Top 93 Nursing Skills, Procedures and Normal Values

TOP 93 NURSING SKILLS, PROCEDURES and NORMAL VALUES
A
1. ABDOMINAL ASSESSMENT
Procedure:
I-A-Pe-Pa
Regular assessment: I-Pa-Pe-A
Sequence: RLQ RUQ LUQ LLQ
Position: dorsal recumbent
AVOID:
A ppendicitis
P heochromocytoma
A bdominal Aortic Aneurysm
W ilms tumor
2. AMNIOCENTESIS vs. ULTRASONOGRAPHY

AMNIOCENTESIS
aspiration of amniotic fluid inside the amniotic
sac through an outside puncture
1. If more than 20 weeks' gestation (empty
bladder) to prevent confusion between it and
the amniotic sac
VARIABLES
2. If less than 20 weeks' gestation (full bladder)

to elevate the uterus and increase
visualization of the fluid pocket
1. If done early in pregnancy: To detect
chromosomal abnormalities
Preparation of the
mother
2. If done late in pregnancy:

To detect fetal lung maturity and to resolve
polyhydramnios
Purpose (s)
Definition
ULTRASONOGRAPHY
visualization of the uterine content including all the
products of conceptus
1. After 20 weeks (empty bladder)
2. Before 20 weeks (full bladder) to increase ultrasonic
resolution and elevate the presenting head for biparietal
diameter measurement
First Trimester
1. Gestational age assessment
2. Evaluation of congenital anomalies;
3. Confirm multiple pregnancy
Second Trimester
1. Guidance of procedure (amniocentesis);
2. Assessment of placental location
Third Trimester***
1. Determination of fetal position
2. Estimation of fetal size/ weight
3. ARTERIAL BLOOD GAS (ABG) ANALYSIS
Serum pH 7.35 7.45

CO2
35 45
HCO3
22 26
PaO2
85 95 mmHg
Increased:
Polycythemia
Decrease:
Anemia
BEFORE:
Allen Test to assess patency of the RADIAL artery***
Avoid suctioning at least 20-30 minutes BEFORE procedure
AFTER: Apply pressure on puncture site for 5 minutes
First step in ABG analysis determine pH***
4. ABDOMINAL PARACENTESIS
Purpose:
Obtain fluid specimen
To relieve pressure on the abdominal organs d/t the excess fluid
BEFORE:
Ask client to void***
DURING:
Position: Sitting position
Common site: midway between the umbilicus and symphysis pubis
Measure abdominal girth at the umbilical level
Maximum amount to be drain is 1500 mL
Strict STERILE technique
1 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
5. ASEPSIS
MEDICAL ASEPSIS
To reduce microorganism
Routine nursing care
Disinfection (clean)
Purpose
Indication
Technique
SURGICAL ASEPSIS
To destroy microorganism including spores
Procedure involving sterile areas
Sterilization (sterile)
B
6. BARIUM SWALLOW AND BARIUM ENEMA
USE
BEFORE
AFTER
BARRIUM
SWALLOW
Examination of
UGT
NPO 6 8 hours
BARIUM ENEMA
Examination of LGT
NPO at midnight (6 8 hrs)

DIET: Low residue diet, Clear liquid diet (1
3 days)
Laxatives, Cleansing enema
Constipation: Increase fluids, Laxative
Stool color: chalky white 1 3 days
7. BENNERs STAGES OF NURSING EXPERTISE***

Stage 1
Novice
Stage 2
Advanced beginner
Stage 3
Competent
Stage 4
Proficient
Stage 5
Expert
No experience
Limited performance
Inflexible
Marginally acceptable performance
Recognizes the meaningful aspect of a real situation
2 or 3 years of experience
Demonstrates organizational and planning abilities
Coordinates multiple complex care demands
3 to 5 years of experience
Perceives situations as wholes rather in terms of parts, as in Stage 2
Has holistic understanding of the client, which improves decision making
Focus on long term goals
Performance is fluid, flexible, and highly proficient
No longer requires rules, guidelines, or maxims
Demonstrates highly skilled intuitive and analytic ability in new situations
8. BLEEDING PRECAUTION (OPEN wounds)

P ressure over the injury
E levate above the heart
C old compress
A rterial pressure
T orniquet
9. BLOOD TRANSFUSION
BEFORE
Check order 2 RNs
o Client name and identification number
o Unit number
o Blood type matching
o Expiration date
o Doctors order/ Informed consent
Obtain baseline VS
warm blood at room temperature for NOT more than 30 minutes
DURING
STAY with the patient and Check every 15 minutes 1st hour
Check every hour succeeding hours
BLOOD COMPONENTS
Blood Component
Whole blood
PRBC
Cryoprecipitate
Platelets
Fresh frozen plasma
Infusion rate
2 to 4 hours
2 to 4 hours
30 minutes
Rapid
Rapid of bleeding; 1 to 2 hours
Volume
450 ml
250 ml
10 ml
35 to 50 ml
250 ml
BT REACTION
REACTION
C irculatory overload/
congestion
H emolytic
A llergic
too rapid
CAUSE
S/SX
dyspnea, HPN, increased PR
MANAGEMENT
Slow down the infusion rate
incompatibility
antigen/ antibody reaction
jaundice, shock HA
urticaria, wheezing, facial edema
Stop the infusion

Stop the infusion
Antihistamine
P yrogenic
fever, chills
Stop the infusion

Paracetamol
Save unit of blood and return
to blood bank for analysis.
BT REACTION MANAGEMENT: (in sequence)***

B T stop
bacterial
L et the tubings be changed

O pen NSS
A lways check the VS
D octor, where are you!
S cold the bank
OTHERS:***
Gauge: 18 or 19
Y set filter IV transfusion set
IV fluid: NSS only (other solution like dextrose causes hemolysis)
Start at KVO for 15 minutes
Monitoring: 15 minutes for the 1st hours and hourly thereafter
Time
o 4 hours: WBC, PRBC
o Rapid: Plasma, Platelets, Cryoprecipitate
10. BONE MARROW BIOPSY/ ASPIRATION

Bones commonly used: sternum, iliac crest, iliac spines, or proximal tibia (children)
DURING
Position:
site is iliac crest Prone
site is sternum Supine

About 1 to 2 mL of bone marrow is obtained.
AFTER: PREVENT BLEEDING

Bed rest for 30 minutes
Ice bag on punctured site
Pressure on the puncture site
Position: Lie on operative/biopsied side for 10 to 15 minutes
11. BOWEL DIVERSIONS
TYPES OF OSTOMY
Ileostomy
Cecostomy
STOMA
watery (prone to Fluid Volume Deficit and Impaired skin integrity)

Ascending colostomy
Transverse colostomy

mushy/ semi-formed
Descending colostomy
Sigmoid colostomy
formed
formed
Color
Sensation
Protrusion
Drain
Appliance size (pouch opening)
brick red (May turn to pink after several months and years)
normally no sensation
to inches
1/3 to full
1/16 to 1/8 inches
COLOSTOMY IRRIGATIONS needed by Descending and sigmoid colostomy

1st stimulate
2nd evacuate
Position: sitting
FOODS
Causes odor
Causes gas
Beans
Asparagus
Garlic
Eggs
Spices
Celery
Cabbage
Corn
Camote
Cauliflower
Champagne
Cucumbers
Carbonated drinks
Thicken stool
Tapioca
Rice
Yogurt
Apple and apple sauce
Banana
Cheese
Permanent colostomy Descending and sigmoid colostomy

Colon cancer sigmoid colostomy
12. BREASTFEEDING
ASSESSMENT OF PROPER LATCHING

C hin to breast
pen mouth widely
L ips turned outward
A reola is visible above only
Nipple touches the posterior tongue 9to promote swallowing reflex)

Nipple (bottle) always filled with milk 9to prevent colic)
Color of stools:
Breast fed: golden yellow
Formula fed: pale yellow
13. BRONCHOSCOPY
BEFORE: NPO for 6-12 hours prior to procedure; no dentures; maintain good oral hygiene
DURING:
uses local anesthetic spray to minimize gagging while inserting the bronchoscope
supine with head hyperextended
AFTER:
POSITION: semi fowler's
NPO till gag returns then start with ice chips then followed by sips of water soft diet regular diet
ice bags to throat
minimize talking, coughing, laughing; warm saline gargles; assess for respiratory distress
C
14. CANCER SCREENING
PROCEDURE
Breast Self Exam (BSE)
Testicular Self Exam (TSE)
Mammogram
Paps smear
Digital rectal Exam (DRE)
SCHEDULE
Monthly, 3 to 5 days after the onset of menstruation
Monthly, after a warm bath
35 to 40 years 1x (baseline)
41 to 50 years every 2 years
51 and above yearly
Onset 40 every 3 years
41 and above yearly
50 and above yearly
40 and above yearly (if high risk)
15. CHEMOTHERAPY SIDE EFFECTS

SIDE EFFECTS
Nausea and
vomiting
Anorexia
GATROINTESTINAL
Oral thrush
Neutropenia
(WBC)
HEMATOPOEITIC
(Bone marrow
suppression)
Thrombocytopeni
a
(Platelets)
Anemia
(RBC)
INTERVENTIONS
Provide antiemetics 30 60 minutes before chemotherapy
AVOID: unpleasant odor, spicy foods, hot
Small Frequent Feedings
Diet: soft bland
Ensure adequate fluid hydration
Frequent oral hygiene
Rinse mouth with strength peroxide and NSS
Brush teeth with soft toothbrush and baking soda
USE: unwaxed dental floss, cotton-tip applicator for viscous
xylocaine over lesions
Neutropenic precaution
o
Handwashing
o
Neutropenic diet/ low-bacteria diet: cooked foods
AVOID: fresh flowers, fruits, vegetables, raw foods, vaccinations
o
Reverse isolation/ private room
o
Assess vital signs every 4hours
Thrombocytopenic precaution
o
AVOID: aspirin, IM, invasive procedures, punctures, contact sports
o
Use soft bristled toothbrush, electric razor, stool softener
Blood transfusion
Bed rest
o
o
o
o
o
o
o
o
o
Alopecia
INTEGUMENTARY
GENITO-URINARY
Cystitis
Sterility/ infertility
o
o
o
o
o
o
Discuss potential TEMPORARY hair loss (2 to 4 weeks)

Use of wigs
If hair grows back color and texture changes
AVOID: excessive shampooing
Increase fluids
Temporary
Nadir lowest point of RBC, WBC and platelets after chemotherapy administration; occurs within 7 to 14 days after
16. CHESTPHYSIOTHERAPY (CPT)

Purpose
Method
Duration
POSTURAL DRAINAGE
To drain by GRAVITY
Positioning
10 to 15 minutes per position
PERCUSSION
To mechanically dislodge
Striking by cupped hands
1 to 2 inches/ lung segment
Sequence:***
1 postural drainage
2 percussion
3 vibration
done BEFORE meals

ask patient to COUGH after chestphysiotherapy
VIBRATION
To loosen mucus secretions
Quivering palm on chest wall
5 exhalation***
17. CHEST TUBE

a.
DRAINAGE BOTTLE
NURSING CONSIDERATIONS:
Keep at least 2 to 3 feet below the chest (to allow drainage by gravity)
NEVER raise the bottle above the level of the heart (to prevent reflux of air or fluid)
NOTE:
COLOR: bloody drainage during the first 24 hours
OUPUT: 500 1000 ml during the first 24 hours
FLUID DRAINAGE: the tube is inserted at 8th or 9th ICS

AIR DRAINAGE: the tube is inserted 2nd or 3rd ICS
COMMON OBSERVATIONS
NO DRAINAGE
Resolution
Obstruction
b.
WATER SEAL BOTTLE

Immerse tip of the tube in 2- 3 cm of sterile NSS to create water seal

COMMON OBSERVATION:
INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration, fall during

expiration)
NO FLUCTUATIONS
Obstruction check and milk the tubing with CAUTION
Low suction
Re expand lungs do chest X- ray for confirmation
CONTINUOUS BUBBLING
Air leakage (except during suctioning)
c.
SUCTION CHAMBER
Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS (to stabilize the normal negative
pressure in the lungs and protects the pleura from trauma if the suction pressure is inadvertently increased)
COMMON OBSERVATION:
CONTINUOUS GENTLE BUBBLING (indicates adequate suction control)

NORMAL
d.
CHEST TUBE REMOVAL
Give analgesics 30 minutes before removal
Clamp on bedside
e.
DURING removal: let the patient EXHALE and hold breath while doing VALSALVA MANEUVER
Maintain dry, sterile, occlusive dressing
EMERGENCY SITUATION
DISLODGE (chest tube removal FROM THE CLIENT)

AT BEDSIDE: vaselinized gauze
Palm pressure (for splinting)
DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage)
ATBEDSIDE:
Extra bottle immersed in sterile water
Clamp (Hemostat)
f.
ALERT! Never clamp the test tubes over an expanded period of time. Clamping the chest tubes IF a client with an air in
the pleural space will cause increased pressure buildup and possible TENSION PHEUMOTHORAX
18. CEREBROSPINAL FLUID (CSF) ANALYSIS
Protects from mechanical trauma

Function of CSF: Carries nutrients to brain
Characteristics
Normal pressure:
5 to 15 mmHg/ 70 to 180 mmH2O
Normal volume:
100 to 200 ml
WBC:
0 - 5 cells/mm
Glucose:
40 to 80 mg/dl (40 to 80 mg/100ml)
Protein:
15 to 45 mg/dl (15 to 45 mg/100 ml)
Meningitis
Increase protein content
Decrease glucose content
Increase WBC content
Cloudy (bacterial meningitis)
Clear (viral meningitis)
19. COMMUNICATION: ATTENTIVE LISTENING
Absorbing both the CONTENT and the FEELING the person is conveying, without selectivity
Listening actively, using all senses (as opposed to listening passively with just the ear)
Active process that requires energy and concentration
Paying attention to the total message (both verbal and non-verbal) and noting whether these communications are
congruent
Conveys an attitude of caring and interest, thereby encouraging the client to talk
20. COMMUNICATION: PHYSICAL ATTENDING***

1) face the other person squarely
2) adopt an open posture
3) lean towards the person
4) maintain good eye contact
5) try to be relatively relaxed
21. CT SCAN
X-ray
Contrast medium warm sensation
AVOID: pregnant women
Before: NPO
After: increase fluid
22. CVP MONITORING
Measure the pressure of the right atrium

Place the zero level of the manometer at the level if the right atrium (4th ICS)
AVOID: coughing and straining
NORMAL: 2 -12 mmHg
23. CYSTOSCOPY
Direct visualization of the LOWER urinary tract (bladder and urethra)

PURPOSE:
specimen collection
treatment of the interior of the bladder and urethra
Prostate surgery
Local anesthesia commonly used
POSITION: dorsal recumbent
CONTRAINDICATIONS: acute cystitis, bleeding disorders
AFTER:
Assess
VS
urine characteristic (NORMAL: pink tinged or tea-colored urine)
I&O
Encourage fluids
Sitz bath
Observe for fever, dysuria, pain in suprapubic region
D
24. DIALYSIS
Urgent indication for dialysis in patient with CRF is PERICARDIAL FRICTION RUB.
Objectives of hemodialysis:
a. To extract toxic nitrogenous substances from the blood
b. To remove excess water
Principles of hemodialysis:
Diffusion toxic and wastes move from an area of higher concentration in the blood to an area of lower
concentration in the dialysate
Osmosis excess water is removed from the blood by osmosis
Ultrafiltration water moving under high pressure to an area of lower pressure accomplished by negative
pressure (suction)
Before peritoneal dialysis, patient should empty bladder and bowels.
E
25. EAR
Ear bones (Ossicles)

M alleus
A nvil
S tapes
Hammer
Incus
Stirrups
Position during drug administration:

Below 3 years old down and back
Above 3 years old up and back
Outer ear problem (otitis externa) conductive hearing loss

Middle ear problem (otitis media, otosclerosis) conductive hearing loss
Inner ear problem (labrynthitis, Menieres disease) sensorineural hearing loss
26. ECG
NORMAL
PR
QT
QRS
0.12 0.20 seconds

0.32 0.40 seconds
0.04 0.10 seconds
HYPERKALEMIA
Tall T wave
HYPOKALEMIA
Flat T wave, presence of u wave
HYPERCALCEMIA
HYPOCALCEMIA
Short ST segment and QT interval***

Lengthened ST segment and QT interval
Atrial flutter
With P wave (saw tooth)
Regular rhythm
Normal QRS
Atrial fibrillation***
No P wave
Irregular rhythm
Normal QRS
Atrial tachycardia
With P wave (different shape)
Regular rhythm
Normal QRS
Ventricular fibrillation
No P wave
Chaotic rhythm
No QRS
Ventricular tachycardia
No P wave
Regular rhythm
Wide and bizarre QRS
27. ENEMA
TYPES:
Cleansing enema
Carminative enema
Return flow/ Harris flush/ Colonel irrigation
cleansing (3x)
flatus
flatus (5 6x)
Retention
soften; lubricate (1 3 hours)
VOLUME-based***
o Small volume (150 to 240 ml) used to cleanse rectum and sigmoid
o Large volume (500 to 1000 ml) used to cleanse entire colon
SOLUTIONS:
Hypertonic
Hypotonic
Isotonic
Irritants
Lubricants
sodium biphosphate
tap water
NSS
soapsuds, Bisacodyl/ Fleet
oil
Position: left-sidelying/ dorsal recumbent***
Enema tube lubricate first; insert in rotating motion

Infant
1 1.5 inches
Child
2 3 inches
Adult
3 4 inches
Cramping:
Lower the solution
Clamp and wait for 30 seconds***
Restart
Temperature: 100oF (37.7oC)
4 factors affecting Force of flow of the solution:

(1) Height of the solution container
(2) Size of the tubing
(3) Viscosity of the fluid
(4) Resistance of the rectum
28. E.S.S.R. feeding method of patients with cleft lip and cleft palate
E nlarge the nipple hole

S timulate the sucking
S wallow
R est
29. ESR (Erythrocyte Sedimentation rate) value:
30 to 40 mm/hr indicates mild inflammation

40 to 70 mm/hr indicates moderate inflammation, and
70 to 150 mm/hr indicates severe inflammation.
30. EXERCISES
TYPES OF EXERCISE
CHARACTERISTICS
OTHER NAME
JOINT MOVEMENT
CONTRACTION
BENEFITS on
MUSCLES
EXAMPLES
ISOTONIC
Dynamic
Increase strength
Increase tone
Increase mass
Joint flexibility
Use of trapeze
Walking
Swimming
Cycling
Running
ISOMETRIC
Static/Setting
x
Increase strength
Increase endurance
Increase heart rate and
cardiac output
Quadricep setting
Squeezing on stress ball
Kegels
ISOKINETIC
Resistive
Increase strength
Increase size
Increase blood pressure and
blood flow to muscles
May be isometric or isotonic with
resistance
Weight-lifting
31. FIRE EXTINGUISHER

Type A trash fire paper, woods, leaves (water under pressure)
B fuel fires oil, gasoline, kerosene (CO2)
C electric fire appliances, wire (dry chemicals)
D any kind (graphite)
F
32. FECAL
C-olor -----------brown/yellow stercobilin
O-dor------------aromatic
C-onsistensy-----------solid-semi-formed moist
A-mount ----------------100-400g/day
S-hape------------------cylindrical
33. FOODS rich in IRON***
Liver
Green leafy vegetables
Dried fruits
Scallops, shrimps
Oyster, clams
molasses
34. PROBLEMS IN STOOL ELIMINATION
M elena
A cholic stool
S teatorrhea
H ematochezia
dark colored stool (upper Gi bleeding)

gray colored stool (bile obstruction)
fat containing stool (malabsorption)
bright red colored stool (lower GI bleeding)
G
35. GTPALM
G Gravida
P Para
refers to the number of pregnancies regardless of outcome

refers to the number of deliveries that reached viability (20 weeks gestation)
born dead or alive; multiple births count as 1 delivery regardless of the number
of newborns delivered
T Term deliveries
P Preterm deliveries
A Abortions
L Live
M Multiple gestations
number of TERM births (infants born after 37 weeks and above)

number of PRETERM births (infants born between 20 to 37 weeks)
number of pregnancies that end in spontaneous or therapeutic abortion prior to
age of viability (20 weeks)
number of children currently alive
number of pregnancy with more than one newborn
(regardless of the number of neonates delivered)
36. GLOVING***
Open-glove technique used when:

o Gloving another team member
o Changing a glove DURING a procedure (self or team member)***
o A sterile scrub or gown is not required
Closed-glove technique used when:

o Anytime you are initially applying sterile gown and gloves
CHANGING GLOVES DURING A PROCEDURE

1. Ask the Circulating Nurse (CN) to remove contaminated glove
2. CN should wear gloves
CN grasp contaminated glove at palm
Scrubbed person holds onto the sleeve of the gown (to prevent riding over)
3.
Using OPEN-GLOVE method, reapply sterile glove***
H
37. COLORS OF HOSPITAL TANKS
Nitrous oxide (laughing gas)

Oxygen
Cyclospropane
Nitrogen
Carbon dioxide
Helium
Medical air
Halothane
Blue
Green
Orange
Black
Grey
Brown
Yellow
Red
38. HOSPITAL COLOR CODES
Code blue cardiac arrest, medical emergency

Code pink infant abduction
Code red fire
Code yellow bomb threat
Code silver combative person with weapon
I
39. IMMUNIZATION
SENSITIVITY
FORM:
Toxoid
killed bacteria
live attenuated
freeze dried
MOST SENSITIVE to heat

LEAST SENSIITVE to heat
OPV, measles
DPT, Hepa B, BCG, TT
Diphtheria and Tetanus

Pertusis
OPV
measles and BCG
40. INFORMED CONSENT
Purpose:
To ensure the clients understanding of the nature of the surgery
To indicate the clients decision
To protect the client against unauthorized procedure
To protect the surgeon and hospital against legal action
2 TYPES:
1) Express consent may be either an oral or written agreement
2) Implied consent nonverbal behaviour indicates agreement
General guidelines/ content of informed consent:

Diagnosis or condition that requires treatment
Purpose of the treatment
What the client can expect to feel or experience
The intended benefits of the treatment
Possible risks or negative outcomes of the treatment
Advantages and disadvantages of possible alternatives to the treatment (including no treatment)
4 elements of informed consent:***

Voluntary no force, coercion, or manipulation
Comprehension all interior and exterior impediments to comprehension have been assessed and removed
Interior anxiety, pain, sedative medication
Exterior transcultural barrier, terminology, speed of presentation

Competence
Can give consent:
must be at least 18 years old
emancipated minor: a person under 18 who is self supporting or married
Cannot give consent:
Unconscious
Sedated
mentally ill and
judged to be incompetent
Discloure all possible options and outcomes
Circumstances requiring an Informed Consent:

R adiation or cobalt therapy
A nesthesia use
B lood administration
I nvasive procedure
o E ntrance into a body cavity
o S - urgical procedure using scalpel, scissors, suture (Invasive procedures)
Requisites for validity of informed consent

Legal age
Mentally capacitated
Secured within 24 hours before the surgery
Secured before pre-op medication administration
Written permission
Signature
Witness nurse, physician
For minors (under 18), unconscious, psychologically incapacitated permission from responsible family member
For emancipated minors (married, college student living away from home, in military service, any pregnant female or
any who has given birth)
4 Criteria are needed to be met if consent is NOT needed anymore:

There is an immediate threat to life
Experts agree that it is an emergency
Client is unable to consent
A legally authorized person cannot be reached
Surgery without consent-- BATTERY!

Role of the physician: to obtain the informed consent
Role of the nurse:
Witness a clients signature after the physician has explained the procedure
Place informed consent in the clients chart
Respond to any questions the client have about the procedure
Notify the physician if the client appears to have concerns
41. ISOLATION PRECAUTION
Tier 1: Standard Precaution

to all blood and body fluids except for sweat
to all clients regardless of diagnosis
hand washing and PPE (clean)
Tier 2: Transmission-based precaution
Airborne
> 3 feet
Droplet nuclei < 5 microns
N95
Droplet
< 3 feet
Droplet nuclei > 5 microns
Mask
Contact
Skin
Gloves
gown
Measles
TB
Varicella (chickenpox)
Meningitis, mumos
Pertussis, pneumonia
German measles, GABHS (Scarlet fever, pharyngitis)
Diptheria
MRSA (Staph)
Impetigo
Scabies
Herpes Simplex
Hepatitis A
Diarrhea
Immunocompromised first
Infectious - last
42. IV SOLUTIONS
Characteristics
HYPOTONIC
Solute < solvent
Fluid movement
Effect to the cell
from Intravascular TO cells

Swell
Indications
Dehydrated patients
Examples
Distilled water
0.45% NSS
0.33% NSS
2.5% dextrose
contraindicated for clients with
increased intracranial pressure,
clients at risk of 3rd space fluid
shift
ISOTONIC
Solute = solvent
O pressure of solution
No movement
expand the intravascular
compartment
Hypovolemia
Burns (resuscitative stage)
D5W
LR
NSS
D5 0.225% NSS
HYPERTONIC
Solute > solvent
From Intracellular TO Intravascular
shrink/ crenation
Edema
10% dextrose in water
5% dextrose in 0.9% saline solution
5% dextrose in 0.45%
5% dextrose in LR
TPN
Dialysate
Avoid D5W if the client is at

risk of increased intracranial
pressure (ICP)
Use LR for BURNS
43. IV THERAPY COMPLICATIONS:

COMPLICATIONS
Circulatory overload
MANIFESTATIONS
Dyspnea
increased BP
SOB, crackles
Air embolism
Dyspnea
ACTIONS
slow down
contact physician
elevate HOB
give oxygen
Discontinue
Phlebitis
decreased BP
Swelling + Heat
Infiltration
Swelling + Cool
Decrease infusion rate***
Pyrogenic reaction
Fever, chills
Left sidelying and trendelenburg

Discontinue
Cold
Elevate
Restart (another site)
Discontinue
Warm/ Moist heat (due to edema)
Elevate
Restart (another site)
Discontinue
Retain IV equipment for C&S
METHODS OF IV ADMINISTRATION
1. Large volume infusion safest and easiest
2. IV Bolus fastest effect
3. Intermittent Venous Access (heparin lock/ Saline lock) increase mobility and comfort
Sequence: SASH methods

o S - Saline
A - Antibiotic
S - Saline
H - Heparin
4. Volume controlled infusions
5. Piggy back
SELECTING A VEIN
First verify the order for I.V. therapy unless it is an emergency situation.
Explain the procedure to the patient.
Select a vein suitable for venipuncture.

o Back of hand (metacarpal vein.) Avoid digital veins, if possible. (The advantage of this site is that it permits
arm movement.)
If a vein problem develops later at this site, another vein higher up the arm may be used.
Forearm (basilic or cephalic vein)

o Inner aspect of elbow, antecubital fossa, median basilic and median cephalic for relatively short-term
infusion. However, use of these veins prevents bending of arm.
Lower extremities.
o Foot - venous plexus of dorsum, dorsal venous arch, medial marginal vein
o Ankle - great saphenous vein
Central veins are used:

o When medications and infusions are hypertonic or highly irritating, requiring rapid, high-volume dilution to
prevent systemic reactions and local venous damage (eg, chemotherapy and hyperalimentation).
o When peripheral blood flow is diminished (eg, shock) or when peripheral vessels are not accessible (eg,
obese patients).
o When CVP monitoring is desired.
o When moderate or long-term fluid therapy is expected.
NURSING ALERT
o The median basilic and cephalic veins are not recommended for chemotherapy administration due to the
potential for extravasation and poor healing resulting in impaired joint movement. In addition, these veins
may be needed for intermediate or long-term indwelling catheters.
o Use lower extremities as a last resort. A patient with diabetes or peripheral vascular disease is not a suitable
candidate. Obtain an order from the health care provider for the I.V. site and monitor lower extremity closely
for signs of phlebitis and thrombosis.
L
44. LASER
a.
L ight
A mplification by
S timulated
E mission of
R adiation
b.
TYPES
Carbon dioxide gas (clear goggles)
ND:YAG Neodymium: Yttrium Alluminum garnet) bright lamp (green goggles)
Argon gas (orange goggles)
c.
HAZARDS
Eyes goggles
Skin gown and gloves
Lungs mask
45. LEVEL OF CONSCIOUSNESS

a.
GLASGOW COMA SCALE

GLASGOW COMA SCALE
VERBAL RESPONSE
EYE OPENING
4 Spontaneous
3 To verbal command
2 To pain
1 No response
5 Oriented, converses
4 Disoriented, converses
3 Uses inappropriate words
2 Makes incomprehensible sounds
1 No response
MOTOR RESPONSE
6 To verbal command
5 To localized pain
4 Withdraws
3 Flexes abnormally (Decorticate)
2 Extends abnormally (Decerebrate)
1 No response
7 and below - in a comatose state

3 lowest score
15 highest score
b.
A.V.P.U. (for Pediatric client)
use to assess neurologic condition (like Glasgow Coma Scale)
Usually used in infants

A Alert and Awake
V Verbal response to stimuli
P Pain response in stimuli
U Unresponsive
c.
Level I (conscious) 3 Cs: conscious, cognitive, coherent

Level II (lethargic) drowsy, sleepy, obtunded, confused
Level III (stuporous) responds to strong stimuli only
Level IV (coma) unresponsive; absent protective reflexes
46. LEOPOLDs MANEUVER
BEFORE:
patient void first

Nurse warm hands
MANEUVER
1. First maneuver
PURPOSE
to determine fetal
presentation
NURSING CONSIDERATIONS
While facing the woman, place the hands on top and side of
the uterus (fundus) and palpate.
HEAD - smooth, hard/firm, and round, freely movable and

ballotable.
BREECH - irregular, rounded, softer, and is less mobile.
Still facing the woman, place hands on either side at the

middle of the abdomen. Determine what fetal body part lies
on the side of the abdomen.
If firm, smooth, and a hard continuous structure FETAL

BACK
If smaller, knobby, irregular, protruding, and moving,

EXTREMITIES
While facing the woman, grasp the part of the fetus situated
in the lower uterine segment between the thumb and middle
finger of one hand.
2. Second maneuver
to determine the
fetal position
to determine fetal
back (heart)
3. Third maneuver
To determine
engagement
to determine fetal
presentation
Using firm, gentle pressure, determine if the head is the

presenting part.
HEAD - will feel firm and globular.
If immobile, engagement has occurred. This maneuver is

also known as Pallach's maneuver or grip
4. Fourth maneuver
to determine fetal
attitude
The examiner faces the woman's feet.

The examiner palpates the abdomen along the side of the
uterus below the umbilicus towards the symphysis pubis
(pelvic inlet) to detect heads degree of flexion, position and
even station.
47. LIVER BIOPSY
BEFORE: Note COAGULATION PROFILE (clotting factors, PT, PTT, APTT and platelet count*
DURING: exhale and hold breath
AFTER: Position: Right side-lying position
48. LUMBAR PUNCTURE (LUMBAR TAP)
PURPOSE: To withdraw CSF to determine abnormalities

Measures CSF pressure (normal opening pressure 60-150 mm H2O)
Obtain specimens for lab analysis (protein [normally not present], sugar [normally present], cytology, C&S)
Check color of CSF (normally clear) and check for blood
Inject air, dye, or drugs (anesthesia) into the spinal canal
AREA: Insert needle between L3 L4 or L4 L5 (spinal cord ends in L2)
BEFORE PROCEDURE:
Obtain consent
Empty bladder
DURING PROCEDURE:
Position of the patient: C-position (flex the shoulders, not the head)
Position of the nurse: infront of the patient
Position of the doctor: at the back of the patient
AFTER PROCEDURE: prevent spinal headache

Position: flat for 6-12 hours (to prevent spinal headache)
Force fluids (to maintain pressure and prevent spinal headache)
Blood patching
label specimen
M
49. MAGNETIC RESONANCE IMAGING (MRI)/ NUCLEAR MAGNETIC RESONANCE (NMR)
Uses radio waves
BEFORE:
remove metals: jewelry, hairpins, glasses, wigs (with metal clips), and other metallic objects.
AVOID:
patients with orthopedic hardware
intrauterine devices
pacemaker
internal surgical clips
or other fixed metallic objects in the body (braces, retainers)
BEFORE:
Have client void before test.
DURING
remain still while completely enclosed in scanner throughout the procedure, which lasts 45-60 minutes.
Teach relaxation techniques to assist client to remain still and to help prevent claustrophobia***
NORMAL: audible humming and thumping noises from the scanner during test.
Sedate client if ordered.
50. MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) Test
Route:
ID, 0.1 mL of PPD is injected INTRADERMALLY, creating a wheal or bleb
Read:
48 to 72 hours
Result:
(+) to exposure
10 mm and above not immunocompromised
5 mm and above immunocompromised (HIV, with history of TB, pediatric and geriatric clients)
0 - 4 mm= NOT SIGNIFICANT
Erythema without induration is NOT considered significant***
51. MASLOWs HIERARCHY OF NEEDS
Physiologic needs basic survival needs

Air, Food, Water
Shelter
Rest, Sleep
Activity
Temperature
Safety and Security needs

physical aspects: comfort***, protection from
bodily harm
psychological aspects: security and stability
Love and belonging needs (Social Acceptance)***
Giving and receiving affection

Attaining a place in a group
Maintaining the feeling of belonging
Acceptance by others
Self-esteem needs
Self-esteem: feelings of independence,
competence, self-respect
Esteem from others: recognition, respect,

appreciation, feel they are valued and worthwhile
Self-actualization
The innate need to develop ones maximum
potential and realize ones abilities and qualities
the need to function at ones optimal level, and to
be personally fulfilled.
52. MEDICATION
a.
b.
Drug interaction
Additive effect
Synergism/ potentiation
Antagonist
Interference
Medication order
STAT (statim)
Single order/ one time
Standing / routine
PRN (Pro Re Nata)
Telephone order
1+1=2
eg. diazepam + alcohol = increase sedation
1+1=3
eg. codeine + aspirin = intense pain relief
1+1=0
eg. Coumadin + Vitamin K
increase or decrease metabolism/ excretion
eg. Probenecid decrease excretion of Penicillin
immediate/ once
eg. Magnesium sulfate (preeclampsia)
once
eg. Anxiolytic (pre-surgery)
carried out indefinitely
eg. antibiotics
no specific time of administration/ as needed
eg. Pain relievers
within 24 hours
Signed
Indicate as Telephone Order
Put decimal number
c.
Components of Medication order (Drug prescription)***
Clients name
Date and time of order
Name of drugs
Dose and route
Time of frequency
Signature
d.
Drug effects
Therapeutic desired
Side effects 2nd effect, expected

Adverse effects severe side effect, unexpected
Allergic reaction immunologic response
N
53. NAEGELEs RULE
If LMP is from APRIL TO DECEMBER, use the formula:

o - 03 + 07 + 01 (MM, DD, YY)
If LMP is from JANUARY TO MARCH, use the formula:
o + 09 + 07 (MM, DD)
54. NASOGASTRIC TUBE (NGT)
TYPES
Levin - single lumen
Salem sump double lumen
INSERTION
Measurement:
adult (N.E.X.), pedia (N.E.M.U.X.)
Position:
high-fowlers and neck hyperextended
Instruction:
ask to swallow
Placement:
1- X-ray
2- Aspirate and pH test
normal gastric pH = 1 to 4 (acidic)

3- Listen/ auscultate for borborygmi sound after introduction of 10 30 ml of air (20 ml)
4- Listen/ auscultate for breath sounds (to double check)
REMOVAL
Instil 50 ml of air
Take deep breath and hold pinch catheter withdraw
Mouth care and blow nose
FEEDING
Check placement
Position: sitting/ upright/ fowlers
Check for RESIDUAL CONTENT dont discard; above 100ml STOP
Hang: 12 inches from point of insertion
Flush : 50 to 100 ml of water
Remain upright 30 minutes
55. NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST)

NON STRESS TEST vs. CONTRACTION STRESS TEST
Non Stress Test
Fetal movement and fetal heart rate
DIFFERENTIATI
ON
Variables
compared
NORMAL (Reactive/ Positive)

Increase FM Increase FHR
(acceleration)
Decrease FM Decrease FHR
(deceleration)
Abnormal or non reactive result needs

further evaluation that same day; usually
needs contraction stress testing
Uterine contraction and fetal heart rate
NORMAL (Non-reactive/ Negative)

Increase UC Decrease FHR
(deceleration)
Decrease UC Increase FHR
(acceleration)
Result
ABNORMAL (Nonreactive/ Negative)

Increase FM Decrease FHR
(deceleration)
Decrease FM Increase FHR
(acceleration)
2 FHR accelerations within a 10min
period, each acceleration increasing to
15bpm and lasting at least 15 sec
Contraction Stress Test
ABNORMAL (Reactive/ Positive)

Increase UC Increase FHR (acceleration)
Decrease UC Decrease FHR
(deceleration)
Two ways: Nipple Rolling and Intravenous

Oxytocin Delivery
3 contractions within 10min, lasting 40 to
60 sec is needed
Not performed until about 38+week
Watch out for Preterm labor
Desired
response
Management
FETAL HEART RATE DECELERATIONS

EARLY
LATE
VARIAB
LE
CAUSE
Head compression
Uteroplacental
insufficiency
Cord compression
MANAGEMENT
Observation
Side-lying position
Oxygenation
Increased IV fluids
Stop Oxytocin (Pitocin)
Call the MD
Caesarean if not corrected
Trendelenburg/ Knee-chest/ Sidelying position
Oxygenation
Increased IV fluids
Stop Oxytocin (Pitocin)
Call the MD
Caesarean section if not corrected
56. NORMAL VALUES
serum protein = 6.0 to 8.0 g/dL.

albumin level = 3.4 and 5 g/dL.
BUN: creatinine ration = 10:1 to 20:2
Electrolytes:
K = 3.5 5.5 mEq/L
Na = 135 145 mEq/ L
Ca = 4.5 5.5 mEq/ L
Mg = 1.5 2.5 mEq/ L
Ph = 2.5 4.5 mEq/ L
Cl = 98 108 mEq/ L
serum amylase level = 25 to 151 units/L.

In chronic pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal
value.
In acute pancreatitis, the value may exceed five times the normal value.
Therapeutic serum drug level

Carbamazepine = 3 to 14 mcg/mL
Phenytoin = 10 and 20 mcg/mL

Magnesium sulfate = 4 to 8 mg/dL
Lithium = 0.5 to 1.5 mEq/L***
Digoxin = 0.5 to 2 ng/dl
Acetaminophen = 10 30 mg/dL
Theophylline = 10 20 mcg/ml
57. O.R. TEAM MEMBERS

SCRUB
Surgeon
Surgical assistant
Scrub nurse
NON SCRUB
Anesthesiologist
Biomed
Circulating nurse
SCRUB NURSE
Performs complete scrub
Prepares and hands out instruments
Hands instruments while maintaining sterile
technique
Ensures everybody in the scrub team practices
sterile technique
Partner in OS and instrument counting
Anticipates the needs of the team
Patient advocate (act in behalf of the patient);
GUARDIAN OF THE PATIENT; doing something that
patient cant do
o
o
o
o
o
o
o
o
o
o
o
o
o
CIRCULATING NURSE
Greets the client upon arrival 1st primary
responsibility of circulating nurse
Checks client identification
Sponge counting together with scrub nurse
Monitors the urine output and blood loss together
with anesthesiologist
Ensures the consent form is signed
Documents the entire procedure
*Scrub and Circulating Nurses best tandem in OR***
P
58. PACEMAKER: CONTRAINDICATIONS
Strong magnetic fields MRI

Electrical fields high powered instruments (microwave oven, TV, radio, vacuum cleaners)
Cellular phones do not place near chest; place in the ear farthest in the pacemaker implant
59. PAIN
LOCATION:
Referred pain appear to arise in different areas***
Cardiac pain left shoulder, left arm
Gallbladder right shoulder
Visceral pain pain arising from organs or hollow viscera
60. PERSONAL SPACE/ COMMUNICATION ZONES

Intimate
distance
Touching to
1.5 feet
Body contact
Heightened sensations of body heat and smell
Voice tone low
Personal
distance
1.5 to 4 feet
Body heat and smell noticed less

Voice tone moderate
Physical contact is allowed (handshake or touching a
shoulder)
Social
distance
4 to 12 feet
Public
distance
12 to 15 feet
Body heat and smell re imperceptible

Voice tone loud enough to be overheard by others
Clear visual perception of the whole person
Loud, clear vocal tones with careful enunciation
Cuddling a baby
Touching a blind client
Positioning a client
Observing an incision
Restraining a toddler for injection
Lovemaking
Confiding secrets
Sharing confidential information
Communication between nurse and patient/
facilitates sharing of thought and feelings
(interviewing)
Sitting with a client
Giving medications
Establishing IV infusions
Bantering
Physical assessment
Nurses rounds
Wave a greeting
Public talk/ giving speech
Gathering of strangers
61. PRESSURE ULCERS

Stage 1 non-blanchable, erythema
2 epidermis and dermis involvement, shallow water blister
3 subcutaneous involvement, deeper crater
4 muscles and bone involvement, tissue necrosis
62. PULSE OXIMETRY/ O2 SATURATION
Measures:
1) Oxygen saturation
2) Pulse rate
Site:
Adult: finger
Pedia: toes
Other sites: nose, earlobe or forehead
Normal: 95 to 100%
70% and below life threatening
SaO2 and SpO2 same***
AVOID:
Sudden movement
Nail polish
Light
R
63. RADIATION THERAPY
Radiation therapy uses high-energy ionizing rays that destroys the cells ability to reproduce by damaging the cells
DNA
TELETHERAPY
External
Not radioactive
Cobalt therapy, Linear Accelerated Radiation
ALLOW
Leave markings
Vitamin A and D
Soap and water and
pat dry
SOURCE
PATIENT
EXAMPLE
S
AVOID
Sunlight
Alcohol
Lotion, powder, cosmetics
Adhesive tape
Tight clothing
BRACHYTHERAPY
Internal
Radioactive
1.
Unsealed oral, IV radioactive iodine 131,

Vitamin B12
2. Sealed implant (seeds) cesium, iridium
S hield:
lead + Dosimeter badge
T ime:
5 min/visit; 30 min/ shift; 1 pt/ day
D istance: 3 feet away
At bedside: forceps and lead container
AVOID: pregnant and children
Aratula: Caution
64. RESTRAINTS
PURPOSE: to prevent injuring self and others
CLASSIFICATION:
1. Physical manual/ physical device
2. Chemical substances/ medications
2 standards for applying restraints:

1. behavioural management standard when the client is a danger to self or others
2. acute medical and surgical care standard temporary immobilization of a client is required to perform a procedure
Guidelines:
1. Obtain consent
o
Should be RENEWED DAILY
o
PRN order is PROHIBITED
2.
3.
4.
Use clove-hitch knot***

Tie the free ends of the restraints on MOVABLE part of the bed frame***
Assess skin integrity per agency protocol (every 15 to 30 minutes)
Release restraints every 2 hours
Reassess the need for restraints every 8 hours
S
65. SENTINEL EVENT
Is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious
injury specifically includes loss of limb or function. (by The Joint Commission
66. SCHILLINGs TEST

PART 1
(CONFIRMATORY)
Vitamin B12
PART 2
(IDENTIFICATION OF CAUSE)
Vitamin B12 and Intrinsic factor
(+) vitamin B12 in urine normal

(-) vitamin B12 in urine (+) Pernicious Anemia
(+) vitamin B12 in urine Pernicious Anemia is stomach in origin

(-) vitamin B12 in urine Pernicious Anemia is small intestine in origin
67. SLEEP
Promoting Sleep: SLEEP PATTERN

Establish a regular bedtime and wake-up time
Establish regular, relaxing bedtime routine
Provide short daytime nap (15 to 30 minutes)***
Promoting Sleep: ENVIRONMENT
Adequate exercise during the day. Avoid exercise at least 3 hours before bedtime
Associate bed for sleep
Keep noise to minimum. Use white noise from a fan, air conditioner, or white noise machine
Sleep on comfortable mattress and pillow
Promoting Sleep: DIET
AVOID heavy and spicy meals 2 to 3 hours before bedtime
AVOID alcohol and caffeine-containing foods (coffee, tea, chocolates) at least 4 hours before bedtime
Alcohol and caffeine act as DIURETICS
If bedtime snacks are necessary: consume light carbohydrates or a milk drink
Promoting Sleep: MEDICATION
Sleeping pills last resort
Take analgesics before bedtime to relieve pains
68. Specimen collection: STOOL
a.
Defecate in a clean bed pan or bedside commode.

Void before the specimen collection (to prevent urine contamination)
QUANTITY:
SOLID STOOL: About a pea-size or 1 inch (2.5cm)
LIQUID STOOL: 15 to 30 mL
Refrigerate and label
FECAL OCCULT BLOOD TESTING (Guaiac Test)
Occult = hidden
Uses a chemical reagent which detects the presence of the enzyme peroxidase in the hemoglobin molecule.
RESULTS:
Changes in color like blue indicates a guaiac positive result
No change or any other color than blue indicates a negative result.
Avoid contaminating the specimen with urine or toilet tissue.
Label
Avoid specified foods and vitamin C 3 days prior to collection and specified medication 7 days prior to collection.
FALSE POSITIVE
RED MEAT (Beef, liver, and processed meats)
RAW VEGETABLES or FRUITS (Particularly radishes, turnips, horseradish, and melon)
MEDICATIONS (NSAIDs, IRON preparations, and ANTICOAGULANTS)
FALSE NEGATIVE
VITAMIN C
69. Specimen collection: SPUTUM
Sputum arises from the tissue of the respiratory tract

Saliva excreted by the salivary and mucus glands
BEST TIME: early morning
BEFORE: Mouth care
DURING:
o Deep breaths then cough up 15 to 30 mL (1 to 2 tablespoons).
o Wear gloves when collection.
o Ask the client to expectorate, not spit
o Should be cough directly into the specimen container
70. Specimen collection: URINE

SPECIMEN
CLEAN VOIDED
PURPOSE
For routine examination
CLEAN-CATCH or
MIDSTREAM URINE
For urine cultures

Done when a woman has menstrual
period
CATHETER
24-HOUR
Collection of sterile specimen usually

done when clients are catheterized for
other reasons
To determine the ability of the kidneys
to concentrate urine
To determine disorders of glucose
CONSIDERATIONS WHEN COLLECTING

Usually collected by the client with minimal
assistance
Preferably done on the first voided specimen in the
morning but it can be collected anytime if needed
At least 10 to 30 mL
Clean container is used
BEST TIME: early morning concentrated urine
Sterile specimen container
Place specimen during midstream flow.
QUANTITY:
30 to 50 ml routine urinalysis
5 to 10 ml C&S
Nurse aspirates from the lumen of a latex catheter
or from a self-sealing port
Collection of all urine produced in 24 hours
The first voided urine is discarded; last urine
voided included
metabolism
To determine levels of specific
constituents
Either refrigerated or preservative is added
71. SPONGE COUNTING

1 Before the operation starts (immediately preceding incision) to establish a baseline
2 Before closure of body cavity
3 Before the skin is closed/ before wound closure starts
The SCRUB and the CIRCULATING nurses should count audibly and concurrently***
72. SUCTIONING
Time per attempt
Interval
insertion
Endotracheal/ tracheostomy
5 to 10 seconds
2 to 3 minutes
5 inches and withdraw 1 to 2 cm
Naso-/ oro- pharyngeal

5 to 10 seconds
20 to 30 seconds
4 to 6 inches
Endotracheal
Position: semi-fowlers
Time: 5 to 10 seconds/ 5 minutes
Interval: 20 to 30 seconds
DURING
Lubricate the catheter with water-soluble lubricant (2 to 3 inches)
Insert during INHALATION in CIRCULAR motion***
DO NOT insert during swallowing (it may enter the esophagus)
o But in NGT let the patient swallow to promote entrance in stomach
Apply suction: during withdrawal
GLOVE: dominant hand
Hyperoxygenate BEFORE and AFTER suctioning

Conscious:
DBE
Unconscious:
ambubag, 3 to 5 times (12 15 LPM)
73. SUTURES (catgut) a thread, wire, or other material used in the operation of stitching parts of the body together
TYPES OF SUTURES:
Absorbable digested by body enzyme

plain gut (yellow)
chromic gut (brown)
Non-absorbable become encapsulated by tissue and remains unless removed (removed 7 days after)
silk (light blue)
nylon (green)
cotton (pink)
Prolene (royal blue)
Mersilenne (Turquoise)
Vicryl (purple)
Dacron (orange)
T
74. T-TUBE
PURPOSE:
To maintain patency***
To drain
To prevent bile leakage to the peritoneum
DRAINAGE
Color: 1st 24 hours reddish brown
Amount: 1st 24 hours 500 to 1000 ml
Normal color of stool after removal brown
Draining does not need doctors order
75. TELEPHONE ORDER
Only RNs may receive telephone orders

The order should be countersigned by the physician within 24 hours
76. TENSILON TEST

edrophonium chloride (Tensilon) IV
evaluation of muscle strength
USE: To diagnose myasthenia gravis
At bedside:
resuscitation equipment
atropine sulfate on bedside for possible CHOLINERGIC CRISIS
neostigmine for possible MYASTHENIC CRISIS

Results:
(+) diagnosis = improvement on muscle function after administration of drug
(-) diagnosis = muscle fasciculations occur as a result of the drug
77. THORACENTESIS
Purpose: To remove excess fluid or air from the pleural space to ease breathing
POSITION: sitting while leaning forward over a pillow
Chest X-ray identifies best insertion site
Within the first 30 minutes, not more than 1000 mL should be removed
AVOID: coughing , deep breathing
AFTER: Unaffected side with head elevation of 30o for at least 30 minutes
78. THYROIDECTOMY: Complications
Bleeding Feeling of fullness at incision site
Check soiled dressing at nape area, sandbag
Accidental removal of parathyroid Hypocalcemia classic sign tetany
Calcium gluconate, slowly administer- to prevent arrhythmia
Laryngospasm DOB, SOB
tracheostomy at bedside, suction
Accidental damage of the laryngeal nerve Hoarseness of voice
Encourage patient to talk post op asap to determine laryngeal nerve damage
Thyroid storm Fever, Irritability, Agitation, restlessness, Tachycardia
beta blockers
79. TOTAL PARENTERAL NUTRITION (TPN)/ PN/ IV HYPERALIMENTATION
Dextrose content 10 to 50%

Duration of TPN 24 hours
Site: central veins (SVC) subclavian vein (an x-ray is done to confirm its placement)***
Position during insertion: trendelenburg
Complication:
Thrombophlebitis
due to hypertonicity of the solution
change access site
Hyperglycemia
rapid infusion
regulate
Hypoglycemia
abrupt discontinuation hyperinsulinism
dont stop abruptly
Infection
unsterile procedure
sterile technique
Fluid overload
rapid infusion
regulate
Air embolism
Allergy
If empty, give hypertonic solution:
D10W pedia
D50W adult
BEFORE:
check label of solution and rate of infusion with medical order
inspect TPN bottle for precipitates or turbidity
administer via an infusion pump
DURING:
Initially administered at 50 ml/hr*** for the FIRST hour
Monitor glucose
Monitor vital signs every 4 hours
AFTER: Monitor WBC
PRIORITY NURSING DIAGNOSIS: High risk for infection
Do not overcorrect flow rate if too slow or fast
STERILE technique***
Use transparent air-occlusive dressing***
80. TRACHEOSTOMY CARE

1)
2)
3)
4)
5)
Position
Open sterile packages
Pour soaking solutions
Suction
Remove inner cannula and place in soaking
solution
6)
7)
8)
9)
10)
11)
Remove dressing
Clean inner cannula
Replace
Clean incision site and flange
Apply dressing
Change ties
81. TRACTIONS
TYPES
Skin traction impaired skin integrity
Skeletal traction risk for infection
Counter traction weight of the patient

Bucks not more than 8 to 10 lbs of weight should be applied
Crutchfield tongs (skull tongs) used to immobilize the cervical spine (indicated for unstable fractures or dislocation of
the cervical spine)
Crutchfield tongs/ Gardner-Wells skull tongs
POSITION: supine
82. TRANSFERRING Patient from BED to WHEELCHAIR

1 assist patient into sitting position
2 position chair parallel to the bed (strong side***)
Client with walking difficulty, angle the chair to 45 degrees***
3 use transfer belt
NURSE: hold belt
PATIENT: hold shoulder of nurse
4 pivot towards the wheelchair
83. TRANSFERRING Patient from BED to STRETCHER

1 lower HOB
2 raise bed slightly higher than stretcher
3 stretcher parallel to the bed
4 nurse press own body against stretcher to secure it against the bed
Client flex neck and arms across chest
5 roll both sides of pull sheet towards the patient
6 grasp and pull the pull sheet towards the stretcher
84. TRIAGE
trier- to sort
To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be
addressed
3 CATEGORIES IN TRIAGE in E.R.
URGENT
Red
Yellow
Life, limb, eye threatening
Needs treatment in 20 minutes
Needs immediate attention
to 2 hours
Chest pain, cardiac arrest,
Fever >40oC, simple fracture,
severe respiratory distress,
abdominal pain, asthma with no
chemicals in the eye, limb
respiratory distress
amputation, penetrating trauma,
severe hemorrhage
EMERGENT
Color
Urgency
Examples
IMMEDIATE
Number
Color
Examples
1
Red
Chest wounds, shock, open
fractures, 2-3 burns
NON-URGENT
Green
Can wait hours or days
sprain, minor laceration, rash,
simple headache. Toothache,
sore throat
4 CATEGORIES IN TRIAGE in DISASTER

DELAYED
MINIMAL
2
3
Yellow
Green
Stable abdominal wound, eye
Minor burns, minor fractures,
and CNS injuries
minor bleeding
EXPECTANT
4
Black
Unresponsive, high spinal
cord injury
85. TUNNING FORK TEST

b.
WEBERS TEST To test for bone conduction by examining lateralization of sound.

Hold and place the base of the tunning fork on top of the clients head; ask the client where he/she hears the
noise.
Results:
Weber negative if sound is heard on both sides or localized at the center of the ear.
Weber positive sound heard better on the impaired ear bone-conductive hearing loss;
sound heard on the normal ear sensorineural disturbance
c.
RINNE TEST To compare air conduction from bone conduction.

Ask client to block one ear intermittently (move a fingertip in and out of the ear)
Hold the handle of the activated tuning fork against the mastoid process (until vibrations can no longer be
felt/heard by the client).
Immediately hold the vibrating fork with the prongs in front of the clients ear canal.
Results:
Positive Rinne Air conduction (AC) is greater than bone conducted (BC).
Negative Rinne BC is equal to or longer than air conduction indicating a conductive hearing loss.
Infants: ring a bell or have the parent call the childs name (to assess gross hearing); newborns
may become silent or open their eyes wide; by 3 or 4 months, child will turn his/her head
toward the sound.
VITAL SIGNS
86. BLOOD PRESSURE

a.
Systolic contraction depolarization

Diastolic relaxation repolarization
b.
DETERMINANTS OF BLOOD PRESSURE***
Pumping action of the heart
strong pumping BP increases
weak pumping BP decreases

Peripheral Vascular Resistance (PVR)
increased vasoconstriction BP increases

decreased vasoconstriction BP decreases
c.
Blood volume
BV increases BP increases
BV decreases BP decreases
Blood viscosity
blood highly viscous BP increases
blood less viscous BP decreas
ASSESSING BLOOD PRESSURE***

The cuff should wrap (A) 40% of the arm length and (B) 80% should encircle the adults arm (arm
circumference)/ 100% of the childs arm
The lower border of the cuff should be 2.5 cm above the antecubital space.
Use the bell of the stethoscope low pitched sounds
Pump about 30 mmHg more from the point the pulse has disappeared.
Deflate the cuff at a rate of 2 to 3 mmHg per second.
Rest the arms for 1 to 2 minutes before taking the blood pressure again, in cases reading is not certain.
Calibrate the sphygmomanometer every 6 months
Allow 30 minutes for resting if the client has exercise, smoking or ingested caffeine
Read lower meniscus of the mercury to prevent error of parallax
o error of parallax if the eye level is higher than the level of lower meniscus
A 40%
B 80%
d.
KOROTKOFF PHASES***
Phase 1 a sharp thump determines the systole
Phase 2 a blowing or whooshing sound (increasing sound)
Phase 3 a crisp, intense tapping (loud tapping)
Phase 4 a softer blowing sound that fades (muffled sound)
Phase 5 Silence determines the diastole
e.
Taking BP in thigh
1 Position patient
Prone (best)
Supine with legs flexed

2 Expose thigh
3 Locate popliteal pulse
4 Wrap the cuff
f.
Common mistakes
FALSE-LOW
Bladder of cuff too wide
Arm above heart level
Deflating cuff too quickly
g.
h.
i.
FALSE-HIGH
Bladder of cuff narrow
Arm below heart level
Deflating cuff too slowly
Inflating too slowly
Smoking, caffeine and exercise for the last 30 minutes
Systolic in legs is higher compared to brachial around 10 to 40mmHg

3 years old and above - Start taking BP routinely
BP of 120/100/80 phase 1/4/5
87. TEMPERATURE
a.
ORAL accessible and convenient

S Smoking*
N Newborn
O Oral surgery
U Ulceration/injury to the mouth
T Tremors/convulsions
H Hot/cold foods & fluids just ingested wait

for 15 to 30 minutes before taking
temperature
b.
AXILLARY Safe and non-invasive

A Axillary injury
X eXercise/activity
I Inadequate circulation
L Laging basa (moist pits)

A After bathing
c.
U Undergone rectal surgery

M Myocardial infarction
RECTAL Reliable measurement (Inconvenient

and more unpleasant)
R Rectal disease/diarrhea
I Immunosuppressed
C Clotting disorders
T Turning to the side is difficult
H Hemorrhoids
d.
TYMPANIC Readily accessible, reflects the

core temperature, very fast 9 Risk of injuring the
membrane)
E Evident cerumen
A An ear infection is present
R Reading may vary between left and right
measurement
88. PULSE the wave of blood created by the contraction of the left ventricle.
Wait for 10 to 15 minutes if he client has been physically active.

Use 2 or 3 middle fingertips lightly over the pulse site.
Doppler ultrasound stethoscope (DUS): transducer probe (gel may be applied) and stethoscope headset; when using a
DUS, hold the probe lightly over the pulse site.
Apical pulse
7 years old and above located at the 5th ICS LMCL
below 7 years old located at the 4th ICS LMCL
PULSE SITES
Infants, palpable:
brachial and femoral
Allens test:
radial
CPR, infants:
brachial
CPR, adults:
carotid
89. RESPIRATIONS The act of breathing.
C
D
F
E
IH
2 Types of breathing
Costal thoracic
Diaphragmatic Abdominal
First to take BEFORE invasive procedures

Physiologic apnea
a. RATE Eupnea (breathing that is normal in rate and depth), bradypnea (abnormally slow), tachypnea (abnormally fast),
and apnea (absence of breathing).
EUPNEA
APNEA
BRADYPNEA
TACHYPNEA
b. DEPTH Hyperventilation (rapid and deep breaths), hypoventilation (very shallow respirations), and Kussmauls
breathing (hyperventilation associated with metabolic acidosis).
HYPERVENTILATI
ON
HYPOVENTILATIO
N
c. RHYTHM Cheyne-Stokes breathing (regular rhythm from very deep to very shallow respirations then temporary apnea)
and Biots respiration (shallow breaths interrupted by apnea).
CHEYNE-STOKES
BIOTS
U
90. URINARY CATHETERIZATION: TYPES
TYPES
NO. OF
LUMENS
Straight Catheter
SINGLE: only for drainage
Indwelling Catheter (Foley or Retention catheter)

DOUBLE:
urine drainage
for inflation of balloon (serves as an anchor)
OR
TRIPLE:
urine drainage
for inflation of balloon (serves as an anchor)
PURPOSE
Inserted only as much times

as it takes to drain the bladder
or obtain a urine specimen
for continuous irrigation

Inserted and stays connected to the bladder for a long time
SPECIAL
CONISDERATIONS
Coude catheter is a variation

of straight catheter which has
a curved and tapered tip,
usually used for male patients
with prostatic hypertrophy
Secure catheter tubing: male - upper thigh or abdomen

Female - inner thigh
NO TUB BATHS, shower is preferable
Collection bag should always be below bladder

Position during procedure: FEMALE Dorsal Recumbent
MALE Supine
Lubricate catheter
Catheter accidentally slips into vagina: leave the catheter in vagina, get
new catheter and insert to urethra then remove the catheter from vagina
Increases susceptibility to infection
2 Main Principles observed:

1) Principle of sterility
2) Principle of gravity
Replace urinary catheter every 5 to 10 days
91. URINE ELIMINATION
Color amber/straw, transplant

Order aromatic
pH 4.5 to 8
Amount 1200-1500 ml/day (30-60 ml/hr)
Sp.gr 1.010-10.25
92. PRESENTING UTI

W ash before and after sex
O n time voiding
M ake us of cotton undergarment
A lways wipe from anterior to posterior
N o sprays, harsh soaps, powder.
W
93. WRITING NURSING DIAGNOSIS
1. Write the diagnosis in terms of response
rather than need.
2. Use related to rather than due to or
caused by to link etiology to problem
statement
3. Write diagnosis in legally advisable terms.
AVOID libellous words or would imply
nursing negligence.
4. Include in the problem statement only

client responses that are unhealthy or that
the client wants to change.
5. AVOID including signs and symptoms of
illness in the problem statement.
6. Express the client statement and etiologic
factors in terms that can be changed;
otherwise, nursing energies are being
directed to a hopeless task
7. Express the problem statement in terms of
unhealthy client responses rather than
environmental conditions
8. AVOID reversing the problem statement
and etiologic statement
9. Make sure that the 2 parts of the diagnosis
do not mean the same thing
10. Write diagnosis without value judgments.
WATCH OUT for your ADJECTIVES!
11. DO NOT include medical diagnosis.
INCORRECT
Needs assistance with bathing related to bed
rest
Noncompliance due to hostility towards
nursing staff
CORRECT
Self care deficit: bathing related to immobility
Spouse abuse related to husbands

immaturity and violent temper.
High risk for violence: spouse abuse related

to husbands reported inability to control
behaviour
Impaired skin integrity related to clients lying

back all night
Mild anxiety related to impending surgery.
Impaired skin integrity related to immobility.
Cough related to long history of smoking.

Alterations in Bowel elimination: Permanent
colostomy related to cancer of the bowel
Ineffective airway clearance related to 20

year history of smoking.
Self-care deficit: Care of colostomy, related to
feeling s of powerlessness
Cluttered home related to inability to discard

anything
High risk for injury related to cluttered home

(inability to discard anything)
Impaired swallowing related to possible

aspiration.
Alteration in comfort related to pain.
Risk for aspiration related to difficulty

swallowing.
Unrelieved incisional pain related to fear of
drug addiction
Impaired home maintenance management
related to low value ascribed to home safety
and cleanliness
related to mobility, endurance and comfort
alterations.
Poor home maintenance management

related to laziness.
related to arthritis.
Noncompliance related to hostility towards

nursing staff
---

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2. AMNIOCENTESIS vs. ULTRASONOGRAPHY

2. If less than 20 weeks' gestation (full bladder)

2. If done late in pregnancy:

3. ARTERIAL BLOOD GAS (ABG) ANALYSIS

Serum pH 7.35 7.45

AFTER: Apply pressure on puncture site for 5 minutes

First step in ABG analysis determine pH***

1 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

NPO at midnight (6 8 hrs)

7. BENNERs STAGES OF NURSING EXPERTISE***

8. BLEEDING PRECAUTION (OPEN wounds)

Stop the infusion

2 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

Stop the infusion

BT REACTION MANAGEMENT: (in sequence)***

L et the tubings be changed

10. BONE MARROW BIOPSY/ ASPIRATION

site is iliac crest Prone

site is sternum Supine

AFTER: PREVENT BLEEDING

11. BOWEL DIVERSIONS

watery (prone to Fluid Volume Deficit and Impaired skin integrity)

watery (prone to Fluid Volume Deficit and Impaired skin integrity)

COLOSTOMY IRRIGATIONS needed by Descending and sigmoid colostomy

Permanent colostomy Descending and sigmoid colostomy

ASSESSMENT OF PROPER LATCHING

Nipple touches the posterior tongue 9to promote swallowing reflex)

15. CHEMOTHERAPY SIDE EFFECTS

4 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

Discuss potential TEMPORARY hair loss (2 to 4 weeks)

16. CHESTPHYSIOTHERAPY (CPT)

done BEFORE meals

17. CHEST TUBE

FLUID DRAINAGE: the tube is inserted at 8th or 9th ICS

WATER SEAL BOTTLE

Immerse tip of the tube in 2- 3 cm of sterile NSS to create water seal

INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration, fall during

CONTINUOUS GENTLE BUBBLING (indicates adequate suction control)

CHEST TUBE REMOVAL

Give analgesics 30 minutes before removal

DISLODGE (chest tube removal FROM THE CLIENT)

DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage)

18. CEREBROSPINAL FLUID (CSF) ANALYSIS

Protects from mechanical trauma

19. COMMUNICATION: ATTENTIVE LISTENING

20. COMMUNICATION: PHYSICAL ATTENDING***

22. CVP MONITORING

Measure the pressure of the right atrium

Direct visualization of the LOWER urinary tract (bladder and urethra)

urine characteristic (NORMAL: pink tinged or tea-colored urine)

Observe for fever, dysuria, pain in suprapubic region

Ear bones (Ossicles)

Position during drug administration:

Outer ear problem (otitis externa) conductive hearing loss

0.12 0.20 seconds

Flat T wave, presence of u wave

Short ST segment and QT interval***

Position: left-sidelying/ dorsal recumbent***

Enema tube lubricate first; insert in rotating motion

Temperature: 100oF (37.7oC)

4 factors affecting Force of flow of the solution:

E nlarge the nipple hole