dehycraton, Muscle dystopy Qate stage), myasthenia grave slabesc nephropathy, glomerulonephriis, ey fl | muscular Sysop, feecarpas,pylonephr itebdorychse sock erhey rec cewcion | caleiem a) {85-102 mg/at|ATN, bactoromia, chronic hopatc seas, respiratory | Akalows, burs, cachex, cae dean, chon ronal aodoss, aso, area, Gl malabrorston Atbumin 24-54 g/t. [Dehycaton Kidey cecese, ver davove Toa bitin Jos-1.9mgra. |phary stricture, cinhoss galbtcdr cancer, galstones, [WA [Gtoor csore, hapetts pancreatic concer Asparatevarsaminase/ _|10-24 UL | Acute pancreatitis, cinhow, hao attack hepatitis, |N/A feu glam omoacatic ny tre, ve’ cancer mononuleoe fronarnare WST/SON Ani srivovensominee/|7-56un [Acute pancreas, cirhons heart tack, hepa, fer | WA serum glutamic pyrave canoes monerctoes | varanrtinae ALTSCPD) Aine phosphatave 44-147 Un | ia obstruction, bone cance chose, hepa, hyper| Malton, potsn deficiency, Wisoncsease | [parebyroddam.lackerns, phoma, Pagers disease” "| ong may vr by ab [Coagulation Screening Tests Coagulation Testing " «Clotting disorders such_2¢ hemophilia Bleeding time (Simplate 25-10ma ‘Coagulation testing is performed on ples- {which a patients blood does not clot) prothrombin time 7) 10-13 see ima and is used to monitor anticoagulant ,/™st.ako be monitored, Parts! thromboplastin time PTT) 25-39 see therapy. ~ Acthoted dotting time, cle blood doting emo 5-15 min *Cenaaten, eae ne peered on ~ Acad patel drorboplein ine rtsrattonsh rated Ra DI ‘2ttacks, oF thrombophlebitis (blood clots). Factor seewity as a! anicoagultion therapy 20-30 ‘Drugs t© prevent clotting and id in — Floinogan and bxin degradation Mechanica hear vaho 2535 voting recurence of he proviousy bet teste Fibinolyie Studies {2d conditions are given porto ths test ~ Intemational normalize ratio - ‘and the patients dotting (coagulation) — Prothrombin time. Evglobutin ysis No bai in 2 bes {orm uae be corel eecenicreet = Troi doting tine Frnogen 200-400 mg/l Complete Blood Count (C80) CC aT ial ‘The most common hematology test is the complete blood Tone SBC Uhh i pee nhs Cee Common Abbreviations a aoeEacimttidemn, oT Sipe gaia ee | ie renee ther sonore, ‘2 belore meals ‘mg mili « Diferental (39 clasts ene counts the ifort types of oe in oe WBC, ot wall as abnormaites In RACs or platelets ee mame Me moodle + Platelet count the nub of pees «Know volume ea meres few * Mean pitlet volume (MPV) etctes late! vlure end az, eee eee ‘ted blood eal BC) our urbe 3 bate ee ene ce

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