COMMON RESPIRATORY INTERVENTION
1. Oxygen therapy
 Avoid use of oil, grease, and alcohol to
prevent combustion
 Check electrical appliance before use
 Avoid woolen blankets and synthetic
fabrics, instead use cotton blankets
 Humidify oxygen (sterile water/ plain
normal saline solution or PNSS)
 Provide good oronasal hygiene
 Lubricate the nares using water
soluble lubricants. don’t use oil.
 Assess relative vital signs
 Assess s/sx of hypoxemia
 Check doctor’s order
 Place in semi-fowler’s position
 Check the equipment
 Regulate oxygen flow. Excessive
administration of oxygen can cause
oxygen narcosis
 Place “no smoking” sign
OXYGEN DELIVERY SYSTEM
The choice of system depends on the client’s
oxygen needs, comfort, and developmental
considerations.
1. Cannula (nasal prongs)
 1-5 liters/min
 It does not interfere with the px’s ability to
eat or to talk. It also is relatively
comfortable, permits some freedom of
movement and is well tolerated by the px.
2. Face mask
 5-10 liters/min
3. Venturi mask Valves
 Responsible for most accurate oxygen
delivery system
 Pulse Oximeter
o Fingers and feet
o To measure oxygen saturation
o Do the milking first
o Earliest sign of decrease o2 is loss of
consciousness (less than 95)
 Pediatric Pulse Oximeter
o Put this alternately to prevent skin
burn
4. Partial Rebreather Mask
 Must not totally deflate during
inspiration to avoid CO2 build up
 Semi or high fowler’s position
5. Non-rebreather mask
 Delivers highest O2 concentration 95-
100% at 10-15 lit/min. one way bag
valves on the mask and between the
reservoir bag and the mask prevent the
room air and the client’s exhaled air
from entering the bag so the O2 is the
only one that is being inspired in the
bag.
6. Face tent
 Can replace O2 masks when masks are
poorly tolerated by clients. Face tents
provide varying concentrations of O2
 for example 30% to 50% concentration
of oxygen at 4 to 8L/mins.
AIRWAYS
1. Oropharyngeal and Nasopharyngeal airways
 Use to keep the upper air passage
open when they may become
obstructed by secretions or the tongue
2. Endotracheal tubes
 Those who have general anesthetics or
for those in emergency situation where
mechanical ventilation is required.
EQUIPMENTS:
a) Readily available stethoscope
b) Bag ventilation
c) 10cc syringe
d) Guide wire
e) Icy jelly for intubation
f) leucoplast or micropore
  Provide good oral hygiene to remove
unpalatable taste of sputum
3. Tracheostomy
INCENTIVE SPIROMETRY
 Long term airways support
 They couldn’t talk  As px inhales, the ball in the spirometer goes
 Opening of trachea to neck up, this signifies good lung expansion
 Pursue lip breathing (to eliminate excessive
\TRACHEOSTOMY CLEANING:
carbon dioxide)
a) Gauze – for scrub  Prevent atelectasis or lung collapse
b) Hydrogen peroxide  It should be done more than 10 times a day
c) Sterile water (PNSS) – IRRIGATION
PROCEDURE:
d) Outer cannula tracheostomy tube – soak in
hydrogen peroxide and PNSS 1) Place in high fowlers
e) Inner cannula – should change every week 2) Inhale – exhale
3) Ipapasok sa bibig
SUCTIONING
4) Inhale – control
 Place px in semi or high fowlers 5) Tanggal
 Practice sterile technique 6) Purse lips breathing – to eliminate CO2
 Hyperventilate with 100% before and after
NASOGASTRIC TUBE INSERTION
oxygen to prevent hypoxia
 Insert catheter with gloved hand (3-5 inches) Purpose:
o The trachea is 4-5 inches in length 1. Lavage – decompress or aspirating fluid
 Apply suction during withdrawal of catheter from stomach
to prevent trauma and bleeding 2. Gavage – administer fluid, food,
 Best time is before meal medication through NGT
 Use sterile gloves
 Take only 5-10 sec (max is 15 sec) to prevent For:
hypoxia, vagal stimulation (hypotension and 1. Comatose px
bradycardia), and bleeding. 2. Risk for Aspiration
 Evaluation: clear breath sounds on 3. Stroke px
auscultation 4. Dysphagia px
NEBULIZATION Needs:
 Purpose: promote bronchoconstriction 1. Kidney Basin
 Place in high fowlers position 2. Micropore
 Side effects: tachycardia with more than 100 3. Leucoplast
bpm 4. NGT tube
 After nebulization do the CPT or chest 5. Scissor
physiotherapy also known as “chest clapping” 6. Aspirating Syringe
7. KY Jelly
CHEST PHYSIOTHERAPY (CPT)
8. 8. Glass of water and straw
 Verify doctor’s order
 Assess area of accumulation of mucus  High fowler’s position
secretions  Before inserting, measure the tube (NEX)
 Position of gravity o Tip of nose
 Do CPT with upper lobes before lower lobes of o Tip of earlobe
the lungs o Xiphoid process
 10-15 mins change of position. Total of 30  Put micropore on the tube for marking
mins per tx.  Let the px extend his neck back before
 Percussion and vibration inserting the tube
 Change position gradually o Must change every month
 Best done before meals or in the morning or o Most comfortable nares
bed time
  Clamp tube then remove the lack to prevent
air from coming in and prevent colic.
 When inserted, flex forward the head and
 Place side lying if there is a difficulty in
take a little sip of water
aspirating
o You can always pause or withdraw
slightly
o Each push of tube, sip water
PH LEVELS AFFECTED BY MEDICATION
 When aspirating is done use litmus paper to
test gastric content Proton-pump H2 Antagonist Antacids
o Blue – alkalynic – tube is in the lungs inhibitors
o Pink – acidic – normal Aspirin Pamotidine Magnesium
 When connected in suction machine, carbonate
continuous aspirating gastric content Omeprazole Cimetidine Magnesium
trisilicate
 Stethoscope and aspirating syringe Dexlansoprazole Nizatidine Aluminum
o Instill air in aspirating syringe hydroxide
o Should hear borborygmic sound Esomeprazole Ranitidine Calcium
 PAG NILUBLUB END NG CATHETER DAPAT carbonate
WALANG BUBBLE lansoprazole Sodium
bicarbonate
 Most accurate – x-ray
 Every 4 hours feeding
 Px should be speaking FEEDING
2 Types of NGT  Water
 Osterized Feeding
1. Regular – hard plastic that needs to soak in
 Water
warm water to soften
2. Silicone – mahal na malambot MEDICATION
MNEMONICS:  Water
A - auscultation  Crashed medicine
A - aspiration  Water
P – pH testing o For medicine that shouldn’t be
I - immersion crashed, soak it in warm water
X – x-ray o 30mL water first
o Position in semi fowlers
INDICATION o Use clean gloves
M - medication
A – aspiration precaution/administration medication  After feeding, remain seated for one hour
D - decompression
 Clean gloves for feeding; sterile or clean for
E – enteral feeding
inserting
L – lavage
 Do not mix medication with oral nutrition
 Should be prescribed by the doctor
FEEDING IN TUBE: doctor’s order
 Consult nutrition nurse specialist for other
1. Osterized Feeding or isotonic liquid nutrition option
2. 50-60 cc of syringe  Use only water-filled during and apply
3. Jag of water (250mL) pressure to plunger to flush and unblock the
4. Litmus Paper tube.
5. Small cups
6. Measuring tape
TO IDENTIFY THE PX
7. Medications
8. Feeding schedule 1. Full name – “what is your name?”
2. Birthday
 Semi fowlers position 3. Hospital number
  If the px has residual of more than 100mL, the  Fahrenheit to Celsius
feeding will hold in 2-3 hours or more
C = 5/9 (F-32)
 If the residual is less than 100mL re-instill the
gastric content and continue feeding PURPOSE:
REMOVING  Establish subsequent evaluation
 Identify if the core temperature is normal
 Collect supplies
 To determine the changes in temperature
 Instruct the px to inhale and hold then pull the
NGT DO’S
VITAL SIGNS 1) Before using, wipe the thermometer form tip
to end with cotton and alcohol (one stroke)
 vital or cardinal signs are the body
2) Explain to px what you’re doing
temperature, pulse, respiration and blood
3) Place thermometer to axilla for 3-5 mins
pressure. Recently, many agencies have
designed pain as a 5th vital sign, to be assessed 4) Document temperature
at the same time as each of the four. 5) After using, wipe from end to tip
6) Wash if necessary.
1. Body Temperature DONT’S
 Reflects the balance between the heat
produce and the heat lost from the body and 1) Don’t use oral route for children below 3,
unless it is non-breakable thermometer
2) Don’t use tympanic route if the px has ear
infection
3) Avoid using rectal route for adult
4 SITES
1) Oral
2) Axilla
3) Tympanic membrane
4) Rectal
3 TYPES
measured in the heat called degrees.
1) Mercury
WHERE CAN WE GET TEMPERATURE? 2) Electronic
a) TEMPORAL 3) Infrared
b) FOREHEAD
c) AXILLARY
d) ORAL 2. Pulse Rate
e) FACE  Pulse is the wave of blood created by
f) EAR – one of the most accurate contraction of the left ventricle of the
g) RECTUM – accurate for babies and to make heart.
sure that there is a perforated anus.  Represents stroke volume output and the
amount of blood enters the artery.
NORMAL BODY TEMPERATURE
STROKE VOLUME
1. Baby
o 36.4°C (97.5F)  Amount of blood that is being pump from the
2. Children heart in a single beat (70mL)
o 37°C (98.6F) FACTORS AFFECTING STROKE VOLUME (SV)
3. Adults
o 36.5°C (97.7F) 1) Heart size
2) Fitness level
CONVERSION 3) Gender
4) Contractility
 Celsius to Fahrenheit
5) Duration of contraction
F = 9/5xC+32 6) Preload
 7) Afterload 2) Don’t get PR if the px is from walk or any
certain activities
FACTORS AFFECTING HEART RATE (HR)
3) A watch with second hand is a must
1) Autonomic innervation
PURPOSE
2) Hormone
3) Fitness levels 1) Establish baseline data
4) Age 2) To identify if the px has normal PR
3) To determine if the pulse rhythm is regular
 SA NODE and pulse volume is appropriate
 Sinoatrial node 4) To monitor px health status
 Primary pacemaker of the heart 5) To monitor px risk for pulse alteration
 60-100 bpm
NORMAL RESPIRATORY RATE
 Conduction and transmission
 AV NODE A. Infants (6 months)
 Atrioventricular node - 120 -160 bpm
 Secondary pacemaker of the heart B. Toddler (2 years)
 40-60 bpm - 90 -140 bpm
 BUNDLE OF HIS C. Pre-schooler
- 20-40 bpm - 80 – 110 bpm
 PURKINJE FIBRES D. School age
- Less than 20bpm - 75 – 100 bpm
E. Adolescent
PULSE DEFICIT - 60 – 90 bpm
 Difference of HR and PR F. Adulthood
- 60 – 100 bpm
SV = EDV – ESV
CARDIAC OUTPUT (CO) = HR x SV
3. Respiration Rate
Preload – initial stretching of the cardiac  Act of breathing
myocytes (muscle cells) prior to contraction.
External
Afterload – the force or load against which the - Interchange of the O2 + CO2 b/w the lungs and
heart has to contract to eject blood.
pulmonary blood
How does the heart beats? Internal
- Interchange of these same gases
Sinoatrial (SA) Node – sends out an electrical
Ventilation
impulse to atria.
- Movement of air in and out
Atrioventricular (AV) Node – sends an impulse Tachypnea
to ventricles. - Quick, shallow
Bradypnea
- Abnormal slow breathing
DO’S Apnea
1) Establish baseline data - Cessation of breath
a. monitor and assess changes in px’s Hyperventilation
health status - Over expansion of lungs
2) explain the procedure to the px Hypoventilation
3) use 2 fingers - Under expansion of lungs characterized by
4) place px in comfortable position shallow respiration
5) get the pulse in 1 full minute, if irregular, Stroke Breathing
another 1 minutes - Rhythmic waxing and waning of respiration
6) for infants use apical pulse from very deep to very shallow breathing and
temporary apnea
DON’T’S
1) Don’t use the thumb
 6. Fine Crackles
- Popping sounds like wood turning
- Discontinuous
- Inspiration and Expiration
Fast or Effort
- Difficult and labored breathing during
which the individual has a persistent,
unsatisfied need for air and feels
distress
Orthopnea
- Ability to breath only in upright sitting
or standing position
- Orthopneic position
DO’S
1. For infants and children
- Observe the rise and fall of chest. You can
place hand to chest to feel the rapid
movement
- Have an adult hold the child to reduce
movement
2. In Elderly
- Ask PX to be quiet or count respiration after
taking the pulse
DON’T’S
ADVENTITIOUS LUNG SOUNDS - Don’t take RR when crying or from
1. Course Crackles activity.
- Low pitched sounds PURPOSE
- Bubbling or gurgling - To acquire baseline data against which
- Coughing won’t clear future measurements can be compared.
- Inspiration/Expiration
2. Wheezing
- Musical sound NORMAL RESPIRATION RATE
- Inspiration + Expiration 1 year
- High pitched - 30 – 40 cpm
- Continuous 1-2 years old
 Bronchoconstriction - Bronchial asthma - 25 – 35 cpm
in acute exacerbation 2-5 years old
3. Rhonchi - 25 – 30 cpm
- Sonorous wheeze 5-12 years old
- Inspiration + Expiration - 20- 25 cpm
- Caused by secretions 12 years old
- Clears with coughing - 12 – 20 cpm
- Continuous
4. Blood Pressure
 Measure of pressure exerted by the blood as it
4. Stridor flows through the arteries
- High pitch
- Inspiration Systolic Pressure
- Upper airway - Contraction of hear
- Snore Diastolic Pressure
5. Pleural Rub - Relaxation of Heart
- Leather sounding - The difference b/w diastolic and Systolic
- Cry grating sound Pressure is Pulse Pressure (120 – 80 = 40)
- Inspiration/Expiration
Hypertension - Wong Baker Face Scale
- Above normal
Hypotension 12 STEPS OF HANDWASHING
- Lower than normal
Orthostatic Hypotension 1. Wet hands
- Blood pressure when sitting or standing 2. Apply soap
Korotkoff’s Sound 3. Rub palm to palm
- Series of sound when taking BP using 4. Rub back of the palm
stethoscope 5. Rub palms with finger interlaced
6. Rub back of fingers with fingers interlocked
DO’S 7. Rub each thumb
1. Explain that you’re doing to PX 8. Rub tips of fingers in a circular motion
2. Locate brachial artery + place the center 9. Rub wrist
3. The bladder cuff must be appropriate to the 10. Rinse hands
age of client 11. Turn off faucet use elbow or tissue
4. The ff should be observed: 12. Dry hands with clean cloth
o Bladder cuff must not wide or narrow
o Arm supported 5 MOMENTS OF HAND HYGIENE
o Sufficient rest - An approach that defines key moment when
5. Take BP 30 mins after meal or after the PX is health care workers should perform hand
relieved from pain hygiene
6. Palpate brachial artery with fingertips 1. Clean hands before touching a PX
7. Pump the cuff until you no longer feel the 2. Clean hands before clean or aseptic procedure
brachial pulse. 3. Clean hands after body fluid exposure risk
8. Position stethoscope properly, as the pressure 4. Clean hands after touching a PX
as the pressure fall when value release identify 5. Clean hands after touching PX surrounding
manometer reading
9. Remove WFF, wipe with disinfectant because it Gallon of Disinfectant
can be contaminated 1. 1 US gallon = 3.79 liters
2. ¼ cup bleach (sodium hypochlorite) = 4
DON’T’S tablespoon
1. Don’t get PX BP on arm or thigh with ff
situation DISINFECTANT VS. ANTISEPTIC
o Shoulder  Widely used for cleaning bot health care,
o Arm, Hip, Knee, or ankle injured or facilities, and house
disease.  Contain various chemical components, a
2. Don’t wrapped cuff too lose or tight majority of which have been used as cleaning
3. Don’t deflate valve too quick or too slow agents for ages
4. Don’t take BP when PX arm is above heart  It’s a fact that they both use for destroying
above disease
5. Don’t take BP after meal, smokes, or in pain. Disinfectant (Hydrogen Peroxide)
6. Don’t take BP to quickly, wait 1-2 mins before
further determination.  Chemical substances that can be applied to
non-living object or surfaces to inhibit the
NORMAL BLOOD PRESSURE growth of microorganism

CATEGORIC SYSTOLIC DIASTOLIC Hydrogen Peroxide

Normal Less 120 Less 80
 Use to clean surgery tools and rooms
Elevated 120-129 Less 80
HPN stage 1 130-139 80-89 Examples: Alcohols, Oxidizing Agents, and Bleach
HPN stage 2 140 or higher 90 or higher
 They may not necessarily eliminate all the
HPN stage 3 Higher than Higher than
microorganism
180 120
5. Pain
- Subjective
  Some microorganism may be resistant to  Against gram-positive and gram-negative
some disinfectant becoming difficult to kill vegetative organism and fungi
them completely  Short-lived persistent
 So the disinfectants can only reduce the  PX allergic with CG use PI with 70% alcohol as
microorganism to a level which they can’t bring alternative.
harm to health or harm the quality of
perishable producers.
 In such cases, the best thing to do is use INTRAVENOUS THERAPY
disinfectants of higher concentration for
maximum results.  Giving medication through IV
 “within the vein”
 Included in the designation of specialty drugs
Antiseptic
 Used to correct electrolyte, imbalances, to
 These or chemical agents use to destroy or deliver medication, for blood transfusion or as
prevent the growth of microorganism that fluid replacements to correct it.
could cause infection or disease  It can also be used in chemotherapy
 They are applied on broken skins to kill disease
CRYSTALLOIDS
causing microorganism that might have
infected the areas or keep them away from HYPOTONIC The cell will Less 240
these areas. shrink
 Therefore meant to applied on living tissue ISOTONIC Remain the size =240
with zero injurious effect on the body surface of cell
 May also act as sanitizers for cleaning the HYPERTONIC The cell will More than 340
hands to remove bacteria when a person shrink
cannot wash hands
COLLOIDS
Examples: Mouthwash, cold, sores, treatment creams
 Larger soluble molecules
Disinfectant
 Volume resuscitation, but not primarily the
1. Inhibit growth of microorganisms blood amount.
2. Disinfects
3. Very toxic Examples:

Antiseptic o Albumin – attracts to pull in the liquid

- kind of protein and looks like
1. Destroy the microorganism sponge
2. Reduce risk of infections - osmotic pressure
3. Have no injurious effect o Plasma Expander – expanding the plasma
Both o Dextran – also called as plasma expander

1. The both inhibits spread of microorganisms HYPOTONIC ISOTONIC HYPERTONIC

2. Differ is on their application 0.45 NSS Irrigating D5LR
solution
Benefits of Chlorhexidine Gluconate 0.3 NaCl PNSS (green) D5NM
D5W or 5% D5NSS or 5%
 Strong affinity for binding to the skin
dextrose in dextrose for
 High antibacterial activity water (red) normal
 Prolonged residual effects on rebound maintenance
bacterial growth PLR or plain Mannitol
 Exhibits excellent activity against gram- lactated
negative vegetative organism and fungi rangers
Benefits of Povidone Iodine
Hypotonic IV fluids are usually used to provide free
 Generally associated with low toxicity and
water for excretion of body wastes, treat cellular
little irritation
dehydration, and replace the cellular fluid.
Hypertonic IV solution – used to treat dehydration 2. Infiltration
and decrease sodium and potassium levels. Used to  Dislodgement of IV cannula, passing
replace electrolytes. through interstitial cells
S/SX:
- Don’t give hypertonic solutions to a patient with any
a. Woolness
condition that causes cellular dehydration such as
b. Swelling
diabetic ketoacidosis nor should any patient with
c. Discomfort
impaired
d. Blanching (+) indentation – pag
BLOOD PRODUCTS pinindot, matagal bumalik
e. Slow IV frate
1. FWB
f. (-) backflow
 fresh whole blood
 RBC, WBC, Plt
 When peripheral Intravenous goes
2. WBC
wrong
 80% WBC, 20% Plasma
 For leukocytopenia px
3. Extravasation
3. RBC
 Inadvertent deposition of intended
 80% RBC, 20% Plasma
intravenous fluids into surrounding
 FOR Hgb and Hct
tissue.
4. Fresh frozen plasma
 Globulin, albumin TX FOR INFILTRATION AND EXTRAVASATION:
 For bleeding disorder a) STOP INFUSION, DISCONNECT IV, and
 Fast drip thoroughly assess
5. Platelet b) Intervention based on assessment
 For thrombocytopenia px o Warm, moist, cool compress
6. Albumin o Cool compress for known
 For pulling pressure irritant (KCI, xray contrast)
COMPLICATIONS OF IVT o Dressings usually not
necessary; use with caution
1. Hematoma o Restart IV with opposite arm
 Ruptured blood vessel c) For extravasation, follow unit
S/SX: protocols, notify M.D., fill out drug
report form, and monitor closely
a) discoloration of skin d) Document infiltration and
b) site swelling and discomfort extravasation in medical record
c) inability to advance the cannula all the
way into the vein during insertion 4. Phlebitis
d) resistance to positive pressure during the  Inflammation of the vein in which the
lock flushing procedure endothelial cells of the venous walls
become irritated and cells roughen,
 Monitor first hour, q15, and monitor v/s allowing platelets to adhere and
 2nd hour, q30 predispose the vein to inflammation-
 3rd hour, q1° induced phlebitis.
 The rest, q2°
S/SX:
TX: a) Tender and warm to try painful
a) apply direct pressure for 2-3 mins after
needle is removed TYPES:
b) have the px evaluate extremity to avoid A) Mechanical – outside
edema B) Chemical – medication
c) apply ice C) Infectious
 TX:  Warm to touch
a. Remove short peripheral catheter  STRICTLY NO MASSAGING TO AVOID
b. Obtain cultures if infection is EMBOLOUS
suspected
c. Cleanse the site with antimicrobial VENIPUNCTURE
solution
d. Apply warm, moist compress  Aspirating blood
e. NSAID, mild exercise  Distal vein first
f. Modify medication if chemical  Easily palpatory with good capillary refill
phlebitis is suspected notify MD  Non-dominant side
 Opposite on surgical opposition
5. Thromboembolism/Thrombophlebitis  Largest diameter
 Occur when a small clot becomes
MUST NOT BE:
detached form the sheath of the
cannula or the vessel wall – prevention a) Areas of flexion
is the greatest form of defense. Flush b) Obvious valves
cannula regularly and consider re- c) Superficial
siting the cannula if in prolonged use. d) Sclerotic
e) Infected site
CIRCULATORY OVERLOAD f) Broken vein
 Excess fluid disrupting homeostasis g) Distal to fracture
caused by infusion at a rate greater
VEINS OF FOREARM:
than the px system is able to
accommodate. 1. Cephalic vein
o KVO – keep vein open (lock) 2. Median cubital vein
o Notify physician 3. Accessory cephalic vein
o High fowler’s (2 pillows) 4. Basilic vein
o Document 5. Cephalic vein
6. Air embolism 6. Median antecubital vein
 At least 9cc fetal VEINS OF HANDS:
 Cyanosis
 There’s air in spaces between blood 1. Digital dorsal vein
stream 2. Dorsal metacarpal vein
TX: 3. Dorsal venous vein
a. Turn to left side to promote backflow 4. Cephalic vein
b. Lower the head 5. Basilica vein
c. Notify physician IV COMPUTATION

7. Infection FORMULA: Volume (mL)/minutes or hr X Drop Factor

 Bacteremia or septicemia (gtt/ml) = Flowrate (gtts/ml)
TX: 1000mL = 1 Liter
a. Aseptic technique
b. Discontinue and restart
c. Obtain WBC count
d. Antibiotic as ordered
11 NURSING CORE COMPETENCIES
8. Venous Thrombosis 1. Safe and quality nursing care
 Affect large veins at dorsalis pedis site - Provides sound decision making in the
 EMBOLOUS – clot is travelling care of individuals/groups.
 THROMBUS – stagnant clots - Promotes wholeness and well-being
including safety and comfort of
DVT – deep vein thrombosis patients.
 Change in color
 Leg pain
 Edema
2. Management of resources and environment
- Utilizes resources to support patient care.
- Ensures availability of human resources.
3. Health education
- Assesses the learning needs of the patient and
family.
4. Legal responsibility
- Adheres to practice in accordance with the
nursing law and other relevant legislation
including contracts, informed consent.
- Identify legal issues affecting the client (e.g.,
refusing treatment)
5. Ethico – moral responsibility
- Respects the rights of individuals/groups.
- Accepts responsibility and accountability for
own decisions and actions.
6. Personal and professional development
- Pursues continuing education.
- Gets involved in professional organizations
and civic activities.
7. Quality improvement
- Utilizes data for quality improvement.
- Participates in nursing audits and rounds.
8. Research
- Utilizes varied methods of inquiry in solving
problems.
- Recommends actions for implementation.
- Disseminates results of research findings.
9. Record management
- Maintains accurate and updated
documentation of patient care.
- Records outcome of patient care.
10. Communication
- Utilizes effective communication in relating
with clients, members with the team and the
public in general.
- Utilizes effective communication in
therapeutic use of self to meet the needs of
clients.
11. Collaboration and teamwork
- Establishes collaborative relationship with
colleagues and other members of the health
team for the health plan.
- Functions effectively as a team player.
Cardiopulmonary Resuscitation (CPR) -
emergency procedure that combines chest
compressions often with artificial ventilation in an
effort to manually preserve intact brain function until
further measures are taken to restore spontaneous
blood circulation and breathing in a person who is
in cardiac arrest.
Actions:
1. Check the area for safety.
2. Check unresponsiveness (Are you ok?). Quick
check for normal breathing.
3. Call for help.
Location: Xiphoid
Chest compressions: 100 to 120 per minute. 30 per
cycle. Total of 4 cycles.
: 2 to 2.4 inches deep (5-6cm)
After 30: Allow chest to recoil
Mouth to mouth resuscitation:
1. Maintain airway
2. Pinch nose shut
3. Open your mouth wide, take a normal breath,
and make a tight seal around outside of
victim’s mouth.
4. Give 2 full breaths (1sec per breath) for every
6s
5. Observe chest rise and fall; listen and feel for
escaping air.
DIAGNOSTIC TEST
Glucometer – assess blood sugar.
- Hyperglycemia and diabetes.
- Diabetes 1: insulin is inadequate
- Diabetes 2: insulin is resistant
1. Assess:
- Fingers (index or all); side part of the finger
(because less nerve ending). Baby = heel
- Check if px is taking any drugs like aspirin
(anticoagulant)
- Activity (the more active the patient is =
decrease blood sugar)
- Food
3. Gather equipment:
- Glucometer
- Reagent strip
- Antiseptic swab
 - Disposable gloves NPO for 8-12hrs
- Sterile lancelet
DM – Diabetes mellitus
3. Explain to the client the procedure
CBG – capillary blood glucose
4. No food or drink
FBS – fasting blood sugar
5. Wash hands
HBA1C – Hemoglobin A1C
6. Provide privacy
- Glycated hemoglobin = no NPO
7. Prepare the equipment - Testing the ability to attach to RBC
- RBC lifespan = 90 – 120 = 3 to 4 months
8. Obtain reagent strip (calibrate )
- Most sensitive
9. Locate the side of the finger
OGTT – Oral Glucose Tolerance Test
10. Milking
(CBG increase = px can tolerate)
11.Put on gloves
12. Place injector
13. Prick the site
SPECIMEN COLLECTION
14. Wipe away the first drop with dry cotton balls Urinalysis (U/a)

15. Gently squeeze 1. Assess: Ability to collect urine sample.

16. Read the result Color: Amber

17. Apply pressure to the site Odor: Distinct/Ammonia like/ Aromatic

Consistency

Result reading: 2. Assemble:

1. Gloves (clean)
Fasting PC 2-3hrs 2. Specimen container (clean)
(After PC Urine culture & sensitivity (sterile)
eating)
Normal 70-110 170-200 120-140
Prediabetic 101-125 190-230 140-160 Label (name, date and time, collector, room #)
Diabetic 126+ 220-300 200+
Good for 1hr.

Hypoglycemia – low blood sugar. Put in ice to maintain quality

- Sleepiness 4. Explain to the client the procedure

- Sweating
5. Wash hand
- Pallor
- Lack of coordination 6. Provide privacy
- Irritability
7. Instruct how to clean the urinary meatus with
- Hunger
antiseptic (Front to back *Women) (Circular motion
Hyperglycemia – high blood sugar. *men)

- Dry mouth Wash with:

- Increased thirst (polydipsia)
Betadine
- Blurred vision
- Weakness Soap and water
- Cephalgia
- Polyuria
- 3 Ps is present (Polyuria (excessive urinating), 30-60mL
Polydipsia (excessive thirst) and Polyphagia
Midstream – less contaminated
(excessive hunger)).
Wee bag – for pedia - Less than 3yrs old (shorter) (downward)
- Greater than 3yrs old (longer) (upward)
*Collect from catheter
Use clean gloves
Suppositories – cone shaped, solid drug that is
Clamp for 30mins if px can’t urinate
inserted into a body opening. It melts in body
temperature.

Fecalysis (F/a) =Side lying position

Clean gloves = collecting stool - A rectal suppository is inserted into the

rectum.
Sterile Gloves = stool culture and sensitivity - Left side lying.
Assess: ability to urinate - Clean gloves

FOBT – Fecal Occult Blood Test Enema – a medical treatment commonly used to
treat constipation where liquid is introduced
ADCF for 3 days to avoid false positive result
Fleet enema – treat constipation
Diaper – scoop
*left side lying
Lactulose (pampadumi) if px can’t excrete
Cleansing enema – cleansing feces
Enema
- Fecal impaction
Suppository (left side lying pos)
Colonoscopy – left side lying
Carminative enema – expel flatus (fart)
Ophthalmic Instillation Peristalsis – movement of intestine
Ophthalmic neonatorum – conjunctivitis of the Paralytic ileus – paralyzed intestine
newborn.
Administration:
Administration:
1. Provide privacy.
1. If ointment is used, discard the first bead. 2. Lubricate the tip of enema tube.
2. Instruct the client to look up. Low enema – hang the container no higher
3. Expose the lower conjunctival sac by placing than 30cm (12in)
the thumb or fingers of your non dominant High enema – hang the container about 45cm
hand. (18in)
4. Avoid touching the tip of medication 3. If pain persist use clamp – explain to px pain
5. Approach the eye from the side and instill the to unclamp
correct number of drops.
6. Instruct to close the eyelids but not squeeze Soap sud enema (18-20in)
them shut.
7. Press firmly for 30seconds
Ear drops
Administration:
1. adults and over 3yrs old pull the earlobe
upward and backward to straighten the
external.
2. Under 3yrs old pull earlobe downward then
backward.
Eustachian tube - a narrow passage leading from the
pharynx to the cavity of the middle ear, permitting
the equalization of pressure on each side of the
eardrum.