FUNDAMENTALS OF NURSING

- 1. B
X 2. D
risk for
- amount
- 3. D >
->
back pain
min
specific
-in-specific
X
size bed
dil: ang
-
4. C X X
-

- not both

** ·
-

12-18 inches ⑧

5. A
-

X side first X
finish one

LEVEL OF PREVENTION

PRIMARY
A - Abstinence
→ healthy INDIVIDUAL B - BE FAITHFUL
7
W C - Condom
GOALS
D - Diagnose
Health promotion → diet, exercise, hygiene, sleep
Health protection → safety, immunization, vaccination, STD protection

SECONDARY
→ high-risk EX. BSE - 20 yrs old BSE CHARACTERISTIC OF A
- q. month, 7 days after INSPECTION - mirror MALIGNANT LUMP
→ means can be menses (regular) → Size, Shape, Symmetry → fixed, non-movable
• IRREGULAR
healthy or sick • PRE/POST MENS PALPATION HWBE → 20-39 y.o (q.3yrs)
• POST-HYSTERECTOMY → hand of the clock → 40 and above (q. year)
GOALS - same day q. month → from outer to inner MAMMOGRAPHY/XRAY
→ baseline (35-39 y.o)
→ early detection → yearly (40 and above)
PREPROCEDURE: no chemical, no metals, tell the pt there
→ early prompt tx might be discomforts.

I ex. prophylaxis
TSE - done after warm shower PSE - 1st to be done
→ testicular self EXAM → Prostate Specific Antigen
→ before 15y/o (same day q.month) → 40↑ (yearly)
→ at risk of cancer 15-35 y/o → (n) level of PSA 0-4 ng/dl
PROCEDURE: thumb and forefinger
TERTIARY DRE - 2nd
or with middle finger
→ Digital Rectal EXAM

→ post treatment → 40↑ (yearly)

→ diagnosed, dying patient FOBT (guiac) - 50 y.o (yearly)

CEA - Carcino Embryonic Antigen
• Restoration of health -↑50 (yearly ) smoker: 0.5 ng/dl nonsmoker: 0-2.5 ng/dl
BARIUM ENEMA - xray of GIT w/ contrast
• Rehabilitation
-↑50 (q.yearly)
• Comfort COLONOSCOPY / PRACTOSIGMOIDOSCOPY
- ↑50 y.o once q.5-10 years old
• Support
PAP SMEAR
- 21y.o / sexually active (q.yearly)
- 3 (-) (q.3yrs)
 - 1. C
A
2. D
- 3. c -
protection
4. C
- en

X
x
5. c
X
-

promotsmoker
ion primate
over

X
-

OXYGENATION
I. TRACHEOSTOMY
→ colorless → opening, to create a artificial airway
→ tasteless → surgery

→ odor
PARTS
1. Obturator - guide tool to insert the inner cannula
2. Inner, unlock: clockwise
PRIORITY: SAFETY
3. Outer
1. No smoking sign:
4. Tracheostomy Ties
→ door, bed (head/foot), tank (wall)
2. No electrical Equipment ex. Phone TRACHEOSTOMY CARE: NR
3. Battery-operated equipment ex. Vape → q. shift in PH 8hrs OC: 12hrs
4. No wooden clothing ex. Static
→ clean inner cannula
→ cotton
5. No Chemical ex. Rebonded hair
STERILE TECHNIQUE
6. Fire extinguisher
① SOAK → half-strength hydrogen peroxide 50%-50%
water
② RINSE → NSS
OXYGEN DELIVERY
③ DRY → no GAUZE
1. Nasal Cannula → tap, shake it dry
→ ( deliver 25-45%) rate: 1-6 LPM
→ most convenient TRACHEOSTOMY TIES → to secure the outer cannula
→ less anxiety "FATHER DONT WAIT"
TIE
2. Simple Face Mask TIE
→ (deliver 40-60%) rate: 5-8 LPM NEW
square
KNOT
two fingers beneath 4
1 finger
KNOT
3. Partial Rebreather Mask w/ reservoir UNTIE
OLD
UNTIE
4. Non Rebreather Mask w/o reservoir
→ highest, use for emergency, MI DISLODGE - after cannula?
→ retract the stoma
5. Venturi AT BEDSIDE
→ the most accurate ① obturator
Red - 40% II. ENDOTRACHEAL TUBE
② sterile forcep
→ intubation
CHILD ③ suction
LIMIT INFANT ADULT → for short-term
④ bvm
→ IF MORE THAN 7 DAYS
P 2 -
5 5-10 10-15 ⑤ tracheostomy set
(depends): risk for infection,
⑥ magic slate
W 50-9595-110 100-120 tracheal tissue necrosis
INCENTIVE SPIROMETER ORO NASO ET/TT
SF SF SF
→ SUSTAINED MAXIMUM DEVICE
Head at Side Hyperextend • insert all till u feel the resistance
→ to promote lung capacity
→ N-E (4-6in) → N-E (4-6in) withdraw 1-inch and then suction
→ before meals / bedtime
→ perform. 4-5x a day 10x/session
→ 5-10 secs → 5-10 secs → 5-10 secs
→ to prevent atelectasis → max: 15 secs → max: 15 secs → interval; 2-3 mins
→ interval: → interval:
20-30secs TOTAL: 5mins
POST-OP 20-30secs
→ splint

CHEST PHYSIOTHERAPHY AND

PARTS
MOUTH PIECE POSTURAL DRAINAGE POSITIONS
PISTON
→ (rise) blue indicator → before meals/ before bed time
GOAL MARKER → not exceeds 30 mins
FLOW INDICATOR → require doctor's order
* always elevate the affected side.
POSITIONING
→ sitting or upright PURPOSE
PERCUSSION
NURSING RESPONSIBILITIES DURATION: not more than 5 minutes
→ splinting and pain medication
→ to dislodge the secretions
→ cupped
1. Exhale fully, seal the lips (mouthpiece)
→ going up
2. Inhale slowly (goal marker) hold breath
→ not allow bare skin
3. Exhale normal
→ not bony structure

1. DBE Not exceeding

VIBRATIONS
2. Oral care 30mims
DURATION: not more than 5 minutes
3. Wash/clean mouth piece every after use
→ palm/heel of the hand
→ loosen / mobilize the secretion
SUCTIONING
→ during exhalation
→ to remove secretion
→ going down
→ to promote patent airway
→ sterile technique: dominant hand
→ PPE: mask, eye goggles
POSTURAL DRAINAGE - aka gravity drain
Is now often to change suction catheter
→ positioning, principle of gravity
IDEALLY → single use, after use.

CHEST DRAINAGE
POSITIONING → for lung expansion
SEMI FOWLERS
BLOOD → Hemotherax
COMA: LATERAL
FLUID → Pleural Effusion
AIR → Pneumothorax
COMPLICATIONS:
1. HYPOXIA - most common
PLEUR EVAC
→ low O2 in the tissue
→ accuracy cancausetensionphenmothaet suction
not
clamping
do

→ prevent: hyperoxygenate → BVM: 3 hyperinflation → O2

↓-pood- clots system
machine
the
change

1
squeeze

↑~
drainge
tank: ↑ 10-15 LPM 1min → Mech Vent -
~
NI
I pinch a
b
I~
I or

towards

2. BLEEDING/TRAUMA
→ no suction during insertion → withdrawal in circular motion
→ check for nicks
D WS S
⑪ intermittent continuos' bubbling &
Etteristics If
on
-

⑯ continuous (airleak) Ifof

no
bubbling
only drainager
-

Aungexpansion necklampin
·
 DISCONNECT
-1. B
→ remove in the system but not in the patient
X2. B
→ submerge or soak the tip in the water/NSS [NCLEX: -3. A
here
- 4. A
if none then reconnect]
- 5. D fiori fety
thing

DISLODGE ⑧ 6
→ disconnected from the patient but not in the system
→ cover the site with sterile dry non occlusive dressing
REMOVAL of the Chest Tube
Confirmatory: CXR
→ semi-fowlers mali-darbase
→ hold breath or bear down -
⑧
→ occlusive dressing.

before BF M

SLEEP
→ physiologic need SLEEP DISORDER MANAGEMENT
→ altered state of consciousness
→ 1/3 of life = 8 hours
① INSOMNIA 1. Sleep diary (sleep log)
→ difficulty falling / remaining asleep 2. Establish bedtime rituals
→ chronic insomnia: for 30 days 3. Warm bath
BIOLOGICAL RYTHMN "CIRCARDIAN RHYTHMN"
4. Warm milk - L.Tryptophan
→ newborn: starts at 6 weeks of life
RISK FACTORS 5. Exercise
→ (n) CR between 3 to 6 months
1. Aging 6. No midnight snacks
2. Female 7. No daytime Nap
TYPES 8. Environmental factors (light,
3. Stimulants (meds, food, smoking)
① NON RAPID EYE MOVEMENT noise, temp)
4. Stress
→ 75 to 80% of sleep
3 TYPES ② SLEEP APNEA
NREM 1 NREM 2 NREM 3 → sensation of breathing
VLS- few minutes LS - 10 to 15 mins DS → "LOUD SNORING"
→ 5x (at least 10 seconds in 1hr)
D - Drowsy and Relax D - Decrease HR, RR, Temp D - Decrease HR, RR, Temp
E - Eyes rolls side to side I - Increased Stimulation (lowest) 2 TYPES OF SLEEP APNEA
A - Awakened easily E - Eyes Still D - Difficult to awaken ① OBSTRUCTIVE SLEEP APNEA
D - slight ↓HR and RR D - Diminished reflexes → nasal polyps
• "Snoring" surgery
→ enlarged tonsils
• ↑production of GH → obesity
CPAP - Continuos Positive Airway Pressure
② RAPID EYE MOVEMENT fatigue
Immunosuppresion ② CENTRAL SLEEP APNEA
→ every 90 mins
NREM increase pain sensitivity → unknown
→ ↑Acetylcholine and Dopamine = Dream
→ Irregular V/S Poor healing
③ HYPERSOMNIA
→ excessive daytime sleepiness
SLEEP CYCLE
NREM - quantity
REM - quality → r/t chronic metabolic disorder: DM,
→ 5 hours of sleep with 5-6 cycles Hypothyroidism
NREM I and II: 20-30 mins Management: the underlying cause

NREM III: 30 mins ④ NARCOLEPSY + cataplexy

→ sleep attack
⑤ PARASOMNIAS
NREM II: 20-30 mins → (-) orexin → found in CSF
→ group of sleep a disorders with no known etiology
→ BRUXISM, grinding teeth
REM: 10-15 mins
→ ENURESIS, bed wetting
→ PLMD, Periodic Limb Movement Disorder, happens during sleep
NREM
→ RKS, Restless Leg Syndrome, during sleep/awake
• 1 awake
→ SOMNAMBULISM, sleep walking PRIORITY: SAFETY
• 2 if continuos
→ SOMNILOQUIY, sleep talking
X 1. A/D -
~
2. B -

X 3. A
uREMI
X

4. B
X NRA2
- 0
-

5. D 2house
it

- X

Nursing Diagnosis r/t COLOSTOMY EXTRA NOTES PEPTIC ULCER

→ fluid electrolytes imbalances BLAND DIET is for pts with → avoid irritants; diet
COLOSTOMY r/t Body Image → GI irritation as tolerated
→ colostomy care using clean gloves → acceptance
1. B
1. Encourage verbalization
2. A
LARGE INSTESTINE - absorption 2. Encourage visualization
3. A
3. Encourage to feel/touch
4. A
TYPES OF COLOSTOMY 4. Encourage to participate in stoma care O

5. A
1. ILEOSTOMY
→ watery, liquid stool DIET r/t COLOSTOMY
2. ASCENDING → bawal: gas/odor forming foods.
→ watery → close to normal food
3. TRANSVERSE AVOIDS 0
O

→ mushy 1. Brocolli
4. DESCENDING 2. Culli flower
→ semi-formed 3. Cabbage
5. SIGMOID COLOSTOMY 4. Mushroom
→ well formed stool 5. Garlic / Onion
6. Carrots
7. Sweet potato
DOUBLED BARRELED COLOSTOSMY
8. Purple yam
→ there is a two stoma
9. Singkamas/Turnips

Sinn fini
G - Gum PAIN
A - Alcohol → Fifth v/s
is a S - Smoking → unpleasant feeling/experience
→ pain is whatever and whenever
FOODS for COLOSTOMY to avoid gas (subjective)
forming
1. Crackers ASSESSMENT - 1st STEP: ACCEPTANCE/
2. Yogurt ACKNOWLEDGEMENT
STOMA 3. Parsley P - Provoke
→ pinkish to redish, or beefy red 4. Buttered Milk → activity, ano yung unang ginawa ng
→ 3-5 days to be functioning pasyente bago siya na saktan.
DIET TO AVOID BAD SMELLING OF COLOSTOMY
1. Charcoal Q - Quality
→ low fiber, low residue to delay the defecation to
2. Peppermint spray → anong klaseng sakit ang nararamdaman
avoid infection, while wala pa nag function.
3. Deodorizer ng pasyente
• slightly moist, slight protrusion/edema, painless
→ abnormal: bluish, purple, dusky, flat, painful → pt's own description
COLOSTOMY IRRIGATION - anytime of the → avoid close ended question or
day: do not perform this before meals. suggestive question
APPLIANCE → descending / sigmoid b/c with formed
118-1/4 inches feces R - Radiate/Region

⑱
1. To cleanse/ regulate the bowel → location. Ipapaturo sa psyente kung
2. Stimulate peristalsis saan yung masakit

EMPTY:1/3-1/2 FULL
S - Severity
I solution:lukewarm;
→ numeric pain scale: 0-10
CHARGE:9.5-7 days tap water → Wong's baker pain scale
500
-

1000mL
Reusable:soak in the
vinegar
then
sunlight Height:12 to 18 inches (shoulder level) T - Time
→ onset, duration and interval
Depth: 2 to 4 inches
RA OA I too
old or young

→ autoimmune → degenerative -
Sanay
na
siya

→ systemic → localize
→ affected: smaller joint → larger joint
X tolerance no sya

X
→ symmetrical/bilateral → asymmetrical/unilateral considered Or
be naiver
→ morning stiffness d/t inactivity
-can
opiols
→ later of the day d/t activity
• to relieve: hot shower; ROM • to relieve: rest
• Tx NSAIDS: COX-2 inhibitor (celecoxib) (less
GI irritation

reater
risk
or
urg
t chill 3 STEPS LADDER OF WHO
7I elder -

OPIODS - Nalaxone Narcan

STEP 1: MILD TO MODERATE ->
pain
is PRN no
matter the
time.

- check RR urge
→ non opioids w/ CA inonspecifical
→ CNS depressant O be use in pain mgt.

→ Morphine
never
pancreatitis I
cholecystitis STEP 2: MODERATE TO SEVERE PAIN ⑧
→ Demerol, long term use: SEIZURE
→ opioids w/ or w/o non-opiods w/ CA
→ Fentanyl
→ weaker, single route
→ Hydromorphone
→ Oxycodone
→ Vicotine
STEP 3: SEVERE PAIN
→ opined st w/ or w/o non-opiods w/CA
⑭
→ stronger, given in multiple route
HOW DOES IT WORKS
SIDE EFFECTS ⑧
1. Drowsiness - 1. B
/
• LOC → opiod naive pt's (firts time user) 2 2.
/ C
NASOGASTRIC TUBE
(24hrs)
→ A/E: respiratory depression
I 3. A
- clean technique, GI
X 4. A/B
1. Urinary retention → Gavage
- 5. C
1. Constipation - universal/most common s/e of → Lavage
opiods, → Decompression
1. Nausea → Medication, not all meds such as coated
2. Pruritus
INSERTION
→ HF/Sitting/Upright
NON- OPIODS / NSAID before insertion : hyperextend
→ not all NSAIDS are NON-OPIODS but not NASOPHARYNX, resistance: flex or lean forward.
all NON-OPIODS are NSAIDS → then ask the pt to swallow

FEEDING
→ during: semi-fowlers
NON-OPIODS NSAIDS → after feeding: 30 mins
→ acetaminophen (tylenol) → ibuprofen (Advil) (analgesics,
(analgesics, antipyretic antipyretic REMOVAL
→ not an anti-inflammatory → anti inflammatory → Semi fowlers
→ common s/e: GI irritation → common s/e: GI irritation → Instruct the pt to hold breath
"heartburn" "heartburn" → Monitor pt of nausea or vomiting
→ nr: is take it with meals → nr: is take it with meals
→ AE:
NURSING RESPONSIBILITIES
① PLACEMENT of the NGT
COANALGESICS (adjuvant ) → CXR (abdominal) (confirmatory)
→ aspiration of the gastric contents (residual
DIAZEPAM → anxiolytics, not a pain voulume less than 50% of the last feeding .
medication but can be used to relax the (n) gastric content: pH 0-4
smooth muscle intestinal content: 6-7 ② PATENCY
respiratory: ↑7 → flush with 30-60cc (water-
BENADRYL → antihistamine, can be effective → auscultation (gurgling sounds) distilled)
to treat pain b/c it has analgesics effects CHECK → IF: before and after feeding
→ IF: before feeding → CF: q.4hrs
→ CF: q.8h.
TOTAL PARENTERAL NUTRITION 1. B
→ any route except GIT 2. C
→ sterile technique - 3. B
4. B
TPN → composed of glucose, proteins, amino acids, vitamins and - 5. C
minerals
→ given in the veins
→ IBD (severe) → naka NPO nani siya
→ Burns PARACENTESIS
→ Pancreatitis → aspiration of fluid in the peritoneal cavity
→ Severe malnutrition → pts with ascites, liver cirrhosis
→ MAX: 1.5L → if too much could lead to HYPOVOLEMIC SHOCK
VEINS PRETEST
→ jugular vein → empty the bladder to prevent puncturing the bladder
→ subclavian vein (most common) INTRATEST
→ sitting or upright position (in pt is able)
INSERTION → supine
SUBCLAVIAN VEIN POST TEST
→ trendelenburg position → POC- position of comfort
- to prevent: pulmonary embolism → check the site immediately: pressure dressing, no leakage
→ supine → v/s q.15 (1hr) hypo tachy tachy
→ measure abdominal girth/weight
COMPLICATION
① Hyperglycemia↓130
→ d/t rapid infusion
THORACENTESIS
→ Insulin (regular) → aspiration of fluid in the pleural space
→ pts with pneumothorax
② Hypoglycemia ↓70 PRETEST
→ d/t abruptly stop the TPN: DEXTROSE D10 → ask to void the bladder to provide comport during the procedure
INTRATEST
③ Infection- the most common → sitting and lean forward
→ d/t sugat then glucose → lateral: unaffected
→ aseptic technique
1/4 = -25 → MAX: 1L to prevent HS
POST TEST
1/2 -50
=

→ lateral recumbent (unaffected) → to allow for lang re-expansion

BMI = Weight (kg) 3/4 =.75 → v/s q.15 (1hr)
Height (m)2 → measure chest circumference and weight

LUMBAR PUNCTURE
ODS wise
he
=

→ containing CSF

Ft Inches
→ ask to void the bladder to provide comport during the procedure
=

6 x 12 72 in
=

-
-
INTRATEST
Inches =

cm 72 x2.54 182.88cm= → L3-L4, L4-L5, L5-S1

→ knee chest, shrimp, lateral recumbent
CM M=

182.88 =
100 1.83m=
POST TEST
→ dorsal recumbent for 1 to 12 hrs
→ to prevent spinal headache (bifrontal occipito headache
UNDERWEIGHT (below 19)
NORMAL (19-24.9)
OVERWEIGHT (25-29.0)
OBESE ( ↑30 )