WHAT YOU SHOULD KNOW BEFORE THE PNLE                                            JULY	  2012	  PNLE	  PEARLS	  OF	  SUCCESS...
WHAT YOU SHOULD KNOW BEFORE THE PNLE                                                                           JULY	  2012...
WHAT YOU SHOULD KNOW BEFORE THE PNLE                                           JULY	  2012	  PNLE	  PEARLS	  OF	  SUCCESS	...
WHAT YOU SHOULD KNOW BEFORE THE PNLE                                          JULY	  2012	  PNLE	  PEARLS	  OF	  SUCCESS	 ...
WHAT YOU SHOULD KNOW BEFORE THE PNLE                                               JULY	  2012	  PNLE	  PEARLS	  OF	  SUCC...
WHAT YOU SHOULD KNOW BEFORE THE PNLE                                                       JULY	  2012	  PNLE	  PEARLS	  O...
WHAT YOU SHOULD KNOW BEFORE THE PNLE                                                JULY	  2012	  PNLE	  PEARLS	  OF	  SUC...
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July 2012 nle tips funda

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July 2012 nle tips funda

  1. 1. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING    I.    NURSING  THEORIST   PLANNING  PHASE   Types  of  Planning        Florence  Nightingale   Environmental  Theory   -­‐ Prioritize  problems   Initial  planning,  admission  Virginia  Henderson   14  Basic  Needs   -­‐ Formulate  goals   assessment.  Faye  Abdellah   Patient  –  Centered  Approaches  to   -­‐ Select  actions   Ongoing  planning   Nursing  Model  /  21  Nursing  Problems   -­‐ Write  nursing  orders   Discharge  planning:  Dorothy  Johnson   Behavioral  System  Model   M  edications  Imogene  King   Goal  Attainment  Theory   E  xercise  Madeleine  Leininger   Transcultural  Nursing  Model   T  reatment/therapy  Myra  Levin   Four  Conservation  Principles   H  ygiene  Betty  Neuman   Health  care  System  Model   O  ut-­‐patient  follow  up  Dorotheo  Orem   Self-­‐Care  and  Self-­‐Care  Deficit  Theory   D  iet/nutrition  Hildegard  Peplau   Interpersonal  Model   S  exual  activity/spirituality   INTERVENTION  /   Types  of  Intervention  Martha  Rogers   Science  of  Unitary  Human  Beings   IMPLEMENTATION   • Independent  Sister  Callista  Roy   Adaptation  Model     • Dependent  Lydia  Hall   Care,Core,Cure   -­‐ Determining  needs   • Collaborative  Jean  Watson   Human  Caring  Model   for  assistance    Rosemarie  Rizzo   Human  Becoming   -­‐ Putting  into  action   Cognitive  or  Intellectual  Skills  Parse   the  plan   Such  as  analyzing  the  problem,     -­‐ Supervising   problem  solving,  critical  II.  NURSING  PROCESS   delegated  care   thinking  and  making  judgments     -­‐ Documenting   regarding  the  patients  needs.  ASSESSMENT  PHASE   Subjective  Data    also  referred  to   nursing  activities   Interpersonal  Skills     as  symptoms  or  covert  data   Which  includes  therapeutic  -­‐ Data  Collection   Objective  Data  also  referred  to   communication,  active  listening,  -­‐ Organize  Data   as  signs  or  overt  data,  are   conveying  knowledge  and  -­‐ Validate  Data   detectable  by  an  observer   information,  developing  trust  or  -­‐ Document  Data   Primary  source  is  the  client   rapport-­‐building  with  the   Secondary  source  is  family  or   patient     anyone  else  that  is  not  the  client   Technical  Skills  Which  includes     knowledge  and  skills  needed  to   Methods  of  Data  Collection   properly  and  safely  done  the   Observing  To  observe  is  to   procedure   gather  data  by  using  the  sense.       Interviewing  Is  a  planned   EVALUATION  PHASE   Collecting  data  related  to   communication  or  a   outcome   conversation  with  purpose   Comparing  data   Examining  Is  a  systematic  data-­‐ Drawing  conclusion   collection  method  that  uses   Continuing,  modifying  or     observation  (i.e.,  the  senses  of   terminating  the  nursing  care   sight,  hearing,  smell,  and  touch)   plan   to  detect  health  problems.         III.   ROLES   AND   FUNCTIONS   OF   THE   PROFESSIONAL  DIAGNOSIS  PHASE   Types  of  Nursing  Diagnosis  -­‐ Analyze  Data     NURSE  -­‐ Identify  Health   Actual  diagnosis  is  a  client     Problem   problem  that  is  present  at  the   • Direct   Care   Provider   -­‐   provides   total   care   using   the  -­‐ Formulate   time  of  the  nursing  assessment.     nursing  process  .   Diagnostic   Risk  nursing  diagnosis  is  a   • Communicator   –   communicates   with   clients,   support   Statements   clinical  judgment  that  a  problem   person  and  colleagues  to  facilitate  all  nursing  action.     does  not  exist,  but  the  presence  Diagnostic  Statements   of  risk  factors     • Teacher  –  provides  health  teaching  Problem  (P):  statement   Wellness  diagnosis   • Counselor   –  helps  the  client  to  recognize  and  cope  with  of  the  client’s  response.   Possible  nursing  diagnosis  is   stressful  pyschological  or  social  problem,    Etiology  (E):  factors   one  in  which  evidence  about  a   • Client   Advocate   –   the   nurse   becomes   an   activist  contributing     health  problem  is  incomplete  or   speaking   up   for   the   client   who   cannot   or   will   not   speak  Signs  and  Symptoms   unclear.     for  self.  (S):  defining   Syndrome  diagnosis  is  a  characteristics   diagnosis  that  is  associated  with   • Change   Agent   –   initiates   changes   and   assists   the   client  manifested  by  the  client   a  cluster  of  other  diagnoses.   make  modifications  in  the  lifestyle  to  promote  health.  POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
  2. 2. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING    • Leader   –   nurse   through   the   process   of   interpersonal   IV.  ISOLATION  PRECAUTIONS   influence  .    • Manager   –   the   nurse   plans,   gives   directions,   develops   Ø Standard  Precautions  /  Universal  Precautions   ü Applies  to  ALL  BODY  FLUIDS   staff,  monitors  operation.   ü Includes:  • Case   Manager   –   coordinates   the   activities   of   other   1. HAND  WASHING   member  of  the  health  care  team.   2. Personal  Protective  Equipment  • Researcher  –  participates  in  scientific  investigation  and   (sequence  of  removing  PPE’s)   uses  research  findings  in  practice.   gloves-­‐mask-­‐gown-­‐eyewear-­‐cap   3. Safe  use  of  sharps  • Collaborator  –  works  in  a  combined  effort  with  all  those   4. Removing  spills  of  blood  and  body  fluids   involved  in  care  delivery.   5. Cleaning  and  disinfecting  equipment       Ø Transmission  Based  Precautions  III.  CHAIN  OF  INFECTION   •  Airborne  precautions       ü A  single  room  under  negative  pressure   ventilation  with  a  wash  hand  basin     ü The  door  must  be  kept  closed  at  all  times   except  during  necessary  entrances  and  exits.     ü Disposable  paper  towels     ü A  high  efficiency  mask,  if  available,  should  be   worn  when  entering  the  room  of  a  patient   with  known  or  suspected  tuberculosis.       •  Droplet  precautions   ü Put  on  a  standard  mask  prior  to  entering  the   isolation  room.       ü Hands  must  be  washed  with  an  antiseptic     preparation  and  must  be  dried  thoroughly     with  a  disposable  paper  towel  or  washed  with     a  waterless  alcohol  hand  rub/gel:    ► MODE   OF   TRANSMISSION   it   indicates   the   potential   of   1. AFTER  contact  with  the  patient  or   the  disease;  conveyance  of  the  agent  to  the  host;  it  can  be   potentially  contaminated  items,       by   common   source   transmission,   contact   source,   air-­‐ 2. AFTER  removing  gloves,  and     borne  transmission.   3. BEFORE  taking  care  of  another  patient.         There  are  four  main  routes  of  transmission   •  Contact  precautions     A. By  Contact  Transmission   ü Non-­‐sterile,  disposable  gloves  are  needed     1.  Direct  contact  (  person  to  person  )   when  there  is  contact  with  an  infected  site,     2.  Indirect  contact  (  usually  an  inanimate  object)     with  dressings,  or  with  secretions.       3.  Droplet  contact  (  from  coughing,  sneezing,  or     ü A  mask  when  performing  procedures  that                                                          talking,  or  talking  by  an  infected  person)     may  generate  aerosols  or  when  performing     suctioning  is  recommended.   B. By  Vehicle  Route  (  through  contaminated  items)   ü Hands  washing  (see  droplet  precautions)     1.  Food  –  salmonellosis         2.  Water  –  shigellosis,  legionellosis         3.  Drugs  –  bacteremia  resulting  from  infusion  of  a     V.  NURSING  SKILLS                                                                      contaminated  infusion  product       4.  Blood  –  hepatitis  B,         A.  Physical  Assessment     Ø Provide  privacy.                  C.        Airborne  Transmission   Ø Make   sure   that   all   needed   instruments   are   available     1.    Droplet  of  nuclei     before  starting  the  physical  assessment     2.      Dust  particle  in  the  air  containing  the  infectious     Ø Be  systematic  and  organized  when  assessing  the  client.                                                          agent   Inspection,  Palpation,  Percussion,  Auscultation.     3.  Organisms  shed  into  environment  from  skin,  hair,     Ø EYES:  Visual  acuity  is  tested  using  a  snellen  chart.  The                                                        wounds  or  perineal  area.   room  used  for  this  test  should  be  well  lighted     Ø EARS:  Weber’s  Test  assesses  bone  conduction,  this  is                      D.    Vector  borne  Transmission,  arthropods  such  as       a  test  of  sound  lateralization,  Rinne  Test    compares   flies,  mosquitoes,  ticks  and  others.       bone  conduction  with  air  condition.     Ø NECK:  Let  the  client  sit  on  a  chair  while  the  examiner     stands  behind  him.      POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
  3. 3. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING     Ø THORAX:    The  client  should  be  sitting  upright  without   Ø Blood Pressure (NV 120/80 mm/hg) support  and  uncovered  to  the  waist.   ü This  is  the  force  exerted  by  the  blood  against  a   Ø HEART:  Anatomic  areas  for  auscultation  of  the  heart   vessel  wall   ü Aortic  valve  –  Right  2nd  ICS  sternal  border.   ü The  pressure  rises  with  age.   ü Pulmonic  Valve  –  Left  2nd  ICS  sternal  border.   ü A  rest  of  30  minutes  is  indicated  before  the  blood   ü Tricuspid  Valve  –  –  Left  5th  ICS  sternal  border.   pressure  can  be  readily  assessed  after  stressful   ü Mitral  Valve  –  Left  5th  ICS  midclavicular  line   activity.   Ø BREAST   ü Interval  of  30  minutes  is  needed  after  smoking  or   drinking  caffeine.   ü After  menopause,  women  generally  have  higher   blood  pressures  than  before.   ü Pressure  is  usually  lowest  early  in  the  morning,   when  the  metabolic  rate  is  lowest,  then  rises   throughout  the  day  and  peaks  in  the  late   afternoon  or  early  evening     Common  Errors  in  Blood  Pressure  Assessment     Errors   Effect     Ø ABDOMEN:  Place  the  client  in  a  supine  position  with   Bladder  cuff  too  narrow   Erroneously  high   the  knees  slightly  flexed  to  relax  abdominal  muscles.   Bladder  cuff  too  wide   Erroneously  low   (Inspection,Auscultation,Percussion,Auscultation)   Arm  unsupported     Erroneously  high     Insufficient  rest  before  the   Erroneously  high  B.  Vital  Signs   assessment     Repeating  assessment  too   Erroneously  high   Ø Temperature  (NV  36  –  37.5  C)   quickly   ü Elderly  people  are  at  risk  of  hypothermia   Cuff  wrapped  too  loosely  or   Erroneously  low   ü Hard  work  or  strenuous  exercise  can  increase   unevenly         body  temperature   Deflating  cuff  too  quickly   Erroneously  low  systolic  and   ü Oral:  most  accessible  2-­‐3  mins.  *  15  minutes   high  diastolic  reading   interval  after  ingestion  of  hot  or  cold  drinks   Deflating  cuff  too  slowly   Erroneously  high  diastolic   ü Rectal:  most  accurate  2-­‐3  mins.   reading   ü Axillary:  most  safest  6-­‐9  mins.   Failure  to  use  the  same  arm   Inconsistent  measurements     consistently     Ø Pulse  (NV  60-­‐100  bpm)   Arm  above  level  of  the  heart   Erroneously  low   ü Wave  of  blood  created  by  contraction  of  the  left   Assessing  immediately  after   Erroneously  high   ventricle  of  the  heart   a  meal  or  while  client     ü Radial:  best  site  for  adult   smokes   ü Brachial:  best  site  for  children   Failure  to  identify   Erroneously  low  systolic   ü Apical:  best  site  for  3  years  old  below   auscultatory  gap  pressure   pressure  and  erroneously     low  diastolic   Ø Respiration  (NV  12/16-­‐20)         Normal  Breath  Sound   C.  Medication  Administration      Vesicular   Soft,  low  pitch   Lung  periphery   Ø FIVE  RIGHTS  Broncho-­‐ Medium  pitch   Larger  airway   The  Right  Drug  with  vesicular   blowing   The  Right  Dose  through  Bronchial   Loud,  high  pitch   Trachea   The  Right  Route  at   The  Right  Time  to   Abnormal  Breath  Sound   The  Right  Patient   Ø Standard  Order,  Carried  out  until  cancelled  by   another  order.  Crackles   Dependent  lobes   Random,  sudden   Ø PRN  Order,  As  needed,  or  only  when  necessary.   reinflation  of  alveoli   Ø Stat  Order,  Carried  out  immediately  and  for  one  time   fluids   only.  Rhonchi   Trachea,  bronchi   Fluids,  mucus   Ø Always  clarify  doubtful  /unclear  order    Wheezes   All  lung  fields   Severely  narrowed   Ø Do  not  leave  medicine  with  the  client  to  take  by   bronchus   himself  Pleural   Lateral  lung  field   Inflamed  Pleura   Ø Do  not  give  drug  that  shows  physical  changes  or  Friction  Rub   deterioration  POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
  4. 4. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING     Ø Report  an  error  in  medication  immediately  to  the   E.  Nasogastric  Tube  (NGT)   nurse  in  charge.     Ø The  nurse  who  prepares  the  medication  must  be   Ø Gavage  (feeding)  /  Lavage  (suctioning)   responsible  for  administering  and  recording  it.    Never   Ø Select  the  nostril  that  has  greater  airflow.   endorse  it  to  another  nurse.   Ø Assist  the  client  to  a  high  fowler’s  position     Ø Always  observe  asepsis  in  preparing  and   Ø NEX  technique  (nose-­‐ear-­‐xiphoid)   administering  drugs.   Ø Checking  the  patency:   Ø Ascertain  client’s  identity  before  administering   ü Aspirate  stomach  contents  and  check  the  pH,   medications.  Check  room  or  bed  or  card,  call  out   which  should  be  acidic   client’s  name,  check  I.D.,  wrist  band   ü Introduce  10-­‐30  ml  of  air  into  the  NGT  and   Ø Care  must  be  taken  to  prevent  instilling  medication   auscultate  at  the  epigastric  area,  gurgling  sound   directly  into  cornea.   is  heard   Ø Apply  ointment  along  inside  edge  of  the  lower  eyelid   ü The  most  accurate  method  of  assessing  the   from  inner  to  outer  canthus.   placement  of  NGT  is  X-­‐ray  study   Ø EAR  MEDS:       Infants:    draw  the  auricle  gently  downward  and   Ø Before  feeding  assess  residual  feeding  contents.  To   backward.   assess  absorption  of  the  last  feeding,  if  50  ml  or   Adults:  lift  pinna  upward  and  backward   more,  verify  if  the  feeding  will  be  given.   Ø Intradermal:  Parallel  to  the  skin,  do  not  massage   Ø Height  of  feeding  is  12  inches  above  the  point  of   Ø Subcutaneous:  45  degree  above  the  skin,  if  obese  90   insertion.   degree   Ø Ask  the  client  to  remain  in  position  for  at  least  30   Ø Intramuscular:  90  degree  above  the  skin,  aspirate  to   min   check  if  blood  vessel  was  hit.   Ø Common  Problems  of  Tube  Feedings     • Vomiting  D.  Urinary  Catheterization   • Aspiration   Ø Use  appropriate  size  of  catheter   • Diarrhea   Male:  Fr  16-­‐18   • Hyperglycemia   Female:  Fr  12-­‐14     Ø Place  the  client  in  appropriate  position:   F.  Enema  Administration   Male:  Supine,  legs  abducted  and  extended     Female:  Dorsal  recumbent   Ø Position  the  client:   Ø Locate  the  urinary  meatus  properly:   Adult:  Left  lateral   Male:  at  the  tip  of  the  glans  penis   Infant/small  children:  Dorsal  recumbent   Female:  between  the  clitoris  and  vaginal  orifice   Ø Lubricate  the  tube  about  5  cm  (  2  in  )   Ø Lubricate  catheter  with  water  soluble  lubricant  before   Ø Insert  7  –  10  cm  (  3  to  4  inches)  or  rectal  tube  gently   insertion   in  rotating  motion   Male:  6  –  7  inches   Ø Raise  the  solution  container  and  open  the  clamp  to   Female:  1  –  2  inches   allow  fluid  to  flow   Ø Length  of  catheter  insertion:   High  Enema:  12-­‐18  inches  above  the  rectum   Male:  6  –  9  inches   Low  Enema:  12  inches  above  the  rectum   Female:  3  -­‐4  inches   Ø If  the  client  complains  of  fullness  or  pain,  use  the   Ø Anchor  catheter  properly:   clamp  to  stop  the  flow  for  30  sec.  and  then  restart   Male:  laterally  or  upward  over  the  lower  abdomen  /   the  flow  at  a  slower  rate   upper  thigh     Ø Encourage  the  client  to  retain  the  enema,  ask  the   Female:  inner  aspect  of  the  thigh   client  to  remain  lying  down      Nursing  Interventions  to  Induce  Voiding/Urination   G.  Colostomy  Care      v Provide  privacy     Ø Stoma  should  appear  red,  similar  to  the  mucosal  v Assist  the  patient  in  the  anatomical  position  of  voiding   linin  of  the  inner  cheek  v Serve  clean,  warm  and  dry  bedpan  (female)  or  urinal   Ø Slight  bleeding  initially  when  the  stoma  is  touched   (male)   is  normal,  but  other  bleeding  should  be  reported.  v Allow  the  client  to  listen  to  the  sound  of  running  water   Ø Change  colostomy  appliance  if  it  is  1/3  full.  v Dangle  fingers  in  warm  water   Ø Use  warm  water,  mild  soap  (optional),  and  cotton  v Pour  warm  water  over  the  perineum   balls  or  a  washcloth  and  towel  to  clean  the  skin  and  v Promote  relaxation   stoma.  v Provide  adequate  time  for  voiding   Ø Apply  skin  barrier  over  the  skin  around  the  stoma  v Last  resort:  URINARY  CATHETERIZATION   to  prevent  skin  breakdown.     Ø Changing  is  best  in  the  morning  before  breakfast.     Ø Control  Odor:  (deodorizer,  charcoal  disk  and     prevent  odor  causing  foods)      POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
  5. 5. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING       Type  of  Discharge    Ileostomy   • Liquid  fecal  drainage   Ø Check  for  cross  matching  and  blood  typing.  To   • Drainage  is  constant  and  cannot   ensure  compatibility   be  regulated   Ø Obtain  and  record  baseline  VS,  Note:  If  patient  has   • Contains  some  digestive   fever  do  not  transfuse   enzymes   Ø Practice  strict,  ASEPSIS   • Odor  is  minimal  bec  of  fewer   Ø At  least  2  nurses  check  the  label  of  the  blood   bacteria  are  present   transfusion,  Check  the  following:  Ascending   • Liquid  fecal  drainage          -­‐  Serial  Number  Colostomy          -­‐  Blood  component   • Drainage  is  constant  and  cannot   be  regulated          -­‐  Blood  type          -­‐  Rh  factor   • Odor  is  a  problem  requiring          -­‐  Expiration  date   control          -­‐  Screening  test  Transverse   Malodorous,  mushy  drainage   • Ø Check  the  blood  for  gas  bubbles  and  any  unusual  Colostomy   color  or  cloudiness.  Note:  Gas  bubbles  indicate  Descending   • Solid  fecal  drainage   bacterial  growth,  Unusual  color  or  cloudiness  Colostomy   indicate  hemolysis  Sigmoidostomy   • Normal  fecal  characteristics   Ø Warm  blood  at  room  temperature  before     transfusion.     Ø Identify  client  properly,  two  nurses  check  the  H.  Suctioning   client’s  identification     Ø Gauge  of  needle:  #18   Ø Suction  only  when  necessary  not  routinely   Ø Drop  Factor:  KVO   Ø Use  the  smallest  suction  catheter  if  possible   Ø Duration:  RBC  –  4  hours;     Ø Client  should  be  in  semi  or  high  Fowler’s  position                                  Platelets,  FFP  –  20  minutes   Ø Use  sterile  gloves,  sterile  suction  catheter   Ø When  reactions  occurs:   Ø Hyperventilate  client  with  100%  oxygen  before   ü STOP  transfusion   and  after  suctioning   ü KVO  with  PNSS   Ø Insert  catheter  with  gloved  hand  (3-­‐5“  length  of   ü Send  remaining  blood,  a  sample  of  client  blood   catheter  insertion)  without  applying  suction.  Three   and  urine  sample  to  the  laboratory.   passes  of  the  catheter  is  the  maximum,  with  10   ü Notify  the  physician   seconds  per  pass.     ü Monitor  VS   Ø Apply  suction  only  during  withdrawal  of  catheter   ü Monitor  I  &  O   Ø The  suction  pressure  should  be  limited  to  less  than   Ø Common  BT  reactions:   120  mmHg   ü Hemolytic:  flank  /back  pain   Ø When  withdrawing  catheter  rotate  while  applying   ü Anaphylactic:  rashes,  itching,  DOB  (worst)   intermittent  suction   ü Febrile:  fever  and  chills   Ø Suctioning  should  take  only  10  seconds  (maximum   ü Circulatory  Overload:  DOB,  crackles   of  15  seconds)   ü Sepsis:  Fever  and  chills         K.  Assistive  Device  I.  Tracheostomy  Care       Ø Canes   Ø Assist  the  client  to  a  semi-­‐Fowler’s  or  Fowlers   ü COAL  (cane  opposite  affected  leg)   position.   ü Angel  is  20-­‐30  degrees   Ø Hydrogen  peroxide  moisten  and  loosens  dried   Ø Walkers   secretions   ü Hand  bar  below  the  client’s  waist  and  the  elbow   Ø Rinse  the  inner  cannula  thoroughly  in  the  sterile   is  slightly  flexed.   normal  saline.   Ø Crutches   Ø When  changing  the  ties:  tie  one  end  of  the  new  tie  to   ü Length  of  the  Crutches:  Subtract  40  cm  or  16   the  eye  of  the  flange  while  leaving  old  ties  in  place.   inches  to  the  height  of  the  client  obtain  the   Ø Put  two  fingers  under  the  tapes  before  tying  it.   approximate  crutch  length.     ü 20  to  30  degrees  of  flexion  at  the  elbow.       ü Four  point  gait:    J.  Blood  Transfusion   *  right  crutch,  the  left  foot,  the  left  crutch,  right     foot.     Compatible   Incompatible   ü Two  point  gait:     A   A  /  O   AB  /  B   *  left  foot  and  right  crutch,  right  foot  and  left   B   B  /  O   AB  /  A   crutch   AB   A  /  B  /  AB  /  O     ü Three  point  gait:     O   O   A  /  B  /  AB   *  left  foot  and  both  crutches,  right  foot.  POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
  6. 6. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING     ü Swing  Through  Gait:  .   ü Observe  for  fluctuation  of  fluid  along  the  tube   *  Advance  both  crutches,  Lift  both  feet  and  swing   (water-­‐seal  bottle  or  the  second  bottle)  and   forward,  Land  the  feet  in  front  of  crutches.   intermittent  bubbling  with  each  respiration.       • Three-­‐bottle  system   ü Going  up  the  stairs:  (good  goes  to  heaven,   bad  goes  to  hell)      L.  Chest  Physiotheraphy  (  CPT  )   Ø Steam  Inhalation   ü Place  the  client  in  Semi-­‐Fowler’s  position   ü Cover  the  client’s  eyes  with  washcloth  to   prevent  irritation   ü Place  the  steam  inhalator  in  a  flat,  stable   surface.   ü Place  the  spout  12  –  18  inches  away  from  the   client’s  nose  or  adjust  distance  as  necessary   ü To  be  effective,  render  steam  inhalation   therapy  for  15  –  20  minutes     Ø Postural  drainage     ü Use  of  gravity  to  aid  in  the  drainage  of   ü The  first  bottle  is  the  drainage  bottle;     secretions.     ü The  second  bottle  is  water  seal  bottle   ü Patient  is  placed  in  various  positions  to   ü The  third  bottle  is  suction  control  bottle.   promote  flow  of  drainage  from  different  lung     segments  using  gravity.     ü Observe  for  intermittent  bubbling  and   ü Areas  with  secretions  are  placed  higher  than   fluctuation  with  respiration  in  the  water-­‐   lung  segments  to  promote  drainage.     seal  bottle   ü Patient  should  maintain  each  position  for  5-­‐15   ü Continuous  GENTLE  bubbling  in  the  suction   minutes  depending  on  tolerability.     control  bottle.       ü Suspect  a  leak  if  there  is  continuous  bubbling     in  the  WATER  seal  bottle  or  if  there  is  M.  Closed  Chest  Drainage  (  Thoracostomy  Tube  )   VIGOROUS  bubbling  in  the  suction  control     bottle.    Types  of  Bottle  Drainage   ü The  nurse  should  look  for  the  leak  and  report   the  observation  at  once.  Never  clamp  the   • One-­‐bottle  system   tubing  unnecessarily.   ü The  bottle  serves  as  drainage  and  water-­‐seal     ü If  there  is  NO  fluctuation  in  the  water  seal   ü Immerse  tip  of  the  tube  in  2-­‐3  cm  of  sterile   bottle,  it  may  mean  TWO  things   NSS  to  create  water-­‐seal.   ü Either  the  lungs  have  expanded  or  the   ü Keep  bottle  at  least  2-­‐3  feet  below  the  level  of   system  is  NOT  functioning  appropriately.     the  chest     ü In  this  situation,  the  nurse  refers  the   ü Observe  for  fluctuation  of  fluid  along  the  tube.   observation  to  the  physician,  who  will  order   The  fluctuation  synchronizes  with  the   for  an  X-­‐ray  to  confirm  the  suspicion.     respiration.   ü In  the  event  that  the  water  seal  bottle   ü Observe  for  intermittent  bubbling  of  fluid;   breaks,  the  nurse  temporarily  kinks  the  tube   continues  bubbling  means  presence  of  air-­‐leak   and  must  obtain  a  receptacle  or  container     with  sterile  water  and  immerse  the  tubing.    In  the  absence  of  fluctuation:   ü She  should  obtain  another  set  of  sterile  bottle                      Suspect  obstruction  of  the  device   as  replacement.  She  should  NEVER  CLAMP   v Assess  the  patient  first,  then  if  patient  is  stable   the  tube  for  a  longer  time  to  avoid  tension   v Check  for  kinks  along  tubing;     pneumothorax.     v Milk  tubing  towards  the  bottle    (If  the  hospital   ü In  the  event  the  tube  accidentally  is  pulled   allows  the  nurse  to  milk  the  tube)   out,  the  nurse  obtains  vaselinized  gauze  and   v If  there  is  no  obstruction,  consider  lung  re-­‐ covers  the  stoma.     expansion;    (validated  by  chest  x-­‐ray)   ü She  should  immediately  contact  the   v Air  vent  should  be  open  to  air.   physician.         • Two-­‐bottle  system     ü If  not  connected  to  the  suction  apparatus     ü The  first  bottle  is  drainage  bottle;       ü The  second  bottle  is  water-­‐seal  bottle    POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
  7. 7. WHAT YOU SHOULD KNOW BEFORE THE PNLE JULY  2012  PNLE  PEARLS  OF  SUCCESS    PART  1:  FUNDAMENTALS  OF  NURSING    N.  Oxygen  Therapy     Ø Nasal  Cannula  (24%  -­‐  45%  )  at  flow  rate  of  2  –  6   L/min.   Ø Simple  Face  Mask    (40%  -­‐  60%)  at  liter  flows  of  5  -­‐  8   L/min   Ø Partial  Rebreather  Mask  (60%  -­‐  90%)  at  liter  flows   of    6  –  10  L/min.   Ø Non-­‐Rebreather  Mask  (95%  -­‐  100%)  at  liter  flows  of       10  –  15  L/min.   Ø Oxygen  is  colorless,  odorless,  tasteless  and  a  dry  gas   that  support  combustion,  therefore  leakage  cannot  be   detected.   Ø Place  cautionary  signs  reading  “  No  SMOKING:   Oxygen  in  Use”   Ø Avoid  materials  that  generate  static  electricity,  such  as   woolen  blankets  and  synthetic  fibers.   Ø Set    up  the  oxygen  equipment  and  the  humidifier   filled  with  distilled/sterile  water.     Ø CANNULA:  Put  over  the  client’s  face,  with  the  outlet   prongs  fitting  into  the  nares.   Ø FACE  MASK:  Fit  the  mask  to  the  contours  of  the   client’s  face,  apply  it  from  the  nose  downward        POSSIBLE  TOPICS  ON  FUNDAMENTALS  OF  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  *Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  

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