FUNDAMENTALS OF NURSING PRACTICE

o >35 hyperactive bowel sounds

Nursing Process o <5- hypoactive bowel sounds
→ Assessment o No sounds for 5 minutes of auscultation-
→ Diagnosis absent bowel sounds
→ Planning
→ Implementation Two Types of Data
→ Evaluation → Subjective
Practice Questions • Symptoms are subjective—described by the
1. When developing a nursing care plan for a client with a patient
fractured right tibia, the nurse includes in the plan of care o Tinnitus
independent nursing interventions, including: o Vertigo
A. Apply cold packs to the tibia.- dependent
o Pain
B. Elevate the leg 5 inches above the heart.
C. Perform range of motion exercises to the right leg
→ Objective
every 4 hours.- patient is fractured (x) ROM • Signs are objective—can be measured or observed
D. Administer aspirin 325 mg. every 4 hours as o Edema
needed.- dependent o Blood pressure

2. When making an occupied bed, it is important for the nurse Two Sources of Data
to: → Primary- patient
A. Keep the bed in the low position- will hurt the nurse’s → Secondary- charts, members of the healthcare team,
back
family, laboratories—ALL except for the patient
B. Use a bath blanket or top sheet for warmth and
privacy- should still have privacy
C. Constantly keep side rails raised on both sides- only The nurse palpates edema on the client’s leg—secondary-
one siderail should be up, opposite side of the nurse objective (secondary- the nurse palpated, objective- edema)
D. Move back and forth from one side to the other when
adjusting the linens- finish one side, before going to The patient complains of difficulty in swallowing—primary-
the other subjective

3. Which statement reflects appropriate documentation in the Nursing Diagnosis

medical record of a hospitalized client? → Interpretation of data
A. "Small pressure ulcer noted on left leg."- not specific
B. "Client seems to be mad at the physician."- Types of Nursing Diagnosis
subjective 1. Actual
C. "Client had a good day."- subjective
• The problem is already existing upon assessment
D. "Client's skin is moist and cool."
of the patient
4. Lino, a nurse taking care of an adult client with constipation, 2. Risk
in performing a high cleansing enema, Lino must keep in mind • Problem is nonexistent yet but problem is
that the maximum height is: (N: 12-18 inches) anticipated
A. 18 inches above the bed • Starts with the word “risk”
B. 16 inches above the rectum 3. Possible/ potential
C. 18 inches above the rectum- should be from the • Problem is unclear or the etiology is unknown
point of insertion
• Starts with the word “potential”
D. D. 16 inches above the bed
4. Syndrome
5. Which of the following is the best example of an accurate • A cluster/ group of symptoms
report? • If there are more than one symptom presented
A. The wound drained a large amount of serous 5. Wellness
drainage- not specific • Used when patient is ready for discharge or ready
B. The client acts as though he has had little to start rehabilitation
discomfort- discomfort should not be used, be • Starts with “readiness for…”
specific
A patient with esophageal cancer is admitted to the hospital
C. Bowel sounds were auscultated on the right
with complaints of fever, fatigue, dysphagia, and weight loss.
upper quadrant
What is your priority nursing diagnosis?
D. The client appeared to have discomfort while
A. Risk for injury
ambulating
B. Altered nutrition
C. Ineffective airway clearance
Assessment D. Activity intolerance
→ The role of the nurse is collection of data
• Physical examination- most accurate Priority nursing diagnosis in patients with colostomy?
o IPPA, except for abdominal assessment A. Risk for infection
• Interview B. Fluid and electrolyte imbalance
C. Impaired skin integrity
• Observation
D. Body image disturbance

Abdominal Assessment If (+) precedence in the statement, choose the answer related
→ IAPePa (abdominal assessment) to the statement
• Auscultation first to not distort bowel sounds How to answer prioritization of nursing diagnosis? (RAM)
• Best position- dorsal → Make sure that the option is related to the question
recumbent (done to → Actual problems are priority over risk because the
relax the abdominal problem is already present
muscles) → Maslow’s hierarchy will be used
• Sequence- RLQ→ RUQ→ LUQ→ LLQ (except if
(+) symptomatic or painful quadrant, examine it Planning
last) → Goal- setting phase
o Appendicitis- RLQ → Short-term goal- within a week, within the hospital
o Pancreatitis- LUQ setting
o Cholecystitis- RUQ → Long-term goal- more than a week, already outside the
• Normal bowel sounds- 5-30 or 35/ minute hospital
→ If time and place is conflicting, follow the time because Specimen Collection
it is a more accurate measurement 1. Urine
→ If no time is mentioned in the situation, base it in the 2. Stool
statement in the question e.g., “the patient can already 3. Sputum
cook”→ already outside the hospital Blood samples are taken by the medical technologists
→ Best time to collect any of these samples are early in
Implementation/ Intervention the morning specifically 6:00 AM
→ Three types → Clean gloves are needed even for sterile cultures
• Independent- the nurse initiates the actions
o Turning of the patient Urine
• Dependent- the physician initiates the actions, 1. Routine urinalysis (UA)
needs orders • Random urine sample
o Administration of all medications • Clean containers are only used
o All heat and cold applications • Collect at least 10 cc
• Interdependent- (+) collaboration between the • Normal characteristics of urine are checked
members of the healthcare team • Color- clear, straw, amber
o Consultation with the dietician • Odor- aromatic, (+) distinct smell
• pH- 4.5- 8.0
Evaluation o Maintained slightly acidic
→ Response of the patient to the nursing process o Prevents UTI (more prone is alkaline)
• Goals are met—nursing process may be For clients with recurrent UTI→ acid ash diet (CPP-
discontinued, proceed to other problems cranberries, prunes, and plums)
• Goals are partially met Continue interventions • Urine specific gravity- 1.010-1.030
• Goals are not met or modify the nursing o Measures the urine concentration
→ Modification is done after the evaluation
process SIADH DI
↑ ADH→ ↓ urine output ↓ ADH→ ↑ urine output
1. A nurse is caring for a 2-day-old infant who requires Oliguria Polyuria
phototherapy for treatment of jaundice. Which information Increased USG Decreased USG
would be included as part of the nurse's subjective But in dehydration→ USG is high
assessment? Urine output is inversely proportional to the urine output
A. The parent had jaundice as a newborn • Blood components
B. The amount of infant's last feeding- can be • Glucose, ketones
measured, time and frequency is measured in • Protein/ albumin
breastfeeding • Pus
C. The most recent bilirubin level- objective
• Crystals
D. D. The infant's weight at birth- objective
• Urine should also be fresh (within 1 hour)
2. What is the most important nursing responsibility post 2. Culture and sensitivity
Barium Enema (x-ray of the lower GI tract, AKA lower GI • To check presence of microorganisms and
series)? determine the type of antibiotic to be used for the
→ For the upper tract, barium swallow or upper GI series specific infection
→ Barium sulfate is given for clearer visualization • Specimen should be sterile to prevent a false
• A chalk-like substance positive result
→ Constipation is expected after
• Two methods of collection
A. Encourage bedrest for at least 4 hours- exacerbate
o Clean catch/ clean voided- midstream urine
constipation
B. Encourage ambulation- the best answer is always (clean- void- catch- void- clean)
an independent nursing action ▪ Clean the meatus with water only before
C. Laxatives as ordered the procedure (avoid soaps, feminine
D. Instruct client that stool may appear white for 48 -72 washes as this may contaminate the
hours- this is expected, should be taught before the specimen)
procedure ▪ Void a little first before catching
If there are drugs in the choices, most probably it is incorrect ▪ For the last cleaning, let the patient use
what they want to use
3. The following statement appears on the nursing care plan
o Catheterized urine
for an immunosuppressed client: The client will remain free
from infection throughout hospitalization. This statement is ▪ Never collect urine
an example of a (an): from the bag→ all
A. Nursing Diagnosis urine from the bag is
B. Short-term goal- within the hospital setting contaminated
C. Long-term goal ▪ Collect urine from the
D. Expected Outcome port (tubings of
catheter bags are
4. After assessing the client, the nurse formulates the

C
self-sealing)
following diagnoses. Place them in order of priority, with the
▪ Clamping- below the
most important (classified as high) listed first.
1. Constipation 2. Anticipated grieving 3. Ineffective airway port for 30 minutes to
clearance 4. Ineffective tissue perfusion. 1 hour
A. 3421 o Done to save urine first
B. 4321 ▪ Cleaning
C. 1324 o Wipe the site of puncture, clean it
D. 3412 with alcohol
▪ Collecting
5. The nurse writes an expected outcome statement in
• Using a sterile syringe (>10
measurable terms. An example is:
A. Client will have less pain
cc)
B. Client will be pain free 3. Timed collection
C. Client will report pain acuity less than 4 on a • 24-hour urine collection
scale of 0-10. o Schilling’s test for pernicious anemia
D. D. Client will take pain medication every 4 hours o Vanillylmandelic acid (VMA) for
around the clock. pheochromocytoma
o Bence jones proteins for multiple myeloma
 o Creatinine clearance Sputum
• How is it performed? → Oral care but gargle with water only before the
o Start- September 1 procedure
o 8 AM- first void, discard • Never use mouthwashes→ contaminate the
▪ This is discarded because this is a residue specimen
from last night’s urine→ stayed in the → Toothbrush but with water only (x) toothpaste
bladder for long→ possibly contaminated → Instruct the patient to perform deep-breathing
o 10 AM- second void, start collecting/ saving exercises to loosen the sputum for easier expectoration
urine → Instruct the patient to hack up and cough out→ to make
o Test will conclude on September 2 at 8 AM (the sure that the specimen is really from the lungs
same hour started) → Oral care after the collection preferably with
o Last void will still be collected mouthwash
o If patient cannot void at the hour when the test • (+) sputum in the mouth, to remove unpleasant
ends→ force the patient to void, even small taste
amounts
o If one urine is not collected, repeat from the 1. Acid fast bacilli (AFB)
start (results will be altered) • Used in PTB
• How to preserve? • Determines of people with (+) PTB to check the
o Should be refrigerated (in an icebox) effectiveness of treatment
2. Culture and sensitivity
Stool • Can also be used for PTB
→ Where to defecate? o More accurate because this determines the
• In any clean surface type of microorganism present
• Double flush the toilet first before defecating • Used for pneumonia→ determines the type of
• Diapers, gloves can also be used pneumonia (bacterial, viral, or fungal)
→ The best portion in the stool to be collected is the part Both x-ray and culture are needed in pneumonia
where there is blood → X-ray- (+) consolidation is pneumonia is present
→ If (-) blood, get the part where there is mucus → Culture- determines the type
→ If (-) mucus or blood→ collect the middle portion 3. Cytology
→ Amount- 1 inch or 1 tsp if the stool is solid • Pap smear of the lungs
→ If stool is watery or liquid (diarrhea)- 10-15 cc • Used to determine malignancies (e.g.,
bronchogenic carcinoma)
1. Routine fecalysis
• Make sure that the specimen is fresh and warm 1. The nurse is preparing to collect a sterile urine specimen
(within 1 hour→ submit, if >1 hour→ discard, obtain from a client who has an indwelling Foley catheter. The nurse
a new specimen) clamped the catheter and returns to the client to collect the
2. Culture and sensitivity specimen 30 minutes later. The correct order of priority that
the nurse should take to collect the specimen is:
3. FOBT fecal occult blood test)/ guaiac test
1. Explain procedure to the client
• Done to detect GI bleeding in peptic ulcer disease, 2. Unclamp the catheter
IBDs, colorectal ca, etc. 3. Draw urine into the syringe
• Instructions before the procedure 4. Insert needle into the tubing
False Positive False Negative 5. Place urine into the specimen container
No dark colored foods for at All foods and supplements 6. Cleanse the needle entry site
least 3 days prior to specimen containing >500 mg of 7. Label the specimen according to agency protocol
collection vitamin C should be A. 1,2,6,4,3,5,7
→ Beef avoided B. 1,6,4,3,5,2,7
→ Red meat C. 1,4,6,3,5,2,7
→ Chocolate D. 1,2,4,6,3,5,7
→ Raisins
Medications (oral) to be 2. The nurse doing the health teaching to a client for testing
avoided feces for occult blood informs the client about what can
→ Iron (causes discoloration produce false positive results: What should the nurse
of the stool) emphasize?
→ Aspirin (may cause false A. If you have eaten red meat or raw radishes and
bleeding) melons, in the last couple of days, the test may
→ NSAIDs be positive and it may be inaccurate.
→ Steroids B. If you have taken more than 250 mg of vitamin C, it
→ All are GI irritants may produce a reading that is too high but is
→ Avoided for at least 7 days inaccurate.
prior C. If you have recently eaten any colored vegetables, it
→ If patient really needs the may color the stool and produce an inaccurate test
drugs mentioned, change result.
the route D. If you have been drinking tea, the result might be
→ Steroids- IV elevated.
→ Iron- IM, z-track technique
3. How should the nurse identify the patient before obtaining
a laboratory specimen from Mr. Daclis?
4. Fat analysis
A. Using at least two patient identifiers- (1) ask their
→ Checks steatorrhea (presence of fat in the stools) name, birthdate, (2) check the ID band- better
→ Used to determine hepatobiliary disorders identifier as not all patients are able to respond or
→ Preparation conscious (if appear in the boards)
• Start three days before B. Looking at the chart before entering the room
• High fat diet to determine if fat can be emulsified C. Asking the patient if he is Mr. Daclis- answerable by
(challenge the hepatobiliary tree) yes or no
→ Also, a timed collection—24-, 48-, or 72-hours D. Checking the patient's arm band twice
collection
4. When discussing the collection of a clean-voided urine
→ Refrigerate the specimen specimen, it is important for the nurse to instruct the patient
to:
A. Use a clean specimen cup
 B. Collect 100 to 150 mL of urine for testing • Ano yung pinakahuli mong ginawa bago lumabas
C. Void some urine first and then collect the sample yung sakit?
D. Wash the perineal area with soap and water • Last activity may determine the cause and relief
immediately before voiding Gastric Ulcer Duodenal ulcer
Pain is felt after eating (30 Pain felt after meals (2-3
5. The nurse needs to obtain a sterile urine specimen for
minutes to 1 hour) hours after meals)
culture and sensitivity (C&S) from a patient who has an
Cause- food Cause- empty stomach
indwelling catheter. The catheter was placed the night before.
Vomiting will cause relief Eating will relieve pain
What must the nurse do in order to obtain the specimen?
Weight loss Weight gain
A. Obtain the urine from the drainage bag- never
collect from the bad → Q- quality
B. Clamp the drainage tubing for 30 minutes • Close- ended→ patient will not be able to
C. Draw urine using a 20-ml syringe describe the type of pain they are feeling
D. Insert the needle into the port- port is for the balloon • Suggestive questions→ patient will only choose
between the choices the nurse gives
Pain • Patient’s own description of pain
→ Considered as the 5th vital sign → R- region/ radiation
→ Universally described as an unpleasant personal • Location is assessed
experience—very subjective • Best answer- allow the patient to point the location
→ Described as “whatever” and “whenever” of pain
• Whatever the patient says it is and whenever the → S- severity
patient feels it is • Pain scale (most commonly used is the numeric
• You cannot argue with the patient about the pain scale; 0-10 scale)
characteristic of pain they are feeling Interpretation Pain Level Interpretation
No pain 0 No pain 0
Types of Pain 1
Mild pain 1
→ Cutaneous- skin Mild 2
• Sunburns, blisters, abrasions, papercuts 3
Moderate 2
→ Somatic- derives from the muscles and joints 4
• Deep somatic pain- still includes the muscles and Moderate 5
Severe 3
joints plus the bones 6
o Bone cancer, fractures, etc. 7
Very severe 4
→ Visceral- pain from internal organs 8
Severe
9 Worst
• Appendicitis, cholecystitis, pancreatitis 5
10 possible
→ Phantom pain- existing pain from a part that is missing
→ In cases of conflicting answers, depend the best answer
or gone
on the choices
• Very common to post mastectomy patients
o E.g., if there is a very severely in the choices use
• Phantom sensation- (-) pain but still feel that the
the by two pain scale, if non use the by three scale
missing part is still there
o Wong-baker’s face scale will be used for pediatric
• Pain medications will still be given because all pain
patients
is real (nerve endings are still present in the area)
• Management- mirror therapy
o Remaining limb will be
moved or exercised
o Done to decrease
phantom pain and for
faster recovery
o FLACC (face, legs, activity, cry, and consolability)
→ Intractable- pain without relief
pain scale is for the infants
• E.g., perforated ulcer
Four layers of the stomach
→ Mucosa
→ Submucosa
→ Muscularis
→ Serosa
• The only management is surgery or rhizotomy
(severing or cutting branches of nerves/ pain
receptors that leads to the area with pain)
→ Psychogenic- pain without physiologic basis
• Brought about by emotional pain
→ Referred
→ Radiating
Referred Radiating
Cholecystitis
Pain is only on the right RUQ pain radiating to the → T- time
shoulder right shoulder • Onset, duration, interval
Pain not felt at the site of
Extension of pain
injury
Pharmacologic Pain Management
Harder to diagnose because
etiology of pain is not
1. Opioids (narcotics/ narcotic analgesics)
pinpointed • Full Agonist- Morphine, Meperidine/ Demerol,
Oxycodone, Fentanyl
Pain Assessment • Mixed Agonist- Nalbuphine Hydrochloride
→ First step in pain assessment is acceptance and (Nubain), Tramadol
acknowledgement, accept that the client is in pain • Known to be CNS depressants
(PQRST will not be done accurately is the nurse does For biliary pain, what pain medication will be chosen?
A. Morphine- will cause more pain d/t spasms of the
not believe that the patient is in pain)
sphincter of oddi
→ PQRST o DOC for biliary pain, because long term use of
→ P- provoking/ precipitating factor meperidine leads to seizure
• Patient’s last activity
 B. Meperidine (demerol)- also causes spasms in the 1. Which client is at greater risk for respiratory depression
sphincter of oddi while receiving opioids for analgesia?
A. An elderly chronic pain client with a hip fracture-
For appendicitis chronic pain, high tolerance
A. Morphine B. A client with a heroin addiction and back pain- high
B. Demerol tolerance
o Pain medications are not given because it will C. A young female client with advanced multiple
mask the pain and rupture myeloma- advanced stage, high tolerance
Side Effects of Opioids D. A child with an arm fracture and cystic fibrosis
→ Drowsiness/ LOC- SE that should be closely monitored,
especially for the first 24 hours 2. The physician has ordered a placebo for a chronic pain
client. You are newly hired nurse and you feel very
• Most importantly the opioid naïve patients—first
uncomfortable administering the medication. What is the first
timers in taking opioids action that you should take?
• Can lead to the adverse effect of the drug→ A. Prepare the medication and hand it to the physician
respiratory depression, give antidote (naloxone/ B. Check the hospital policy regarding use of the
Narcan an opioid antagonist) placebo. - considered unethical, check policies
• Check the patients RR before and after C. Follow a personal code of ethics and refuse to give
administration it.
Side effects vs. Adverse effects D. Contact the charge nurse for advice.
→ Both are expected but SE are normal effects while AE is
toxicity 3. What is the best way to schedule medication for a client
→ If not expected→ idiosyncratic effects with constant pain?
A. PRN at the client's request
What is the adverse effect of Lupron (GNRH- LHRH)? B. Prior to painful procedures
A. Sterility C. IV bolus after pain assessment
B. Dizziness D. Around-the-clock- schedule should also be
C. Rash constant
These are considered as side effects
D. Drowsiness
4. A family member asks you, "Why can't you give more
Opioids do not lead to addiction but causes tolerance medicine? He is still having a lot of pain." What is your best
response?
→ Urinary retention
A. "The doctor ordered the medicine to be given every
→ Constipation- universal side effect 4 hours."- makes the patient wait
→ Nausea B. "If the medication is given too frequently, he could
→ Pruritus- most common SE in the elderly suffer ill effects."- negative response
C. "Please tell him that I will be right there to check
2. Non-opioids/ NSAIDs of him."
• Non-opioids D. "Let's wait about 30-40 minutes. If there is no relief,
o Acetaminophen (Tylenol) I'll call the doctor."
Both are analgesics, o Never let the patient WAIT in pain
• NSAIDs
antipyretic, but only management
o Ibuprofen (advil)
the NSAIDs are anti-
inflammatory 5. Which route of administration is preferable for
administration of daily analgesics (if all body systems are
→ NSAIDs are maintenance drugs of rheumatoid arthritis→ functional)?
prone to ulcerations, therefore, COX- 2 will be prescribed A. Intravenous
for long-term use (celecoxib) B. Intramuscular or subcutaneous
→ NSAIDs are COX 1 and COX 2 inhibitors C. Oral- if the GI is functional, then it is always the best
→ Opioids and non- opioids can be given together route
A. D. Transdermal
Side Effects
→ GI irritation Oxygenation
→ Common complaint- heart burn → Still a physiologic need
→ Management- always take it with meals as it can cause → Oxygen- a colorless, odorless, and tasteless gas that is
ulcers slightly heavier than air
o When (+) leakage, not detected→ danger
3. Coanalgesics
• Former name- adjuvant Safety for Patients under Oxygen Therapy
• These are drugs that are not pain medications but → “No smoking” signs
can be used for pain management e.g., diazepam • Should have three:
(anxiolytic), benadryl (antihistamine) o At the door
• Can be used with opioids and non-opioids o Bed- at the head or foot of the bed
o If (+) O2 tank→ place on the tank, for
Three Step Ladder Approach of WHO installed→ place it on the wall where it is
installed
→ Electrical equipment near the tank
→ Battery operated materials near the tank
4-6 → Woolen clothing near the tank—blanket, linens
1-3 • Can create static electricity→ fire
• Cotton should be used
→ Chemicals e.g., rebonded hair d/t
1-3 presence of chemicals
• Also creates static
7-10 → Fire extinguisher nearby
• Full agonist
opioids are used
• Mixed agonist • Multiple routes of
opioids are used administration
• Single route of
administration
Types of Oxygen Delivery System Maintain on
Percen Liters semi-fowler’s
Length Tip of the nose Tip of the nose to Insert until point
t of Per
Types to the earlobe the earlobe (4-6 of resistance is
Oxyge Minut (4-6 inches) inches) met (carina)
n e then withdraw 1
Nasal cannula inch
→ Lowest delivery system, most Per suction- 5-10 seconds
commonly used Time But for ↑ secretions, maximum is 15 Maximum is 10
25-45 1-6 seconds seconds
→ Most convenient, still allows patient
to perform activities—eat, drink, Interval 20- 30 seconds 2-3 minutes
talk Total Should not be more than 5 minutes
time
Simple facemask 40-60 5-8
Partial rebreather mask 60-90 6-10
Non-rebreather mask Pressure Setting of Suction Machines
→ Highest O2 delivery system Age Portable Wall Unit
→ Used in emergency cases—shock, 95-100 10-15 Infant 2-5 mmHg 50-95 mmHg
severe burns especially those with Child 5-10 mmHg 95-110 mmHg
smoke inhalation, MI Adult 10-15 mmHg 100-120 mmHg
Venturi mask
→ Has color coded valves- used for Incentive Spirometry
accurate O2 delivery (percentages → Commonly used for patients with CAL/ COPD or postop
are dependent on the brand) patients
25-60 4-10 • Reinflates lungs after surgery to prevent lung
complications
→ AKA SMID (sustained maximum inhalation device)
• Measures the inspiratory volume
→ Most accurate O2 delivery system
→ Different parts of the spirometer
Chronic airflow limitation (CAL)- emphysema and chronic
• Mouthpiece- placed in the
bronchitis
→ Nasal cannula and venturi mask can be used for these patient’s mouth
conditions, but if both are in the choices choose • Piston- inside the device
venturi→ more specific and accurate can be seen moving up
COPD (outdated)- emphysema, chronic bronchitis, asthma, and down every time the
bronchiectasis patient breathes, this
should reach the goal
Suctioning marker
→ Aspiration of secretions through a catheter connected • Goal marker- where the
to a suction machine or wall suction outlet piston should reach
→ Done to remove secretions and clear the airways depending on the desired
→ This is an interdependent→ at first, the physician should volume
give a standing order then the nurse will decide when to o Increased each day until patient reaches
suction maximum inhalation
→ A sterile procedure (use sterile gloves)—respiratory is • Flow indicator- the ball, also moves up when the
sterile patient breathes
• Dominant hand should remain sterile all throughout o Aids the patient to control breathing
the procedure → Best position when performing spirometry- sitting or
→ PPE should be complete when suctioning to prevent upright position
contamination with secretions → Best time to perform- before meals or before bed time
→ How often is a suction catheter changed? Every after
use (only used one time) Preprocedural Management
→ Ds of suctioning → May cause discomfort on the incision site→ splint the
→ Dyspnea site before the procedure
→ Drooling • Pillows, towel, hands may be used
→ Decreased breath sounds or presence of adventitious → Pain medications to promote comfort of the patient
breath sounds during the procedure to postop patients only
→ Decreased O2 saturation
How to Use the Spirometer?
Complications of Suctioning 1. Hold spirometer upright, exhale fully before beginning,
→ Most common- hypoxia (lack of O2 in the tissues) place the mouthpiece in your mouth, should be tightly
• O2 is also suctioned sealed
• To prevent this→ Hyperoxygenate the patient 2. Slowly, deeply, and steadily inhale,
• If the patient is on BVM (bag valve mask)→ three flow indicator should be at the better/
hyperinflations best position, control your breathing
• If patient is connected to an O2 tank→ raise it to until piston reaches the goal marker,
10-15 LPM for one whole minute before suctioning at the end on inhalation hold your
• If connected to a mechanical ventilator→ press the breath for 2-6 seconds to allow the
hyperoxygenation button piston to fall back to zero
• CAL patients can be hyperoxygenated because it 3. Remove the mouth piece and exhale normally
will be suctioned right after 4. Done 4-5 times/ day, 10 times/ session

Types of Suctioning Post Procedural Nursing Responsibility

Oropharyngeal Nasopharyngeal
Endotracheal/ → Instruct the patient to perform DBE
Tracheostomy
→ Oral care
Position → Best position- semi-fowler’s (if Semi- fowler’s
of the conscious) → Clean the mouthpiece after, wash with water every after
patient → Lateral or side lying (if use
unconscious) facing the nurse
Position (+) danger of Hyperextend the Head not
of the aspiration with neck for easier moved d/t
head the head turned insertion tendency of
to the side dislodgement
Tracheostomy Important Articles at Bedside if there is a Tracheostomy
→ -ostomy- opening → Obturator
→ Opening into the trachea through the neck, a tube is → Sterile forceps/ clamp- used in case of OC
inserted and artificial airway is created dislodgement
→ This will always be the last choice (more invasive) → Suction machine
→ Created for long term use → Spare tracheostomy set
• ETT cannot be left longer→ prone to infection and → Magic slate for communication
tissue necrosis in the trachea d/t compression of
the ETT Chest Drainage
→ Parts of the tracheostomy tube → AKA CTT (chest tube
• Obturator thoracotomy)
• Inner cannula → Main purpose is for lung
• Outer cannula reexpansion through restoration
• Tracheostomy ties of negative pressure in the
• Tracheostomy cuff pleural space
→ Cases where CTT is needed
• Hemothorax
• Pneumothorax
• Pleural effusion
→ Three-way bottle
→ Pleur-evac
• Has accurate measurements
• Not easily broken
• Portability, patient can easily be
transported
Sequence in Inserting a Tracheostomy
• Disposable
→ Once opening is made on the neck towards the trachea
• (+) Alarms when there is something
→ Outer cannula together with the obturator is inserted
wrong in the system
first
→ Insertion site- 5th ICS MAL, nipple line may be used as
→ Remove the obturator because it is only a guide for the
landmark or depending on the site of drainage
outer cannula
→ Size of catheter- F36- F40 especially for trauma patients
→ Insert inner cannula, lock→ clockwise, removal→
→ Position- semi-fowler’s
counterclockwise
→ Tracheostomy will be sutured in place to prevent
Chambers/ Bottles
dislodgement
→ Drainage bottle- connected to the patient
• Should not have any bubbling, blood, secretions,
Tracheostomy Care
and fluids should only be seen
→ A sterile procedure
• Monitor and document amount, level, and color of
→ Done qshift, q8
drainage
→ Inner cannula is the focus of the trach care
• Included in the patients output
• Soak in half strength hydrogen peroxide to remove
• Air from the drainage bottle will go to the water seal
hardened secretions (diluted- 50% NSS, 50%
→ Water seal bottle
hydrogen peroxide)
• (+) oscillation, intermittent bubbling, tidaling,
o Brush with a sterile brush
fluctuation
• Dry- never use gauze because (+) lint and can stick
• Bubbling should be non-continuous
to the inner cannula
• If (+) continuous
o Tap or shake it dry only
o Check for air leakage—check connections, site,
• Rinse- with NSS
suction machine, look for the source of leakage
→ Tracheostomy ties- secures outer cannula
• If (x) bubbling- blockage
• Clean gloves can be worn when cannula is
→ Suction bottle- connected to the suction machine
removed
• (+) continuous bubbling if suction machine is ON
• Soak in solution
• If suction machine is OFF no bubbling will be seen
• Change to sterile gloves
• If vigorous bubbling suction pressure is too high
• In changing the ties leave the old ties on until the
→ Nursing responsibility- monitor functioning of the CTT
new tie is secured (use a square knot away from
the carotid artery)
Findings
o Make sure 1-2 fingers can be inserted under
→ Blood clots in the tubings is normal because blood is
the ties before ties are secured (1 is the best
draining
answer)
o But this can cause obstructions if clots are
→ Tracheostomy cuff
already large
• A balloon inflated in the outer cannula
If (+) blood clots, what should the nurse do?
• If (+) tracheostomy→ epiglottis will not function → Clamp- never clamp the tubing→ increase pressure in
because of the tube obstructing→ ↑ risk of the lungs d/t backflow of air→ tension pneumothorax
aspiration→ cuff will create an airtight seal to → Squeeze/ pinch→ towards the drainage bottle
prevent aspiration → Flush- there are no ports, no tubes to flush
• Also prevents air from coming out of the trachea → Milk- never strip or milk, will also cause tension pneumo
• Inflated when patient would eat or drink → Disconnection- patient is still connected to the bottles
• There are cuffless tracheostomies but dislodge form the system
If tracheostomy is dislodged what should the nurse first do? → Dislodgment- disconnected from the patient but still
A. Reinsert outer cannula connected to the system
B. Retract the stoma- this will open the patient’s But these two can be interchangeable, therefore, relate it to
airway the situation given; both are common problems
o Look for something sterile to open the airway
C. Cover with light sterile dressing- airway will be
If Dislodged/ Disconnected…
obstructed
D. Notify the physician- make sure to do something first
→ From the system- submerge the tip of the tube in sterile
before notifying the physician water or NSS (1 inch or 2.54 cm)
 • If not in the choices, second o Both lungs but in the upper portion→ high
choice is to reconnect fowler’s sitting, orthopneic, upright
→ From the patient- cover with sterile, o Both lungs but in the lower portion→ place
dry, non-occlusive dressing pillows on the back near the lower portion of
• Tape three sides for air to still the lungs
drain o Anterior- supine
o Posterior- prone
If dislodged accidentally from the patient, what should the • Done for 10-15 minutes
nurse do?
→ Petrolatum dressing
→ Sterile dry dressing
→ Sterile moist dressing- similar to petrolatum and
vaselinized
→ Vaselinized dressing
Petrolatum and vaselinized dressings are used when the site
of insertion will be totally closed already, if (x) air is already
drained, during the removal of the chest tube, no positive
pressure already

If accidentally dislodge, what should the nurse cover the

opening with?
→ Non-occlusive- to prevent tension pneumo
→ Occlusive- will cause increase pressure→ tension
pneumo

While on the way to the x-ray department, the tube got

dislodged. What should the nurse do?
→ Cover using the hand of the nurse- the answer should Difference between Trendelenburg, modified
always be a nursing intervention and never the patient’s Trendelenburg, and reverse Trendelenburg
intervention
→ Cover using the hand of the patient
→ Cover using the hand of the nurse and patient

Removal of CT → In modified rendelenburg, patient is only in supine only

→ Removal can be confirmed through CXR that lungs are the legs are elevated→ best position for shock because
already reexpanded rendelenburg increases ICP
• Place the patient on semi-
Congestion in the right posterior→ left
fowler’s position
sims lateral
→ Tell the patient to perform Valsalva → Sims- halfway between prone and
maneuver (bear down) while tube sidelying
is removed
• Cover with occlusive dressing,
tape the four sides 1. Which client statement informs the nurse that his teaching
about the proper use of incentive spirometer was effective?
Chest Physiotherapy A. "I should breathe out as fast and hard as possible
→ Composed of three steps (PVD) into the device".- should be slow and steady
• Percuss B. "I should inhale slowly and steadily to keep the
balls up".
• Vibration
C. "I should use the device, three times a day after
• Drainage/ postural drainage meals".- (x) after meals
→ Best done to perform- before meals and before bedtime D. "The entire device should be washed thoroughly in
→ Duration should not be more than sudsy water once a week".- washed every other use,
30 minutes (entire procedure) only the mouthpiece is washed
→ Percussion- done to dislodge
secretions 2. While a client with chest tubes in ambulating, the
• Hands should be cupped, if connection between the tube and the water seal (from the
system) dislodges. Which action by the nurse is most
not cupped properly→ painful
appropriate?
• Going up in one direction A. Assist the client to ambulate back to bed.- safety
• Percuss bare skin, should of the patient first, the client is ambulating
have cover B. Reconnect the tube to the water seal.
• Bony prominences→ can C. Assess the client's lung sounds with a stethoscope.
cause fractures of the bone D. Have the client cough forcibly several times.
→ Vibrations- loosens and mobilize secretions
3. The nurse is planning to perform percussion and postural
• Palm or heel of hand is used for vibration
drainage. Which is an important aspect of planning the client's
• Going down in one direction→ mechanisms to care?
loosen secretions A. Percussion and postural drainage should be
• Vibrate during exhalation only, let the patient to done before lunch.
inhale deeply then vibrate upon exhalation B. The order should be coughing, percussion,
→ Done 5 minutes each positioning, then suctioning.- coughing is last in the
→ Postural drainage- last step sequence
• A technique in which different positions are C. A good time to perform percussion and postural
drainage is in the morning after breakfast when the
assumed to facilitate the drainage of secretions
client is well rested.- should be before meals
from the bronchial airways D. Percussion and postural drainage should always be
o AKA gravity drainage, because principle of preceded by 3 minutes of 100% oxygen.- absolute
gravity is used words are wrong
• General rule- always elevate the AFFECTED SIDE
o E.g., affectation is the right lung→ left side lying 4. Which action by the nurse represents proper
position nasopharyngeal suction technique?
A. Lubricate the suction catheter with petroleum jelly
before and between insertions.- never use
 petroleum jelly (an oil-based lubricant), should be → Overweight- 25-29.9
water- based → Obese- >30
B. Apply suction intermittently while inserting the
suction catheter.- should be during withdrawal
Nasogastric Tube
C. Rotate the catheter while applying suction.
D. Hyperoxygenate with 100% oxygen for 15 minutes
→ Used for people who cannot eat proper, gag reflex
before and after suctioning.- hyperoxygenation too problems, unconscious patients, (+) problems in the GI
long → Clean technique during insertion because the GIT is not
sterile
5. A client with emphysema is prescribed corticosteroid → Measurement→ NEX (tip of the nose→ earlobe→
therapy on short term basis for acute bronchitis. The client xiphoid process)
asks the nurse how the steroids will help him. The nurse → Two types of NGT
responds by saying that corticosteroids will do which of the
• Rubber
following?
o Harder to insert- submerge in ice cold water to
A. Promote bronchodilation.
B. Help the client to cough. harden
C. Prevent respiratory infection. • Plastic
D. Decrease inflammation of the airways. o Easier insertion (harder than rubber) but
should be lubricated with KY jelly to prevent
Nutrition trauma
Food Pyramid
→ S- sparingly Insertion
• Oils, fats, and sweets → Best position- high fowler’s, sitting, or upright
→ 2-3 servings of meat → Neck should be hyperextended
• The size of a matchbox→ because there are still • Then flex/ leaned forward if (+) slight resistance→
other foods to be eaten this means that the tube has passed through the
→ 2-3 servings of milk larynx
→ For the elderly, same food pyramid is used but there is → Sips of water during insertion if the patient is able→ to
additional of 8 or more servings of water and additional direct the tube to the GIT
supplements → Best position when feeding- semi-fowler’s
• Especially calcium supplements→ to prevent → After feeding- maintain on semi-fowler’s for at least 30
osteoporosis minutes
• Vitamin D → Removal- ask the patient to hold their breath while the
• Vitamin B12 nurse is removing the NGT

Nursing Responsibilities
→ Check placement- done before feeding
• Abdominal x-ray will confirm the placement of the
NGT
• Aspiration of the gastric content- pH- 0-4
o More accurate than auscultation, mas
manwaila ka sa nakikita mo
o Best way to check for placement before
feeding
o Residual volume can also be checked when
this is done
• Auscultation- (+) gurgling sounds
→ Check patency- before and after feeding
• Flush the tube with water (any drinking water is
used)
o 30-60 cc
Caloric Requirement • Done every before and after feeding to clean the
→ For average weight and average activities tube from any residue of the feeding
• Males- 2,500 kcal/day
• Females- 2,200 kcal/day Total Parenteral Nutrition
o Pregnancy- add 300 kcal/ day → Given when the GIT does not function at all,
o Lactating- add 500 kcal/ day administered through large or central veins
o If pregnant and lactating- add 500 kcal/ day • Jugular
→ Formula to compute for calories • Subclavian- more commonly used, below the
• CHO- 1 g x 4 cal clavicles
• CHON- 1 g x 4 cal Par- outside
• Fats- 1 g x 9 cal Enteral- GIT
→ BMI formula Parenteral- outside the GIT
• Feet to m→ 0.30 → Usually runs for 12 hours
• Inches to m→ 0.025
• More accurate if (+) Composition
decimal point → Glucose- 50%-70%
E.g., • Main component
Weight- 14 lbs. / 2.2= 67.27 kgs → Lipids/ fats- 10%-15%
Height- 6 ft * 12= 72 inches * 2.54→ 182.88 cms/ 100→ 1.83 → Protein- 3%-15%
m
→ Electrolytes, vitamins, fluids, trace elements
→ Feet (*12)→ inches (*2.54)→ cm (/100)→ m
67.27/ 1.83^2
67.27/ 3.35 Insertion
20.1 kg/ m^2 → Through the subclavian- trendelenburg (best position)
• But if contraindicated→ supine with head of bed
Interpretation of BMI lowered
→ Underweight- <19 • Head and neck should be lowered to distend the
→ Normal- 19- 24.9 vein and allow visualization
 • Another reason is to prevent air from entering (air
embolism) because vein is filled with blood (x) room
for entry of air→ prevent pulmonary embolism
→ Removal is in the same position to prevent embolism
also

Complications
1. Hyperglycemia- too rapid infusion of TPN
• Standby regular insulin at bedside
2. Hypoglycemia
• Occurs when TPN is abruptly stopped e.g.,
dislodgment, running out of TPN
• Rebound hypoglycemia
• Run dextrose solution (preferrable D10) to prevent
hypoglycemia if no longer able to buy another TPN
3. Infection
• (+) insertion site plus the continuous administration
of glucose
o Glucose attracts bacteria (this is the food for
bacteria)
• Prophylactic antibiotics may be ordered
• Maintain aseptic/ sterile technique to ↓ risk of
infection
• Most inevitable complication, most common

1. Which of these interventions indicates the nurse needs

more information regarding how to safely ensure proper
NGT placement?
A. When confirming tube placement, place the
tube's end in a container of water.
B. Use a tongue blade and penlight to examine mouth
and throat or signs of a coiled section of tubing.
C. Stop advancing tube when tape mark reaches the
client's nostril.
D. Inject 10cc of air into tube. At same time, auscultate
for air sounds with stethoscope placed over the
epigastric region.

2. The nurse reads a food label that indicates the following:

CHO -35 grams, Fat-19 grams and CHON -30 grams. The
nurse calculates the number of total calories to be:
A. 506 calories
B. 516 calories
C. 413 calories
D. 431 calories

3. Three days after admission for a cerebral vascular

accident, a client has a nasogastric tube inserted and is
receiving intermittent feedings. To best evaluate if a prior
feeding has been absorbed the nurse should:
A. Evaluate the intake in relation to the output
B. Aspirate for a residual volume and re-instill it
C. Instill air into the stomach while auscultating
D. Compare the client's body weight to the baseline
data

4. During nasogastric tube feedings, the nurse is safely able

to administer:
A. Antibiotics- not usually given through NGT
B. Syrup-based medications- not specified what syrup
C. Enteric-coated tablets- never crush!
D. Liquid vitamin preparation

5. Organize these steps in chronological order for client who

is having a nasogastric tube removed.
1. Assist client into semi-fowler's position.
2. Ask client to hold her breath.
3. Assess bowel function by auscultation of peristalsis
4. Flush tube with 10ml of NSS
5.Withdraw the tube gently and steadily
6. Monitor client for nausea and vomiting
A. 314625
B. 314526
C. 314256
D. D. 315426
 Levels of Prevention

Primary Secondary Tertiary

Target Healthy High-risk Post treatment, dying patients for
patients • Those who do not have illnesses palliative care
yet but have predispositions
• Genetics
• Family history
• Vices
Goals Health promotion Early detection and early prompt • Restoration of health
• More on health teachings treatment • Rehabilitation
• Diet • All screenings are included here
• Exercise • Breast self-examination Common to post treatment
• Hygiene • Start at 20 years old, done late patients
because thelarche is also late)
Health protection • Done monthly 1 week after • Comfort
• Vaccines/ immunizations menstruation (count from the • Support
• Safety measures first day of menstruation)- for For dying patients
• Use of PPEs regular
• STD prevention • Irregular- same day every
A- Abstinence month
B- Be mutually faithful • Circular motion, start at the tail
C- Condoms of spence and end on the
nipples
• TSE (before 15 years old,
qmonth)
Done early because testicular
cancer occurs early (15-35 years
old)
• Best time to perform is after a
warm bath→ more relax and
descended
• Role the testicles between
the forefinger and thumb
• Pap smear (at the age of 21
years old or three years after
first intercourse)
Done q1 year
• History of positive result
• Sexually active
• >40 years old

q3 years
• Virgin with three consecutive
negative result

Sexually active→ (+) sex once a

month
• Mammography (x-ray of the
breast)
Baseline mammogram- done
between 35-39 years old once
• This will be the comparison
>40 years- every year
• Digital rectal exam
Done >40 years old yearly

Early prompt treatment

• Prophylactic surgeries