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TOP DISEASES, SURGERIES and NURSING PROCEDURESBy: Lyzander A. Sardonido, RNABDOMINAL ASSESSMENTProcedure: I-A-Pe-PaRegular assessment: I-Pa-Pe-ASequence: RLQ ? RUQ ? LUQ ?LLQPosition: dorsal recumbentAVOID:A – ppendicitisP – heochromocytomaA – bdominal Aortic AneurysmW – ilm’s tumorABSENT MECONIUM PASSAGECystic fibrosisHirschprung’s diseaseImperforate anusARTERIAL BLOOD GAS (ABG)Serum pH7.35 – 7.45CO235 – 45HCO322 – 26PaO285 – 95 mmHgIncreased:PolycythemiaDecrease:AnemiaBEFORE: Allen Test to assess patency of the RADIAL artery***Avoid suctioning at least 20-30 minutes BEFORE procedureAFTER: Apply pressure on puncture site for 5 minutesABDOMINAL PARACENTESISPurpose:Obtain fluid specimenTo relieve pressure on the abdominal organs d/t the excess fluidBEFORE:Ask client to voidDURING:Position: Sitting positionCommon site: midway between the umbilicus and symphysis pubisStrict sterile techniqueMeasure abdominal girth at the umbilical levelMaximum amount drained is 1500 mLInstruction:ACROMEGALYIncrease growth hormone AFTER pubertyIncrease glucose levelS/Sx:Broad and bulbous noseEnlarged hands and feetContinuous grow of soft tissues (ear, nose)ComplicationsEnlarged heartDiabetes mellitusHeart failureReason of seeking for medical care: change in appearanceManagement:Octreotide (Sandostatin) ? give SQ if given 3x a weekACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)“shock lung”Pathophysiology:Decreased surfactantsDecreased surface tensionDamage to alveolar-capillary membraneLeakage of fluid into the ITSResulting to pulmonary edemaS/Sx:Dyspnea, retractionsADDISON’s and CUSHINGS DISEASEADDISON’sCUSHING’s“All STEROIDS (S.S.S.) are DOWN except for Potassium”“All STEROIDS (S.S.S.) are UP except for Potassium”MAIN PROBLEM AND its symptomsDOWN: SUGAR (HYPOGLYCEMIA)DOWN: SALT (HYPONATREMIA)HYPOVOLEMIA ? DHN, weight lossHYPOTENSIONDOWN: SEX HORMONESDecrease sexual urge or libidoUP: Potassium ? HYPERKALEMIAWeakness, fatigueTachycardia, ArrhythmiaDiarrheaMetabolic acidosisTall/ Tented T waveUP: SUGAR (HYPERGLYCEMIA)UP: SALT (HYPERNATREMIA)HYPERVOLEMIA ? Edema (Moonface, Weight gain)HYPERTENSIONUP: SEX HORMONESDecrease sexual urge or libido Virilization (mascularity in female) ? Amenorrhea, Hirsutism, Enlargement of clitorisOsteoporosisGynecomastia (males)DOWN: Potassium ? HYPOKALEMIAWeakness, fatigueBradycardiaConstipationMetabolic alkalosisFlat T waveMNGT:YES steroids (pro-Na, anti-K)Monitor VS, I&O, weightDIET: high calorie, high CHO (glucose), high NA, low KNO steroidsMonitor VS, I&O, weightDIET: low calorie, low CHO, low Na, high K, high CHONReverse isolation*BILATERAL ADRENOLECTOMYGIVE Calcium (for osteoporosis)S.S.S (Sugar, Salt, Sex hormone) ? steroidsCushing’s disease ? prone to infectionANEMIA – Decrease oxygen carrying capacity of RBCCommon Nursing diagnosis: Activity intoleranceTYPESPernicious anemia – immature RBC due to lack of vitamin B12Aplastic Anemia – decrease RBC, platelet, WBCSickle cell anemia – sickled RBCManagement:H - ydrationO - oxygeantionP – ain managementANGINA2 GOALS IN ANGINAL MANAGEMENT:Goal # 1: Increase oxygen supply to the myocardium (vasodilation)Goal # 2: Decrease oxygen demandNitrates – Goal # 1Example: Nitroglycerin, Isosorbide mononitrate (Imdur), Isosorbide dinitrate (Isordil)Side effects: flushing, throbbing headache, hypotension, dizzinessKeep drug only for 6 months, cool, dry and dark environmentCarry all timesDO NOT administer with Sildenafil (Viagra)AVOID: hot baths (vasodilation)Beta Blockers – Goal # 2Example: Propranolol (inderal), Metropolol (Lopressor)Calcium Channel Blockers – Goal # 1 and 2Examples: Amlodipine (Norvasc), Verapamil, Nifedipine, Diltiazem (Cardizem), ANEURYSM– is ballooning of the blood vesselTYPESSaccularFusiformDissecting - a TEAR in the intima of the blood vessel***Type A – affects the ascending aortaType B – affects the descending aortaComplication: rupture/ internal hemorrhage/ shockAPPENDICITISInflammation of the appendix LOCATION: RLQ/ right iliac/ Mc Burney’s pointCAUSE: due to obstruction from fecalithlow fiber dietCOMPLICATION: PeritonitisAPPENDICITIS, manifestationsincrease WBC, feverPECULIAR SIGNS:Rovsing’s signpressure on the LLQ causes pain in the RLQMc Burney’s signpain at RLQ upon palpationPsoas signpain on passive extension of right hip (lateral position with right hip flexion)Obturator signpain with passive flexion and internal rotation of the right hipBlumberg signrebound tenderness (peritonitis)(+) cough signRLQ pain on coughingWith pain – inflammationWithout pain – ruptureTachycardia – late signAbdominal distention and paralytic ileus/ decreased or absent bowels soundsAPPENDICITIS, managementNPOPOSITION: (acute phase)most comfortable position; Semi fowler’s to relieve pain and discomfort(rupture)uprightSx: AppendectomyPosition: flat on bedALLOW: cold applicationAVOID:warm compressanalgesics – will mask the pain*Laxatives, enema, palpation (increase peristalsis)ARNOLD-CHAIRI MALFORMATIONRelated to neural tube defectS/Sx:Swallowing difficultyWeakening of the extremitiesStridorARTHRITISRHEUMATOID ARTHRITISOSTEOARTHRITISGOUTY ARTHRITISAutoimmune/ SystemicDegenerative disease (“wear and tear”)Common aggravating factor: obesityMetabolic Altered purine metabolismBODY PART AFFECTEDSmall joints (wrist, elbow)BilateralWeight bearing joints (hips, spine, knee, ankle)Unilateral/ progressiveBig toeS/SxUlnar driftBoutenniere deformitySwan neck deformitySjogren’s syndrome – excessive dryness of eyes, mouth and vaginaFelty’s syndrome – leukopenia, spleenomegalyHeberdend’s – distalBouchard’s – proximalTophi/ podagra – uric acid crystallizationElevated uric acidMANAGEMENTGold therapyAspirin regularly-w/o for tinnitus-toxicitySteroidsHot and cold compressW-weight control (decrease calorie)H-hot compress or ice packsA- aspirin useT- trunk assistive devices- caneAVOID: organ meats, alcohol legumes, sardinesIncrease fluid intakeP-probenecid - excretion of uric acidA-allopurinol - decrease production of uric acidC-colchicine - analgesic, anti-inflammatoryS-sulfinpyrazone- reduces uric acid in the bloodASEPSISMEDICAL ASEPSISSURGICAL ASEPSISPurposeTo reduce microorganismTo destroy microorganism including sporesIndicationRoutine nursing careProcedure involving sterile areasTechniqueDisinfection (clean)Sterilization (sterile)AVPU SCALEA – Alert and AwakeV – Verbal response to stimuliP – Pain response to stimuliU – UnresponsiveBARIUM SWALLOW AND BARIUM ENEMABARRIUM SWALLOWBARIUM ENEMAUSEExamination of UGTExamination of LGTBEFORENPO 6 – 8 hoursNPO at midnight (6 – 8 hrs)DIET: Low residue diet, Clear liquid diet (1 – 3 days)Laxatives, Cleansing enemaAFTERConstipation: Increase fluids, LaxativeStool color: chalky white 1 – 3 daysBLEEDING PRECAUTION (OPEN WOUND)P – ressure over the injuryE – levate above the heartC – old compressA – rterial pressureT – orniquetBLOOD TRANSFUSIONBEFORECheck order – 2 RN’sClient name and identification numberUnit numberBlood type matchingExpiration dateInformed consentBlood matchingObtain baseline VSwarm blood at room temperature NOT more than 30 minutesDURINGSTAY with the patient and Check every 15 minutes – 1st hourCheck every hour – succeeding hoursOTHERS:Gauge: 18 or 19***Y set filter IV transfusion set***IV fluid:NSS only (other solution causes hemolysis)Time4 hours: WBC, PRBCRapid: Plasma, Platelets, CryoprecipitateBLOOD TRANSFUSION, Blood ComponentsBlood ComponentInfusion rateVolumeWhole blood2 to 4 hours500 mlPRBC2 to 4 hours250 mlCryoprecipitate30 minutes10 mlPlateletsRapid35 to 50 mlFresh frozen plasmaRapid of bleeding; 1 to 2 hours250 mlBLOOD TRANSFUSION, ReactionC – irculatory overload too rapiddyspnea, HPN, increased PRH – emolyticincompatibilityjaundice, shock HAA – llergicantigen/ antibody transfusionurticaria, wheezingP – yrogenicbacterialfever, chillsBLOOD TRANSFUSION RECTION, management(in sequence)B – T stopL – et the tubings be changedO –pen NSSA – lways check the VSD – octor, where are you!S – cold the bankBONE MARROW BIOPSY/ ASPIRATION Bones commonly used: sternum, iliac crest, iliac spines, or proximal tibia (children)DURINGPosition: site is iliac crest ? Pronesite is sternum ? SupineAbout 1 to 2 mL of bone marrow is obtained.AFTER: PREVENT BLEEDINGBed rest for 30 minutesIce bag on punctured sitePressure on the puncture sitePosition: Lie on operative/biopsied side for 10 to 15 minutesBOWEL DIVERSIONS, Types of OstomyIleostomywatery (prone to Fluid Volume Deficit and Impaired skin integrity)Cecostomywatery (prone to Fluid Volume Deficit and Impaired skin integrity)Ascending colostomywatery (prone to Fluid Volume Deficit and Impaired skin integrity)Transverse colostomymushy/ semi-formedDescending colostomyformedSigmoid colostomyformedBOWEL DIVERSIONS, StomaColor brick redMay turn to pink after several months and yearsSensationnormally no sensationProtrusion? to ? inchesDrain1/3 to ? fullAppliance size (pouch opening) 1/16 to 1/8 inchesBOWEL DIVERSIONS, Types of OstomyCOLOSTOMY IRRIGATIONS – needed by Descending and sigmoid colostomy1st – stimulate2nd – evacuatePosition: sittingBOWEL DIVERSIONS, FoodsCauses odorBeansAsparagusGarlicEggsSpicesCauses gas: CeleryCabbageCornCamoteCauliflowerChampagneCucumbersCarbonated drinks Thicken stool: TapiocaRiceYogurtApple and apple sauceBananaCheesePermanent colostomy – Descending and sigmoid colostomyColon cancer – sigmoid colostomyBREASTFEEDING, Assessment of proper latchingC – hin to breastO – pen mouth widelyL – ips turned outwardA – reola is visible above onlyNipple – touches the posterior tongue 9to promote swallowing reflex)Nipple (bottle) – always filled with milk 9to prevent colic)Color of stools:Breast fed: golden yellowFormula fed: pale yellowBRONCHIAL ASTHMAMost common triggering factor: dustTRIAD symptoms;B – ronchoconstriction ? caused by leukotrienesI – nflammation ? caused by IgEM – ucus production ? caused by GOBLET CELLSGive BRONCHODILATOR first, followed by STEROIDSBRONCHOSCOPYBEFORE: NPO for 6-12 hours prior to procedure; no dentures; maintain good oral hygieneDURING: uses local anesthetic spray to minimize gagging while inserting the bronchoscopesupine with head hyperextendedAFTER: POSITION: semi fowler'sNPO till gag returns then start with ice chips then followed by sips of water ?soft diet ? regular dietice bags to throatminimize talking, coughing, laughing; warm saline gargles; assess for respiratory distressBURNS, causes/ typesCAUSES/ TYPES:Thermal burnsScald burns – hot fluidsFlame – ignition/ fireFlash – explosioncontact with hot objectsChemical burns – acids, alkaliElectrical burns – electrical wiresRadiationBURNS, 2 Parameters to meaasure1) Extent – percentage Rule of 9 – quick wayPalm method – use for scattered burn2) Severity – 1st to 4th degree (Depth)BURNS, classificationPARTIALFist degreeSuperficial burnEpidermispain, reddened (erythematosus), no edemasunburnSecond degreeSuperficial Partialthickness burnEpidermis and dermisVery painful, very red, blistered, edema, blaches with pressureScalds (contact with hot liquids)FULLThird degreeDeep Partial thickness burnSkin to SQPainlessRed to Gray/ waxy white colorWet surface (broken blisters)EdemaFire ? Electricity or lightning ? Prolonged exposure to hot liquids/ objectsFourth degreeFull thickness burnEpidermis, Dermis, SQ tissue, bone and musclespainless, dry, pale, white or charredHEALING PROCESS1st degree – 3 to 7 days2nd degree – average of 21 days3rd degree – skin grafting ? compartment syndrome4th degree – amputation; skin graftingBURNS, stages of burn injury1st stageFluid Accumulation2nd stageFluid remobilization3rd stageRecovery/ ConvalescnceIV to ITHypovolemia/ shockOliguriaDecrease Blood volumeDecrease BP Increase HR, Increase RRIncrease HCTIncrease potassium Decrease sodium and waterMyoglobinuriaIT to IV(Hypervolemia)DiuresisIncrease Blood volumeIncreased BPFluid overload ? CHFDecrease HCTDecrease potassium Decrease sodium and waterHealing processDecreased calcium (calcium is used in wound healing)BURNS, phases of burn managemenBEGINSENDSGOAL/ FOCUSEMERGENT;usually 24 to 48 hours following injuryBegins at the time of injuryends with the retoration of capillary permeability (fluid resuscitation)Fluid resuscitation Fluid replacement are calculated from the TIME of INJURY and not from the TIME OF ARRIVAL at the hospitalAmount of fluid: based on the client’s weight and extent of injuryACUTE;Begins 48 to 72 hours after the time of injuryBegins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begununtil the burn is healedinfection controlwound care, wound closure, nutritional support,pain management, and physical therapyREHABILITATIVEbegins with wound closureuntil the patient has reached the highest level of functioningDesigned so that the client can gain independence and achieve maximal functionBURNS, “must-to-know”Burns to the chest, back, neck, and face, PRIORITY nursing diagnosis:Ineffective airway clearance***IV fluid used in FLUID RESUSCIATION: Lactated Ringers (LR)Patient is burning:“DROP and ROLL”***AVOID:Standing – to prevent inhalationRunning – to prevent fanning of fireElectric burn, first to be done:***Turn OFF the electric soourceComponents of FIRE:***Oxygen (open window, oxygen tank)Friction (drapes, electric spark, friction producing equipment)Combustible material (kerosene, LPG)Patient with burns with diarrhea, suspected organism: Clostridium DeficileChemical burn to the eyes, first thing to do is:flush the eyes with water continuously for 20 minutesSKIN GRAFTHeterograft (xenograft) – is a graft of skin obtained from another species, such as a pig. Autograft – is a graft of skin obtained from the patient itselfHomograft – is a graft of skin obtained from same species like a cadaver 6 to 24 hours after deadFIRE management, sequence***1- Protect patient2- Activate alarm3- Confine the fire4- Extinguish the fireFIRE EXTINGUISHER, types***Type A – for Trash fire ? paper, woods, leaves (contain water under pressure)Type B – for Fuel fire ? oil, gasoline, kerosene (contains carbon dioxide)Type C – for Electric Fire ? appliances, wire (contains dry chemicals)Type D – any kind (contains graphite)CANCER, RSIK FACTORSBreast CancerEarly menarcheLate menopauseNulliparity1st pregnancy at 35 years oldBladder CancerSmokingHair dyeGastric CancerSmoked foodsPeptic Ulcer Disease: gastric ulcerRaw foodsCANCER SCREENINGPROCEDURESCHEDULEBreast Self Exam (BSE)Monthly, 3 to 5 days after the onset of menstruationTesticular Self Exam (TSE)Monthly, after a warm bathMammogram35 to 40 years – 1x (baseline)41 to 50 years – every 2 years51 and above – yearlyPaps smearOnset – 40 – every 3 years41 and above – yearlyDigital rectal Exam (DRE)50 and above – yearly40 and above – yearly (if high risk)CHEMOTHERAPY SIDE EFFECTSSide effectsInterventionsGATRO-INTESTINALNausea and vomitingAnorexiaProvide antiemetics 30 – 60 minutes before chemotherapyAVOID: unpleasant odors, spicy foods, hotSFFDiet: soft blandEnsure adequate fluid hydrationFrequent oral hygieneOral thrushRinse mouth with ? strength peroxide and NSSBrush teeth with soft toothbrush and baking sodaUSE: unwaxed dental floss, cotton-tip applicator for viscous xylocaine over lesionsHEMATOPOEITIC(Bone marrow suppression)Neutropenia(WBC)Neutropenic precautionHandwashingNeutropenic diet/ low-bacteria diet: cooked foodsAVOID: fresh flowers, fruits, vegetables, raw foods, vaccinationsReverse isolation/ private roomAssess vital signs every 4hoursThrombocytopenia(Platelets)Thrombocytopenic precautionAVOID: aspirin, IM, invasive procedures, punctures, contact sportsUse soft bristled toothbrush, electric razor, stool softenerAnemia(RBC)Blood transfusionBed restINTEGUMENTARYAlopeciaDiscuss potential TEMPORARY hair lossUse of wigsIf hair grows back – color and texture changesAVOID: excessive shampooingGENITO-URINARYCystitisIncrease fluidsSterility/ infertilityTemporaryCHEST TUBEDRAINAGE BOTTLENURSING 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 hoursOUPUT: 500 – 1000 ml during the first 24 hours***FLUID DRAINAGE: the tube is inserted at 8th or 9th ICSAIR DRAINAGE: the tube is inserted 2nd or 3rd ICSCOMMON OBSERVATIONSNO DRAINAGEResolutionObstructionWATER SEAL BOTTLENURSING CONSIDERATIONS:Immerse tip of the tube in 2- 3 cm of sterile NSS to create water sealCOMMON OBSERVATION:INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration, fall during expiration)NO FLUCTUATIONSObstruction – check and milk the tubing with CAUTIONLow suctionRe expand lungs – do chest X- ray for confirmationCONTINUOUS BUBBLINGAir leakage (except during suctioning)SUCTION CHAMBERNURSING CONSIDERATIONS: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 OBSERVATIONSCONTINUOUS GENTLE BUBBLING (indicates adequate suction control)NORMALCHEST TUBE REMOVALGive analgesics 30 minutes before removalClamp on bedsideDURING removal: let the patient EXHALE and hold breath while doing VALSALVA MANEUVERMaintain dry, sterile, occlusive dressingEMERGENCY SITUATIONDISLODGE (chest tube removal FROM THE CLIENT)AT BEDSIDE: vaselinized gauzePalm pressure (for splinting)DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage)ATBEDSIDE: Extra bottle immersed in sterile waterClamp (Hemostat)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 PHEUMOTHORAXCEREBROSPINAL FLUID (CSF) ANALYSISProtects from mechanical traumaFunction of CSF: Carries nutrients to brainCharacteristicsNormal pressure: 5 to 15 mmHg/ 70 to 180 mmH2ONormal volume: 100 to 200 mlWBC: 0 - 5 cells/mmGlucose: 40 to 80 mg/dl (40 to 80 mg/100ml)Protein: 15 to 45 mg/dl (15 to 45 mg/100 ml)Diagnostic test for meningitis, resultIncrease protein contentDecrease glucose contentIncrease WBC contentCloudy (bacterial meningitis)Clear (viral meningitis)CHOLECYSTITISCHOLELITHIASIS: stones in the gall bladder (occurs due to hypercholesterolemia)CHOLECYSTITIS: inflammation of the gall bladderStone: cholesterol*, bile pigments, calcium: may cause obstruction, infectionstones may spread to:common bile duct (choledocholithiasis) pancreatic duct (pancreatitis) 6F’s:Female (contraceptives)Fat (obesity)Forty (low estrogen levels)Flatulence FairFertile (decrease estrogen, high progesterone)MANIFESTATIONS:TRIAD symptoms:RUQ pain – that radiates to midsternum, scapular area or right shoulder***FeverJaundice/ pruritusIncreased bilirubin*** Increased alkaline phosphatase if with obstruction***(+) Murphy’s sign – pain during inhalation when the physician’s hand is placed on the patient’s RUQ abdomenDecrease ADEK – bleeding (low Vitamin K)Acholic stools (pale/ gray stools/ clay-colored)Steatorrhea (no bile to emulsify the fats)DIAG AND LABERCP (endoscopic retrograde cholangiopancreatography)Oral cholecystography – PROCEDURE OF CHOICE!***UTZINTERVENTIONPain controlNarcoticsantipasmodics and anticholinergics (to reduce spasms and contractions of the GB)NGT insertion – for gastric decompressionDIET: high CHO, moderate CHON, low fatgive Vitamin K as orderedSURGICAL INTERVENTIONS:Cholecystostomy: incision into the GB for the purpose of drainageAbdominal cholecystectomy: removal of the GB for the purpose of drainageLaparoscopic cholecystectomy: removal of GB thru an endoscope inserted thru the abdominal wallCholedochotomy: incision into the CBD for removal of stonesCORONARY ARTERY BYPASS GRAFTUsed for multiple vessel affectionSources of Grafts:Saphaneous veinInternal mammary arteryRadial arteryCT SCANX-rayContrast medium – warm sensationAVOID: pregnant womenBefore: NPOAfter: increase fluidCVP MONITORINGMeasure the pressure of the right atriumPlace the zero level of the manometer at the level if the right atrium (4th ICS)AVOID: coughing and strainingNORMAL: 2 -12 mmHgCYSTOSCOPYDirect visualization of the LOWER urinary tract (bladder and urethra)PURPOSE:specimen collectiontreatment of the interior of the bladder and urethraProstate surgeryLocal anesthesia – commonly used POSITION: dorsal recumbentCONTRAINDICATIONS: acute cystitis, bleeding disordersAFTER:Assess VSurine characteristic (NORMAL: pink tinged or tea-colored urine)I&OEncourage fluidsSitz bathObserve for fever, dysuria, pain in suprapubic regionDIABETES INSIPIDUS and SIADHDIABETES INSIPIDUSSIADHMAIN PROBLEMDecrease ADH secretionIncrease ADH secretionNURSING DIAGNOSISFluid Volume DeficitFluid Volume ExcessS/SXDecrease urine specific gravity – DILUTEDIncrease urine specific gravity - CONCENTRATEDDehydration, ConstipationEdemaPolyuria, PolydipsiaOliguriaWeight lossWeight gainHypotensionHypovolemiaHypernatremia (CONCENTRATIONAL)Hemoconcentration (increase HCT)Hypertension HypervolemiaHyponatremia (DILUTIONAL)Hemodilution (decrease HCT)COMPLICATIONShockWater intoxicationDIETHydration - Force fluids (2 – 3 L/ day)AVOID foods that exert diuretic effect (coffee, tea)Restrict fluidALLOW foods that exert diuretic effect (coffee, tea)DRUGSVasopressinDiuretics (Loop and Osmotic)Demeclocycline (Declomycin)DUMPING SYNDROMES/sx:Shock-like symptoms: diaphoresis, cold and clammyDiarrheaPosition after feeding: LEFT SIDE LYING (to delay drainage to stomach)Common complication of gastrectomyEAREar bones (Ossicles)M – alleusHammerA – nvilIncusS – tapesStirrupsPosition during drug administration:Below 3 years old – down and backAbove 3 years old – up and backECGNORMALPR ? 0.12 – 0.20 secondsQT ? 0.32 – 0.40 secondsQRS ? 0.04 – 0.10 secondsHYPERKALEMIATall T waveHYPOKALEMIAFlat T waveHYPERCALCEMIAShort ST segment and QT intervalHYPOCALCEMIALengthened ST segment and QT intervalAtrial flutterWith P wave (saw tooth)Regular rhythmNormal QRSAtrial fibrillation***No P waveIrregular rhythmNormal QRSAtrial tachycardiaWith P wave (different shape)Regular rhythmNormal QRSVentricular fibrillationNo P waveChaotic rhythmNo QRSVentricular tachycardiaNo P waveRegular rhythmWide and bizarre QRSENEMATYPES:Cleansing enemacleansing (3x)Carminative enemaflatusReturn flow/ Harris flush/ Colonel irrigationflatus (5 – 6x)Retentionsoften; lubricate (1 – 3 hours)SOLUTIONS:Hypertonicsodium biphosphateHypotonictap waterIsotonicNSSIrritantssoapsuds, Bisacodyl/ FleetLubricantsoilPosition: left-sidelying/ dorsal recumbentEnema tube – lubricate first; insert in rotating motionInfant1 – 1.5 inchesChild2 – 3 inchesAdult3 – 4 inchesCramping:Lower the solutionClamp and wait for 30 seconds***RestartTemperature: 100oF (37.7oC)EPIGLOTTITISTripod position***Always an emergency situationEssential equipment for epiglottitis: tracheostomyE.S.S.R. ? feeding method of patients with cleft lip and cleft palateE – nlarge the nipple holeS – timulate the suckingS – wallowR – estEXERCISES, typesCHARACTERISTICSISOTONICISOMETRICISOKINETICOTHER NAMEDynamicStatic/SettingResistiveJOINT MOVEMENTxCONTRACTIONBENEFITS on MUSCLESIncrease strengthIncrease toneIncrease massJoint flexibilityIncrease strengthIncrease enduranceIncrease heart rate and cardiac outputIncrease strengthIncrease sizeIncrease blood pressure and blood flow to musclesEXAMPLESUse of trapezeWalkingSwimmingCyclingRunningQuadricep settingSqueezing on stress ballKegel’sMay be isometric or isotonic with resistanceWeight-liftingEYES: OTITIS MEDIA (ear problem)Causes:Propping the bottlePassive smoking ***Frequent tonsillitisS/Sx:Otalgia – ear painOtorrhreaManagement:Myringotomy with tympanostomy tubeFirst line of drug: AmpicillinSecond line of drug: CotrimoxazoleEYES: CATARACTS/sx:Absent red eye reflexBlurring of visionClouding of lens – from inner to outerManagement: SURGERY ONLY***EYES: BLIND PATIENT 20/ 200POSITION of the Nurse: Nurse walk one step ahead of the patientNever rearrange things (familiarization of environment)***EYES: GLAUCOMAS/sx: Tunnel vision/ PERMANENT peripheral vision loss (“I can’t see the person besides me.”)***Eye painHalo lights***Eye meds for lifeNO need for water restrictionAVOID: Midriatics (dilation)EYES: POST-SURGERYPatch AFFECTED eyeNight shield at NIGHTAVOID: Coughingsneezing, lifting more than 5 5lbsbending (from waist), prolonged watching or reading after surgeryALLOW: bending (from knees)sneezing (mouth open)NORMAL:mild to moderate eye painABNORMAL:Severe eye pain – infection/ hemorrhageFECALC-olor -----------brown/yellow – stercobilinO-dor------------aromaticC-onsistensy-----------solid-semi-formed moistA-mount ----------------100-400g/dayS-hape------------------cylindricalFOODS rich in IRONLiverGreen leafy vegetablesDried fruitsScallops, shrimpsOyster, clamsmolassesGeriatric client, hearing impairmentSpeak infrontTalk slowlyAVOID mounting (lip exaggeration)AVOID: high pitched voice (shouting)Geriatric client, poor vision Blind patient: 20/ 200Stimulating color: red, orange and yellowNurse walk one step ahead of the patientGTPALMG – Gravida refers to the number of pregnancies regardless of outcomeP – Pararefers 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 deliveredT – Term deliveriesnumber of TERM births (infants born after 37 weeks and above)P – Preterm deliveries number of PRETERM births (infants born between 20 to 37 weeks) A – Abortionsnumber of pregnancies that end in spontaneous or therapeutic abortion prior toage of viability (20 weeks)L – Livenumber of children currently aliveM – Multiple gestations and births (not the number of neonates delivered)GUILLIAN BARRE SYNDROMEacquired inflammatory disease (12 cranial and 31peripheral nerves)Bilateral, Symmetrical, PolyneuritisMANIFESTATIONS:Clumsiness - 1st signASCENDING PARALYSIS: progressive, bilateralDysphagia, Dysarthria, DyspneaSensory findings: paresthesia, burning pain, numbness COMPLICATION: respiratory failureMANAGEMENT: SymptomaticSteroidSAFETY: Side railsSelf-limitingHEARING LOSSSeverity of hearing lossLOSS IN DECIBELSINTERPRETATION0–15 Normal hearing>15–25 Slight hearing loss>25–40 Mild hearing loss>40–55 Moderate hearing loss>55–70 Moderate to severe hearing loss>70–90 Severe hearing loss>90 Profound hearing lossHEPATIC ENCEPHALOPATHYS/Sx:Altered LOC changes: memory loss, confusion to comaASTERIXIS – flapping tremor DRUGS: lactulose (NH3 binding effect)neomycin sulfate (Mycifradin) – inhibits action of intestinal bacteria (that produces ammonia)Diet: decrease protein (to reduce ammonia)HEPATITISHepatitis A and E – fecal-oral (contaminated food and drink)Hepatitis B, C and D – blood (needle stick, sex)HOSPITAL EMERGENCY COLOR CODINGCode blue – cardiac arrest, medical emergencyCode pink – infant abductionCode red – hospital fireCode yellow – bomb threatCode silver – person with weapon (combative)HOSPITAL TANKS COLOR CODINGNitrous oxide (laughing gas)BlueOxygenGreenCyclospropaneOrangeNitrogenBlackCarbon dioxideGreyHeliumBrownMedical airYellowHYPERKALEMIA, managementG – lucose (D50)I – nsulinC – calcium replacement (to force potassium back in the IC compartment)K – ayexalate (retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea.)S – odium bicarbonate+DIALYSISDIURETICSHYPOTHYROIDISM AND HYPERTHYROIDISMHYPOTHYROIDISM (myxedema, Hashimoto, cretinism: children)HYPERTHYROIDISM (Grave’s disease, Parry’s disease, Basedow’s disorder, Toxic diffuse goiter, Thyrotoxicosois)MAIN PROBLEMDecrease T3 – decrease BMR, wt. GainDecrease T4 – decrease body heat production, catabolismDecrease Thyrocalcitonin – increased serum calcium Increase T3 – increase BMR, increase VSIncrease T4 – increased body heat productionIncrease Thyrocalcitonin – decreased serum calciumS/SXDecrease GI motility (constipation)Decrease Appetite ? increased lypolysis ? atherosclerosis ? MIDecrease VS (Cold intolerance, bradycardia, hypothermia ? most fatal)Decrease Energy (fatigue, lethargy, hypoactive)Decrease MEtabolic rateDecrease SKIN moist (dry, brittle/ coarse hair/ skin)Increase weight (fluid retention, edema)Increase menstruation (menorrhagia)Increase GI motility (diarrhea)Increase AppetiteIncrease VS (Heat intolerance, tachycardia)Increase Energy (Restlessness, nervousness, tremors insomnia)Increase MEtabolic rateIncrease SKIN moist (diaphoresis)Decrease weight (tissue wasting)Decrease menstruation (amenorrhea)ExopthalmusMNGTDIET: Low calorie, High fiberIncrease fluid intake/ IVF (constipation) or decrease fluids (edema)High CHON, Low CHO, Low FATSSkin careWarm environmentDIET: High calorie, Low fiberIncrease fluidsHigh CHON, High CHO, High FATSSkin careCool environmentSx: SUBTOTAL THYROIDECTOMYDRUGSLifetime thyroid hormone (Levothyroxine (Synthroid))SE: insomniaAtrophine SO4, isopreterenol (bradycardia)Diuretics (edema)Stool softeners/ laxatives (constipation)NOTE: never give SEDATIVES, narcotics, other CNS depressantsRadioactive iodine (131I) therapyAnti-thyroid agents (Thionamides): Propylthiouracil (PTU), Methimazole (Tapazole) SE: agranulocytosisBeta blockers: Propranolol (Inderal)IODIDES:KISS: Potassium Iodide Saturated solution (lugols solution)Steroids: DexamethasoneCOMPLICATIONMYXEDEMA COMAHypothermiaAltered LOC leading to comaBradycardiaTHYROTOXIC CRISIS (THYROID STORM)FeverAgitationTachycardiaHYPOPARATHYROIDISM AND HYPERPARATHYROIDISMHYPOPARATHYROIDISM HYPERPARATHYROIDISMMAIN PROBLEMDecrease CalciumIncreased Phosphate Increase CalciumDecreased PhosphateS/SXTetany (Chvostek and Trousseau)LaryngospasmParesthesiaBone pain/ fractureRenal colicAnorexia, nausea and vomitingDIETHigh calcium dietLow phosphate dietLow calcium dietHigh phosphate dietDRUGSCalcium gluconateAlOH (Amphogel)CalcitoninFurosemideVitamin DCOMPLICATIONSeizureRenal stonesFOODS high in CALCIUM:OrangeSpinachMilkYogurtAluminum hydroxide (Amphogel), given in HYPOparathyroidismAntacid but the side effect is phosphate binderFurosemide (Lasix), given in HYPERparathyroidismDiuretic that eliminates calcium as well as sodium and potassium in urineINCREASED INTRACRANIAL PRESSURECushing’s symptoms:Increased BP and MAPDecreased RR and PRWide pulse pressurePosition: high-fowlers positionDRUGS: mannitol, steroidsAVOID:Straining/ constipationLifting heavy objectsINFORMED CONSENT, purposeTo ensure the client’s understanding of the nature of the surgeryTo indicate the client’s decisionTo protect the client against unauthorized procedureTo protect the surgeon and hospital against legal actionINFORMED CONSENT, circumstances requiring an informed consentR – adiation or cobalt therapyA – nesthesia useB – lood administrationI – nvasive procedureE – ntrance into a body cavityS - urgical procedure using scalpel, scissors, suture (Invasive procedures)INFORMED CONSENTRequisites for validity of informed consentLegal ageMentally capacitatedSecured within 24 hours before the surgerySecured before pre-op medication administrationWritten permissionSignatureWitness – nurse, physicianFor minors (under 18), unconscious, psychologically incapacitated ? permission from responsible family memberFor 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 lifeExperts agree that it is an emergencyClient is unable to consentA legally authorized person cannot be reachedSurgery without consent-- BATTERY!ISOLATION PRECAUTIONTier 1: Standard Precautionto all blood and body fluids except for sweatto all clients regardless of diagnosishand washing and PPE (clean)Tier 2: Transmission-based precautionAirborne> 3 feetDroplet nuclei < 5 micronsN95MeaslesTBVaricella (chickenpox)Droplet< 3 feetDroplet nuclei > 5 micronsMaskMeningitis, mumosPertussis, pneumoniaGerman measles, GABHS (Scarlet fever, pharyngitis)DiptheriaContactSkinGlovesgownMRSA (Staph)ImpetigoScabiesHerpes SimplexHepatitis ADiarrheaImmunocompromised – firstInfectious - lastIV THERAPY, typesHYPOTONICISOTONICHYPERTONICCharacteristicsSolute < solventSolute = solventO pressure of solutionSolute > solventFluid movementfrom Intravascular TO cellsNo movementFrom Intracellular TO IntravascularEffect to the cellSwellexpand the intravascular compartmentshrink/ crenationIndicationsDehydrated patientsHypovolemiaBurns (resuscitative stage)EdemaExamplesDistilled water 0.45% NSS0.33% NSS2.5% dextroseD5WLRNSSD5 0.225% NSSD10WD50WD5NSS5% dextrose in 0.45%D5LRTPNDialysatecontraindicated for clients with increased intracranial pressure, clients at risk of 3rd space fluid shiftAvoid D5W if the client is at risk of increased intracranial pressure (ICP)Use LR for BURNSEXAMPLES:D5W/ D10W/ D50W – redNSS – greenD5NSS – yellowD5LR – pinkPlain LR – blue0.45 NSS – sky blueD5NM – orangeIV THERAPY, complicationsCirculatory overloadDyspnea, increased BPSOB, cracklesslow downAir embolismDyspnea, decreased BPDiscontinueLeft sidelying and trendelenburgPhlebitisSwelling + HeatDiscontinueColdElevateRestartPyrogenic reactionFever, chillsDiscontinueRetain IV equipment for C&SInfiltrationSwelling + CoolDiscontinueWarm/ Moist heat (due to edema)ElevateRestart (another site)L.A.S.E.R.L – ightA – mplification byS – timulatedE – mission ofR – adiationTYPESCarbon dioxide – gas (clear goggles)ND:YAG – Neodymium: Yttrium Alluminum garnet) – bright lamp (green goggles)Argon – gas (orange goggles)HAZARDSEyes ? gogglesSkin ? gown and glovesLungs ? maskLATEX ALLERGYFOODS:AvocadoBananasChestnutsKiwi fruitsGrapesPineapplePotatoesPassion fruitsTropical fruits (mango)StrawberrySoy beansCatheters, rubbers, condom, balloonsContraindicated with spina bifida patientsAssess for signs and symptoms: STRIDOR (best option) – harsh, high pitch sound caused by air passing through constricted air passagesUrticariaWheezingWatery eyesNon latex gloves ? vinyl glovesNon latex balloon ? mylarLEVEL OF CONSCIOUSNESSGLASGOW COMA SCALEGLASGOW COMA SCALEEYE OPENINGVERBAL RESPONSEMOTOR RESPONSE4 – Spontaneous3 – To verbal command2 – To pain1 – No response5 – Oriented, converses4 – Disoriented, converses3 – Uses inappropriate words2 – Makes incomprehensible sounds1 – No response6 – To verbal command5 – To localized pain4 – Withdraws3 – Flexes abnormally (Decorticate)2 – Extends abnormally (Decerebrate)1 – No response7 and below - in a comatose state3 – lowest score15 – highest scoreA.V.P.U. (for Pediatric client)A – Alert and AwakeV – Verbal response to stimuliP – Pain response in stimuliU – UnresponsiveLevel I (conscious) – 3 C’s: conscious, cognitive, coherentLevel II (lethargic) – drowsy, sleepy, obtunded, confusedLevel III (stuporous) – responds to strong stimuli onlyLevel IV (coma) – unresponsive; absent protective reflexesLEUKEMIAIncreased immature WBCDecrease matured WBC ? risk for infectionDecrease RBC ? activity intoleranceDecreases platelets ? risk for bleedingLIVER BIOPSY BEFORE: Note blood clotting defects, prothrombin time, and platelet countDURING: exhale and hold breathAFTER: Right side-lying positionLIVER CIRRHOSISMost common type: Laennec (due to alcohol)PORTAL HYPERTENSIONPortal HPN, Increase collateral circulationCaput medusa (dilated veins over the abdomen)Hepatomegaly, SpleenomegalyHemorrhoidsAscites and edema (unable to metabolize protein)Spider angioma/ telangiectasia (dilated vein/capillaries over the face and trunk)Esophageal varices, GI bleedingLeg varicosititesLUMBAR PUNCTURE (LUMBAR TAP)PURPOSE: To withdraw CSF to determine abnormalitiesMeasures 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 bloodInject air, dye, or drugs (anesthesia) into the spinal canalAREA: Insert needle between L3 – L4 or L4 – L5 (spinal cord ends in L2)BEFORE PROCEDURE:Obtain consentEmpty bladderDURING PROCEDURE: Position of the patient: C-position (flex the shoulders, not the head)Position of the nurse: infront of the patientPosition of the doctor: at the back of the patientAFTER PROCEDURE: prevent spinal headachePosition: flat for 6-12 hours (to prevent spinal headache)Force fluids (to maintain pressure and prevent spinal headache)Blood patchinglabel specimenMAGNETIC RESONANCE IMAGING (MRI)/ NUCLEAR MAGNETIC RESONANCE (NMR)Uses radio wavesBEFORE:remove metals: jewelry, hairpins, glasses, wigs (with metal clips), and other metallic objects.AVOID: patients with orthopedic hardwareintrauterine devicespacemakerinternal surgical clipsor other fixed metallic objects in the body (braces, retainers)BEFORE:Have client void before test.DURINGremain 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.MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) TestRoute:ID, 0.1 mL of PPD is injected INTRADERMALLY, creating a wheal or blebRead:48 to 72 hoursResult:(+) to exposure10 mm and above ? not immunocompromised5 mm and above ? immunocompromised (HIV, pedia, with history of TB, geriatric clients)0 - 4 mm= NOT SIGNIFICANTErythema without induration is NOT considered significantMEDICATIONDrug interactionAdditive effect1 + 1 = 2eg. diazepam + alcohol = increase sedationSynergism/ potentiation1 + 1 = 3eg. codeine + aspirin = intense pain reliefOHA + NSAIDs = hypoglycemia***Antagonist1 + 1 = 0eg. Coumadin + Vitamin KInterferenceincrease or decrease metabolism/ excretioneg. Probenecid decrease excretion of PenicillinMedication orderSTAT (“statim”)immediate/ onceeg. Magnesium sulfate (preeclampsia)Single order/ one timeonceeg. Anxiolytic (pre-surgery)Standing / routinecarried out indefinitely eg. antibioticsPRN (“Pro Re Nata”)no specific time of administration/ as neededeg. Pain relieversTelephone orderwithin 24 hoursSignedIndicate as Telephone OrderPut decimal numberDrug effectsTherapeutic – desiredSide effects – 2nd effect, expectedAdverse effects – severe side effect, unexpectedAllergic reaction – immunologic responseMEDICATION ORDER, componentsClients nameDate and time of orderName of drugsDose and route Time of frequencySignatureMRSA (methicillin-resistant Staphylococcus aureus)2 types of infection:Hospital-associated MRSA – happens to people in healthcare settings. Community-associated MRSA – happens to people who have close skin-to-skin contact with others, such as athletes involved in football and wrestling.Practice good hygieneKeep cuts and scrapes clean and covered with a bandage until healedAvoid:contact with other people’s wounds or bandagessharing personal items, such as towels, washcloths, razors, or clothesWash soiled sheets, towels and clothes in hot water with bleach and dry in a hot dryerMYELOSUPPRESSIONTHROMBOCYTOPENIA ? PetechiaeANEMIA ? FatigueNEUTROPENIA ? Fever and sore throatMYOCARDIAL INFARCTIONCardiac enzymesafter 1 hourMyoglobinafter 2 hourTroponinafter 4 hourCPK-MBafter 24 hourLDHECG changesPathologic Q waveST elevationT wave inversionNAEGELE’s RULEIf LMP is from APRIL TO DECEMBER, use the formula: - 03 + 07 + 01 (MM, DD, YY)If LMP is from JANUARY TO MARCH, use the formula: + 09 + 07 (MM, DD)NASOGASTRIC TUBE (NGT)TYPESLevin -single lumenSalem sump – double lumenINSERTIONMeasurement: adult (N.E.X.), pedia (N.E.M.U.X.)Position:high-fowlers and neck hyperextendedInstruction:ask to swallowPlacement:X-rayAspirate and pH testnormal gastric pH = 1 to 4 (acidic)Listen/ auscultate – after introduction of 10 – 30 ml of air (20 ml)REMOVALInstil 50 ml of airTake deep breath and hold ? pinch catheter ? withdrawMouth care and blow noseFEEDINGCheck placementPosition: sitting/ upright/ fowlersCheck for RESIDUAL CONTENT ? dont discard; above 100ml – STOPHang: 12 inches from point of insertionFlush : 50 to 100 ml of waterRemain upright – 30 minutesNEPHRITIS and NEPHROSIS (NEPHROTIC SYNDROME)NEPHROSIS(NEPHROTIC SYNDROME)NEPHRITIS(NEPHRITIC SYNDROME)Increase glomerular membrane permeabilityInflammation of the kidneysAutoimmuneGABHS1. Hypoalbuminemia2. Proteinemia3. Hyperlipidemia4. Edema (anasarca)Hematuria (gross)Edema (periorbital)HPNProteinuriaOliguria/ AnuriaIncrease BUN/ creatinineDIET: high protein, low sodium, decrease OFIAmbulateDIET: low sodium, decrease OFIBed restNormal BUN = 10 – 20Normal creatinine 0.4 – 1.2NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST)NSTCST (OCT)VariablesFM andFHRUC and FHRResultsNORMAL (Reactive/ Positive)Increase FM ?Increase FHR (acceleration)Decrease FM ? Decrease FHR (deceleration)NORMAL (Non-reactive/ Negative)Increase UC ? Decrease FHR (deceleration)Decrease UC ? Increase FHR (acceleration)ABNORMAL (Nonreactive/ Negative)Increase FM ? Decrease FHR (deceleration)Decrease FM ? Increase FHR (acceleration)ABNORMAL (Reactive/ Positive)Increase UC ? Increase FHR (acceleration)Decrease UC ? Decrease FHR (deceleration)2 FHR acceleration/ 10 minutesEach acceleration increase to 15 bpm/ 15 sec.3 contraction/ 10 minutesEach contraction = 40 to 60 secondsFETAL HEART RATE DECELERATIONSCAUSEMANAGEMENTEARLYHead compressionObservationLATEUteroplacental insufficiencySide-lying positionOxygenationIncreased IV fluidsStop Oxytocin (Pitocin)Call the MDCaesarean if not correctedVARIABLECord compressionTrendelenburg/ Knee-chest/ Side-lying positionOxygenationIncreased IV fluidsStop Oxytocin (Pitocin)Call the MDCaesarean section if not correctedOBSTRUCTIVE SLEEP APNEA (OSA)OSA – is the most common type of sleep apnea syndromeCause:ObesityOld menSmokingPathophysiology: decrease diameter of the upper airwayS/Sx:InsomniaSnoringMorning headachesHypertensionEnuresisComplications:CAD, HPNCVAPremature deathMI, dysrhythmiasManagement:AVOID: sleeping in supine, alcoholLose weightOR TEAM MEMBERSSCRUBNON SCRUBSurgeonSurgical assistantScrub nurseAnesthesiologistBiomedCirculating nurseSCRUB NURSECIRCULATING NURSEPerforms complete scrubPrepares and hands out instrumentsHands instruments while maintaining sterile techniqueEnsures everybody in the scrub team practices sterile techniquePartner in OS and instrument countingAnticipates the needs of the teamPatient advocate (act in behalf of the patient); GUARDIAN OF THE PATIENT; doing something that patient can’t doGreets the client upon arrival – 1st primary responsibility of circulating nurseChecks client identificationSponge counting together with scrub nurse Monitors the urine output and blood loss together with anesthesiologistEnsures the consent form is signedDocuments the entire procedurePACEMAKER: CONTRAINDICATIONSStrong magnetic fields – MRIElectrical 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 implantPANCREATITISAcute pancreatitis can become chronic AVOID: Morphine sulfate is not used to treat pain since it can cause the sphincter of Oddi to spasm Stimulation of the pancreas: DO NOT USE enteral feedingsMANAGEMENT:Position: Side-lying ? to lessen the painMeperidine (Demerol)Pancreatic enzymes and bile salts with meals***IV fluids (to prevent shock) insulin for hyperglycemia calcium replacement decrease stimulation of pancreas NPO-TPN (nothing by mouth; total parenteral nutrition) NG tubeanticholinergicsH2-receptor antagonistsPARKINSON’s DISEASETremors (resting and pillrolling)Rigidity (cogwheel)Akinesia/ BradykinesiaMask like facePEPTIC ULCER DISEASERisk factors:H. pyloriNSAIDSIronSteroidsSmoking and alcoholStressPERICARDITIS***Pain is aggravated by:Cough***Deep inspiration (so the patient do shallow inspiration)***SwallowingLying down, turningCharacteristic of breathing pattern: shallowPosition to relieve pain: sitting and leaning forward (orthopnic)PHEOCHROMOCYTOMATumor of adrenal MEDULLAMain problem: increased production of catecholamines (epinephrine and norepinephrine)S/Sx:HPNHyperhydrosisHigh PRPOLYCYTHEMIA VERAS/Sx:***Ruddy complexion ? capillary congestion in the skin and mucous membranesSplenomegalyErythromelalgiaGeneralized pruritus (due to basophils)***HPNIncreased hematocritIncreased bilirubinIncreased liver enzymesIncreased RBCIncreased WBCIncreased platelets (immature)Complication:Thrombus formation (MI, CVA)Heart failureBleeding due to congestion and overdistention of capillaries and venulesPeptic ulcer due to increased gastric secretionsGout due to increased uric acid released by nucleoproteinManagementIncrease fluidsPhlebotomy ? removal of excess blood then DISCARD***Drugs:Radioactive phosphorus (32P) ? reduces RBC productionNitrogen mustard, busulfan, chlorambucil, cyclophosphamide ? to effect myelosuppressionAVOID: iron rich foods ? will enhance the production of RBC***PREGNANCY: DISCOMFORTS OF PREGNANCYASSESSMENTNURSING MANAGEMENTNausea and vomiting (morning sickness)Eat small frequent meals; eat dry crackers on arising;may occur any time of dayBreast sorenessWell-fitting bra, decrease caffeinated and carbonated drinksNasal stuffinessUse cool air vaporizer, increase fluid intake, place moist towel on the sinusesPtyalismUse mouthwash as needed, chew gum or suck on hard candyUrinary frequencyKegel’s exercise, decrease fluids before bed, report signs of infection, avoid caffeineConstipationIncrease fiber and fluidshave a regular bowel movementLeg CrampsIncrease calcium intakeavoid pointing your toes, dorsiflex feet, local heat applicationBackacheEmphasize posture, careful lifting, good shoes (low heeled), stoop to pick up objectsHeartburnSmall, frequent mealsavoid overeating, spicy and fatty foodsDizzinessSlow, deliberate movements, support stockings, lie on left side when at restAnkle edemaRest with your feet elevated, avoid restrictive garments on the lower half of the bodyFatigueSchedule a rest period daily, use extra pillow for comfortHemorrhoidsAvoid constipation and straining with bowel movement, take a sitz bath, apply witch hazel compressVaricose veinsWalk regularlyrest with feet elevatedavoid long periods of standing and sitting do not cross your legsPREGNANCY: Presumptive signs and symptomsFatigue – response to increased hormonal levelsUrinary frequency – caused by pressure of expanding uterus in the bladderNausea and vomiting (morning sickness)Quickening - sensations of fetal movement in the abdomen) - occurs between the 16th and 20th week after the onset of the last menses.Pigmentation of the skinMelasma gravidarum (Chloasma) – mask of pregnancyAbdominal striae (striae gravidarum) – due to stretching, rupture and atrophy of deep connective tissues of the skinLinea nigra Amenorrhea – cessation of mensesBreast changes – enlarge and become tenderPREGNANCY: Probable signs and symptomsPositive Pregnancy test/ HCG in urine or serumBallottement - sinking and rebounding of the fetusBraxton Hicks contractions - painless, palpable contractions occurring at irregular intervals, more frequently felt after 28 weeks. They usually disappear with walking or exerciseLeukorrhea - increase in vaginal dischargeUterine changes – from pear shape to spherical around 8 weeks gestation and becomes ovoid from 16 weeks until termEnlargement of abdomen - at about 12 weeks' gestation, the uterus can be felt through the abdominal wall, just above the symphysis pubisHegar's sign - lower uterine segment softens 6 to 8 weeks after the onset of the last menstrual periodChadwick's sign - bluish or purplish discoloration of cervix and vaginal wallGoodell's sign - softening of the cervix; may occur as early as 4 weeksPREGNANCY: Positive signs and symptoms – definite signs of pregnancyFetal heart tones (FHTs) - usually heard between 16th and 20th week of gestation with a fetoscope or the 10th and 12th week of gestation with a Doppler stethoscopeFetal movement felt by the examiner (after about 20 weeks gestation) Fetal body outline through the maternal abdomen in the second half of pregnancyFetal sonographical evidence (after 4 weeks' gestation) using vaginal ultrasound. Fetal cardiac motion can be detected by 6 weeks' gestationPREGNANCY: Effects of smokingCongenital heart defectsSGARespiratory distressPremature deathSIDSSTAGES OF PRESSURE ULCERSStage 1 – non-blanchable, erythema2 – epidermis and dermis involvement, shallow water blister3 – subcutaneous involvement, deeper crater 4 – muscles and bone involvement, tissue necrosisPULSE OXIMETRY/ O2 SATURATION/ CONCENTRATIONMeasures the oxygen concentration and pulseSite: finger, toes, nose, earlobe or foreheadNormal:95 to 100%70% life threateningAVOID:MovementNail polishLightPRURITUSBathe in tepid water and apply emollient lotionAVOID soaps and detergentspetroleum, mineral oilALLOWCalamineAntihistamineoatmeal bathCocoa-butterMenthol/ camphorCornstarchCool environmentProvide cool, light, nonrestrictive clothingKeep nails shortApply cool and moist compressQuality Assurance (QA) – focus upon “doing it right” A systematic process of organization-wide participation and partnership in planning and implementing improvement methods to understand and meet customer needs and expectationsemphasis is on maintaining minimum standards of caretended to be REACTIVE rather than proactiveinvolves such methods as:chart auditsreviewing incident reportsdetermining whether performance conforms to standards.Structure Evaluation – evaluating the “physical setting”Process Evaluation – evaluating “how the nursing care is rendered”Outcome Evaluation – evaluating the demonstrable changes brought by the nursing processTOTAL QUALITY MANAGEMENT (TQM) – focuses on “doing the right thing”aka Quality Improvement (QI)/ Process Improvement (PI)QI’s emphasis is upon identifying real and potential problemsparticipation and partnership in planning and implementing improvement methods to understand and meet customer needs and expectations.tends to be PROACTIVE instead of reactive.General Principles of TQM:quality is achieved through the participation of everyone in the organizationimprovement opportunities are developed by focusing upon the work processthe improvement of the quality of services is an ongoing (continuous) processdecisions to change or improve a system or process are made based on data (not majority rule)uses such methods as building quality performance into the work processmeeting the needs of the customer proactively.principle benefitsviewing every problem as a possible opportunity for improvementinvolving staff in how the work is designed and delivered (improves staff satisfaction)empowering staff to identify and implement improvement resulting in increased patient outcomesincreasing the customer’s perception that you care by designing health care processes to meet customer needs, as opposed to the health care provider’s needs.RADIATION THERAPYTELETHERAPYBRACHYTHERAPYExternalSOURCEinternalNot radioactivePATIENTRadioactiveCobalt therapy, Linear Accelerated RadiationEXAMPLESUnsealed – oral, IV ? radioactive iodine 131, Vitamin B12Sealed – implant (seeds) ? cesium, iridiumALLOWLeave markingsVitamin A and DSoap and water and pat dryAVOIDSunlightAlcoholLotion, powder, cosmeticsAdhesive tapeTight clothingS – hield: lead + Dosimeter badgeT – ime: 5 min/visit; 30 min/ shift; 1 pt/ dayD – istance: 3 feet awayAt bedside: forceps and lead containerAVOID: pregnant and childrenAratula: “Caution”SEIZURESPriority DURING: safetyPriority AFTER: airwaySeizure PrecautionP – osition: side-lyingL – oose the clothingsA – VOID: resrictionsN – ote: duration and characteristics of the seizureO – xygenate: jaw-thrustD – rugs: diazepam,phenytoin, carbamazepineR – emove harmful objects at the bedsideA – t the bedside: suction machineP – ad and raise the side railsE – liminate environmental stimuli (bright lights, noise)SCHILLING’s TESTPART 1(CONFIRMATORY)PART 2(IDENTIFICATION OF CAUSE)Vitamin B12Vitamin B12 and Intrinsic factor(+) vitamin B12 in urine ? normal(+) vitamin B12 in urine? Pernicious Anemia is stomach in origin(-) vitamin B12 in urine ? (+) Pernicious Anemia(-) vitamin B12 in urine ? Pernicious Anemia is small intestine in originSHOCK -Reduction of arterial pressure leading to decrease blood flow Types:Cardiogenic – loss of cardiac pumping action (MI, CHF)Hypovolemic – decrease blood volume (burns, bleeding/ hemorrhagic shock, dehydration) ? most commonDistributive/ CirculatoryNeurogenic (SCI, drug depressants)Vasogenic – massive vasodilationAnaphylactic – massive reaction to food, drugs and chemicalSeptic Septic – massive infectionStages:COMPENSATORYPROGRESSIVEIRREVERSIBLENormal BPIncreased RR and PRcold clammy skinoliguriahypoactive bowel soundsDecreased BPIncreased RR and PRAltered LOC Oliguriaincreased BUN and Creatininestress ulcers and increased risk for GI bleeding.metabolic acidosis (due to accumulation of lactic acid)severe organ damageCommon Symptom:***Decrease BP, MAP (Mean Arterial Pressure)Increase RR, PRNarrow Pulse PressurePosition: modified trendelenburg***In neurogenic shock, the patient is also at an increased risk for ?deep vein thrombosis.Major cause of septic shock ?gram-negative bacteriaFirst drug to be given for SHOCK ?EpinephrineSpecimen collection: STOOLDefecate 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 mLRefrigerate and labelFECAL OCCULT BLOOD TESTING (Guaiac Test)Occult = hiddenUses 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 resultNo change or any other color than blue indicates a negative result.Avoid contaminating the specimen with urine or toilet tissue.LabelAvoid specified foods and vitamin C 3 days prior to collection and specified medication 7 days prior to collection.FALSE POSITIVEFALSE NEGATIVERED MEAT (Beef, liver, and processed meats)RAW VEGETABLES or FRUITS (Particularly radishes, turnips, horseradish, and melon)MEDICATIONS (NSAIDs, IRON preparations, and ANTICOAGULANTS)VITAMIN CSpecimen collection: SPUTUMSputum – arises from the tissue of the respiratory tractSaliva – excreted by the salivary and mucus glandsBEST TIME: early morningBEFORE: Mouth careDURING: Deep breaths then cough up 15 to 30 mL (1 to 2 tablespoons).Wear gloves when collection.Ask the client to expectorate, not spitShould be cough directly into the specimen containerSpecimen collection: URINESPECIMENPURPOSECONSIDERATIONS WHEN COLLECTINGCLEAN VOIDEDFor routine examinationUsually collected by the client with minimal assistancePreferably done on the first voided specimen in the morning but it can be collected anytime if neededAt least 10 to 30 mLClean container is usedCLEAN-CATCH or MIDSTREAM URINEFor urine culturesDone when a woman has menstrual periodBEST TIME: early morning – concentrated urineSterile specimen containerPlace specimen during midstream flow.QUANTITY:30 to 50 ml – routine urinalysis5 to 10 ml – C&SCATHETERCollection of sterile specimen usually done when client’s are catheterized for other reasonsNurse aspirates from the lumen of a latex catheter or from a self-sealing port24-HOURTo determine the ability of the kidneys to concentrate urineTo determine disorders of glucose metabolismTo determine levels of specific constituentsCollection of all urine produced in 24 hoursThe first voided urine is discarded; last urine voided includedEither refrigerated or preservative is addedSPONGE COUNTING1- before opening2- before closure of a body cavity (depends on the surgery done)3- before skin closureThe SCRUB and the CIRCULATING nurses should count audibly and concurrentlySTILLBORN CHILD Management:Parents need to see, touch, wash, and dress baby Get footprints, pictures, lock of hair, ID band, name the child and use the name often. If they don’t see their baby; the parents often never face reality and stuck in the grieving process. Again, encourage to hold, rock, and cuddle their baby. Allow and encourage them to take photos of their angel.SUCTIONINGEndotrachealPosition: semi-fowlersTime: 5 to 10 seconds/ 5 minutesInterval: 20 to 30 secondsDURINGLubricate the catheter with water-soluble lubricant (2 to 3 inches)Insert during INHALATION in circular motionDO NOT insert during swallowing (it may enter the esophagus)But in NGT ? let the patient swallow to promote entrance in stomachApply suction: during withdrawalHyperoxygenate BEFORE and AFTER suctioningConscious:DBEUnconscious:ambubag, 3 to 5 times (12 – 15 LPM)SUDDEN INFANT DEATH SYNDROME (SIDS)Causes:smoking, drinking, or drug use during pregnancypoor prenatal careprematurity or low birth-weightmothers younger than 20tobacco smoke exposure following birthoverheating from excessive sleepwear and beddingstomach sleepingSUTURES (catgut) – a thread, wire, or other material used in the operation of stitching parts of the body togetherTYPES OF SUTURES:Absorbable – digested by body enzyme/ use in internal organs***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)SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)AutoimmuneS/SX:FatigueArthritisSensitivity to sunlightButterfly rashManagement:NO CUREGOAL: controlling symptomssteroidsTELEPHONE ORDEROnly RN’s may receive telephone ordersThe order should be countersigned by the physician within 24 hoursTENSILON TESTedrophonium chloride (Tensilon) IVevaluation of muscle strengthUSE: To diagnose myasthenia gravisAt bedside: resuscitation equipmentatropine sulfate on bedside for possible CHOLINERGIC CRISISneostigmine for possible MYASTHENIC CRISISResults:(+) diagnosis = improvement on muscle function after administration of drug(-) diagnosis = muscle fasciculations occur as a result of the drugTETRALOGY OF FALLOT4 Defects:Pulmonic StenosisRight Ventricular HypertrophyVentricular Septal DefectOverridding of the AortaTet spells – severe acute cyanosisPosition: Knee-chest/ Squatting***SignMachine-like murmursClubbing of fingersCyanosisManagement:Surgery: Blalock Taussig procedure ? shunting of the subclavian artery and pulmonary arteryTHORACENTESISPurpose: To remove excess fluid or air to ease breathing POSITION: sitting while leaning forward over a pillowChest X-ray identifies best insertion siteWithin the first 30 minutes, not more than 1000 mL should be removedAVOID: coughing , deep breathingAFTER: Unaffected side with head elevation of 30o for at least 30 minutesTHYROIDECTOMY: ComplicationsBleeding – Feeling of fullness at incision siteCheck soiled dressing at nape area, sandbagAccidental removal of parathyroid – Hypocalcemia – classic sign tetanyCalcium gluconate, slowly administer- to prevent arrhythmiaLaryngospasm – DOB, SOBtracheostomy at bedside, suctionAccidental damage of the laryngeal nerve – Hoarseness of voiceEncourage patient to talk post op asap to determine laryngeal nerve damageThyroid storm – Fever, Irritability, Agitation, restlessness, Tachycardiabeta blockersTOTAL PARENTERAL NUTRITION (TPN)/ PN/ IV HYPERALIMENTATIONDextrose content ? 10 to 50%Change the solution after ? 24 hoursSite: central veins (SVC) ? subclavian vein (an x-ray is done to confirm its placement)Position during insertion: trendelenburgComplication:Thrombophlebitisdue to hypertonicity of the solutionchange access siteHyperglycemiarapid infusionregulateHypoglycemiaabrupt discontinuation? hyperinsulinismdon’t stop abruptlyInfectionunsterile proceduresterile techniqueFluid overloadrapid infusionregulateAir embolismAllergyIf TPN is emptied and no doctors follow up order give ? hypertonic solutionD10W ? pediaD50W ? adultBEFORE: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 hourMonitor glucoseMonitor vital signs every 4 hoursAFTER: Monitor WBCPRIORITY NURSING DIAGNOSIS: High risk for infection Do not overcorrect flow rate if too slow or fastSTERILE technique***Transparent air-occlusive dressing***T-TUBEPURPOSE:To maintain patency***To drainTo prevent bile leakage to the peritoneumDRAINAGEColor: 1st 24 hours – reddish brownAmount: 1st 24 hours – 500 to 1000 mlNormal color of stool after removal – “brown”Draining – does not need doctors orderTRACTIONSTYPESSkin traction – impaired skin integritySkeletal traction – risk for infectionCounter traction – weight of the patientBucks – not more than 8 to 10 lbs of weight should be appliedCrutchfield tongs (skull tongs) – used to immobilize the cervical spine (indicated for unstable fractures or dislocation of the cervical spine)Crutchfield tongs/ Gardner-Wells skull tongsPOSITION: supineTRIAGE“trier”- to sortTo sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be addressed3 CATEGORIES IN TRIAGE in E.R.EMERGENTURGENTNON-URGENTColorRedYellowGreenUrgencyLife, limb, eye threateningNeeds immediate attentionNeeds treatment in 20 minutes to 2 hoursCan wait hours or daysExamplesChest pain, cardiac arrest, severe respiratory distress, chemicals in the eye, limb amputation, penetrating trauma, severe hemorrhageFever >40oC, simple fracture, abdominal pain, asthma with no respiratory distresssprain, minor laceration, rash, simple headache. Toothache, sore throat4 CATEGORIES IN TRIAGE in DISASTERIMMEDIATEDELAYEDMINIMALEXPECTANTNumber1234ColorRedYellow Green BlackExamplesChest wounds, shock, open fractures, 2-3 burnsStable abdominal wound, eye and CNS injuriesMinor burns, minor fractures, minor bleedingUnresponsive, high spinal cord injuryTUNNING FORK TESTWEBER’S TEST – To test for bone conduction by examining lateralization of sound.Hold and place the base of the tunning fork on top of the client’s 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 disturbanceRINNE 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 client’s 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 child’s 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.VENOUS DISORDERSManagement:Elevate legsExercise legsEarly ambulationElastic stockingsVITAL SIGNSBLOOD PRESSURESystolic – contraction – depolarizationDiastolic – relaxation – repolarizationDETERMINANTS OF BLOOD PRESSUREPumping action of the heart(strong pumping – BP increases; weak pumping – BP decreases)Peripheral vascular resistance(increased vasoconstriction – BP increases)Blood volume(BV decreases – BP decreases; BV increases – BP increases)Blood viscosity(blood highly viscous – BP increases)ASSESSING BLOOD PRESSUREThe cuff should wrap (A) 40% of the arm length and (B)80% should encircle the adult’s arm (arm circumference)/ 100% of the child’s armThe 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 monthsAllow 30 minutes for resting if the client has exercise, smoking or ingested caffeineRead lower meniscus of the mercury to prevent error of parallaxerror of parallax – if the eye level is higher than the level of lower meniscus144081523495A 40%B 80%BP in THIGH***1- Position the patient (prone/ supine with knees flexed)2- Expose the thigh3- palpate the pulse4- wrap the BP cuffCommon mistakesFALSE-LOWFALSE-HIGHBladder of cuff too wideBladder of cuff narrowArm above heart levelArm below heart levelDeflating cuff too slowlyInflating too slowlySmoking, caffeine and exercise for the last 30 minutesKOROTKOFF PHASESPhase 1 – a sharp thump ? determines the systolePhase 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 diastoleegBP – 104/100/90 (Phases I/ IV/ V)TEMPERATUREORAL – accessible and convenientS – Smoking*N – NewbornO – Oral surgeryU – Ulceration/injury to the mouthT – Tremors/convulsionsH – Hot/cold foods & fluids just ingested ? wait for 15 to 30 minutes before taking temperatureAXILLARY – Safe and non-invasiveA – Axillary injuryX – eXercise/activityI – Inadequate circulationL – Laging basa (moist pits)A – After bathingRECTAL – Reliable measurement (Inconvenient and more unpleasant)R – Rectal disease/diarrheaI – ImmunosuppressedC – Clotting disordersT – Turning to the side is difficultH – HemorrhoidsU – Undergone rectal surgeryM – Myocardial infarctionTYMPANIC – Readily accessible, reflects the core temperature, very fast 9 Risk of injuring the membrane)E – Evident cerumenA – An ear infection is presentR – Reading may vary between left and right measurementPULSE – 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 pulse7 years old and above – located at the 5th ICS LMCLbelow 7 years old – located at the 4th ICS LMCLPULSE SITESInfants, palpable: brachial and femoralAllens test: radialCPR, infants: brachialCPR, adults:carotidRESPIRATIONS – The act of breathing.2 Types of breathingCostal – thoracicDiaphragmatic – AbdominalFirst to take BEFORE invasive proceduresPhysiologic apneaCDRATE – Eupnea (breathing that is normal in rate and depth), bradypnea (abnormally slow), tachypnea (abnormally fast), and apnea (absence of breathing).APNEAEUPNEABRADYPNEATACHYPNEAEFHIDEPTH – Hyperventilation (rapid and deep breaths), hypoventilation (very shallow respirations), and Kussmaul’s breathing (hyperventilation associated with metabolic acidosis).HYPERVENTILATIONHYPOVENTILATIONRHYTHM – Cheyne-Stokes breathing (regular rhythm from very deep to very shallow respirations then temporary apnea) and Biot’s respiration (shallow breaths interrupted by apnea).CHEYNE-STOKESBIOT’SURINARY CATHETERIZATION: TYPESTYPESStraight CatheterIndwelling Catheter (Foley or Retention catheter) NO. OF LUMENSSINGLE: only for drainageDOUBLE: urine drainagefor inflation of balloon (serves as an anchor)ORTRIPLE: urine drainagefor inflation of balloon (serves as an anchor)for continuous irrigationPURPOSEInserted only as much times as it takes to drain the bladder or obtain a urine specimenInserted and stays connected to the bladder for a long timeSPECIAL CONISDERATIONSCoude catheter is a variation of straight catheter which has a curved and tapered tip, usually used for male patients with prostatic hypertrophySecure catheter tubing: male - upper thigh or abdomenFemale - inner thighNO TUB BATHS, shower is preferableCollection bag should always be below bladderPosition during procedure: FEMALE – Dorsal Recumbent MALE – SupineLubricate catheterCatheter accidentally slips into vagina: leave the catheter in vagina, get new catheter and insert to urethra then remove the catheter from vaginaIncreases susceptibility to infectionURINE ELIMINATIONColor – amber/straw, transplant Order – aromatic pH – 4.5 to 8Amount – 1200-1500 ml/day (30-60 ml/hr)Sp.gr – 1.010-10.25PREVENTING UTI W – ash before and after sexO – n time voiding M – ake us of cotton undergarment A – lways wipe from anterior to posteriorN – o sprays, harsh soaps, powder. ................
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