Professional Documents
Culture Documents
AED use:
Sequence
1. Establish unresponsiveness
2. Check pulse and respirations in 10 seconds or less
3. Activate the response team
4. Start compressions
5. Defibrillate with the AED as soon as it is available
a. Turn on the device
b. It will give step by step instruction
c. Single shock is delivered instead of a sequential 3 shocks.
d. When it says analyzing the rhythm, any direct contact with the victim must stop
e. Once AED is charged, the instruction will state stand clear
Uses properly
sized cuff for
forearm;
Place midway
between the
elbow and the
wrist
Auscultate
over radial
artery
Palpating the BP
Implementation
1. Perform hand hygiene.
2. Maintain sterile technique
3. Note date, time, size and type of
catheter inserted, amount of water
in balloon, any problems
encountered and amount and
character of urine obtained initially.
Special considerations
1. After urine starts to flow,
insert the catheter an
additional 1 to 2 inches and
then hold the catheter in
place.
1.
Nursing considerations:
a. Clear liquid are started when the patient has a return of bowel sounds
detected by auscultation. The goal is to introduce fluids that have low
b.
c.
d.
e.
f.
to prevent dehydration
Initial feeding after complete
bowel rest
Used initially to feed
malnourished person or a
person who has not had any
oral intake for some time
Bowel preparation for surgery
or test
Postsurgical diet
Initial diet in gastroenteritis and
pancreatitis
b.
c.
d.
e.
f.
g.
The use of protective device must help the patient or be needed for the continuation of medical therapy
Use the least amount of immobilization needed for the situation
Obtain a written order for all devices that limit movement or immobilize the patient. Notify the physician as soon as
the device is no longer needed
Apply the device snugly but not so tightly as to interfere with blood circulation or nerve function, you should be able to
fit your index and middle fingers between the patient and the device.
Release the ties and change the patients position at least 2 hours (according to the agency policy). Perform active or
passive exercises for immobilized joints and muscles.
Check patient at least every 15 to 30 min as directed by your agency and observe neurovascular function
Place the ties under the armrest of a chair and secure at the back. This prevents the patient from sliding the tie up
and off the back of the chair.
Use half-bow knot to secure the device to the bed frame or chair.
When the patient refuses the medication, place a circle in medication administration record around the time the
medication was to be given and record an explanation for the refusal in the progress notes.
Any refusal of treatment are also recorded in the chart. The exact word the patient uses when refusing to comply with
the treatment regimen should be documented.
Characteristics
Liquid suspension
Semisolid, thick preparation containing a
medicinal agent
Semisolid, thin preparation containing a
medicinal agent
Medication dissolved in alcohol
Liquid medication provided in a dropper
bottle with a detachable dropper
Tincture
Drops
Patch
Inhalant
Suppository
13.
14.
15.
16.
17.
Prescription
Abbreviation
Oint
Tinct, tr
Gt, gtt
This route is
for pt. who
are vomiting
Route
Applied to the skin
Applied to the skin or mucous
membrane
Applied to the skin or mucous
membrane
Applied to the skin
Usually formulated for nose, eye or
ear, although infant vitamins and
other medications are made as
drops
Applied to the skin for up 7 days for
transdermal absorption
Inhaled through the mouth or the
nose
Placed in the vagina, rectum, or
urethra depending on the type of
suppository
O2 Saturation device measures O2 saturation by determining the hemoglobin that is bound with the oxygen.
Finger or toe clip-on probe is most commonly used but adhesive sensors can be applied to the nose or the forehead.
A clip-on probe is available for use on an earlobe or an infants foot.
A pulse oximeter reading lower than 91% necessitates HCP notification; if the reading is lower than 85%, oxygenation
to the body tissues is compromised; and a reading lower than 70% is life threatening.
Tachypnea increased or rapid breathing, results from the presence of fever and a number of diseases. Breathing
rate increases about 4 breaths for each 1F increase in temperature.
Hyperventilation pattern of breathing in which there is an increase in rate and depth of breaths and carbon dioxide
is expelled, causing the blood level of CO2 to fall. The condition is seen after severe exertion, during high levels of
anxiety or fear, and with fever and condition such as diabetic acidosis.
Kussmaul fast deep respirations. Increased rate and depth with panting and long, grunting exhalation. Can be
seen on patients with diabetic acidosis and renal failure.
Biot fast deep respirations with abrupt pauses.
Cheyene-stokes respirations become faster and deeper, then slower and shallower with a period of apnea.
19. **
20. Fundamental Medical Surgical, Basic Nursing Skill: Elimination, Urine clean catch
Clean catch or midstream Urine Specimen to obtain specimen for culture and sensitivity test when
UTI is suspected. The purpose is to obtain a specimen that is relatively free form external contamination.
23. Fundamental Medical Surgical, Basic Nursing Skill: mobility ambulation safety
Guidelines for moving and Lifting: Body mechanics:
o Obtain help whenever possible
o Ask the patient to help if able
o Bend or flex knees
o Use the greatest number of muscles possible
o Use thigh, arm, leg muscles rather than back muscles
o Use wide base of support. Keep feet about shoulders width apart.
o Use smooth coordinated movement; avoid jerking or sudden pulling motions.
o Keep elbows and work close to your body.
o Work at the same level of height as the object to be moved.
o Remember that pulling actions require less effort than pushing or lifting
o Directly face the object or person to be moved
o Keep trunk straight; do not twist when lifting or pulling.
o Use arms as levers when pulling the patient toward you. Lock the elbows and rock back on your heels, using the
weight of your body to move the patient.
24. Fundamentals Medical Surgical, Basic Nursing Skill: Nutrition, diarrhea, intestinal flora
a.
b.
c.
d.
Patient who experienced diarrhea from antibiotics should be counseled to eat yogurt, drink buttermilk, or take
acidophilus when they begin taking antibiotics. Replacing the normal bacteria with those contained in these food
products reestablishes the right balance and stops diarrhea.
When diarrhea is thought to be caused by bacteria or a virus, the physician will let it run its course for at least 24 hrs.
Diarrhea from other causes simply leads to fluid and electrolyte loos and should not be allowed to continue for long
periods. Treatment involves placing the patient on clear liquid diet to rest the bowel, replacing fluids and electrolytes, and
seeking medication to stop the loose stools.
Observe for signs of dehydration when the patient has severe diarrhea: decreased skin turgor, dry mucous membranes
with thick saliva, and increased thirst. Self-medication for diarrhea should not be continue for more than 48 hours with
consulting the physician.
25. Fundamental Medical Surgical, Basic Nursing Skill: Nutrition, hypoglycemia diet
Hypoglycemia and Pt. able to swallow:
1. cup of juice
2. 1 cup of 2% skim milk
3. cup of regular soda
4. 6 or 7 hard candies such as life savers (not sugar free)
5. 1 small box of raisins
6. 3 glucose tablets
7. 1 tbsp of honey
8. 1 tbsp of sugar
9. 5 small cubes of sugar
10. 1 small tube of cake icing (2oz)
5.
26. ***
27. Fundamental Medical Surgical, Basic Nursing Skill: Medication administration, allergy intranasal medication
Safety Alert! Nasal medication that are intended for local effect on the nasal mucosa, such as saline nose drops for seasonal
allergies, are administered in both nostrils. Nasal medications that are intended for systemic effects, such as sumatriptan
(Limitrex), should be given in one nostril only.
28. Fundamentals Medical Surgical, Basic Nursing Skill: Medication administration pillocarting instruction (eye drops,
self-administration medication) (p.656F)
Instilling Eye Medication:
o If patient has contact lenses or glasses, assist patient in storing it properly.
o Check medication with MAR, follow six rights and double check whether the instillation is for right eye, the left eye or
both eyes.
o Wash hands and remove cap from the bottle of medication; place it upside down on the table and cap must be sterile.
o Drop the directly into the conjunctival sac without touching the surface of the eye. Do not place drops on the cornea.
o Replace the cap on the bottle without contaminating the dropper tip or the rim of the top.
Uses
Prevention of
chemotherapy-induced and
postoperative nausea,
vomiting, hyperemesis in
pregnancy, bulimia, spinal
analgesia-or gallbladder
induced pruritus
Adverse
Reaction
Headache,
fatigue,
drowsiness,
sedation,
constipation,
hypoxia
Dosage
5-HT3
8 mg
orally
BID or
TID; 32
mg IV
Factors such as age (over 40), gender and race contribute to the disease.
Those who have one or more immediate family members die of coronary artery disease during middle age are
considered to be at high risk for disorder.
Postmenopausal women and women who use oral contraceptives or hormone replacement therapy are at greater risk
for CAD.
Digoxin (cardiac glycosides) inhibit the sodium-potassium pump, thus increasing intracellular calcium which causes
the heart muscle fibers to contract more efficiently.
These medications are contraindicated in those with ventricular dysrhythmias and second or third degree heart block
and should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia (because
hypokalemia can increase digoxin toxicity).
An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, or hypothyroidism.
Monitor the potassium level. If hypokalemia occurs (K lower than 3.5 mEq/L) notify HCP.
Hold the medication if apical pulse is <60 bpm or >120 bpm.
Polydipsia
Polyuria
Polyphagia
Blurred vision
Weakness
Weight loss
Syncope
*not enough insulin
Nursing action:
Assess for ketoacidosis: Urine ketones, Urine glucose, Administer insulin as directed
Nursing Actions:
Usually occurs rapidly, and potentially life-threatening, treat immediately
with complex CHO. Example: graham cracker and peanut butter twice
and if no response, seek medical attention. Check blood glucose, may
seize if less than 40
After thyroidectomy: check for bleeding, support the neck when moving, watch for laryngeal edema by assessing
for hoarseness or inability to speak clearly. Monitor serum calcium (8.5 to 10.9 mEq/L), check for tingling of toes,
fingers, and around the mouth, check for Chvostek or Trousseau sign.
42. Medical Surgical, GI: Hepatic, Tylenol and liver toxicity
The client should avoid alcohol and over the counter medications, particularly acetaminophen (Tylenol)
and sedatives because these medications are hepatotoxic.
43. Medical Surgical, GI: Hepatic, Ulcers
2 most common peptic ulcers:
a. Gastric ulcer Gnawing, sharp pain in or left of the
midepigastric region occurs 30 to 60 minutes after meal
(food ingestion accentuates the pain). Hematemesis is
common than melena.
b. Duodenal Ulcer Burning pain in the midepigastric are
1.5 to 3 hours after a meal and during the night (often
awakens the client). Melena is more common than
hematemesis. Pain is often relieved by the ingestion of
food.
Interventions:
1. Monitor vital signs and for signs of bleeding.
2. Administer small, frequent bland feedings during
the active phase.
3. Administer H2 receptor antagonists or proton pump
inhibitors as prescribed to decrease the secretion
of gastric acid.
4. Administer antacids as prescribed to neutralize
gastric secretions.
Assess for generalized edema by checking for weight gain over a short time. Ask about the shoe and ring tightness
and sock patterns left on the ankles when socks are removed.
Look for hand and eye puffiness and abdominal fullness.
To check for dependent edema, press the fingers into the tissue over the tibia just above the ankle. If an indentation
remains, pitting edema is present.
Adverse Effects: Gastrointestinal effects, including sore mouth and furry tongue
Superinfections, hypersensitivity reactions, including anaphylaxis
During the first 24 to 48 hours after any cast has been applied to an extremity, the extremity should be elevated to
minimize swelling.
Never try to pry open the patients mouth or insert something into it once the jaw is clamping down, as teeth may be
broken and the airway may become obstructed. If supplemental oxygen is near, it should be administered, if possible.
When the seizure is over, turn the patient to the side and suction the airway if needed. Check oxygen with pulse
oximeter. Stay with the patient until she is completely conscious.
Breast self-examination should be done monthly, about 1 week after menstruation begins, or on specific date each
month after menopause.
Mammography to screen the breast for abnormal growths, particularly cancer. Done in radiology department with
special radiographic equipment. A full filled digital mammography machine records images on a computer screen and
can computer enhance questionable images for increased accuracy. Nursing Implications: breast discomfort from
compression of tissue during the test, occasional mild bruising. Instruct patient to wear no deodorant or lotion on the
upper body and to wear clothing that allows top to be easily removed. Take acetaminophen and hour before the
scheduled test.
New test that may replace current mammography for breast cancer are currently being researched; these include the
cone-beam breast computed tomography scan.
Before reparative surgery, the patient should lie supine with the knees flexed. The wound should be covered with a
sterile towel or sterile dressings moistened with sterile normal saline.
In case of dehiscence or evisceration at home: moisten sterile gauze with sterile water (or fresh water is sterile is
unavailable and place over the expose bowel to keep the bowel membrane moist.
Sulfonamides (trimethoprim-sulfamethoxazole)
Antifungals (amphotericin B)
Antitubercular (rifampin)
Cephalosporins (cefaclor)
Tetracyclines (doxycycline)
Condition that impairs blood supply to the penis like impairs pathology of the nervous system or hormonal supply or
impairs psychosocial responses.
Organic causes include diabetes mellitus and other endocrine disorders, and disorder of urinary tract,
Chronic illness such as sickle cell anemia, hypertension, cardiovascular disease, liver disease and cancer.
Anti-Parkinson medications can enhance sexual desire but not the ability to perform.
63. Medical Surgical, Respiratory: COPD risk
Heart sounds will be located at or close to the fifth intercostal space at the midclavicular line
S1 is the lub sound and S2 is the dub sound.
S1 is heard as the AV valves close and is heard loudest at the apex of the heart
S2 is heard when the semilunar valves close and is heard loudest at the base of the heart.
S3 is heard if ventricular wall compliance is decreased and structures in the ventricular wall vibrate; this can occur in
the conditions such as congestive heart failure or valvular regurgitation. However S3 sound may be normal in
individuals younger than 30 years.
S4 sound may be heard on atrial systole if resistance to ventricular filling is present, this is an abnormal finding, and
the causes include cardiac hypertrophy, disease, or injury to the ventricular wall.
o
o
Adrenal glands are located on the anterior upper surface of each kidney; each is composed of the cortex and the
medulla. It regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein metabolism; influences
the development of sexual characteristics; and sustains the fight or flight.
Adrenal cortex the outer shell of adrenal gland. It synthesizes glucocorticoids and mineralocorticoids; secretes
small amounts of sex hormones (i.e. androgens, estrogens)
Adrenal medulla the inner core of adrenal gland. It works as part of the sympathetic nervous system; produces
epinephrine and norepinephrine.
71. ***
72. Pathophysiology, Renal: Micturition
Micturition (voiding) Urine passes from the bladder through the urethra during urination. Pathophysiology are urinary
incontinence (involuntary passing of urine), bladder capacity decreases to as little as 200 mL and frequent emptying is needed
when aging, nocturia (urination during night) and lowered estrogen levels in women results in tissue atrophy in the urethra,
vagina and trigone of bladder which predisposes to infection and incontinence.
Alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchange.
Type II alveolar cells in the walls of alveoli secrete surfactant, a phospholipid protein that reduces the surface tension
in the alveoli. Without surfactant the alveoli would collapse.
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The lens of the eye changes after age 40, gradually losing water and becoming harder. Cataracts may form.
Cataract is opacity of the lens that distorts the image projected onto the retina and that can progress to blindness.
Causes include aging process (senile cataracts), heredity (congenital cataracts). It can also result from another eye
disease (secondary cataracts). Cloudy appearance of lens.
Causes of secondary cataracts include diabetes mellitus, maternal rubella, severe myopia, ultraviolet light exposure
and medications such as corticosteroids.
Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or
adversely affects lifestyle.
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