FUNDAMENTALS

Position

 ENEMA: (Lt) Lateral with (Rt) Knee flexed

Catheter insertion = 3-4 inches ( 6.6 – 8.8.cm)
 Most of the gynecological procedures = Lithotomy
 After Heamorrhoidectomy = side lying position
To prevent bleeding
 After Thyroidectomy = Semi fowlers position
 After tonselectomy = side lying Lt lateral
To prevent aspiration
Complication (Hemorrhage)
 After hip replacement = Supine with abduction of limbs by keeping pillows
below legs.
 Maintain abduction without dislocation.
 Do not cross the legs
 Do not lay on the affected side
 After mastectomy position- semi fowlers with affected extremities elevated
with pillow to prevent lymph edema

Exercise: floor exercise/ walking finger against the floor to prevent edema

Note: for any person who is at risk of edema fluid and salt must be avoided.

 Eg- Heart failure, liver failure, renal failure,

After mastectomy
 Tamoxifen citrate should be taken 5years.
 Action: antiestrogen pills – to prevent recurrence of tumor
 Goal- pt should accept altered body image.

After vitrectomy(opthal) (vitrial fluid removal)

 Indication- retinal detachment

 Position- prone

DVT( Deep Vein Thrombosis)

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Causes:- Venus stasis or venous congestion
Homan Sign – Positive indicates DVT
When you dorsiflex the foot, if there is severe pain on calf muscle it indicate DVT.

 Life threatening condition of DVT- Pulmonary embolism.

Note: if any person with thrombus history suddenly complaints of chest pain that
would be pulmonary embolism

Management:- foot end elevation to increase venous return to the heart

 Initial
 Elastic stoking (to increase venous return)
 Use of pneumatic compression device.
 Administer low molecular Heparin (Prophylactic means to prevent)
Note:- while the patient is on Heparin therapy P.T.T should be monitored.
 If the patient requires long term treatment for DVT Warfarin or
Coumadin is the drug of choice.
Note:- if the patient is on Warfarin therapy P.T& INR should be monitored.
 Prior to monitoring anticoagulants weight should be monitored because
dose is fixed with weight.
 After amputation of lower extremity

1st 24 hours elevate the stump or residue with pillow.

Next 24 hours intermittently provide prone position.

 Phantom limb sensation –

it is a false sensation which is safely by the client after amputation. Eg:-
patient complaints of Rt.foot itching after (Rt)B. amputation.

Expected outcome after amputation

 There will be relief in incision pain but will have intense phantom limb
sensation.
 The nurse should assist grievance to prevent phantom limb sensation

Grievance is a grief process

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DABDA

 Denial
 Anger
 Bargaining
 Depression
 Acceptance
 The purpose of applying shrinkage device after amputation to achieve
cylindrical blunt shape of residual limb.
 The purpose of massaging the residue limb after amputation in order to
purpose for prosthesis.

LIVER BIOPSY(Rt) Liver (Lt)Spleen

 While doing position:- supine with (Rt) arm extended towards (Lt
Shoulder.(To promote maximal response of liver)
 After biopsy:- (Rt)lateral with sand bag under the punctured site.
Note:- before any biopsy coagulation study should be done.
Complication after liver biopsy- bleeding of bile.

LAMBAR PUNCTURE

Site – L3-L4 FETAL

C shape position (while doing) to increase intervertibral space.
After procedure- supine position
Complication :- Hypotension
Spinal headache
Mx:- Adequate fluids.

TRANSMISSION BASED PRECURTION

Air borne: (Code MTV)

MEASELS
T.B

VERICELLA ZOSTER (CHICKENPOX)

Precautions:-
Wearing mask.
Maintaining negative pressure room.
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Droplet:- (Code- SPIDERMAN)
Sepsis, Scarlet fever, Streptococcal pharyngitis.
Parovirus, Pertusis, Pneumonia
Influenza
Diphtheria
Epiglottis
Rubella
Mumps, meningitis, Mycoplasmal Pneumonia
Adinovirus

Precautions:-
Wearing mask, negative pressure room

CONTACT(RISEME)
RSV:- Respiratory Synctial Virus
Influenza
Skin infection (scabies, pediculosis, impentigo, vericella)
Eye infection ( conjunctivitis)
MRSA( Meythycilliresistant Staphylococcus Aurias)
Enteric Infection (Clostridium difficle)

Precautions:-
Handwashing
Wearing gloves, gown

Nuring Process
Assessment- data collection eg. Temperature 1020F
Diagnosis- Hyperthermia infection- identify the problem
Planning- tapid sponge- what treatment should be initiated – Health education
Implementation- Give tapid sponge (actualization, health education,working )
Evaluation – Recheck temperature- checking the effectiveness of treatment.

SUBJECTIVE DATA AND OBJECTIVE DATA

What the patient tell is Subjective data
What is observed in the client is objective data.

ANTIDOTES

OPIODS – Nalaxone Hydrochloride or NARCAN

PARACETAMOL- N- Acetylcystine or mucomist

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DIGOXIN – Digibind or Digifab
Heparin – Protamine Sulphate
WARFARIN – Vitamin k
Diazepam or Calmpose- Flumarenil
Iron – deferoxamine myeslate (Deferal)
Alcohol – Librium
MgSo4 – Calcium Gluconate
Lead - Diamercaprol or chelation therapy
Cyanide – Sodium nitrate
Atropine – Physostigmine
Dopamine- Phantolamine
Anticholinesterase – Atropine
OP poison – Atropine
Asprin – Charcoal (Universal antidote)
Eg- OPIODS
Morphine, Fortwin, Fentanyl, Pethedine

CPR
Indications
 MI
 Cardiac arrest
 V.F
 Pulse less V.T
 When to stop CPR
 When the physician informed death
 When the pulse returned
Ratio- Adult = 30:2
Pediatric = 15:2
Deapth – Adult 1.5 - 2 inches
Pediatric- 1/3rd – ½ the depth of the chest.
Compression rate- 100-120 compression
Pulse palpated on
Adult - carotid
Paed- Bracheal/Femoral
When a person is unconscious,
Check the responsiveness
Call for help (activate emergency alarm)
Check the pulse
Check the airway
Check breathing

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How to open the airway
Head tilt and chin lift
Note:- If you suspect for spinal cord injury – Jaw thrust maneuver

Foreign body aspiration

Signs and symptoms
 Restlessness
 Chocking
 Coughing
 Cyanosis
 Catch his own neck (universal sign)
Management
Adult:- Abdominal thrust
Note:- If the victim is obese or pregnant chest thrust is used
For infant/ child
Fine back blows+ 5 chest thrust
T.P.N (Total Parental Nutrition)
It consist of
Carbohydrate
Protein
Fat Emulsion
Vitamins & minerals
Indications
 Malnourished
 Those who cannot take food by mouth for a prolonged days
 Paralytic illeus (absence of bowel sound and peristalsis)
Contraindication
Patient with egg allergy
Note- TPN always administer through infusion pump to control the drop

Complications
Air embolism
Causes
Open catheter system or while changing I.V tube
C/M
 Chest pain

 Hypotension
Management
 Turn off the TPN

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  Place the patient in (Lt) lateral with head lower than the feet to trap air in the Rt
atrium of the heart.
 Administer O2
 Notify the physician
 Airembolism p[osition- Trendlenberg position

Hypervolemia

Causes
 Rapid administration
 C/M increased B.P
 Increased wt
 Increased pulse (Bounding)
 Jugular vein distension
 Crackles in the lungs.
Mx
 Turn the TPN
 Notify the physician
 Administer diuretics
 Heamodyalisis in extreme cases

Hyperglycemia
Causes- Rapid administration of TPN (increased carbohydrate )
C/M
 Polyurea
 Polydipsia
 Weakness
 Diaphoresis
 Blood sugar above 200 mg/dl
 Warm flushed skin
Mx
 Slow / stop TPN
 Notify the physician
 I.V fluids (initial)
 Regular insulin I.V
 Monitor the blood sugar level

Hypoglycemia
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Causes- sudden or abrupt discontinuation

C/M
 Weakness
 Hungerness
 Shakiness
 Diaphoresis
 Confusion
 Blood sugar below 70 mg/dl
 Cold clammy skin
Mx
 Notify the physician
 Administer I.V dextrose/ subcutaneous glucogon
 Monitor the blood sugar level

 Infection
Causes- unsterile techniques
C/M- Fever with chills- Elevated WBC, redness around the catheter, elevated ESR

Mx
 Stop the TPN
 Notify the physician
 Prepare for removal of catheter- sent the tip to lab for c/s
 Administer antibiotics

Pneumothorax(air in the pleural space)

C/M
 Dysponea
 Tachypnea
 Restlessness
 Hypoxia
 Tracheal deviation away from the affected site
 Abscence of breath sound on the affected side
Mx
 Semi flowers position
 Administer O2
 Notify the physician
 Small pneumothorax
 Large pneumothorax reveals intercoastal drainage.
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 Chest Tube Drainage System

It is to remove excessive fluid and air from the pleural cavity.

1. Water seal chamber (2) Drainage system
Water seal chamber
 Water oscilates (moves up and down) in accordance with thoracic movements.
 Intermittent bubbling the water seal chamber is normal
 Water level should be at least 2 cm
 Continuos bubbling indicate air leakage.
Suction control chamber- it provides continues suction and maintains –ve pressure in
the lungs.
it indicates suction is going on

Drainage system
 It should be always below the level client to maintain gravity & flow.
 Never clamp the tube unless doctors order.
 Notify the physician if the drainage more than 100 ml/hr
 Semi flowers position while removing chest tube.
 Serosangenous drainage from the chest tube is normal.
 Bright red drainage indicates bleeding.
 If a chest tube cracks or brake down from middle place the distal tube into
N/S/ sterile water (kept at bedside)
 If the chest tube accidently pulled over from the site apply petroleum gauze
(this mx is same fro sucking chest wound)
 Promote valsalva maneuver while removing the chest tube.(deep breath hold &
slowly bear down)

N.G Tube
 Measurement of the nose to ear lob to the Xiphi sternum.
 Position – High flowers with chin bend towards chest to close the trachea.
 Gastric secretion aspiration should be below 4 to confirm the placement.
 While removing NG tube deep breath and hold it.

CALCULATIONS

 IV fluid calculation =

 Drug Dosage =

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  BMI Calculation =
 Normal BMI = 18-25 Kg /m2
 25-30 kg/m2=over weight
 30 kg/m2 = obese
 Below 18 = under weight
BURNS CALCULATION
Head and neck = 9%
Anterior Trunk = 18%
Post trunk = 18%
Each arm = 9%
Each leg = 18 %
Perineum = 1%

MASLOW HIERARCHY

GASTRO

Functions
 Digestion
 Absorption
 Excretion
 Synthesis of Vit K, Vit B12
 Provide an environment for micro-organism
UPPER GT STUDY- BARIUM SWALLOW

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Pre-procedure
 Informed consent
 NPO from the mid night before the day of the test
Post procedure
 Admin. Adequate fluids & lactulose to expel barium. Otherwise it can lead to
intestinal obstruction
Note- if any procedure done with contrast after that procedure contrast will be
eliminated because each of the contrast is having hidden side effects.
 Chalky/white appearance of stool indicate barium has expelled.

BARIUM ENEMA
Pre-procedure
 Informed consent
 NPO from the midnight
 Low fiber diet
 2 days before the test to d decrease the stool production
 Cleansing enema on the morning of the test.
Post procedure
 Same as upper GI study
ENDOSCOPY
Pre-procedure
 NPO at least 6 hrs
 Informed consent
 Admin. Atropine sulphate to decrease secretion
 Admin. Glucogone to release the smooth muscle
Note- airway status should closely assessed because the chance of Aspiexia

Post procedure
 Assess the gag reflux/ Asphexia reflux
 Monitor abdominal pain
 Decreased BP, Increased pulse, pallor
 I.V Fluids
 Vit K

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