Fundamentals of Nursing Flashcards
Refresher Course (Day 1) Sir Daclis
Types of fire extinguisher: Class A
Ordinary Combustible: Paper, plastic, wood, cloth
Types of fire extinguisher: Class B
Flammable Liquids: Gasoline, Oil, Grease, Paints
Types of fire extinguisher: Class C
Electrical fires: Office equipments
Types of fire extinguisher: Class D
Metal fires: Sodium, Aluminum, Mg, K
Extinguisher how to use:
“RACE PASS”
Remove
Activate the alarm
Confine
Extinguish
Pull
Aim
Squeeze
Sweep side to side
Intrinsic factors in fall
Dizziness, Disorientation, Low LOC
Morse fall scale if more than
50 high risk
History of fall
25 pts
Ambulatory aids
15 pts
IV contraptions
20 pts
Gait
Weak 10
Impaired 20
Mental status impaired
15
Preventions of falls side rails
3 sides only
4 sides may indicate false imprisonment
Physical assessment standard
IPaPeA
massess, tenderness, organ enlargment
Palpation
Dull sound
Soft tissue
Resonant
LUng
Hyperressonance
High air (COPD)
Tympanu
Fluids (Stomach)
High pithc
Diaphgram
Bell
Low pitched
Abdominal:
IAPePa
Auscultation of bowel sounds pattern
RLQ, RUQ, LUQ, LLQ
Each area 5 mins
Normal bowel sounds:
5-20 per min
Respiratory assessment position
Upright
Abdominal assessment position
Dorsal recumbent
Best time to perform BSE
5-7 days after menstruation,
IF menopause same day of the month
Start at age 20 y.o
Sign of inflammation in BSe
Peau de orange
Most common area of breast tumor
Upper outer quad
group of lymph nodes in the axilla
Tail of spence
Xray of the breast
Mammography
35-39 y.o
Detects cervical cancer
Pap smear
Age 21 y.o every 3 yrs
Lithotomy
Detect testicular cancer
Testicular self exam
After warm shower for
13 y.o
Best time for Sputum exam
Early AM
Hidden blood in the stool exam for Colorectal CA, peptic ulcer dx
Guiac test
False positive in Guiac test
Rich in iron
Red meat
False negative in Guiac test
High vit C
More than 250 mg
False positive in Guiac test AVOID
Aspirin
Anticoagulants
NSAIDs
Steroids
Normal result in Guiac test
(+) Blue/green
(-) No color change
CBC
.5 use N
Male: 5.0 - 6
F: 4.5 - 5.5
Normal WBC
5k-10k
routine urinalysis
30-50 ml
Culture and sensitivity urine
5-10 ml
most common cause of UTI in hospitals
Catheter: E coli
for creatinine clearance
24 hour urine collection
Schilling test
Pernicious anemia
Vanillymandelin Acid Test VMA
Pheocromocytoma
neutrophils
1500-6000
Not for immunocompromised
below 500 sevre
FRESH flowers, fruits
Pitcher of water
Infected individuals
Platelets
150k-450k
high platelet count
AVOID
Contact sports
Straight razor
Regular toothbrush
Invasive procedure
Coagulation studies bleeding time
1-10 mins
Prothrombin time
10-12 secs
AST and ALT:
10-40
Albumin
3.5-5
Amylase
25-150
BUN
10-20
S. creatinine
0.6-1.2 mgdl
Chloride
95-105
Before extraction of ABG
Allen’s test
ABG values
pH 7.35-7.45
CO2
35-45
HCo3
22-26
Upper GI series
Laryngo
Bronchp
EGD
Esophago
GAstro
Duodenoscopy
Lower GI
Colonoscopy
Prep for Upper GI endoscopy
“CNAVA”
Consent
NPO post midng
Atropine SO4
Valium
Anesthetic spray
WOF (Upper GI endoscopy)
Bleeding
Perforation
Prep for Lower GI
“LLNC”
Low residue diet
Laxative
NPO midnt
Cleaning enema
Left sims
Post op care for Lower GI
Bleeding and Perforation
Series of Xray with fluoroscopy
Barium studies
Stool not excreted within 24 hrs
Bowel obstructio
LGIS
Barium enema
UGIS
Barium swallow
CPT technique
“PVP”
Percussion
Vibration
Postural drainagw
Do CPT when
before meals or 2 hrs post meals
After nebu
Mouth care after procedure
position for suctioning in unconscious pt
Side lying
For consciousn
Fowlers
Nasopharyngeal tube
tip of the nose to earlobe
Tracheal suction
1-2 cm
most accurate oxygen deliverer
Venturi mask
Best for COPD
Oxygen for suctioning
Non rebreather
Oxygen for magnesium poisoning severe hypoxemia
High flow nasal cannula
nursing int before suction
Hyperoxygenate for 1 mins
Apply suction during WITHDRAWAL
Durations of suctioning
Duration 5-10 max of 15
Interval 20-30 secs
Total of 5 mins
2 types of suction machine and its power
Durable: 10-15 mmHg adult
Wall mounted: 100-120 mmHg adult
removes fluid in the pleural space
Thoracentesis
prep for thoracentesis
“CLCUC”
Consent
Lidocaine allergy
Coagulation studies
UTZ/Xray b4 procedure
Chest tube remain
During thoracentesis
Sitting at the edge
Lateral recumebnt
Post op thora
Unffected side to avoid leak
Monitor after thoracentesis
RR
Expetorate blood
Respiratory distress: USe of accessory muscles
Chest tube thoracostomy
Negative pressure immersed in H2o for 2cm
Normal in CTT
Tidaling or intermittend bubbling
Continous bubbling in CTT
Air leak
Absent bbbling in CTT
check for KInks
if not kinks report to physician to re expand lungs
Drainage for CTT
100 ml per hr
if 400 ml or more for 24 hrs in CTT
REMOVE
if disconnected tube
Cover dry sterile gauce and petroleum gauge
tape at 3 sides
if bottle break in CTT
immersed in basin of water or NSS
cuff pressure in tracheostomy
20-30 mmhg
which at bedside in tracheostomy
Obturator as Guide
Cleaner in tracheostomy
Hydrogen peroxide half strength mixed with NSS or water
Must be at bedside if patient is in tracheostomy
Suction machine
Inner cannula
Obturator
Lavage
Drainage
Gavage
Feeding
Single lumen
Levin tube
Double lumen
SAlem sump
Insertion of NGT
High fowlers
Hyperextended neck
Flex n eck
Length of NGT “NEX”
Tip of NEX
Nose - Earlobe - Xiphoid
Check for placement of NGT
Aspirate gastric content
pH 1-4
Xray (CONFIRMATORY)
After feeding in NGT
Semif owlerrs
If 100 ml drainage
Hold the feeding
flushing of NGT
before and afterr
30-60 ml
Regular stoma large intestine
Colostomy
Smaller stoma in the RLQ small intestine
Ileostomy
Ileostomy stools
Liquid stoold
Diarrhea
WOF in ileostomy
Obstructoon
Avoid
Raw vege
Nuts
Popcorn
Transverse colon
Mushy stools
Ascending colon
Liquid stool
Descending colon
Semi formed
Sigmoid colon
Well formed
Stoma assesssment: Pale pink
Anemia
Stoma assesssment: Black
Necrotic
Stoma assesssment: Bluish
Ichemia
Empty bag when
1/2-1/3 full
Wafer
Into the skin
Foods that cause stoma odor
Oily
Fatty
Spicy
Brocolli, cabbage, spinach
Foods that reduce odor
(PaBuYoCOT)
Parsley
Buttermilk
Yogurt
Cranberry juice
Orange juice
Tomato juice
COAL in crutchesq
Cane
Opposite
Affected
Leg
upstairs
goodleg
Downstairs
Basd leg
right cruthc then left
2 pt gait
Catheter: Single lumen
Straight cath
Double lumen
Foley cath
Triple lumen
Cystoclysis (continous bladder irrigation)
Male secure cath
Lower abdomen
Upper thigh
Female secure cath
Inner thigh
Position upon catheter
M: Supine leg extended
F: Dorscal recumben
Clean procedures
eyes
Git
Vagina
Enema position
Left sims
Rectal cath
Water based lube 1-2 inch
Low flow enema
12 in above
High flow enema
18 inch above
