53119942 Fundamentals of Nursing Nursing Board Review
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Transcript of 53119942 Fundamentals of Nursing Nursing Board Review
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Fundamentals of Nursing
Nursing Board Review
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Outline of review for the boards
History of Nursing- World and Philippines
The Nursing theories
Concepts of Health and Illness
Human Basic Needs
Stress and Adaptation
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Outline of review for the boards
ASSESSING HEALTH STATUS
VITAL SIGNS
PHYSICAL ASSESSMENT
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Outline of review for the boards
CLIENT CARE
ASEPSIS
SAFETY
HYGIENE
MEDICATIONS
SKIN INTEGRITY
TERMINAL CARE
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Outline of review for the boards
HEATH PROMOTION AND DISEASEPREVENTION
ACTIVITY and EXERCISE
REST and SLEEP
PAIN managementNUTRITION
FECAL ELIMINATION
URINARY ELIMINATION
OXYGENATIONCIRCULATION
Fluids and Electrolytes
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History of Nursing
Intuitive Nursing
Apprentice Nursing
Dark Period of Nursing
Educated Nursing
Contemporary Nursing
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History of Nursing
Intuitive Nursing
Primitive and untaught
Code of HAMMURABI
Moses- Father of Sanitation
Hippocrates- Developed standards for clientcare, medical standards and need for nurses
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History of Nursing
Educated Nursing Florence Nightingale- born May 12, 1820 in
Florence ITALY
Trained: Germany at Kaiserswerth School Founded the St. Thomas School of Nursing
in England Teachers are devoted clinical instructors solely
for teaching The first nurse to exert political pressure on
government
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Nursing in the PHILIPPINES
First School of Nursing= ILOILO MISSIONhospital school of nursing
Anastacia Giron-Tupas= Founder of the PNA
Rosario Delgado= first PNA president
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Theories in Nursing
Four concepts Central to Nursing:
P-E-H-N
Person
Environment
Health
Nursing
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Theories in Nursing
ENVIRONMENTAL THEORY
Relate nature with the bird- Nightingale
The act of utilizing the environment of the
patient to assist him in his recovery
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Theories in Nursing
INTER-PERSONAL RELATIONS Model Remember PEP talk
Hildegard PEPLAU
Therapeutic relationship:
Orientation= assist client tounderstandproblem
Identification= Client dependence, inde andinter he recognizes his problems in this phase
Exploitation/Exploration= Derives full valueini-exploit!!
Resolution= old andnew goalsput aside
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Theories in Nursing
Nature of Nursing- Definition of Nursing
The meaning of Nursing is VIRGIN
Recall the 14 needs!!!!!
Associate 14 virgin HENS VirginiaHENDERSON
She believes that clients need to express theiremotions, remain independent, autonomous
They must work in such a way that they feel a senseof accomplishment
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Theories in Nursing
21 nursing problems
Faid 21
Faye Abdellah
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Theories in Nursing GENERAL THEORY OF NURSING-
SELF- CARE Associate Self care to ORAL care or
per orem
Dorothea OREM 1. WHOLLY compensatory= unable to
control
2. PARTLY compensatory= unable to
performSOMEself care 3. SUPPORTIVE- EDUCATIVE= who
needs to learn and needs assistance
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Theories in Nursing
BEHAVIORAL SYSTEM MODEL
Associate behavior with John (inJohn and Marsha)
kaya JOHN(son) magsumikap ka Dorothy Johnson
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Theories in Nursing
Conservation Theory
the Divine is Conservative
Levin levine, divine
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Theories in Nursing
GOAL ATTAINMENT
Recall that the KING of the land has aGOAL to attain for his kingdom
IMOGENE KING!
Her theory is applicable to the child
bearing women and their families
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Theories in Nursing
UNITARY BEING: Man as theCENTRAL Focus
Roger , Roger, let us unite our Man
in the center of the battlefield
The whole is greater than its parts
Martha ROGERS
She believes in the use of theprinciples of NON CONTACTtherapeutic touch
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Theories in Nursing
HEALTH CARE SYSTEMS model
Betty NEUMAN
Stresses, reactions to stress andadaptation to stressors
After overcoming the stresses you willbecome a NEW-Man
Intrapersonal stressor= illness
Extrapersonal stressors= financialconcerns, community resources
Interpersonal stressor= unrealistic roleexpectations
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Theories in Nursing
ADAPTATION MODEL
Individual is a BIOPSYCHOSOCIAL
ADAPTIVE system with input andoutput
associate this with a Nun
SISTER ROY= nag a adopt ng mgabata
Her theory supports the unitybetween the client and God
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Theories in Nursing
CULTURAL CARE DIVERSITY
Transcultural Nursing
Madeleine LEININGER
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Theories in Nursing
Nursing Process theory and CARE,CORE and CURE
The nurse who coined the wordnursing process and stated I care, Icore and I cure
Hall of Fame award!!!
LYDIA HALL
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Theories in Nursing
DYNAMIC NURSE-PATIENTRelationship
Associate dynamic action to theteam of ORLANDO
Ida Jean ORLANDO!!!
Go Orlando, the dynamic team!!!!!
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Theories in Nursing
HUMAN BECOMING THEORY
Remember to become a rose per se ,
you must be a bud first!!!!!!!!!!!!
Rosemarie Parse
Her theory emphasizes that clients arethe AUTHORITY figures and decision
makers for their personal health
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Theories in Nursing
HUMAN CARING THEORY
Whatis caring?
Jean WATSON Caring for clients during their end-of-
life experiences
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Patricia Benners Stages of nursing
expertise (NACPE)
Stage 1 = novice No experience, performance is limited,inflexible
Stage 2= advanced
beginner
Demonstrates MARGINALLYacceptableperformance, recognizes the meaningful
aspects of a real situationStage 3=competent
Has 2-3 years experience, demonstratesORGANIZATIONAL and planning abilities
Stage 4= proficient Has 3-5 years of experience, perceives
situations as whole, has HOLISTICunderstanding of patient
Stage 5= expert Performance is FLUID, flexible and HIGHLYProficient, No longer requires rules,maxims.Demonstrates HIGHLY skilled
intuitive and analytic ability
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Health Definition
A state of complete physical,mental and social well-being and
not merely the absence of diseaseor infirmity
WHO, 1948
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Wellness
State of well-being
Seven Components- seven wishingWELL
Physical= carry out task
Social= interact with peopleEmotional= express feelings
Intellectual= learn and use info
Spiritual= belief in supernatural
Occupational= leisure and work
Environmental= standard of living incommunity
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Health Theories
CLINICAL
Health is absence of disease
ROLE PERFORMANCE Health is ability to fulfill societal
functions
ADAPTIVE Heath is a creative process of
adaptation
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Health Theories
EUDEMONISTIC
Health is a condition of self-actualization
ECOLOGIC
Health is interaction of three elements:
1. Agent
2. Host
3. Environment
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Health Theories
Dunn
doon, dito, dine and dire
Four quadrants
HIGH level Wellness is functioning at the BESTpossible level
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Illness and Disease
DISEASE
Alteration in body functions
ILLNESS
A state of physical, social, emotional,intellectual, developmental or spiritualfunctioning is DIMINISHED
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Stages of Illness: S-A-M-D-R
SYMPTOM experiences
Client believe something is wrong
ASSUMPTION of the sick role Excuse form work and family role
MEDICAL care contact
DEPENDENT CLIENT role RECOVERY or REHABILITATION
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Abraham Maslows Hierarchy of needs
Physiologic needs- oxygen, water, food
Safety and security
Love and belonginess Self esteem
Self actualization
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Abraham Maslows Hierarchy of needs
Safety and security
Physical safety
Psychological safety
Shelter from harm
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Abraham Maslows Hierarchy of needs
Love and belonginess
Need to love Need to belong
Need for affection
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Abraham Maslows Hierarchy of needs
Self esteem
Self-worth
Self-identity
Self-respect
Self-image
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Abraham Maslows Hierarchy of needs
Self actualization
Self-fulfillment
Spiritual fulfillment
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Man and His needs
Self-
Actualization
Self-Esteem
Love and Belongingness
Safety and Security
Physiologic Needs
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Mans Need
Need is something desirable anduseful
Needs are UNIVERSAL
Needs are MET in different WAYS Needs are influenced by different
FACTORS
Priorities may be CHANGED Needs may be POSTPONED
Needs are INTER-RELATED
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Mans Need
Need is something desirable anduseful
Prioritization of needs mat be dictatedby the clients perception
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Mans Need
Nursing goal is this area is to:
Meet the PHYSIOLOGICAL needs of thepatient
Assess the patient's perception of hisother needs
Employ nursing Interventions according to
the PERCEIVED NEEDS of the patient NOTof the nurse
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Evaluation Parameters of nursing care
The nurse checks if the desired criteriadictated by patients needs are achieved
Check which interventions were helpful
Revise the plan as needed
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Man achieves self-actualization
(Udan)
A self-actualized person is basically a
MENTALLY healthy person
And self-actualization is the essence ofmental Health
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Cultural care nursing
It is the provision of nursing care acrosscultural boundaries and takes into accountthe context in which the client lives
It is professional nursing that is culturallysensitive, culturally appropriate, and culturally
competent
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Cultural care nursing
The suggested steps for culture care are:
1. Become aware of ones own culture heritage
2. Become aware of the clients heritage and health
tradition3. Identify clients preference in health practices, diet,
hygiene, etc. These will affect their healthpractices
4. Formulate a culture care plan
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Stress and Adaptation
STRESS A condition in which the person responds to
changes in the normal balanced state
Selye: non specific response of the body to anykind of demand made upon it
STRESSOR
Any event or stimulus that causes an individual toexperience stress
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Stress and Adaptation
SOURCES OF STRESS
1. Internal
2. External
3. Developmental
4. Situational
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Stress and Adaptation
Physiological indicators of stress: Sympatheticresponse
Dilated pupils
Diaphoresis
Tachycardia, tachypnea, HYPERTENSION,
increased blood flow to the muscles Increased blood clotting
Bronchodilation
Skin pallor
Water retention, Sodium retention Oliguria
Dry mouth, decrease peristalsis
Hyperglycemia
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S d Ad i
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Stress and Adaptation
SELYES General Adaptation Theory
A-R-E
ALARM:sympathetic system is mobilized!RESISTANCE:adaptation takes place
EXHAUSTION: adaptation cannot be
maintained
ANXIETY
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ANXIETY
CATEGORY MILD MODERATE SEVERE PANIC
Perceptionandattention
Increasedarousal
Narrowedfocus
Inability tofocus
Distortedperception
Communication
Increasedquestioning
Voicetremors
Focus onparticularobject
Difficult tounderstand
Easilydistracted
Tremblingunpredictable response
VS changes NONE SlightIncrease
Tachycardia,Hyperventilation
Palpitation,choking,chest pain
A i f
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Anxiety versus fear
ANXIETY FEAR
State of mental uneasiness Emotion of apprehension
Source may not beidentifiable
Source is identifiable
Related to the future Related to the present
Vague Definite
Result of psychologic oremotional conflict
Result of discrete physicalor psychological entity,definite and concreteevents
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VS
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VS
T
P
R
BP
TEMPERATURE
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TEMPERATURE
Reflects the balance between the heatproduced and the heat lost from the body
CORE TEMPRATURE: deep tissues of body
T M i i
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Temperature Monitoring
Oral- accessible and convenient
Rectal- very accurate
Axillary- preferred for newborns
Tympanic- reflects core temperature
B d t t h di l i ti
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Body temperature has a diurnal variation
POINT of Highest body temperature isBETWEEN 8 pm to 12 midnight
POINT of Lowest body temperature isBETWEEN 4 am to 6 am
T Al i
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Temperature Alteration
FEVER, PYREXIA, HYPERTHERMIA
1. Intermittent:Periods of fever and normaltemp
2. Remittent: Fever fluctuates BUT abovenormal
3. Relapsing: Fever for few days, thennormal for few days
4. Constant: ALWAYS above normal,minimal fluctuation
H t l
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Heat loss
Mechanism Description
Conduction Transfer of heat form one object toanother by direct contact
Convection Movement of air and heat by air current
Evaporation Loss of heat through evaporation ofwater/sweat
Radiation Transfer of heat from warm objects tocool objects in the form ofelectromagnetic waves
P l
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Pulse
A wave of blood created by contraction of theleft ventricle of the heart
Normal range: 60-100 BPM
P l
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Pulse
Pulse pressure: Systolic pressure MINUS diastolic pressure
Pulse deficit
Apical pulse MINUS peripheral pulse Pulsus paradoxus
Systolic pressure falls by more than 15mmHg during INHALATION
Pulsus alternans Alternating strong and weak pulses
Li id Di t V S ft di t
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Liquid Diet Vs Soft diet
Clear liquid Full liquid Soft diet
Coffee
Tea
Carbonated
drinkBouillon
Clear fruit juice
Popsicle
Gelatin
Hard candy
Clear liquidPLUS:
Milk/Milk prod
Vegetablejuices
Cream, butter
Yogurt
PuddingsCustard
Ice cream andsherbet
All CL and FLplus:
Meat
VegetablesFruits
Breads andcereals
Pureed foods
F d G id p r id
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Food Guide pyramid
Bread, cereals, rice and pasta= 6-11 servings
Fruit and vegetables
Meat, poultry, fish, dry beans, eggs
Milk, yogurt, cheese
Fats, oils and sweets
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Primary Prevention Health promotion andSpecific protection
Secondary Prevention Health maintenance
Screening and casefinding
Early diagnosis
Prompt treatment
Tertiary Prevention Rehabilitation
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Primary
PreventionEducation, Exercise, Diet and
Nutrition, Immunization
Secondary
Prevention
Physical Examination, Paps
smear, BSE, TSESputum AFB, DRE
Providing medication andtreatment
Tertiary
PreventionPhysical therapy, Self-monitoring
of DM, Speech therapy
Levels of Prevention
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Levels of Prevention
1. ENCOURAGING MEDICALCONSULTATIONS AND DENTAL CHECK-UPS
Levels of Prevention
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Levels of Prevention
1. ENCOURAGING MEDICALCONSULTATIONS AND DENTALCHECK-UPS
Secondary Prevention
Levels of Prevention
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Levels of Prevention
2. Assessing growth and development ofchildren for nutritional evaluation
Levels of Prevention
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Levels of Prevention
2. Assessing growth and development ofchildren for nutritional evaluation
Secondary Prevention
Levels of Prevention
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Levels of Prevention
3. Family Planning and marriage counseling
Levels of Prevention
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Levels of Prevention
3. Family Planning and marriage counseling
primary prevention
Levels of Prevention
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Levels of Prevention
4. Teaching a client with diabetes self-monitoring of glucose level
Levels of Prevention
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Levels of Prevention
4. Teaching a client with diabetes self-monitoring of glucose level
Tertiary prevention
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DIAGNOSTIC
EXAMINATIONS
Duke J. Trillanes III, RN, MAPRA Gapuz Review Center
MUST KNOWS
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MUST KNOWS
KNOW NORMAL VALUES FIRST
DISEASE CONDITIONS AND THESIGNIFICANCE OF CERTAINLABORATORY DATA
POSITIONING FOR THIS TESTS
PURPOSE AND NURSING ALERT
SPECIMEN COLLECTION AND PATIENT
PREPARATION
POST TEST RESPOSIBILITIES
SPECIMEN COLLECTION
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SPECIMEN COLLECTIONUrine
Clean-catch urine specimen For routine urinalysis and culture and sensitivity test
Perineal care before collection
The best time to collect the specimen is early in the
morning (first voided-specimen) Amount needed: 30-50 cc for urinalysis; 5-10 ml for
culture and sensitivity test
24 Hours urine Specimen
discard the first voided urine
Soak specimen in a container of ice
Add preservative as ordered and indicate in the labelthe type of preservative added.
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Second voided Urine Specimen
Ask the patient to urinate and discard the first
urine specimen and offer a glass of waterafterwards
After few minutes, ask the client to void again andcollect the specimen
Catheterize Urine Specimen
Clamp the catheter for 45 mins
Practice aseptic technique
Do not collect specimen from the urine bag Obtain 3-5 ml of specimen for culture and
sensitivity test and 10-15 ml for urinalysis
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Stool Specimen
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Routine Fecalysis Use to assess gross appearance, and presence of ova
or parasite in the stool Sterile specimen container must be secured Instruct the client to defecate in the bedpan and obtain
1tbsp or 1 inch long stool specimen using a steriletongue depressor
Label the specimen and bring immediately to thelaboratory
Stool Culture and Sensitivity Test This is done to assess for specific microorganisms and
etiologic agents causing gastroenteritis, and bacterial
sensitivity to various antibiotics Sterile technique must be employed Label the specimen properly and send immediately to
the laboratory
Guiac Stool Exam (Occult Blood)
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( )
It detects bleeding at the GI tract and
cancer of the stomach Meatless diet for 3 days prior to the
procedure
No to red or dark colored foods tom preventfalse positive result
No to iron: discontinue temporarily for 3days prior to the procedure
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Sputum specimen
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Sputum specimen
Gross Appearance
Collect early morning specimen Sterile container must be used
Mouth care before: gargle only with water (no tomouthwash, or toothpaste)
Instruct the client to deep breath and hack-upsputum from the lungs.
Sputum Culture and Sensitivity test
Used to assess the etiologic agent causingRespiratory tract infection and bacterialsensitivity to various antibiotics
Acid Fast Bacillus (AFB) staining
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Acid Fast Bacillus (AFB) staining
To determine active PTB
Sputum specimen is collected in 3consecutive mornings
Papanicolao or Cytologic Examination of thesputum
To assess for cancer cells
Blood Specimen
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p
Blood Tests that does not require fasting:
Complete Blood Count
Hemoglobin
Hematocrit Level test
Clotting studies
Enzyme studies
Serum electrolyte studies
Requires Fasting
Fasting Blood Sugar
Blood Urea Nitrogen
Serum Creatinine
Serum lipids (cholesterol level, glyceride level)
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Body Secretions
Culture and sensitivity test
To assess causative agent causing infection, and
bacterial sensitivity to various antibiotics Practice aseptic technique
Arterial blood gas analysis
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PURPOSE: To monitor the patients response tooxygen therapy and detects the presence of acid-
base balance. NURSING KEYPOINTS:
No to Suctioning prior to obtaining blood specimen
Assess for bleeding and hematoma at the puncturesite
Apply firm pressure at the puncture site for 5-10minutes
Specimen should be placed in iced-container
Assess for metabolic alkalosis for patient withvomiting, and on the other hand, observe for signs andsymptoms of metabolic acidosis for patients withdiarrhea.
Barium enema
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PURPOSE: To assess the large intestines
NURSING KEYPOINTS:
Provide a Liquiddietbefore the procedure.
Ensure that a laxative is given before theprocedure to promote better visualization, and
after the procedure to prevent constipation Report to the doctor if bowel movement does
not occur in 2 days
Instruct the patient to increase fluids and eat
foods rich in fiber The patient should also increase intake of
fluids
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Friends and Enemas What is an ENEMA?
A solution introduced into the rectum andlarge intestine for the purposes of:
1. To relieve constipation2. To relieve flatulence
3. To administer medication
4. To evacuate feces in diagnostics or surgery
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Enema types
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yp
1. Cleansing Enema= intended to remove
feces to prevent escape during surgery,for visualization procedure andconstipation
Purposes To1. Prevent escape of feces duringsurgery
2. Prepare intestines for diagnostics
and surgery3. Remove feces inconstipation/impaction
Enema types
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yp
2. Carminative enema= to expel flatus, 60-80mL of fluids instilled
3. Retention enema= oil or medication is
instilled to treat infection4. Return flow enema= also to expel flatus,
repeated 6 times
Enema Solutions
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Hypertonic Draws water into thecolon
SE: Retention of sodium
Hypotonic Distends colon, softensfeces
SE:F and E imbalance,water intoxication
Isotonic Distends colon SE: possible sodiumretention
Soap suds Irritates colon SE: May damage mucosa
Oil enema Lubricates feces
The Height of the ENEMAS
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g
During MOST enemas For HIGH enema
No higher than 30 cm above rectum Up to 45 cm above rectum
The TIME of the ENEMAS
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Cleansing Enema For Oil retention enema
5-10 minutes 30 minutes
The Length of the ENEMA tube
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g
insertion
The rectal tube isinserted 3 to 4 inches
Barium swallow
PURPOSE T f th h
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PURPOSE: Toassess for the esophagus,stomach, and some portion of the small
intestines. NURSING ALERT:
NPO for 6-8 hours before the procedure
Laxative is administered after the procedureto counteract the constipating effects of thebarium
Withhold anticholinergics and narcotics for 24
hours before the test Instruct patient to increase fluids and intake
of fiber-rich foods
Cardiac catheterization PURPOSES: To measure oxygen concentration, saturation,
i d i i h b f h h T
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tension and pressure in various chambers of the heart. Todetermine a need for cardiac surgery.
NURSING KEYPOINTS: Check for informed consent Assess allergy to iodine NPO for 6-8 hours before the procedure Check for distal pulses after the procedure
Check for bleeding at the arterial puncture site and applypressure Keep a 20 lbs sandbag at the bedside as a pressure instrument
if bleeding occurs Keep the patient flat on bed with the lower extremities
hyperextended for 4-6 hours Neurovascular assessment must be performed distal to the
catheter insertion site and report any abnormal findings
Catheterization, urinary PURPOSE: To determine residual urine and obtain sterile specimen. It can
b t i ht th t bi i d lli th t d t l d i
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be a straight catheter, suprapubic, indwelling catheter, and external devicecatheter.
NURSING ALERT:
Know the necessary facts:
Principles Male Female Position Supine Dorsal recumbent Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in. French number or
Circumference #14- 16 #18 Length of tube to be inserted 2-3 in. 6-9 in. Balloon size 5-10 ml. 5-10 ml (30 ml)Can be used to achieve hemostasis of the prostatic area following prostatectomy Place to secure lower abdomen Inner thigh
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The procedure is sterile
Maintain a close system
The draining bag must always be below thebladder
The catheter bag should not be allowed to lieon the floor
Do not allow the drainage spout to touch the
collection receptacle or on the toilet bowlwhen draining it
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Chest X-RAY
PURPOSE: To detect abnormalities of theorgans in the thoracic area
NURSING KEYPOINTS:
Remove any metallic object before theprocedure
Lead shield for women of childbearing age
Computerized Tomography (CT)
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Definition1. Cross-sectional visualization of the brain determined
by computer analysis of relative tissue density as anx-ray beam passes through; also known ascomputerized axial tomography (CAT) scan
2. Provides valuable information about location andextent of tumors, infarcted areas, atrophy, andvascular lesions
3. May be done with or without intravenous injection of
dye for contrast enhancement
Computerized Tomography (CT)
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Computerized Tomography (CT)
Computerized Tomography (CT)
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Computerized Tomography (CT)
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Computerized Tomography (CT)
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Nursing care
1. Explain procedure; inform the client that it will benecessary to lie still and that the equipment is complexbut will cause no pain or discomfort; infants andcognitively impaired or anxious clients may need to besedated
2. If the facility is small, arrange transportation to a largerfacility that has the required equipment3. Evaluate for possible allergy to iodine, a component of
the contrast material4. Withhold food for approximately 4 hours prior to testing;
dye may cause nausea in sensitive patients5. Remove wigs, clips, and pins prior to the test6. Evaluate client's response to procedure
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NURSING ALERT:
If contrast medium will be used, assess for anyallergy to iodine and instruct the patient to beon NPO for 4 hours prior to the procedure
Assess for any fear of close spaces
(claustrophobia)
This procedure is contraindicated to patientswho are pregnant and obese (>300 lbs)
Let the patient lye still during the whole courseof the procedure
CVP (Central Venous Pressure) monitoring
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CVP (Central Venous Pressure) monitoring PURPOSE: It measures the pressure of the Right
Atrium NURSING KEYPOINTS:
The nurse should place the zero level of themanometer at the level of the Right atrium at the 4thintercostals space to get an accurate reading
Instruct the client to avoid coughing and straining asit alters the readings
Normal CVP reading is 2-12 mm Hg ( when the tubeis at the superior vena cava)
Cystoscopy
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PURPOSE: To assess the bladder and urethra
NURSING KEYPOINTS: Check for the informed consent.
If general anesthesia will be used have the clienton NPO; liquid diet if local anesthesia will be used.
Monitor intake and output. After: Force fluids as prescribed.
Administer sitz bath for abdominal pain.
Pink-tinged or tea-colored urine is expected.
Notify the doctor if bright red urine or clots occur.
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Doppler ultrasound
PURPOSE: Evaluates patency of veins andarteries in the lower extremities.
NURSING KEYPOINT:
Inform the patient that it is painless.
Doppler UTZ
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ECG (Electrocardiogram)
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ECG (Electrocardiogram)
PURPOSE: Records electrical waves of theheart.
NURSING KEYPOINTS:
Instruct the patient to lie still, breathenormally during the procedure
Let the patient refrain from talking duringthe test.
ST segment elevation or T wave inversion,indicates MI
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EEG (Electroencephalogram)
PURPOSES: Records the electrical activity of
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PURPOSES: Records the electrical activity ofthe brain, detects intracranial hemorrhage and
tumors NURSING KEYPOINTS:
Advise the client to shampoo hair before andafter the procedure
If the electrode gel is non removed byshampooing, the patient may use acetone
Withhold stimulants, antidepressants,
tranquilizers, and anticonvulsants for 24-48hours prior to the test
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Fasting Blood Sugar level PURPOSE: Detects diabetes mellitus
NURSING KEYPOINTS:
Normal blood sugar level is 80-120 mg/dl A blood sugar level of more than 140 mg./dl
confirms diabetes.
Gastric analysis
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y
PURPOSES: This test is used to detect
ulcers, and to rule-out pernicious anemia. Itmay also be done to analyze acidity,appearance and volume of gastricsecretions
NURSING KEYPOINTS:
In gastric ulcer, HCL is normal,
In duodenal ulcer, HCL is elevated.
Refrigerate gastric samples if NOT testedwithin 4 hours.
IVP (Intravenous pyelography)
PURPOSE: Visualization of the urinary tract
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y
NURSING KEYPOINTS:
Check for the consent. NPO for 8-10 hours before the procedure
Administer laxative to clear bowels before the procedure.
Check for allergy to iodine, seafoods or shellfish beforethe procedure since the procedure requires the use of iodine
based dye. Keep epinephrine at the bedside to counteract possible
allergic reaction. IVP requires the use of a contrastmedium while KUB does not.
Inform the patient about the possible salty taste that may
be experienced during the test. Increase fluid intake after the procedure to facilitate excretion
of the dye.
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KUB PURPOSE: Determines the size, shape and
position of kidneys, ureters and bladder.
NURSING KEYPOINT: No special preparation needed.
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Liver biopsy
PURPOSE: To determine liver disorders
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PURPOSE: To determine liver disorders.
NURSING KEYPOINTS:
Check for the consent.
Obtain the result of blood tests before biopsy sincebleeding may occur
Let the patient assume left side or supine duringbiopsy
Instruct the patient to inhale, exhale and hold breathduring the insertion of to stabilize position of the liverand prevent accidental puncture of the diaphragm
Position the patient on the Right side after liver biopsywith pillows underneath to prevent bleeding
Bedrest for 24 hours after the procedure
Lumbar Puncture
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PURPOSE: To withdraw CSF to determine
abnormalities. NURSING KEYPOINTS:
Before the procedure: empty bladder and bowel.
Position: C-position. (fetal posistion)
During the procedure: needle is inserted between L3 -L4 or L4-L5 to prevent accidental puncture to thespinal cord since the spinal cord ends at L2.
After: Position the patient flat for 6-12 hours to preventspinal headache. Increase fluid intake.
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Mammography
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PURPOSE: Detects the presence of breast tumor.
NURSING KEYPOINTS: Instruct the patient not to use deodorant, talcum
powder, lotion, perfume or any ointment on the day ofexam as these may give false-positive result
Let the patient know that her breasts will be
compressed between 2 x-ray plates Provide teachings related to Self-breast examination
Done 7 days after menstruation Position: lying down with pillow under the shoulder of
the breast being examined or sitting in front of a mirrorwhile raising the hands of the side of the breast beingexamined.
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Mantoux test PURPOSE: A test to determine exposure to TB NURSING KEYPOINTS: A positive test yields an induration of 10 mm. or more for foreign
born children below 4 years old An induration of 5 mm or more is considered positive in patients
with HIV, with treated TB, and if he has had a direct exposure TBPatients.
BCG may cause false positive reaction. Assess for previous history of PTB and report immediately to the
doctor
Result is read after 48-72 hours
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MRI (Magnetic Resonance Imaging) PURPOSE: Provides cross-sectional images of
brain tissues, more detailed than a CT scan. NURSING KEYPOINTS: Contraindications:
pregnant women, obesity (more than 300 lbs.), claustrophobic patients, patients with unstable vital signs
patients with metal implants like pacemaker, hipreplacements and jewelries.
Magnetic Resonance Imaging (MRI)
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Definition1. This procedure utilizes magnetism and radio wavesto produce images of cross-sections of the body
2. The MRI machine registers the existence of odd-numbered atoms in the cross sections of the body,
yielding data about the chemical makeup of thetissues
3. MRI can produce accurate images of blood vessels,bone marrow, gray and white brain matter, the spinalcord, the globe of the eye, the heart, abdominalstructures, and breast tissue, and can monitor bloodvelocity
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Magnetic Resonance Imaging (MRI)
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Nursing care1. Assess ability to withstand confining surroundings
because client must remain in the tunnel-like machinefor up to 90 minutes; open MRI may be an option for
clients who cannot tolerate closed spaces2. Instruct client to toilet prior to test, since this will be
impossible during the procedure
3. Advise client to remove jewelry, clothing with metalfasteners, dentures, hearing aids, and glasses prior toentering scanner
Magnetic Resonance Imaging (MRI)
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4. Since this procedure is contraindicated for certainclients, before the test assess for:a. Metal prostheses, such as orthopedic screws,
since the magnetic force can dislodge thedevices
b. Pacemakers, since the scanner deactivatespacemaker
c. Dysrhythmias, because the magnetic field canaffect the conduction system of the heart
d. Unstable medical conditions, since monitoringof the client is limited during the test5. Evaluate client's response to procedure
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Stool analysis PURPOSE: Assessment of bacteria, virus,
malabsorption and blood.
NURSING KEYPOINT: Avoid aspirin, red meat and vitamin C
three days before the test as these may givea false positive result.
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Tonometry PURPOSE: Measures intraocular pressure.
NURSING KEYPOPINTS:
Normal reading is 12-21 mm Hg A reading of 25 mm Hg indicates glaucoma.
Urinalysis
PURPOSE: To assess characteristics of urine
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PURPOSE: To assess characteristics of urine.
NURSING KEYPOINTS: First voided morning sample preferred: 15 ml.
Use clean container
Decreased specific gravity: diabetes insipidus Increased specific gravity: diabetes mellitus,
dehydration, SIADH
(+) Protein: PIH, nephrotic syndrome. (+) Glucose: Diabetes mellitus, Infection
Urine Collection
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As fresh as possible
Mid stream cleancatch
First morningspecimen best, but formost purposesdoesnt make much
difference
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HematuriaEven small amounts of blood are visible
1 part per 1000 is easily seen
Urine collection 24 hour
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Urine collection, 24 hour
PURPOSE: Determines the excretion of substancesfrom the kidneys, adrenal glands and the stomach.
NURSING KEYPOINT:
Required for ACTH test and schillings test (B12
absorption),
Discard the first voided urine
Place urine output in a clean container preserved in
ice chest
Thank
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You!