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Virtual Eli - NURSING PROCEDURES PART 2
 

Virtual Eli - NURSING PROCEDURES PART 2

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  • GENERAL OBJECTIVES: I aim for retention & understanding in each concepts to every single soul in here. Concept-based  substantial and detailed informations about the topic Mastery drills  in a form of blanks , a stimulation ur memory Critical pathway  board exam is not all about objective type of exam, it’s not all about what it black and what is white  it’s like mixing black and white and you will play in the gray matter And at the end of the day  let’s sum-up by bullets and min-mapping activity. I do believe that this is a good formula in LEARNING.
  • OXYGENATION NUTRITION ELIMINATION MOBILITY MEDICATION
  • Color: ___bright red___________ Stabilization of stoma: ___6-8 weeks________ Expected functioning: ___3-5 days from the creation of stoma__________ Appearance: __Protrudes ½ - 1 slightly edematous (Edema subsides after 6 weeks)__________________ Position: ______Sitting or lying position _________________ Irrigant: _____tap water (lukewarm)__________________ Amount: ____1000 mL (first irrigation 500mL)___________________ Height of container: ____12”__________ Temperature: ____warm (105-110 F)_______________ Duration: ____5-6 minutes___________________
  • Concern: Acidic feces Intervention: __karaya gum_____________ Concern: Unpleasant odor Interventon: __deodorizer, small amount of vinegar or charcoal-filtered disc__________ Diet of choice  high residue diet like green leafy veg (to minimize odor)
  • 1. When are pouches emptied? 1/3 to 1/2 2. When is the best time to perform ostomy appliance change? Not be close to meal or visiting hours, drainage is least likely to occur 3. Where is the best place to change the client’s appliance? bathroom 4. What is the preferable position in changing the client’s stoma? Lying,sitting,standing facilitate smoother pouch application avoid wrinkles 5. What Aseptic technique is used in this procedure? 6. If the area around the site is hairy, the nurse should clip or shave the hair? shave 7. Before removing the appliance, what should the nurse do first to its content? Empty the content with its bottom opening into the bedpan, prevent spillage into the skin. assess
  • 8. In cleaning the stoma, the nurse should use what? 9. What paste is used as an adhesive to attach the face plate and the appliance properly? 10. What is the normal color of the stoma? 11. How frequent should the nurse change the pouch? [Disposable 1 week, reusable, twice a week]
  • to empty the colon of feces, gas, or mucus, cleanse the lower intestinal tract, and establish a regular pattern of evacuation so that normal life activities may be pursued. performed at the same time each day, preferably 1hr after a meal lie on side/sit on the toilet itself 500 to 1500 mL of lukewarm tapwater/ PNSS hung 18 to 20 in above the stoma (shoulder height when the patient is seated) No more than 3 inches
  • 1. What is the main purpose of Colostomy irrigation? 2. How frequent should the patient irrigate? 4. When is the best time to perform colostomy irrigation? 3. How much and what type of fluid is used during colostomy irrigation? 4. Where is the irrigation performed? 5. If cramping is felt during irrigation, you would instruct the client to? 6. How long is an irrigation performed? 7. If the client experience difficulty in inserting the tube, what should you instruct the client?
  • Purpose: Lower GI BEFORE: Liquid diet laxative NPO 6-8 hrs no narcotics and anticholinergics for 24 hrs Check allergies to seafoods AFTER: Laxative to counteract the constipation effect of barrium white stool is normal in 3 days Increase fluid intake
  • Purpose: upper Gi Before: NPO 6-8 hrs Assess for allergy After: Laxative White stool is normal Increase fluid intake
  • Position: _____Tripod position (6 “ lateral foot and 6” anterior foot)________________ Handle: ___level of the greater trochanter___________________ Elbow flexion: ___20-30 degree angle (to prevent contracture)_____________ Distance of the axillla from axialy bar: _1-2 inches__
  • Once recovered  advance simulataneously the weak leg and the cane ff by the good leg
  • Rights of drug administration Right Drug Right Dose Right Time Right Route Right Patient Right Documentation Right Approach
  • Note: In choosing an IV site: - choose DISTAL vein first - Avoid client’s dominant hand and arm. - Avoid an area of skin affected by a rash or infection. TORNIQUET: 6-8 inches above the site Insert: BEVELS UP (5-25 degree) Advance needle 1⁄4–1⁄2 in after successful venipuncture
  • Note: Change IV tubing every 24-72 hours Change venipuncture site every 48-72 hours Change IV dressing every 72 hours DO NOT let an IV bag or bottle of solution hang for more than 24 hours DO NOT allow the IV tubing to touch the floor
  • Complications 1. Infiltration and Extravasation - coolness at site; - remove IV device stat; elevate extremity and apply warm compresses 2. Phlebitis and Thrombophlebitis - heat at the site - apply warm, moist compresses , remove IV, notify, restart 3. Air Embolism - clamp tubing - turn the client on the left side with the head of bed lowered (Trendelenburg) to trap air in the right atrium, - notify
  • Isotonic Solution – equal ratio of solute & solvent – zero pressured solution all plain sol’n., Plain IMB, Plain NSS – there is no change cell structure   Hypertonic Solution – more solute than solvent (ispiso) – high gradient pressured solution all D 5 , all D 10 , all D 50 – cell shrinkage / crenation – Ex. given to edema, fluid volume excess   Hypotonic Solution – more solvent than solute (lasaw) – low gradient pressured solution .30, .35, .45 – cell swells; if not regulated, cells will burst – Ex. given to diarrhea, fluid volume deficit * Major electrolyte  Potassium (K + )  needed for contraction [affects mobility] Sodium (Na + )  for water regulation / retention  because Na + attracts water  is regulated by aldosterone (adrenal cortex)  
  • Legal basis  RA 7719 Mian principle: IT is a humanitarian act Possible donors: Age: 16-65 yo (if minor parental consent is needed) Hgb: 12.5 Weight: 110 lbs  donate 450 mL Contraindicated: AIDS KIDNEY d/o CANCER DM Epileptic pt Hepatatis and Malaria pt Recipients: Leukemia, liver d/o, loss of blood from surgery Aftercare: Adhesive tape  3-12 hours No smoking 2 hours No alcohol – 12 hours Free arm activity – 24 hours
  • Note: RBC : 250 ml Whole blood : 500 ml Solution: NSS 1 unit = 4 hours only 20-30 minutes interval from Blood bank to administration DO NOT REFRIGERATE Stay for first 15-30 minutes
  • Note: If transfusion reaction occurs: STOP transfusion, (CBQ) change IV tubing down to the IV site, keep IV line open with NS, notify physician and blood bank, return blood bag and tubing to blood bank; Do NOT leave client alone
  • Type A – A antigen anti-B antigen Type B B antigen anti-A antibodies Type AB Both A and B antigen has no A or B antibodies universal recipient Type O Has no A or B antigen has both A and B antibodies Universal donor
  • Blood products: PRBC  1 unit raises Hct by 4% WB  for volume expansion FFP  Replace coagulation factos (use within 6 hours) Platelets  infuse 10 minutes per unit Cyoprecipitate  restores factor VII and fibrinogen in tx HEMOPHILIA A
  • Acetaminophen Acetylcysteine Benzodiazepine Flumazenil Coumadin Vitamin K Cyanide Poisoning Methylene Blue Digitalis Digibind Heparin Protamine Sulfate Iron Deferoxamine Mesylate Lead Edetate Disodium (EDTA) Dimercaprol (BAL) Succimer (CHEMET) Magnesium Sulfate Calcium Gluconate Morphine Naloxone Hydrochloride Penicillin Epinephrine
  • 2 types: Peritonela dialysis Hemodialysis *Give 1,000 units of heparin *What do you call that test that evaluates the therapeutic effect of heparin? Answer: PTT (Partial Thromboplastin Time) *What is the antidote for heparin toxicity? Answer: Protamine sulfate *What is that test that calls for the therapeutic effectiveness of warfarin? Answer: PT (Prothrombin Time) *What is the antidote for warfarin toxicity? Answer: Vitamin K Heparin  prevents coagulation  injected in the artery
  • Solution/dialysate: Hypertonic dialysate Site: Peritoneum (semipermeable membrane) weigh the bag (dialysate) and patient (before and after) inflow 10-20 minutes dwell: 30-45 minutes drain: unclamp after 45 minutes observe solution color  NORMAL: CLEAR PALE YELLOW Cloudy  ineffective,  indicative of peritonitis ( PATHOGNOMONIC SIGN : boardlike abdomen )
  • Weight before and after Heparinized solution (inject into artery) Void before and after Assess c/s q 30 minutes COMPLICATIONS: DIALYSIS DISEQUILIBRIUM SYNDROME due to rapid removal of urea in the system or circulation *Initial running rate of blood to machine: 90 – 120 ml/min  increase gradually til 300 mL Symptoms: Nausea & vomiting  Blood pressure Disoriented Leg cramps (2ndary to rapid electrolyte loss)  administer NSS as ordered Seizures Peripheral paresthesia Air Embolism – check the tubings  head must be lower than the body on left side-lying position RATIONALE: So that air bubbles will just be absorbed by the pulmonary arteries. Infection  due to exposure of the blood to the external environment. AIDS Left Ventricular Hypertrophy Bone problems  
  • R – requires physician’s order; consent E – emergency, get MD’s order ASAP S- shortest duration (least restrictive) To protect patient and others Assess q 15-30 mins & document Individualized supervision (one-on-one) Never used punishment Total documentation Seclusion as last step
  • Before: LLP Exhale – diaphragm going up NPO 2-4 hrs After: right side position bed rest for 24 hours
  • Hemoglutest: Normal value: 60-120 mg/dL Mx 30 minutes before meals Protect test tips from direct light  store in brown bottle container TIP (LATERAL) finger  less nerve endings, less pain
  • To assess the contents of the peritoneal fluid Position: Large fluid  supine Less fluid  sitting Empty bladder  avoid puncture Maximum fluid removal: 4-5 liters Duration: 5-20 minutes Report abdominal pain:
  • Purpose: To withdraw CSF Empty bowel and bladder C-position (fetal position or shrimp position) Insertion site: L3-L4 or L4-L5 (prevent puncture of the spinal cord since it ends at L2) After: FLAT Position 6-12 hours to prevent spinal headache
  • Purpose: Use to detect Vitamin B12 absorption Excretion of Vitmin B12 8-40% is normal >40 % excretion of Vit B12  indicates Pernicious anemia Test: 24-hour urine speicmen
  • Snellen chart – to check visual acuity E-Chart – to check visual acuity of illiterate patient Tonemetry – to check IOP. Normal level 12-21 mmHg Perimetry – to check peripheral vision Ishihara plate – to check color bilndness
  • Caloric test – alternate instillation of warm and cold water into the ear of the patient Otoscopy – Visualization of the inner ear
  • Hgb Hct WBC RBC Neutrophils Lymphocytes Basophils
  • Types of bathing: 1. Cleaning bath COMPLETE - bedridden PARTIAL – some parts (perineum, groin and axilla) SELF-HELP BATH – parts that cannot be reached by pt Therapeutic bathing COOL BATH – for muscle tension (30 mins) WARM BATH – for muscle spasm (3 mins) COLLOIDAL BATH (oatmeal bath of cornstarch) – for pruritus
  • Temperature  COLD  WARM MUST have  USE MOISTURIZER  Use astringent Frequency  LESS  more Instruction  Avoid scratching the skin  avoid fatty and oily food
  • Shampooing: use circular motion Combing: from root to tip Brushing teeth: hold toothbrush 45 degree angle If unconscious: use padded toungue depressor Position: Lateral position If there is dentures: Grasp upper denture plate with 4x4 gauze Cleaning eyes: inner to outer canthus Wash the limbs: distal to proximal Cutting nails: straight across Shaving the hair: follow the hairline Washing perineum: (finishing bath) Male: meatus first in circular motion to tip and to base Position: Flat position Equipment: Clean gloves Female: Inner to outer Equipment: forceps
  • Washing the perineum: MALE: Position: Equipment: FEMALE: Inner to outer Position: Dorsal Recumbent Position Equipment: forceps

Virtual Eli - NURSING PROCEDURES PART 2 Virtual Eli - NURSING PROCEDURES PART 2 Presentation Transcript

  • Elizalde D. Bana CMT,RN (www.virtualeli.net) NURSING PROCEDURES (PART 2 )
  • REVIEW FORMULA
    • CONCEPT-BASED
    • MASTERY DRILLS
    • CRITICAL PATHWAY
    • BULLETS/MIND-MAPPING
    • PART 2:
    • NURSING SKILLS
  • OSTOMIES
    • Definition of Terms
    • 1. Gastrostomy to the stomach
    • 2. Jejunostomy to the jejunum
    • 3. Ileostomy- (Permanent)
    • 4. Colostomy – (Permanent)
    • 5. Ureterostomy
    • 6. Ileal Conduit
    • 7. Stoma – (Permanent)
    • Classification by
    • 1. Permanence
    • 2. Anatomic location
  • Intestinal Ostomies
    • Color: BRIGHT RED
    • Stabilization of stoma: 6-8 weeks
    • Expected functioning: 3-5 days from the creation of stoma
    • Appearance: Protrudes ½ - 1 slightly edematous (Edema subsides after 6 weeks)
    • Position: Sitting or lying position
    • Irrigant: tap water (lukewarm)
    • Amount: 1000 mL (first irrigation 500mL)
    • Height of container: 12 inches
    • Temperature: warm (105-110 F)
    • Duration: 5-6 minutes
  • ILEOSTOMY
    • Concern: Acidic feces
    • Intervention: karaya gum
    • Concern: Unpleasant odor
    • Interventon: deodorizer, small amount of vinegar or charcoal-filtered disc
    • Diet of choice  high residue diet like green leafy veg (to minimize odor)
  • CRITICALPATHWAY
    • A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
    • A . increasing fluid intake to prevent dehydration .
    • B. wearing an appliance pouch only at bedtime.
    • C. consuming a low-protein, high-fiber diet.
    • D. taking only enteric-coated medications.
  • OSTOMIES: Consideration
    • Handwashing before and after
    • Fecal pouch is removed every 3 days to assess for signs of skin breakdown
    • Avoid gas forming foods like EGG & ONION
    • Complication: DEHYDRATION & ACID-BASE BALANCE
  • OSTOMIES
  • Changing ostomy appliance?
    • CBQ: Critical Pathway
    • 1. When are pouches emptied? 1/3 to ½ full
    • 2. When is the best time to perform ostomy appliance change? Not be close to meal or visiting hours, drainage is least likely to occur
    • 3. Where is the best place to change the client’s appliance? bathroom
    • 4. What is the preferable position in changing the client’s stoma? Lying,sitting,standing facilitate smoother pouch application avoid wrinkles
    • 5. What Aseptic technique is used in this procedure? Sterile
  • Changing ostomy appliance?
    • 6. If the area around the site is hairy, the nurse should clip or shave the hair? shave
    • 7. Before removing the appliance, what should the nurse do first to its content? Empty the content with its bottom opening into the bedpan, prevent spillage into the skin. assess
  • Changing ostomy appliance
    • CBQ: Critical Pathway
    • 8. In cleaning the stoma, the nurse should use what? Use warm water, mild soap (optional), and cotton balls or a washcloth and towel to clean the skin and stoma.
    • 9. What paste is used as an adhesive to attach the face plate and the appliance properly? Use a special skin cleanser to remove dried, hard stool.
    • 10. What is the normal color of the stoma? BRIGHT RED
    • 11. How frequent should the nurse change the pouch? [Disposable 1 week, reusable, twice a week]
  • COLOSTOMY
    • Normal stoma: red or pink
    • - Bright red
    • Fecal matter should not be allowed to remain on the skin
    • Empty pouch when half to one-third full
    • Avoid gas-forming foods (ex. Cabbage, onions)
  • Colostomy Irrigation
    • Purpose: to empty the colon and establish a regular pattern of defecation
    • Best time to perform: performed at the same time each day, preferably 1hr after a meal
    • Position: lie on side/sit on the toilet itself
    • Irrigation solution: 500 to 1500 mL of lukewarm tapwater/ PNSS
    • Height of sol’n: 18-20 inches in above the stoma (shoulder height when the patient is seated)
    • Insertion of catheter: No more than 3 inches
  • Colostomy Irrigation
    • Insert the catheter no more than 3 in
    • Never force the catheter!
    • Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest before progressing.
  • Colostomy Irrigation
    • CBQ: Critical Pathway
    • 1. What is the main purpose of Colostomy irrigation? TO ESTABLISH REGULAR PATTERN OF DEFECATION
    • 2. How frequent should the patient irrigate? Daily (same time)
    • 4. When is the best time to perform colostomy irrigation? 1 hour after meal
    • 3. How much and what type of fluid is used during colostomy irrigation? 500 to 1500 mL of lukewarm tapwater/ PNSS
    • 4. Where is the irrigation performed? Comfort Room/ toilet room
  • Colostomy Irrigation
    • 5. If cramping is felt during irrigation, ? STOP
    • 6. If the client experience difficulty in inserting the tube, what should you instruct the client? NOTIFY THE PHYSICIAN – sign of obstruction or occlusion of site
  • CRITICAL PATHWAY
    • The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
    • A . Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma
    • B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water
    • C. Stopping irrigation for cramps and clamping the tubing until cramps pass
    • D. Washing hands with soap and water when finished
  • BARRIUM ENEMA
    • Purpose: Visualize Lower GI
    • BEFORE:
    • Liquid diet
    • laxative
    • NPO 6-8 hrs
    • no narcotics and anticholinergics for 24 hrs
    • Check allergies to seafoods
    • AFTER:
    • Laxative to counteract the constipation effect of barrium
    • white stool is normal in 3 days
    • Increase fluid intake
  • BARRIUM SWALLOW
    • Purpose: upper Gi
    • Before:
    • NPO 6-8 hrs
    • Assess for allergy
    • After:
    • Laxative
    • White stool is normal
    • Increase fluid intake
  • CRITICAL PATHWAY
    • If the order is to give Barrium swallow and Barrium Enema at the same time, what is the initial action of the nurse?
    • 1 st : Administer Barrium Enema
    • 2 nd: Barrium swallow
  • MODULE 9: NURSING SKILLS
    • MOBILITY
  • ASSISTIVE DEVICE: CRUTCHES
    • Position: Tripod position (6 “ lateral foot and 6” anterior foot)
    • Handle: level of the greater trochanter
    • Elbow flexion: 20-30 degree angle (to prevent contracture)
    • Distance of the axillla from axillary bar: 1-2 inches (November 2009 NLE question)
  • ASSISTIVE DEVICE: CRUTCHES
    • When climbing stairs: GOOD LEG FIRST, FOLLOWED by BAD Leg & CANE
    • When going down the stairs: BAD LEG & cane first, then GOOD LEG
    • A NONSLID SHOE is required.
  • ASSISTIVE DEVICE: CANE
    • COAL  CANE OPPOSITE AFFECTED LEG (meaning hawakan ang Cane sa Unaffected leg )
    • Advance cane: Cane then Affected leg first
    • Advance first the cane, then the weak leg followed by the good leg
    • Once recovered: advance simultaneously the weak leg and the cane ff by the good leg
  • Cane
    • Notes:
    • flex the elbow at a 30-degree angle
    • level with the greater trochanter
    • tip of the cane 6 inches lateral to the base of the fifth toe
    • tip with its concentric rings provides optimal stability
  • ASSISTIVE DEVICE: Traction
    • ALWAYS : (Notes)
    • Maintain correct body alignment
    • Make certain that ropes are in the wheel grooves of the pulleys, ropes are not frayed, that the weights hang free , and that the knots in the rope are tied securely
    • Maintain traction with prescribed weight
    • Perform neurovascular checks every hour for the first 24-48 hours
    • Use fracture pan for toileting
  • Traction
    • SKIN TRACTION
      • adhesive tapes, Velcro straps , or a fitted brace
    • RUSSEL TRACTION
      • FEMUR fractures
      • Bed is FLAT always
    • BUCK’s TRACTION
      • lower limbs fractuers
      • 8-10 lbs weight
      • Elevate FOOT of bed
    • BRYANT’s TRACTION
      • for CHILDREN
      • FLEXED at a 90-degree
      • buttocks raised 1-2 in off the mattress
      • Child act as COUNTERTRACTION
  • Traction
    • Notes:
    • SKELETAL traction:
    • use of a metal pin or wire .
    • Tongs use to immobilize cervical fractures.
    • is balanced traction
  • Traction
    • Notes:
    • SKIN TRACTIONS:
    • Cervical traction: cervical injury .
    • Pelvic belt or girdle: lower back .
    • Humerus traction: upper arm fractures
  • Casts Fiberglass Plaster of Paris (Traditional Cast) Dries instantly Delayed drying (24-72 hours) May get wet Softens when wet Dull appearance Shiny appearance Light weight Heavy weight Higher durability Durable (may crack)
  • Casts
    • Notes:
      • HANDLE using PALMS only . (NOT FINGERS)
      • elevate above the heart
      • Don’t scratch under the cast
      • Cushion rough edges of the cast with tape  P ______
      • for wet fiberglass use hair blow dryer on a COOL SETTING
      • REPORT to MD if 6 P’s occur
      • Note odors and WARM SPOTS  infection
      • Do not attempt to fix broken cast
  • PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: WATER BED
  • PREVENTION of immobility
  • PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: TRAPEZE
  • PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: FOOTBOARD
  • PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: TOWEL
  • PREVENTION of SKIN DAMAGE DUE TO IMMOBILITY: TROCANTHER ROLL
  • MODULE 9: NURSING SKILLS
    • MEDICATIONS
  • MEDICATION ORDERS
    • STAT
    • Single Order
    • Standing Order
    • PRN Order
    • Determine the types of order of the following: You answer this
    • Acetaminophen, po q4h X 5 days
    • Demerol, IM qid
    • Valium, 50mg prn
    • Brevital, 100mg hs 1 day before surgery
    • Brevital, 50mg qhs at bedtime
    • Morphine, 20mg IM STAT
    • Oxytocin, 8 mU/min IV at 10:00 A.M
  • RIGHTS in medication
    • Rights of drug administration
    • Right Drug
    • Right Dose
    • Right Time
    • Right Route
    • Right Patient
    • Right Documentation
    • Right Approach
    • Right Evaluation
    • Right to Educate
    • Client’s right to refuse
    • Right Assessment
  • Medicine Administration Route Length Gauge Degree ID 3/8 – 1/2 G 25-27 10-15(bevel up) SC ½ - 5/8 G 25-27 45 degree (90 degrees in INSULIN and Heparin admin IM 1-1.5inches G 20-24 (G 22 children, G24 Infant) 90 degrees
  •  
  • MASTERY DRILL: What ROUTE? ChoiceS: IM,ID,SC
    • BCG ___________
    • Measles _________
    • Hepa, DPT _______
    • Heparin: _________
    • Insulin ___________
    • Depoprovera ______
    • Iron (Dextran): Z-tract method (Common board question)
  • SALIENT POINTS: SITE
    • Z-tract method – best route for IRON
    • Dermis – Intradermal (DO NOT MASSAGE)
    • Ventrogluteal – best IM site for adult (1-3 years old)
    • Dorsogluteal – best IM site > 3 years old
    • Vastus lateralis – best IM site for infant (<1 year old)
  • Administering Medication via Z-track Injection
  • Z-tract Medication
    • Use (DOMINANT or NONDOMINANT) to hold the skin?
    • NONDOMINANT
    • You can (MASSAGE or NOT MASSAGE) the injection site.
    • DO NOT MASSAGE
  • Common Routes of Medication Administration
    • 1. PO
    • 2. Sublingual
    • 3. Topical - skin
    • 4. Subcutaneous
    • 5. Intramuscular
    • 6. Intravenous
    • 7. Rectal
    • 8. Intrathecal – drug is administered through SPINE
    • 9. Intraosseous – drug is administered through BONE
  • MASTERY DRILL (ROUTE)
    • OPV
    • Lumbar Puncture
    • Suppository
    • Visine
    • SUBLINGUAL place medication under the tongue and allow it to dissolve completely.
    • BUCCAL place the medication in the mouth against the cheek until it dissolves completely.
  • CRITICAL PATHWAY
    • Correct or Incorrect Approach?
    • The nurse practiced strict surgical asepsis when administering a rectal suppository. I C
    • The nurse validated a doctors order because it was unclear. C
    • The nurse administered an unfamiliar medication I C
    • Narcotics are placed in a locked cabinet C
    • The nurse administered a drug endorsed by the previous shift C
  • CRITICAL PATHWAY
    • Correct or Incorrect Approach?
    • The nurse, who administered potassium unincorporated prepared an incident report and then report the situation to the nurse in charge. C
    • The client is very uncooperative during medication administration. The nurse hid the drug on the client’s meal observing the bioethical principle of paternalism. C
    • The nurse returned an intermediate NPH insulin because it is cloudy. IC
    • The nurse Relabeled a drug because the label fell. C
    • The Nurse reads to label thrice, upon opening the cabinet, during administration and after administration of the drug. C
  • OTHER NURSING PROCEDURES
    • BLOOD TRANSFUSION
    • INTRAVENOUS INSERTION
    • DIALYSIS
    • MECHANICAL VENTILATION
  • Intravenous therapy
    • Note:
      • In choosing an IV site:
        • - choose DISTAL vein first
        • - Avoid client’s dominant hand and arm.
        • - Avoid an area of skin affected by a rash or
        • infection.
      • TORNIQUET: 6-8 inches above the site
      • Insert: BEVELS UP (5-25 degree)
      • Advance needle 1⁄4–1⁄2 in after successful venipuncture
  • Intravenous therapy
    • Note:
    • Change IV tubing every 24-72 hours
    • Change venipuncture site every 48-72 hours
    • Change IV dressing every 72 hours
    • DO NOT let an IV bag or bottle of solution hang for more than 24 hours
    • DO NOT allow the IV tubing to touch the floor
  • Intravenous therapy
    • Complications
    • 1. Infiltration and Extravasation
    • - coolness at site;
    • - remove IV device stat; elevate extremity and apply warm compresses
    • 2. Phlebitis and Thrombophlebitis - warm at the site
    • - apply cold moist compresses , remove IV, notify, restart
  • Intravenous therapy
    • Complications:
    • 3. Air Embolism
    • - clamp tubing
    • - turn the client on the left side with the head of bed lowered (Trendelenburg) to trap air in the right atrium,
    • - notify
  • IV FLUIDS
  • IVFLUIDS: SALIENT POINTS
    • Isotonic Solution – equal ratio of solute & solvent
    • – zero pressured solution all plain sol’n., Plain IMB, Plain NSS
    • – there is no change cell structure
    • Hypertonic Solution – more solute than solvent (ispiso)
    • – high gradient pressured solution all D 5 , all D 10 , all D 50
    • – cell shrinkage / crenation
    • – Ex. given to edema, fluid volume excess
    •  
  • IVFLUIDS: SALIENT POINTS
    • Hypotonic Solution – more solvent than solute (lasaw)
    • – low gradient pressured solution .30, .35, .45
    • – cell swells; if not regulated, cells will burst
    • – Ex. given to diarrhea, fluid volume deficit
    • * Major electrolyte  Potassium (K + )  needed for contraction [affects mobility]
    • Sodium (Na + )  for water regulation / retention  because Na + attracts water
    • - is regulated by aldosterone (adrenal cortex)
  • BLOOD DONATION
    • Legal basis  RA 7719
    • Mainn principle: It is a humanitarian act
    • Possible donors:
    • Age: 16-65 yo (if minor parental consent is needed)
    • Hgb: 12.5
    • Weight: <110 lbs  donate 250 mL
    • >110 lbs  donate 450 mL
    • BP – Systolic 100-140 mmHg and Diastolic of 60-90 mmHg
  • BLOOD DONATION
    • Contraindications:
    • AIDS
    • KIDNEY d/o
    • CANCER
    • DM
    • Epileptic pt
    • Hepatitis and Malaria pt
    • Recipients:
    • Leukemia, liver d/o, loss of blood from surgery
  • BLOOD DONATION
    • Aftercare:
    • Adhesive tape  3-12 hours
    • No smoking - 2 hours
    • No alcohol – 12 hours
    • Free arm activity – 24 hours
  • Blood Transfusion
    • Note:
      • RBC : 250 ml
      • Whole blood : 500 ml
      • Solution: NSS
      • 1 unit = 4 hours only
      • 20-30 minutes interval from Blood bank to administration
      • DO NOT REFRIGERATE
      • Stay for first 15-30 minutes
  • Blood Transfusion
    • Note:
    • If transfusion reaction occurs:
      • STOP transfusion, (CBQ)
      • change IV tubing down to the IV site,
      • keep IV line open with NS,
      • notify physician and blood bank,
      • return blood bag and tubing to blood bank;
      • Do NOT leave client alone
  • Blood Transfusion
    • Note:
      • Gauge: 18
      • transfusion: confirming product compatibility and verifying client identity
      • Verify by 2 nurses
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  • BLOOD TRANSFUSION
    • Type A –
    • A antigen
    • anti-B antigen
    • Type B
    • B antigen
    • anti-A antibodies
  • BLOOD TRANSFUSION
    • Type AB
    • Both A and B antigen
    • has no A or B antibodies
    • universal recipient
    • Type O
    • Has no A or B antigen
    • has both A and B antibodies
    • Universal donor
  • MASTERY DRILL: PLEASE ANSWER
    • ___________has B antigen
    • ___________ has A or B antibodies
    • ________has both A & B anitbodies
    • ___________ has anti-B antibodies
    • ___________ has A antigen
    • ___________ has no A or B anitgen
    • ________has both A and B antigen
  • TYPES OF BLOOD PRODUCTS
    • Blood products:
    • PRBC  1 unit raises Hct by 4%
    • WB  for volume expansion
    • FFP  Replace coagulation factos (use within 6 hours)
    • Platelets  infuse 10 minutes per unit
    • Cyoprecipitate  restores factor VII and fibrinogen in tx HEMOPHILIA A
  • Mechanical Ventilation
    • Note:
    • High Pressure Alarm:
    • Indication: Obstruction
    • Cause: Secretions, kinked tubing, bucking
    • Low Pressure Alarm:
    • Indication: A Leak or Disconnection
  • Responding to Accidental Poisoning DRUGS WITH ANTIDOTE Acetaminophen Acetylcysteine Benzodiazepine Flumazenil Coumadin Vitamin K Cyanide Poisoning Methylene Blue Digitalis Digibind Heparin Protamine Sulfate (NLE question July 2010) Iron Deferoxamine Mesylate Lead Edetate Disodium (EDTA) Magnesium Sulfate Calcium Gluconate Morphine Naloxone Hydrochloride Penicillin
  • Mastery Drill: Please answer
    • Digitalis
    • Cyanide Poisoning
    • Lead
    • Iron
    • Heparin
    • Coumadin
    • Magnesium Sulfate
    • Morphine
    • Acetaminophen
    • Penicillin
  • DIALYSIS
    • 2 types:
    • Peritonela dialysis
    • Hemodialysis
  • DIALYSIS
    • * Give 1,000 units of heparin
    • *What do you call that test that evaluates the therapeutic effect of heparin?
    • Answer: PTT (Partial Thromboplastin Time)
    • *What is the antidote for heparin toxicity?
    • Answer: Protamine sulfate
  • DIALYSIS
    • *What is that test that calls for the therapeutic effectiveness of warfarin?
    • Answer: PT (Prothrombin Time)
    • *What is the antidote for warfarin toxicity?
    • Answer: Vitamin K
    • Heparin
    •  prevents coagulation
    •  injected in the artery
  • PERITONEAL DIALYSIS
  • HEMODIALYSIS
  • RESTRAINTS
    • R – requires physician’s order; consent
    • E – emergency, get MD’s order ASAP
    • S- shortest duration (least restrictive)
    • To protect patient and others
    • A- ssess q 15-30 mins & document
    • Individualized supervision (one-on-one)
    • Never used punishment
    • Total documentation
    • Seclusion as last step
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  • LUMBAR PUNCTURE
    • Purpose: To withdraw CSF
    • Empty bowel and bladder
    • C-position (fetal position or shrimp position)
    • Insertion site: L3-L4 or L4-L5 (prevent puncture of the spinal cord since it ends at L2)
    • After: FLAT Position 6-12 hours to prevent spinal headache
  • SCHILLING’s TEST
    • Purpose: Use to detect Vitamin B12 absorption
    • Excretion of Vitmin B12 8-40% is normal
    • >40 % excretion of Vit B12  indicates Pernicious anemia
    • Test: 24-hour urine specimen
  • EYE EXAMINATIONS
    • Snellen chart – to check visual acuity
    • E-Chart – to check visual acuity of illiterate patient
    • Tonemetry – to check IOP . Normal level 12-21 mmHg
    • Perimetry – to check peripheral vision
    • Ishihara plate – to check color bilndness
  • EAR EXAMINATIONS
    • Caloric test – alternate instillation of warm and cold water into the ear of the patient
    • Otoscopy – Visualization of the inner ear
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  • COMPLETE BLOOD COUNT
    • Hgb - Female: 12-16g/ml; Male : 14-18g/ml
    • Hct: Female: 36 - 46 percent Male :41 - 53 percent
    • Platelet count: 150,000 – 400, 000 /mm3
    • WBC: 5,000-10,000/mm 3
    • RBC : 4.5-6.2 million/mm 3
    • Neutrophils : 60-70% (inflammatory response)
    • Lymphocytes : 20-30% (immune system)
    • Eosinophils : 1-4 % (allergic reaction)
    • Basophils : 0 – 0.5% (allergic and parasitic reaction )
    • NORMAL LABORATORY VALUES
    • RED BLOOD CELL: HEMOGLOBIN
    • 4.5-6.2 million/mm 3 male : 14-18g/ml
    • WHITE BLOOD CELL: female: 12-16g/ml
    • 5,000-10,000/mm 3
    • Neutrophil PLATELET
    • - 60-70 250-000-45000/mm 2
    • -inflammatory responses BLOOD UREA NITROGEN (BUN) :
    • Eosinophil -detect renal failure
      • -1-4% -10-20 mg/dl
      • -allergic reaction
    • Basophil
    • -0-0.5%
    • -allergic reaction and parasitic reaction
    • Monocyte
    • -2-6%
    • -immune function
    • Lymphocyte
    • -20-30%
    • -vertebrate immune system
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  • MODULE 10: HYGIENE
    • Types of bathing:
    • 1. Cleaning Bathing
    • 2. Therapeutic bathing
  • HYGIENE: BATHING
    • Types of bathing:
    • 1. Cleaning bath
    • COMPLETE - bedridden
    • PARTIAL – some parts (perineum, groin and axilla)
    • SELF-HELP BATH – parts that cannot be reached by pt
    • 2. Therapeutic bathing
    • COOL BATH – for muscle tension (30 mins)
    • WARM BATH – for muscle spasm (3 mins)
    • COLLOIDAL BATH (oatmeal bath of cornstarch) – for pruritus
  • MODULE 10: HYGIENE DRY SKIN OILY SKIN TEMPERATURE COLD WARM MUST- HAVE Use Moisturizer Use Astringent FREQUENCY Less More INSTRUCTION Avoid scratching the skin Avoid fatty and oily foods
  • HYGIENE: BATHING
    • Shampooing: use circular motion
    • Combing: from root to tip
    • Brushing teeth: hold toothbrush 45 degree angle
    • Clean the eyes: inner to outer canthus
    • Wash the limbs: distal to proximal
    • Cut the nails: straight across
    • Shave the hair: follow the hairline
  • HYGIENE: BATHING
    • Washing the perineum:
    • MALE
    • Position: Supine position
    • Equipment: Clean gloves
    • FEMALE
    • Position: Dorsal recumbent pos (Inner to Outer )
    • Equipment: Forceps/gloves
  • THANK YOU.
    • END.
    • Please notify the admin if you have questions/clarifications by text/call 09215688278. Thank you