Fundamentals of nursing

Metaparadigm of nursing:
• 4 major concepts in nursing
Person
Environment
Nursing
Health

Basic human needs:

• maslow's hierarchy of needs
Safety & security
• tragedy
• fire
• poisoning
• restraining

Safety and security Sex is the least priority

1) tragedy - internal (inside the institution); external (outside the institution)
• Priority: activate the disaster plan
• #codes:
1 - bomb
5 - fire
9 - earthquake
0 - mass casualty
• color codes (inside the institution)
Black -death
Blue - cardiac arrest (management: CPR)
• best time to CPR = (-) pulse; (-) breathing
Red - medical emergency, but no arrest
Yellow - infectious material (syringe, gloves)
• puncture proof container-blue
Amber - (pink) abduction
Orange - chemotherapeutic agents
 Protocols in external tragedy:
1) survey the scene
2) call for help
3) assess CAB (primary survey)
to identify life threatening conditions to save life of a person
4) secondary survey
to perform 3-5 series of physical examination

"Triage is performed when primary survey is initiated"

Triage:
black - death
red - life-threatening current man management)
yellow - potential life threatening (emergent; can be delayed)
Orange - radioactive material
green - walking; minor injuries; walking wounded
white - no injuries
2) fire
General considerations to remember:
• No use of oxygen Types of extinguisher:
• No use of elevator
A - Paper, plastic, wood, clothing
B - Flammable (paint, gas,
•self is on fire: thinner, alcohol)
- STOP E - Electrical (faulty wirings)
- DROP
- log-roll
Methods of extinguishing:
• protocols:
R - rescue pt. /evacuate P - pull the pin
A - activate fire alarm A - aim at the base
C - confine the base S - squeeze lever
E - extinguish fire S - sweep nozzle from side to side
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3) poisoning
don't induce vomiting if:
• 1st, call the poison control center • strong / corrosive chemicals
• administer an agent that can induce • unconscious (aspiRaTon preumonia)
vomiting • milk , yogurt, carbonated beverages
SYRUP OF IPECAC = cardiotoxic/neurotoxic

Dosage:
• 15-30 mL + 1 glass of water, after only administering the drug
• 5-15 mL + 1 glass of water, before and after
vomiting time:
• after 20-30 mins, if pt did not vomit:
Repeat the dosage at once
• If no vomiting, STILL:
Call the nearest institution

Management:
• administer activated charcoal (absorbent)
• gastric savage (decompression) /aspiration /evacuating components
• administer antidote
4) restraining
• limitation of a body movement relating to a condition
Types:
• physical - "device"
• chemical - "drugs" anesthesia
• environmental - "seclusion, isolation" "quarantine"
General nursing considerations:
1) no order, no restraint
2) no restraining to unconscious patients / pregnant woman
3) no prn orders (should always be planned)
4) time considerations: physical restraining
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Nursing considerations: ⑧
• q 30 - assess / check restrained part
• q 1 - medical / doctor evaluation
• q 2 - possible removal of the restraint
• q 12 - obtain verbal ) medical order prior to execution of restraining order
• q 24 - max duration of restraining order

Patient's bill of rights:

• promulgated by American hospital association
privacy - applied to body parts
autonomy - freedom / right to self- determination
treatment w/ confidentiality - information
When is the best time to divulge information?
1) threat to public safety ⑧
2) requested by the honorable court to be used as evidence: subpoena duces tecum
• If the nurse testifies: subpoena ad testificandum
3) during nursing rounds
4) during nursing endorsement
information and education - health teaching
need not to be restraint
treatment refusal
• explain: doctor
• reiterate: nurse
• sign: patient
services - hospital admissions an detentions; issues ⑧
• refer patient to social worker if they can't pay their bills
 nursing theorists:
• Florence - environmental (adaptation + environment)
• Hildegard - interpersonal relations (npi)
• Virginia - 14 basic needs
• Lydia - 3 C's (core, care, cure)
• Dorothy Johnson - behavioral system model
• Dorothea Orem - self care deficit
• Faye Glenn Abdellah - dimensions of individuals; 21 areas of nursing problem
• Ernesten - clinical model: a helping art model
• Martha Rogers - science of unitary human beings
• Imogene king - goal attainment theory
• Myra estrine - 4 conservation principles; (personal energy, social, structural)
• Sr. Callista Roy - adaptation theory (adaptation + condition)
• Betty Neuman - health care delivery system model
• Jean Watson - human caring model
• madeleine leininger - transcultural nursing
• Rosemarie parse - human becoming
• Joyce travelbee - interpersonal aspect of nursing (levels of clientele)
• Patricia benner - level of nursing expertise
Number of

11
Characteristics Example
years
Novice O No experience (adheres rules, inflexible, Bsn graduate , student nurse
limited)
Advance beginner Newly passer, r.n, trainee
1-2 Acceptable performance demonstration

Competent 2-3 Consciously plans nsg actions / organize Staff nurse

Perceives nsg situations carefully • Academe: ci, dean

Proficient 3-5 Follows maxim protocols, guidelines, and • hospital: head nurse,
standard supervisor, chief nurse
Expert +5 Excellent nurses, perfect state of art BON, review center lecturers
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Nursing documentation system
• computerize - nsg informatics (1992)
• manual - charting

Types of manual charting:

1) source oriented - (narrative charting; pgh / up)
2) problem - oriented - soapie
3) planning, intervention, evaluation - shortest
4) charting by exemptions - charting abnormal, significant,
untoward observation, ICU
5) focus- charting - FDAR
Who primarily owned patient's chart?
• health care facility / institution
-

How to document a mistake in the document:

• draw a horizontal line, initials, time and date (institutional)
• (put open and close parenthesis) mistaken entry / "error"
Nursing process - ADPIE
• Systematic, dynamic Types: IPET
• integral part • initial: upon admission
• "nurse" initiator • problem-focus: gathering information
• blueprint is NCP based on the concurrent condition
• emergency - based on vulnerability
Assessment: (unpredictable)
• main issue "data" • time-lapse assessment: gathering
information
collection
observation After hospitalization
validation • patient follow-up care
documentation • check up
multi-focal approach
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Pattern of assessment:
• interaction - subjective
• observation - signs and symptoms, contraptions, machines
• measurement - vital signs, intake and output, BMI
Diagnosis:
• formulation of nursing diagnosis
• NANDA
problem
etiology
signs and symptoms

Analysis (breakdown of information) Systhesis/ summarization/ conclusion (Nursing

Etiological causes: implication)
• immediate - related to Goal: to identify gaps and inconsistencies of data
Types:
• intermediate - reason of r/t
wellness - most unique, single-labeled statement
• root - disease process
risk - no r /t
actual
potential - manifestation only happens once
syndrome - clustering of condition or event
Outcome identification:
• pertaining to the pathophysiology of the disease
Planning:
• forecasting, futuristic Long-term = goal
• common act of nurse under planning Short-term = objective
1) setting priorities
2) establishing goals and objectives V/s: Bp = 10 mins
3) planning interventions T = 7 mins
• bp
• TPR Pr = 1 min
Rr = 1 min
• pain Pain = 1 min
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Types of planning
• initial
• ongoing
• discharge-upon admission;
"Flow sheets" are seen in charts (pile of paper)
"small paper" - kardex (include patient's S.0)

Implementation: Skills:
1) validation 1) cognitive - decision-making
2) giving continuous care 2) interpersonal - communication
3) collection of nursing interventions 3) technical - hands on procedure
Types of implementation:
• independent - nurse initiates
• dependent - doctor
• interdependence / collaborative - to refer & re-integration
Nursing evaluation phase
1) comparison of previous to present condition
2) re-assessment because of feedback mechanism
3) IOT
initial
ongoing
terminal
Parameters:
• perform effectiveness
• efficiency
• adequacy
• availability
• attainability
• appropriateness
Standards of evaluating patient care:
• quality assurance
• quality improvement - incident report
• nursing audit

Standards of nursing quality.

1) structural evaluation - where ( builds laboratory)
2) process evaluation - how (care is given - NGT insertion)
3) outcome evaluation - result (development of abdominal cramping )
Example:
• incident report - unusual occurrence report (UOR)
Systematic and factual
no conclusion and over generalization
write the name: who committed the crime; witness; who is within the crime
submission - no delay of report
• submit it to your immediate superior (head nurse, nurse supervisor, chief nurse)
• delay only if patient is in emergency
• incident report is not a part of your chart
Nursing audit:
• chart: in order to rule out nurse-patient ratio
evaluative sheet: peer evaluation sheet (scoring)
Nurse - patient interaction

Phases: POWT
• Pre-orientation:
only phase where there is no patient involvement
review of records (chart)
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• Orientation phase:
T - trust
I - initial assessment
M - mild anxiety (emotion management)
E - environment orient

"Mild anxiety related to fear of the unkown"

Environment orientation: ⑧
Best time to terminate nurse-pt relationship:
• Place
• orientation (to prevent sepanx)
• Date
• Time

• Working phase: • Termination phase:

t - teaching R- reintegration
l - learning E- enhancing independence (goal)
c - change (attitude, knowledge, skills) S - synthesis / summary
Goal: to enable patient to be independent T - termination
 Concepts of immobility

Exercises:
1) good appetite
2) range of motion
3) improve GI motility

Range of Motion - comfortable movement of the joint

Types:
• active - patient alone
• passive - aided by healthcare workers

Mobility:
Body mechanics
• efficient
• coordinative
• safe transfer from one place
Principles:
1) lessen body's energy expenditure
• body parts used appropriately
• use of rhythmical movement @a normal speed
• reduces friction
• push/pull rather than lift
• hold the object close to your body
• Breathe normally (inhale nose, breathe mouth)
• use of assistive devices (wheelchair, Kelly)
2) improvement of safeties
• face direction of workplace
• ask for help/assistance
• > 35 % BW of patient ⑧
• contract abdominal muscles to stabilize pelvis (SPP) or (starting point position)
⑧
• Eliminate all objects that may hinder - banana
• Use safe and coordinated movements rather than fast and jerky movements
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3) stabilization promotion
• place feet wide apart: body mechanics (broad stance)
• adjust height of workplace
Side knowledge:
placenta is buried under a banana tree
amputated part is buried ahead to the cemetery
if there is a wake, you may go, but don't gamble/ disperse information, just support
sleep with the poorest of the poor
⑧
to identify morbidity and mortality rate - home visit
Transferring

Nursing consideration:
• plan the transfer
• complete all materials needed
• redirect all personal during transfer
• eliminate all object that may hinder
• document (time, type of transfer, number of personnel utilized, reaction before, during and
after)
Ways:
1) angling the chair @ the bedside 90 degrees
position @ foot - if patient is very weak
2) transfering patient without a belt
chest - back (interlock) - minimum support
chest - shoulder - maximum support
3) transferring with a belt
2 nurses@ both sides of pt
4) three-person carry
head- first person gives instructions
buttocks - 2nd personal is strongest; 3rd is accessory
5) using a sliding board
side-lying
place belt (3); (1) chest; (2) waist; (3) knees

Assistive devices

1) walker
Types:
two - wheeled (standardized)
four-wheeled
• too high: reacher
• too low: stoops
Gait:
• 2 point gait (minimum)
• 3 point gait (maximum)
1) 2 point gait: advance the walker + affected leg → unaffected
2) 3 point gait: advance walker → affected leg → unaffected leg
Affected leg always moves first!
2) cane
Types:
straight -legged (minimum)
quad cane (maximum)
Gait:
• 2 point gait: advance the cane + affected leg → unaffected
• 3 point gait: advance the cane → affected leg → unaffected leg

3-point gait

2-point gait
Characteristic of affected leg = cane and affected leg always in line with each other
to promote balance
Characteristic of unaffected leg = slightly forwarded to both the cane and the
affected leg to regenerate walking
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3) crutches
• U - underarm/axillary crutch - most common
• L - loft strand
• P - platform - rare
Gait:
1) 4-point
2) 3-point
3) 2-point
4) swing to / swing through

4-point - not applicable to narrowed; "visualized as a normal walk"

• right crutch → left leg → left crutch → right leg
3-point: advance both crutches → affected leg → unaffected leg
2-point: right crutch + left leg → left crutch + right leg (military walk)
swing to gait - paralysis; below the knee amputation
• advance both crutches → swinging body to move to through the crutch to move
swing through gait: advances both crutches → swinging body to move through the
crutch to move
 General nursing considerations:
• rubber tint, worn out rather than others
• no flat shoes;
• no laces; rubber shoes w/ properly secured laces can be used
• use low - heeled shoes
⑧
• non-skid shoes
/

Complications: ⑧
• tingling sensation, numbness, cyanosis (crutch palsy) = radial nerve

Going up the stairs: unaffected leg first → nurse at the back, sliding on the affected leg
Going down the stairs: affected leg first → nursing one step down the affected leg
 Nursing diagnostic procedures
1) visualization procedure
2) collection of specimens
general considerations:
1) use of gloves
2) labeling the container
3) sending to laboratory

purpose: Sputum collection

1) Sputum analysis
2) Culture and sensitivity - identify specific microorganisms and drug sensitivities)
3) Cytology - identify origin, structure, function, & pathology of cells.
- identify lung cancer and its specific cell type (e.g. Bronchogenic carcinoma)
- require colllection of 3 early-morning specimens.
4) Acid fast bacilli (AFB) - check presence of Active Tuberculosis
- require collection of 3 consecutive days
Nursing considerations:
S - spit out ( 4 - 10ml )/ ( 1 -2 teaspoon )
P - postural drainage
U - universal precaution (gloves, gown, mask)
T - teach deep breathing (pause 2-3 secs), then cough vigorously for 3 times
U - unpleasant tasting (observed post-sputum collection)
M - morning (best time to collect)
• allow pt to gargle water
• no foods prior to sputum collection
Urine collection
• Clean → quantity: 15-30 ml (Urinalysis, Midstream clean catch)
• Sterile → quantity: 5 ml (24 hour urine collection (timed collection), culture and
sensitivity, urine collection using a catheters bag)
l Urinalysis or clean voided → gross appearance of the urine

Color: amber / strong

Odor: aromatic (has a distinct smell)
Ph: 4.5 - 8.0 (Average 6) → slightly acidic (concentrated or diluted) → dehydrated
Specific gravity: 1.010-1.025-30
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• amount → at least 10 cc
• when to perform → 1st voided in the morning (contains higher and more concentration and
more acidic)
example: pregnancy test
Reminders:
• specimen must be free of fecal contamination
• avoid putting tissue on the bedpan
Melt Clean - catch or Midstream Urine specimen → detects Urinary Tract Infection
Container: Sterile
• UTI:
Diet → Acid Ash Diet (to acidify urine and kill bacteria)
prunes juice
Cranberries
plums
Increase Oral fluid Intake (to flush out)
Hygiene
Cotton underwear (absorbent)
• No silk, nylon
Regular voiding
Shower but no tub bath
void after sex / coitus
/
24 hr urine collection, culture and sensitivity,
• renal function test; glomerular function rate
• discard first flow rate
• collect all succeeding urine
• store for 24 hrs (keep it cool, refrigerate);
if no refrigerator, use ice bucket
⑧
if no ice bucket, ice pack and attach
• add preservatives as per institutional policy (boric acid)
-
urine collection using catheter bag
Nursing management:
• clamp - 30 mins - 1 hr
• clean - alcohol wipe
• collect - sterile; puncture 45 degrees
No clamping if pt is post-genitourinary surgery
random urine collection:
• anytime of the day, send it to lab
don't store urine (will harbor microorganisms)
second voided urine sample:
• checking of glucose and
albumin
Dispose all of the urine
drink 1 glass of water
collect urine sample

Semen collection

Purpose: sperm count; sperm analysis

• 3-5 ml per ejaculation
Health teaching: (prior)
• instruct pt to abstain for 72 hrs (3 days)
• collect all specimen sample
• send to laboratory
 Stool collection

• 1 inch sample & send it to laboratory

Purposes:
1) fecalysis - gross appearance of stool; presence of ova & parasites

• sterile container
• fecal material on a dry bed pan or commode
• no contamination of urine, soap and toilet paper (bismuth compound)
2) fecal occult blood test (guaiac test)
Purpose:
• hidden blood in the stool
Mechanisms:
• hemoccult - filter paper impregnated with guaiac
• hematest - an ortholidin agent/ test
• colon care - newest; no smearing (most expensive)
Result: ⑧.
• no change in color - negative
• color blue - positive
• color light blue - re-test
Nursing considerations: prior
1) diet: high residue diet
2) no red meat for 3 days (beef, pork)
3) no citric acid intake
4) no NSAIDs Alert: test all portions of stool sample
5) no steroids
6) no vit. C
7) no dark colored foods (vegetables)
8) no bismuth compound
9) no contamination of urine, soap, and toilet paper
3) stool culture and sensitivity
-

• to search for etiological agent ( gastro enteritis )

• bacterial sensitivity for antibiotic

Blood

• Arterial blood gas - contains oxygen

• venous - without oxygen (routine blood examination)
• capillary - newborn: ra 9288 newborn screening of 2004 (site: heel stick)
- adult: hemoglucose test or CBG (site: finger stick)
Blood examination:
• fasting: bun, creatinine, lipid profile
• non-fasting: CBC, hgb, hgt, serum electrolytes, enzyme studies, clotting factors
Nursing management:
• apply direct pressure to prevent bleeding
Consider:
• No cold application, alcohol use, elevation of extremities, no pricking at the central
site
Thoracentesis

• lung tap; pleural tap

• aspiration of fluids in the pleural spaces to relieve the following conditions:
pneumothorax
Hemothorax (blood)
Pyothorax (pus)
Hydrothorax (water)
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Pre-op:
• secure the consent
• Monitor vital signs (baseline data)
Intra-op:
• position: sitting position, lean forward using an overbed table
• Insertion:
stay still and instruct patient not to cough to avoid perforation of the lungs
Post-op: ⑧
Alert: position is on unaffected side (to promote lung expansion) - 2 hours
• Expect bleeding
Assess for:
• sputum (blood)
• difficulty of breathing (breath sounds) wheezing and stridor
• oxygen saturation
• pneumothorax
• chest X-ray
Paracentesis

• Abdominal tap
• removal of fluids in the peritoneum to relieve ascites
media
• liver cirrhosis
• gastric cancer
• trauma
Pre-op:
• secure consent • Measure of
• npo (8-10 hrs) abdominal girth (tape
measure at the level of
• monitor vital signs ( bp, rr, pr) the umbilicus and then
• empty bladder and bowel (to prevent puncturing bowel) wrap around)
Intra-op:
• position: sitting, supine, (both arms are extended upward), lateral decubitus
• site (trocar):
2-3 cm below the umbilicus
2-4 cm lateral of the anterior superior iliac spine
Post-op:
• monitor vital signs every 15 mins (1st hour)
• measure of abdominal girth, weight
• check for peritonitis

Liver biopsy
• Liver tap
• small slender coil of liver tissue sample aspiration
Types:
• percutaneous (most common)
• transjugular (rarest)
• laparoscopic (expensive)
Pre-op:
• secure consent
• monitor vital signs
• npo (6-8 hrs)
• monitor clotting factors (pt); vitamin K @ bedside
• monitor for use of anticoagulant (plavix, coumadin, eliquis)
• monitor for use of anti-thrombolytics (aspirin)
• instruct to avoid: Shaving (bleeding)
• not necessary to empty the bladder and bowel
Intra-op: 5 mins
• position: supine @right side of the bed
Aspiration:
• instruct pt to deep breath for several times
• hold breath (doctor will insert needle for extraction)
• exhale
Post-op:
• Position: affected side (right side-lying) 4 hrs, to apply pressure and prevent
bleeding
• bed rest (24 hrs)
• check for further complication: peritonitis

Lumbar puncture

• lumbar tap, spinal tap

• aspiration of cerebrospinal fluid
• L3- L4, L4 - L5, L5 - S1
Purpose:
• check bacterial, fungal, viral infection of the brain (meningitis, encephalitis, syphilis)
• check bleeding around brain (subarachnoid hemorrhages)
• condition of brain and spine
• inflammatory conditions: myasthenia gravis and GBS
• autoimmune disorders
• Alzheimer's and other forms of dementia
Pre-op:
• secure consent
• monitor v/s
• empty the bladder or bowel
Intra-op:
• position: side lying in fetal position, c-position, shrimp position
Health teaching:
• instruct pt to remain still
Post-op:
• position: flat on bed (12 hrs) to prevent CSF leakage leading to
spinal headache (severe frontal headache) ⑧

Visualization procedures

1) X-ray/radiography/ fluoroscopy - no special preparation done

2) UTZ - ultrasonography
• sound waves
2 types:
abdominal - full bladder
transvaginal (1st trimester) - empty bladder
3) Ct scan - computed tomography scan • assess for claustrophobia
• radiation (preliminars) • assess for allergy if using
contrast dye (iodine) check for
4) MRI allergic reaction
• magnetic waves (definitive) • increase oral intake to remove
dye
5) mammography - X-ray of breast
• Visualization of breasts; to rule out breast cancer
• breast self examination - 7 days after menses
common site - right upper quadrant

Alert:
cancer management:
1) surgery (ablative) - removal of a site, exposed to cancer ⑧
2) chemotherapy - drug of choice: methotrexate, vincristine (oncovin)
• cycle - coblic cycle: 6 sessions (1 session= 26 days max: 22 days min)
8@·.
• 132 - 156 days
3) radiation therapy -
external - (teletherapy /skin sparing ) machine
• 1st organ involved: skin
• primary manifestation: erythema
• late manifestation: moist desquamation
Nursing considerations:
• no use of lotion, liniments, creams, talc, ointments, powder
• no removal of skin markings until treatment is complete (breast cancer)
internal - (brachytherapy) radiation implants ⑧
• room: led lined private room away from nurses station
-

• time: (exposure) 5 mins/entry (30 mins/shift)

• distance: 6 feet away (max)
• protection: lead apron, film badge
• activity: complete bed rest without bathroom privileges
• position: flat on bed (supine) to prevent dislodging the implant
if dislodged:
No touch
No re-insertion
management:
• long-handled forcep
• use lead container
• report to radioactive technician
measurement of radiation exposure - dosimeter
Contraindications:
• age: below 16 years old
• pregnant
4) adjuvant chemotherapy - chemotherapy + surgery
 Medications in nursing

Principles of pharmacology
• pharmacokinetics movement of drug in and out for elimination
1) absorption - blood stream bioavailability
2) distribution - target cell
3) metabolism - liver
4) excretion - kidneys, skin
• pharmacodynamics - physiological effect of medication
1) side effect - stinging sensation in nitroglycerin is normal
2) hypersensitivity -

Doc: diphenhydramine hydrochloride (Benadryl)

3) allergic reaction S E: drowsiness
Intervention:
• avoid driving
• avoid machine operating
• or focused activities
4) anaphylactic shock
• epinephrine (fowler's position) (only shock in fowler's)
5) tolerance - normal close of a drug
6) toxicity - over dosage of medication
• pharmacotherapeutics - desired effect of a medication
10 rights to medication administration (JCAHO)
• 5 standard rights
M - medication/drug Right client/patient: identification
E - education/health teaching • most common/usual: asking patient's name;
D - dosage stating his/her name
I - ideal route • safest: identification band, tag, bracelet
C - client
A - assessment • ideal: chart
T - time
I - ideal documentation
O - oath to refuse
N - need an evaluation
Right assessment: Cardiac glycosides, digitalis
Drug of choice: digoxin (lanoxin); digitoxin ( crystodigin)
Assess: HR
Therapeutic range: 0.5-2.0 mg/ ml
Mode of action:
• (+) intotrope - increases myocardial contractility
• (-) chromotropic - decreases output
• (+) dromotropic - increases myocardial power
Digitalis toxicity:
CNS: headache, drowsiness, confusion (late)
CVS: bradycardia, sa and av node blockage, premature ventricular contractions (ECG)
(lidocaine is administered)
EENT: blurred vision, visual hallucination (late), photophobia, flickering dots (common in
retinal
-
detachment)
• halo appearance (pathognomonic sign of digitalis toxicity)
• single colored vision(greenish-yellowish)
GIT: A - anorexia
N - nausea and vomiting
D - diarrhea
A - abdominal cramps
Antidote: digi bind (immune-fab)

Right time: Anti - myasthenia drugs

Drug of choice: neostigmine methylsulfate, pyridostigmine bromide, endrophonium (tensilon)
Myasthenia gravis Ach Cholinesterase Anticholinesterase
Cholinergic crisis Too much, early
Myasthenic crisis Little, late
&
Management: all family members should be knowledgeable to CPR
 📌
Right drug: diuretics
Best: early in the morning
Classification:
• k sparing - increases potassium
Ex: spironolactone (aldactone)
• K wasting - decreases potassium
Ex:
Carbonic anhydrous inhibitor - acethazolamide (diamox)
Osmotic - mannitol (osmitrol)
Loop - Furosemide (lasix)
Thiazide - chlorothiazide (diuril), hydrochlorothiazide (hydrodiurnal)
Side knowledge:
Increased intracranial pressure (normal: 0-15 mmhg)
• monroe-kellie hypothesis: CVPO = CVPI= normal
Factors:
Brain traumatic injury - vehicular accident
Brain surgical interventions
Craniotomy (opening)
1) suprotentorial - Semi-fowler's
2) infratentorial - HOB elevated 10-15 degrees
Craniectomy - removal of apart of brain
Cranioplasty - titanium replacement or synthetic ( bone is placed on the abdomen to
maintain normal flora ) (bone bank)
brain tumor
B - bradycardia, bradyprea
L - level of consciousness changes, restlessness, sleepiness
A- apnea; Cheynne - stokes
P - projectile vomiting (late)
H - hypertension
W- widened pulse pressure (difference of systolic to diastolic; normal= 40)
Pathognomonic sign:
• Cushing's triad
Grave sign:
• herniation and occlusion of the brainstem
Management:
• position: hob elevated at 10-15 degrees
• osmotic diuretic
• reduce stimuli (dark - litted room, strategy nursing care)
Potassium rich foods:
Fruit - 2- 3 servings per day
Vegetable - 3-5 servings per day
⑧
A - avocado, apricot, apple
B - banana Best rich in potassium:
C - cantaloupe • raisins
S - strawberry

A - asparagus
B - broccoli
C - carrots
Anti-retrovival therapy
• HIV / aids
• t-lymphocytes / t-killer cells (CD4)
• viral replication
1) nucleosides (NRTI )- non-nucleoside reverse transcriptase inhibitor "vudine"
• stavudine
• lamivudine
• zidovudine
2) protease inhibitors "navir"
• retonavir
• saquinavir
• indinavir
3) miscellaneous antiviral therapy "clovir"
• acyclovir - cytomegalovirus, herpes simplex, "tidine"
chicken pox, influenza • Amantidine
• famciclovir • Rimantidine
• ganciclovir
 Anti-ulcer agents:
1) antacid- aluminum, magnesium, calcium, combined
• aluminum - aluminum hydroxide, "-gel" (constipation)
• magnesium - milk of magnesia (diarrhea)
• calcium - tums
• combined - maalox
2) h2 receptor blocker
• ranitidine
• Cimetidine
• famotidine
• nizitidine
3) PPI
• omeprazole
• esomeprazole - gastroesophageal reflux disease
• pantoprazole
• lansoprazole
• rabeprazole
4) cytoprotective
• sucralfate
• carafate
• misoprostol
• cytotec

Seizure: phenytoin (Dilantin) ⑧

Common side effect: gingival hyperplasia
Intervention: soft bristle tooth brush
 📌
📍
Forms of medication:
• oral - enteric coated (do not crush,it increases gi irritability)
• topical - patches (nitroglycerin) for angina, common cause is atherosclerosis; for
cancer pain (duragesic fentanyl), suppositories are also topical
dry the skin area
avoid hairy areas (decreases absorption)
rotate the site
single-use
• inhalation - nebulization
• solutions - optic drops (eyes)
drug of choice:
mydriatics (adrenergic drugs: atropine sulfate) for cataract
miotic drugs (pilocarpine)
anti-infection
Instillation:
supine position and look up
dominant hand: holds the medication
non-dominant: pull or lower or retract the lower conjunctival sac.
prevent systemic effect by using dominant hand (index finger) applying
a pressure on the lacrimal duct
Ouitment:
inner canthus to outer canthus ( least to contaminated )

Miotic drugs
• Warm
• Instruct to side-lie on the unaffected side
• pull or retract pinna (auricle) depending on what age group
• child - down and backward
• adult - upward and backward (to prevent temporary hearing loss)
 Intravenous therapy
Purposes:
• to correct fluid and electrolyte imbalances
• Route for medication administration via iv push (1 ml/min; don't kink)
• blood transfusion
• parenteral nutrition ISO Hypo Hyper
⑳ ⑳ ⑳
- W

E Er ↳
Balance Swell Shrink
Isotonic Hypotonic Hypertonic
• PNSS (0.9 Na cl) • 0.45% • D5LR
• PLR • 0.33% • D1OW
• D5W (considered hypotonic inside) • 0. 225% • D5 PNSS
• D normosol M • D5 3%
• D 225% NaCl • D5 5%

Nursing intervention:
• No kink no pinch! Dressing change: 48 - 72 hrs
• every 8 hrs (monitor)
Gauges:
Common complication: • 16 - orange
• infiltration - cold • 18 - gray
• phlebitis - warm • 20 - yellow
• infusion (max) - 72 hrs • 22 - pink
• 24 - blue
Colloid: • 26 - pink, violet
• plasma expanders
• shock cases
• substitute for blood transfusion
Ex:
• hespan, dextran, albumin
 Parental Best sites
• intradermal Ventral mid-forearm (lightly pigmented) 0.5 mm

• subcutaneous Abdomen (insulin)

4 R's:
( sustained roll
systemic
absorption ) rotate (prevent lipodystrophy),
refrigerate
room temperature

• intramuscular • Vastus lateralis

• intravenous • Metacarpal
• intrathecal • Spine
Z-track: Iron dextran
Guidelines for verbal or telephone orders: • dominant: holds meds
• repeat order • non-dominant: holds site
• evening shift usually to seal the skin
• write the order in the prescription pad
• require co-medical doctor to sign w/in 24 hours (if not available, resident on duty
should sign)
• identify the pt
• two nurses to validate
• emergency situations
Nursing procedures
hand hygiene:
• friction is most important factor
• water is most important material
⑧
Surgical hand scrubbing - medical hand hygiene first before hand scrubbing
 Endotracheal tube

Purpose: patent airway

Nursing diagnosis:
• impaired verbal communication
• impaired swallowing
• risk for infection
• risk for aspiration
Intervention:
• humidify air
• auscultate both lungs
• monitor or document lipline, nose, uneven cuff pressure (seals the airway) or
separates upper respiratory from the lower respiratory
• normal pressure: (20 - 30 cm water) 22 - 32 mmhg
Complication:
• hardening of cartilaginous membrane of trachea (tracheomalacia)
Measure
• French - internal diameter of the catheter
Extubation:
• deflate the cuff
• suction (pulling upward and downward)
• monitor unusualities: Principles of suctioning:
1) deep breathing
sore throat 2) increase oxygen flow rate
hoarseness of the voice normal 3) bag valve mask
occasional pink sputum
presence of dyspnea Bottles needed in suctioning:
report!! • 2 bottles
abnormal breath sounds
 Tracheostomy
Purpose: patent airway
Nursing diagnosis: risk for infection; risk for aspiration
Materials:
• metal: reusable
• plastic: disposable
1) outer cannula
• flange
• fenestrator " speech"
• tracheostomy cuff
• tie attachment area
Outer cannula
2) obturator - guide to insert @ bedside -

3) inner cannula Inner cannula

• lock: clockwise L

• unlock: counterclockwise
Nursing interventions:
• pull-out: outward downward
• soaking: 1/2 strength hydrogen peroxide + PNSS
/

• cleansing: PNSS Obturator

no drying
insertion, upward inward
• changing ties: attack the new tie first before
removing old
• dressing: 4 X 4 lint free dressing
 ✅📌
CTT
Chest thoracostomy tube
Thoracotomy
Water - seal drainage system
Purposes:
• drain air, water, blood, pus
How will you drain?
• using y-connector on 2nd-3rd
(first tube) and 5th - 7th
intercostal space (second tube)
Bottle system:
1) A (drainage / collection chamber)
color , consistency, amount
bleeding = bright red; > 100 cc ml/ hr
2) B (water seal)
oscillation, titration, fluctuation (movement of water)
no movement = kink, tube obstruction, pt lying on tube; failure to suction; lung re-expansion
Mechanism:
• positive expiratory pressure
• gravity (placed lower than the chest)
• suction
3 materials@ bedside:
• forceps (hemostat, mosquito forcep)
no order - no clamp; (to prevent
tension pneumothorax)
• bottle with PNSS ( for disconnection of
tube from machine)
• sterile gauze (dislodgement of tube
from patient)

*
Attached to Attached to
bubble: gentle and intermittent chest tube suction
Atmospheric air
if continuous: air leakage: leakage of the system
3) C (suction chamber) Chamber (b)
bubbles: gentle and continuous Chamber (a)
(water seal)
(collection) Chamber (c)
(suction control)
General nursing considerations:
• to promote lung re-expansion
Signs that chest tube is to be removed (patient achieves lung re-expansion):
• no oscillation and no breath sounds
Diagnostic:
• X-ray (confirmatory)
 Nasogastric tube

Purpose:
• gastric gavage (food and medication)
• gastric lavage
• 0. 5- 1 ml (sample for aspiration )

Materials:
1) single-lumen (levin) Salem - sump Levin tube
2) double lumen (salem's - sump)

Checking of NGT placement: NGT insertion:

• chest X-ray (best) Measure
• aspirate • Adult - NEX
• auscultate - 10 ml of air (gurggling, • Child - nose earlobe, midline of
whooshing) xiphoid process and umbilicus
• submerging the tip of the catheter to
water Catheter:
Rubber = soak into a cold water to
stiffen
Plastic = soak into a warm water to
soften tube

Insertion:
• upon inserting hyperextend lubricate catheter 2-3 inches
• then hyperflex, and advance the catheter and instruct patient to
swallow sips of water

NGT feeding:
• position upright
• feeding container must be changed 24 hours
• complication: dumping syndrome
 📌

Residual assessment:
• regurgitated gastric content
• >50 % (>100 ml), withold - to prevent metabolic alkalosis
NGT irrigation:
• 30 - 60 ml
NGT removal:
• pull the not tube gently and continuously for 3-6 secs during exhalation

Total parental nutrition

Peripheral parental nutrition - temporary Nursing cons:
• hypertonic
Components: • prepared by pharmacist
• fluid and electrolytes • 2 nurses
• vitamins and minerals • sterile technique
• dextrose • no infusion pump, no TPN
• amino acids • no filtration set, no TPN
• emulsified lipase • no medication on TPN line but sometimes,
heparin is used
Monitor: • always secure connections
1) infection
2) intake and output (1-2 lbs per week) Without lipid = 0.22 um microfilter
3) glucose With lipid = 1.2 um microfilter
4) renal function test
5) liver function test
Complications:
• hyperglycemia Management:
• hypoglycemia • side-lying + trendelenburg
• fluid over load
• sepsis
• air embolism
 Blood transfusion
Introduction of blood and it's components:
1) whole blood
2) red blood cells
3) white blood cells
4) thrombocytes
5) plasma
6) cryoprecipitate

• Blood donation: gauge 16

1) autologous coronary certify bypass
surgens)
2) blood salvage
3) designated donor (homologous)

Blood transfusion:
1) pathology department
2) 2 nurses
3) BT set with macrofilter Nursing intervention:
4) PNSS (to avoid nemolysis) no to LR (will
clot the blood because of calcium) • vital signs before
5) gauge: 18 • post 15 mins for 1st hour
6) blood warmer • every 1 hour until post transfusion
• start within 20 mins
• 1st 15 mins of transfusion is the most
crucial (blood transfusion reaction) Universal donor - o (-)
allergic reaction Universal recipient - ab (+)
20 gtts/ min = 5ml per min

RBC - 4 hours
Without ABC - fast drip