FUNDAMENTALS OF NURSING result and not sexually

Levels of prevention active

1. Primary f. Digital rectal examination
-Target: Healthy clients (DRE)- Screening for
-Goal: Health promotion (e.g. prostate cancer
diet, exercise, hygiene) and -40 years old and above
health protection (e.g. (yearly)
immunization, safety measures) -Position: Knee-chest,
2. Secondary dorsal recumbent, sims’
-Target: High risk lateral
-Early detection (screening) to g. Prostate specific antigen
provide early prompt treatment (PSA)- Prostate cancer
(e.g. prophylaxis) screening
a. Breast self examination -40 years old and above
(BSE)- 20 years old (every (yearly)
month) -Normal values: 0-4 ng/dL
-7 days post menstruation h. Carcino embryonic antigen
-Malignant- Fixed, non- (CEA)- Colorectal cancer
mobile, non-tender, screening
irregular-shaped -50 years old and above
b. Health worker breast (yearly)
examination/ clinical -Normal values:
breast examination ● Smokers: 0-5 ng/dL
(HWBE/CBE)- 20 to 39 years ● Non-smokers: 0-2.5
old (every 3 years) ng/dL
-40 and above (yearly) 3. Tertiary
c. Mammography- Baseline: 35 -Target: Post-treatment
to 39 years old (once) -Goals:
-40 and above (yearly) a. Restoration
-Discomfort during b. Rehabilitation
compression c. Comfort
-No chemicals during d. Support
mammogram (e.g. lotion) Medical records
-Wash breast with plain -Rightful owner:
water before mammogram Institution/hospital
d. Testicular self -Access to client’s record:
examination (TSE)- 12 to Client, health care team,
15 years old- High risk medical students and graduates
for cancer -Purpose:
-Same day every month 1. Research
after a warm bath 2. Education
e. Papanicolaou smear- 18 3. Auditing- For quality
years old and above assurance
-Yearly if sexually active 4. Legal document
and 40 years old and above 5. Communication
-Every 3 years if 3 6. Planning
consecutive negative 7. Reimbursement
-Types:
1. Source oriented medical h. Radiating- Extension of
record (SOMR)- Each person or pain
department make notations in -Pain assessment:
separate sections of the chart a. Provoked/precipitating
(narrative) factor- Activity
-Traditional type b. Quality
-Easily located c. Region/radiation- Location
2. Problem-oriented medical d. Severity- Pain scale
record (POMR)- Data are e. Time- Onset, duration,
arranged according to problems interval
a. Database- Info -Pain management
b. Problem list (pharmacologic):
c. Progress notes a. Opioids- CNS depressant
d. Plan of care ● Full agonist-
3. Focus charting (FDAR) Morphine, meperidine
a. Focus- Condition (dx, (prolong use may
s/sx) cause seizure),
b. Data- Subjective/objective oxycodone, fentanyl
c. Action- Intervention ● Mixed agonist-
d. Response- Evaluation Nalbuphine
4. Charting by exception (CBE)- hydrochloride
Documentation system in which (nubain)
only abnormal or significant -Side effects: Nausea,
findings or exceptions to norms drowsiness, constipation
are recorded (most common), urinary
-Eliminates lenghty charting retention, pruritus (most
5. Electronic health record common SE in elderly)
(EHR)- Are used to manage the b. Non-opioids/NSAIDS-
huge volume of information Acetaminophen, aspirin
required in contemporary health -Side effect: GI
care irritation, heartburn
-Computerized documentation c. Coanalgesic/adjurant- Have
Pain properties that may reduce
-Unpleasant experience pain alone or in
-Subjective combination with other
-Types: analgesics, relieve other
a. Cutaneous- Skin discomforts, potentiate
b. Somatic- Muscles/joints the effect of pain
c. Visceral- Organs medications, or reduce the
d. Phantom- Missing organ side effects of pain
e. Intractable- Without medications
relief -Antidepressants,
f. Psychogenic- Pain without anxiolytic,
physiologic basis anticonvulsants,
g. Referred- Pain is not felt antispasmodic
at the site of injury or -3 step ladder (WHO)
damage
 ● Stress
● Stimulants (e.g.
synthroid)
-Management:
● Warm bath
● Warm milk
● Sleep diary
● Bedtime rituals
● Exercise
Sleep ● Avoid bedtime snacks
-Physiologic need ● Environment (light,
-It is a universal biologic temp, sound)
process common to all people b. Sleep apnea- Loud snoring
-Altered state of consciousness ● Obstructive- Presence
-Biologic rhythms- Circadian of nasal polyps,
rhythms enlarged tonsils,
-Types: obesity
a. Non rapid eye movement ● Central- Unknown cause
(NREM)- 75 to 80% c. Hypersomnia- Excessive
b. Rapid eye movement (REM)- sleepiness
every 90 minutes d. Narcolepsy- Sudden attacks
-Stages of sleep: of sleep
a. NREM I (very light sleep)- e. Parasomnias- Disruptive
Drowsy and relaxed, eyes sleep-related disorders
roll from side to side, -Unknown cause
awakened easily, decrease in ● Bruxism- Clenching of
HR and RR (slight) teeth
b. NREM II (light sleep)- 10 to ● Emuresis- Bed wetting
15 minutes ● Periodic limb
-Decrease HR, RR, and temp., movement/restless leg
intense stimulus, eyes still syndrome (PLM/RLS)
c. NREM III (delta sleep)- ● Sleeptalking/sleepwalk
Snoring ing
-Difficulty to awaken, ● Sleep paralysis
diminished reflexes, Oxygenation
decrease in HR, RR, temp. -Colorless, odorless, tasteless
(lowest) Safety measures:
d. REM- Every 90 minutes 1. “No smoking” signs on door,
-Increase acetylcholine and tank, and bed
dopamine 2. Avoid electrical equipment near
-5 to 6 times per 8 hours oxygen tank
-Increase GI secretions 3. Avoid battery operated
-Sleep cycle: NREM I&II (20 to 30 equipment near oxygen tank
minutes)→ NREM III (30 minutes)→ 4. Avoid woolen clothing near
NREM II (20 to 30 minutes)→ REM oxygen tank
5. Avoid rebonded hair near oxygen
(10 to 15 minutes)
-Sleep disorders: tank
a. Insomnia- Difficulty in 6. Fire extinguisher
falling/maintaining sleep -Oxygen delivery system:
-Chronic- More than 30 days a. Nasal cannula- 24-44% at a
-Risk factors: rate of 2-6 LPM
● Female (hormone) -Convenient
● Aging
 -For pt with chronic airway -Time: 5 to 10 seconds (10 max)
limitation (emphysema, -Interval: 2 to 3 minutes
chronic bronchitis) Incentive spirometer
b. Simple face mask- 40-60% at -Sustained maximum inhalation
a rate of 5-8 LPM device
c. Partial rebreather mask- 60 -For post-op patients, to prevent
to 90% at a rate of 6-10 LPM pulmonary complications
-Mixed inspired and expired -Measure the flow of air inhaled
gas through the mouthpiece
d. Non-rebreather mask- 95 to -Position: Upright
100% at a rate of 10-15 LPM -Steps:
-One-way valve 1. Seal the lips
e. Venturi- 25-50% at a rate of 2. Inhale slowly and hold breath
4-10 LPM for 2 to 6 seconds
-Most accurate 3. Exhale normally
-For pt with chronic airway Tracheostomy
limitation (emphysema, -Opening into the trachea through
chronic bronchitis) the neck, a tube is inserted and
Suctioning artificial airway is created
-Is the aspiration of secretions -Equipment:
through a catheter connected to a 1. Obturator
suction machine or wall suction 2. Inner cannula- Soak with half-
outlet stength hydrogen peroxide, rinse
-Sterile technique with NSS
-Complications: 3. Outer cannula
1. Hypoxia- Most common 4. Tracheostomy ties- Secures
2. Trauma- Do not apply suction outer cannula
during insertion, check for nicks 5. Tracheostomy cuff- Provides air
-Hyperoxygenate before suctioning tight seal to prevent aspiration
(BVM- 3 hyperinflation, O2 tank- Chest drainage (CTT)
10 to 15 LPM for 1 min, mechanical -Inserted into pleural cavity to
ventilator- 100% FiO2 for 2 min) restore negative pressure (lung
-Routes: re-expansion)
1. Oropharyngeal- Position: Semi- -Indications: Pneumothorax,
fowler’s, head placed on side to hemothorax, pleural
facilitate drainage, if effusion/hydrothorax
unconscious, lateral or side-lying Postural drainage
-Length: Tip of nose to ear lobe -A technique in which different
(4 to 6 inches/10 to 15 cm) positions are assumed to
-Time: 5 to 10 seconds (15 facilitate the drainage of
maximum) secretions from the bronchial
-Interval: 20 to 30 seconds airways
2. Nasopharyngeal- Position: Semi -Always elevate the affected side
fowler’s, hyperextension Aspiration procedures
-Length: Tip of nose to ear lobe 1. Paracentesis- Peritoneal cavity
(4 to 6 inches/10 to 15 cm) (max: 1.5 L)
-Time: 5 to 10 seconds (15 max) -Nursing responsibilities:
-Interval: 20 to 30 seconds a. Pre-test: Empty bladder
3. Endotracheal tube/tracheostomy b. Intra-test:
tube (ET/TT)- Position: Semi- Sitting/upright/supine
fowler’s (unconscious)
-Length: Until point of c. Post-test:
resistance, withdraw 1 inch ● Position of comfort
 ● Pressure dressing b. Remove dentures
● VS every 15 c. Meds:
● Measure abdominal ● Lidocaine spray- To
girth numb the oral cavity
2. Thoracentesis- Pleural space of the pt
(max: 1 L) ● Anxiolytics
-Nursing responsibilities: ● Cholinergic
a. Pre-test: Void -Post:
b. Intra-test: Sitting a. VS especially RR
(lean)/lateral (unaffected) Colostomy
c. Post-test: -Types:
● Lateral (unaffected) 1. Ascending colostomy- Watery
● Pressure dressing stool
● VS every 15 minutes 2. Transverse colostomy- Mushy
● Assess breathing stool
3. Lumbar puncture- Cerebrospinal 3. Descending colostomy- Semi-
fluid formed
-Nursing responsibilities: 4. Sigmoid colostomy- Well-formed
a. Pre-test: Void -Normal characteristics:
b. Intra-test: Lateral 1. Pink-red “beefy red”
recumbent 2. Slight moist
c. Post-test: 3. Slight protrusion
● Dorsal recumbent for 4. Painless
12 hours -Diet: Close to normal diet,
Biopsy procedures avoid gas forming food (gum,
1. Liver biopsy- Position: Supine/ alcohol, smoking)
left side lying, post: R side -Recommended food: Yogurt,
lying with sandbags parsley, crackers
-Post: NPO for 4 hours, bedrest -Colostomy irrigation: Cleanse,
for atleast 24 hours, no lifting regulate, stimulate peristalsis
of heavy objects for 1 to 2 weeks (primary purpose)
2. Renal biopsy- Position: Prone, 1. Solution: Lukewarm tap water
post: supine with sandbags (500 to 1,000 ml)
-Post: NPO for 4 hours, bedrest 2. Height: 12 to 18 inches above
for atleast 24 hours, no lifting stoma
of heavy objects for 1 to 2 weeks 3. Depth: 2 to 4 inches
Scope procedures
1. Lower endoscopy- Colonoscopy,
sigmoidoscopy, proctoscopy,
anoscopy
-Pre:
a. Low fiber diet 3 days prior
to procedure
b. Clear liquid 1 day prior
c. Night before procedure-
Laxatives, NPO
d. Morning before procedure-
Cleansing enema
-Post: Monitor for bloody stool
2. Upper endoscopy-
Esophagogastroduodenoscopy
-Pre:
a. NPO for 6 to 8 hours