rn stuff!

Insulin Chart

2008-09-02T08:54:00.002+08:00

Generic Name	Brand Name	Onset (hr)	Peak (hr)	Duration (hr)
Insulin aspart	Novolog	0.25	1-3	3-5
Insulin lispro	Humalog	0.25	0.5-1.5	3-4
Regular human Insulin	Humulin R Novolin R	0.5 0.5	2-4 2.5-5	6-8 8
Human insulin isophane suspension	NPH	1.5	4-12	24
Human insulin zinc suspension	Lente	2.5	7-15	22
Human insulin extended zinc suspension	Ultralente	4-6	8-20	28
Insulin glargine	Lantus	2-4	None	24
70% insulin aspart protamine suspension/30% insulin aspart	Novolog Mix 70/30	0.25	1-4	24
75% insulin lispro protamine suspension/30% insulin lispro	Humalog Mix 75/25	0.25	1-2	24
70% Human insulin isophane suspension (NPH)/30% regular insulin	Humulin 70/30 Novolin 70/30	0.5 0.5	2-12 2-12	24 24
50% Human insulin isophane suspension (NPH)/50% regular insulin	Humulin 50/50	0.5	3-5	24

Technorati Tags nclex-rn

SATA Questions in NCLEX-RN

2008-09-02T08:02:00.002+08:00

ESRD DIET • Restricted protein intake • Increase CHO • Low K, P • Restrict Na	SUPERIOR VENA CAVA OCCLUSION • Sx occur in the morning • Edema of face, eyes & tightness of shirt/ (Stoke’s sign) • Late sx: edema of arms, hands, dyspnea, erythema, epistaxis
NORMAL IN 8 MONTH OLD CHILD - can sit with out support - can roll from front to back - can hold a bottle - closure of ant. fontanel - can say mama and dada - 2 teeth present	ULCERATIVE COLITIS Sx: • Severe diarrhea with blood & mucus • Abdominal tenderness & cramping • Anorexia • Wt. Loss • Vit. K deficiency • Anemia • Dehydration • Electrolyte imbalance • Low residue & high protein diet
DILANTIN • do not floss throughout the day • do not use hard bristled toothbrush • Gingivitis S/E	ANAPHYLACTIC REACTION (steps) • Stop medication • Maintain airway • Notify MD • Maintain IV access of 0.9 NSS • Place in supine position with legs elevated • Monitor VS • Administer prescribed emergency drugs
BLADDER CA Risk Factors: • Hx of smoking • Exposure to radiation • Working in industrial Factory	S/S OF DKA • Fruity breath Odor • Oliguria • Kusmaull'’s (deep & nonlabored)
SITE FOR IM INJECTION ADULT • Deltoid • Ventrogluteal • Vastus Lateralis • Gluteus Maximus	S/S OF BACTERIAL MENINGITIS • N & V • Seizures • Stiff Neck • Photophobia • Positive Brudzinski sign
TB • Waking up sweating at night • Low grade fever • Dull aching chest pain • Cough streaked with blood • Weight loss • Anorexia • Fatigue	LIVER CIRRHOSIS • N & V • Edema • Ascites

Technorati Tags stuff,SATA,nclex-rn

Nurse's Thoughts

2008-08-19T08:10:00.001+08:00

For other health or nursing related articles, news and stories visit:

Dopamine and Dobutamine Computations

2008-03-08T12:56:00.002+08:00

for DOPAMINE, the constants are
single dose = 13.3 (translates to 200/250 or 400/500)
double dose = 26.6 (translates to 400/250 or 800/500)

... for DOBUTAMINE, the constants are
single dose = 16.6 (translates to 250/250 or 500/500)
double dose = 33.3 (translates to 500/250 or 1000/500)

the formula for the above computation is always...

DOSAGE x WT
___________
constant

FOR THE EXPLANATION OF CONSTANT:
notice in the sample computation of double-dose dopamine: pt wt. 176lbs. doctor ordered 5mcg/kg/MIN. available is 400/250 DOPAMINE in D5 water. how many ml/hr to give?

(5 mcg / kg min) x (80 kg) x
(250 ml / 400 mg) x (1 mg / 1000 mcg) x (60 min / 1 hr)

if we summarize the 2nd line, this can be reduced to:
(5 mcg / kg min) x (80 kg) x (0.0375 ml min / mcg hr)

the short-cut it is:

(5 mcg / kg min) x (80 kg)
________________________________
26.6 <-- (this is the RECIPROCAL of 0.0375)

: so in actuality the unit of 26.6 is (mcg hr / ml min)

WHY IS THERE A NEED TO KNOW THE CONSTANT?
IN SOME CASES, 400/250 IS NOT BEING MENTIONED IN NCLEX... SOMETIMES THE QUESTION WOULD BE LIKE

pt wt. 176lbs. doctor ordered 5mcg/kg/MIN. available is DOUBLE-DOSE DOPAMINE in D5 water. how many ml/hr to give? so in this case we know that we will be using 26.6...

for the rest of the computation... just remember to elimitate the UNITS thru multiplication process in order to come up with the CORRECT DESIRED UNITS... REMEMBER YOUR CONVERSION FACTORS FOR TIME,WEIGHT & VOLUME......

lets have an example...

Infuse Nitroprusside 25 mg in D5W 250 ml at 50mcg /min using microdrip tubing.Determine the ml/hr and the gtts/min.

Given:
25 mg/250 ml ( there is 25 mg NA Nitroprusside PER 250 ml...based on the given)
50 mcg/min
60 mcgtts/1 ml <---- microdrip

Find: ml/hr :
(250ml/25mg) x (1 mg/1000 mcg) x (50mcg/min)

= 0.5ml/min
= (0.5ml/min) x (60min/1 hr) = 30 ml/hr <---answer

Find: gtts/min :
(30ml/hr)x(60gtts/ml)x(1hr/60min)
= 30 gtts/min <----answer

example 2

Infuse Dobutamine 500 mg in 250 ml D5W at 5 mcg/kg/min using microdrip tubing.The client weighs 182 lbs. Determine the ml/hr and the gtts/min.

Given:
500mg/250ml (this is double-dose dobu)
5 mcg/kg/min
182 lbs
60gtts/ml <------- microdrip

Find:ml/hr
182 lbs x (1kg/2.2lbs) = 82.7kg

(5 mcg/kg min) x (82.7kg) = 413.5 mcg/min

413.5 mcg/min x 1mg/1000mcg = .4135 mg/min

.4135 mg/min x 250ml/500mg <--- ML is the numerator since were looking for ML/HR
= 0.20675ml/min

= 0.20675ml/min x (60 min / 1 hr) = 12.4 ml/hr <--ans

... using the short-cut: 33.3 is constant for double dose dobutamine...
5mcg/kg-min x 82.7kg divide by 33.3 = 12.41 ml/hr <--same answer.^^

Find: gtts/min
12.41 ml/hr x (1 hr/60 min) x (60gtts/ml) =
= 12 gtts/min... <---answer (Drops Per Minute MUST always be in WHOLE NUMBERS while ml/min, ml/hr,etc may have decimal points)

Various BON

2008-01-10T21:03:00.000+08:00

California Board of Registered Nursing 1625 North Market Boulevard, Suite N-217 Sacramento, CA 95834-1924 Phone: 916.322.3350 Fax: 916.574.8637 Contact Person: Ruth Ann Terry, MPH, RN, Executive Officer

Florida Board of Nursing Mailing Address: 4052 Bald Cypress Way, BIN C02 Tallahassee, FL 32399-3252 Physical Address: 4042 Bald Cypress WayRoom 120 Tallahassee, FL 32399 Phone: 850.245.4125 Fax: 850.245.4172 Contact Person: Rick García, MS, RN, CCM, Executive Director

Georgia Board of Nursing 237 Coliseum Drive Macon, GA 31217-3858 Phone: 478.207.2440 Fax: 478.207.1354 Contact Person: Sylvia Bond, RN MSN, MBA, Executive Director
Guam Board of Nurse Examiners Regular mailing address: P.O. Box 2816 Hagatna, Guam 96932 Street address (for FedEx & UPS): 651 Legacy Square Commercial Complex, South Route 10Suite 9Mangilao, Guam 96913 Phone: 671.735.7406 Fax: 671.735.7413 Online: N/A Contact Person: Margarita Bautista-Gay, RN, BSN, MN, Acting Nursing Administrator

Maryland Board of Nursing 4140 Patterson Avenue Baltimore, MD 21215 Phone: 410.585.1900 Fax: 410.358.3530 Contact Person: Patricia Ann Noble, MSN, RN Executive Director

New Jersey Board of Nursing P.O. Box 45010124 Halsey Street, 6th FloorNewark, NJ 07101 Phone: 973.504.6430Fax: 973.648.3481 Contact Person: George Hebert, Executive Director

New Mexico Board of Nursing 6301 Indian School Road, NESuite 710 Albuquerque, NM 87110 Phone: 505.841.8340 Fax: 505.841.8347 Contact Person: Allison Kozeliski, RN, Executive Director

Nevada Board of Nursing 5011 Meadowood Mall Way, Suite 300 Reno, NV 89502 Phone: 775.688.2620 Fax: 775.688.2628Online: Contact Person: Debra Scott, MS, RN, Executive Director

New York State Board of Nursing Education Bldg.89, Washington Avenue 2nd Floor West Wing Albany, NY 12234 Phone: 518.474.3817, Ext. 280 Fax: 518.474.3706 Contact Person: Barbara Zittel, PhD, RN, Executive Secretary

Northern Mariana Islands Commonwealth Board of Nurse Examiners Regular Mailing Address: P.O. Box 501458 Saipan, MP 96950 Street Address :(for FedEx and UPS)#1336 Ascencion DriveCapitol HillSaipan, MP 96950 Phone: 670.664.4812 Fax: 670.664.4813 Online: N/A Contact Person: Rosa M. Tudela, Associate Director of Public Health & Nursing

Pennsylvania State Board of Nursing P.O. Box 2649 Harrisburg, PA 17105-2649 Phone: 717.783.7142 Fax: 717.783.0822 Contact Person: Laurette D. Keiser, RN, MSN, Executive Secretary/Section Chief

South Carolina State Board of Nursing Mailing Address: P.O. Box 12367Columbia, SC 29211 Physical Address: Synergy Business Park, Kingstree Building110 Centerview Drive, Suite 202Columbia, SC 29210 Phone: 803.896.4550 Fax: 803.896.4525 Contact Person: Joan K. Bainer, RN, MN, CNA BC, Administrator

Texas Board of Nursing 333 Guadalupe, Suite 3-460Austin, TX 78701 Phone: 512.305.7400 Fax: 512.305.7401 Contact Person: Katherine Thomas, MN, RN, Executive Director

Vermont State Board of Nursing Office of Professional Regulation National Life Building North F1.2 Montpelier, Vermont 05620-3402 Phone: 802.828.2396Fax: 802.828.2484 Contact Person: Anita Ristau, MS, RN, Executive Director

Virgin Islands Board of Nurse Licensure P.O. Box 304247, Veterans Drive Station St. Thomas, VI 00803 Phone: 340.776.7131 Fax: 340.777.4003 Contact Person: Diane Ruan-Viville, Executive Director

Virginia Board of Nursing Department of Health Professions Perimeter Center 9960 Mayland Drive, Suite 300 Richmond, Virginia 23233 Phone: (804) 367-4515 Fax: (804) 527-4455 Contact Person: Jay Douglas, RN, MSM, CSAC, Executive Director

Washington State Nursing Care Quality Assurance Commission Department of Health HPQA #6310 Israel Rd. SETumwater, WA 98501-7864 Phone: 360.236.4700 Fax: 360.236.4738 Contact Person: Paula Meyer, MSN, RN, Executive Director

Wisconsin Department of Regulation and Licensing 1400 E. Washington Avenue, RM 173Madison, WI 53708 Phone: 608.266.0145 Fax: 608.261.7083 Contact Person: Kimberly Nania, PhD, MA, BS, Director, Bureau of Health Service Professional

Click here for more State Board of Nursing Addresses

Bronchitis

2008-01-10T20:52:00.000+08:00

Hypernatremia

2008-01-10T20:28:00.000+08:00

Upgrading RN in Canada

2007-11-06T05:50:00.000+08:00

Before our scheduled interview in the Canadian Embassy, I started to browse the net on how I can upgrade my nursing in Canada. We were planning to go to Edmonton. Alberta Canada coz thats the only place where my husband's cousins are living. It is so hard to move when you dont know anybody right? We wanted to go to Vancouver at first coz thats one of the beautiful place to live according to some people.

So I check the website of College and Association of RN of Alberta (CARNA). Everything you want to know is there. I just download and print the application form, form for school and for the PRC. After I passed the IELTS exam I didnt send it to them yet coz Im still not sure if they going to reply. After 8 months I received a letter from them telling me that they got all my credentials except my IELTS result. So I mailed it to them through IDP.

September of 2006 when I got a letter saying I need to take the Substantially Equivalent Competence (SEC) Assessment Exam. It's a 5 days exam where they test your nursing knowledge and skills in all the different fields of nursing such as Med-Surg, Maternity and Child, Pediatrics and Psychiatric Nursing. It's a pencil and paper based multiple choice exam in each field plus a short answer portion. There is also the "Triple Jump Assessment", a case presentation type. Another component of the assessment is the "clinical judgment one on one exam" which is like an oral exam and the last part is the return demonstration where the examiners will tell you to do certain procedures in a clinical setting. I tell you its difficult and its downright crazy if you are not familiar with what they are asking! I will give you some details about that on my next blog.

As soon as we arrived here in Edmonton, Canada, I phoned the one who is in charge of the assessment exam appointment. We talked and she booked me for Aug 12-16 exam in Mt. Royal College in Calgary. Calgary is the biggest city here in Alberta, travel time is 3 hours by bus from Edmonton. I have to wait for 3 months again before I can take that exam. I'm so eager to challenge their exam coz I just reviewed in KAPLAN for NCLEX. I think I have enough knowledge but Im not confident with my skills. Sort of saying .... Maybe I got the knowledge but not enough of the skills!

While waiting for that, I have to look for a job. I applied as Nursing Assistant (NA) in a continuing care facility under the Capital Care Group. Luckily, I was hired. Right now, I'm still working as an NA pending compliance of all the requirements needed to be an RN here in Canada.

Applying as a Canadian Immigrant

2007-11-05T10:01:00.000+08:00

I applied as immigrant in Canada after I finish my Nursing in Davao Doctors College. If you ask me why, hmmm... I don’t even know why. My Mom wanted me to go and work abroad. I was easy go lucky then and I don’t even care of working abroad. So my mom kept on insisting about it, so I went to one of the agencies in Davao who caters about living in Canada. I submitted all the necessary requirements they needed and paid all the processing and filing fee. It cost me around 45K. After 4 years, I received a letter from the Canadian Embassy, telling about the scheduled interview. I was already married then and Have a son. I didn’t update my files coz I’m not expecting it anymore. When I asked my husband about it, He said NO. I can’t blame him, he is a Doctor and we managed our family business. Financially, we were fine then. So what I did was I went to my agency and told them that I will not resume my application and so they sent a letter to the Embassy. After a year the embassy sent me a letter giving me another chance for an interview. This time, I convinced my husband that we will attend the interview and see what will happen next. The hardest part about it is raising additional funds coz the embassy demands a certain amount for a family of three to immigrate to Canada. This comes to roughly around 800K. On the day of the interview, I was so nervous. I hate interviews! I was even shaking when they asked me to take an exam coz I didn’t have an English exam yet. When the Consul interviewed us, it was fine. We are able to answer all her practical questions. She was trying to tell us that life in Canada is not easy coz we have to start from nothing. Finally she told me to take IELTS exam in order for me to get the points I needed. Canada is a “points system”, there are certain points for your age, course, diploma, language and if you have immediate family in Canada. She said if I got a passing score in IELTS then they will send us for medical exam after. That interview was last Oct 2005, 2 months after, I took the IELTS EXAM and January 2006 I got my result. I passed! I sent my result to the Canadian Embassy then on March I got a letter for our Medical exam. April 22 when we had our medical exam at Davao Doctors Hospital. It’s going to be expire after a year, so we better fly to Canada before one year. While waiting, I decided to take CGFNS Exam. September 2006 when I took it and I luckily passed it. My husband finally got his Nursing Diploma but he did not take the Nursing Board Exam. It was December, when I received a call from the Embassy. They were asking for our passport for the visa. We went to Singapore for a Christmas vacation and I told them that I'll send our passport on January 2007. Carlo, my hubby took and passed his IELTS last February. I was also reviewing at KAPLAN for NCLEX. Me and my hubby finally got our ATT and we both scheduled for NCLEX at Saipan in March 13. We both passed it with flying colors. It’s April 11, 2007 when we arrived in Canada.

Paulo Coelho Quotes - fave author

2007-11-04T16:17:00.000+08:00

Paulo Coelho is one of my favorite authors (I hate to think he's comparable to JK Rowling and Bob Ong, hehehe). Here are the quotes that might help you understand why I read his books:

“Everyone seems to have a clear idea of how other people should lead their lives, but none about his or her own”

“People need not fear the unknown if they are capable of achieving what they need and want”

“There is only one thing that makes a dream impossible to achieve: the fear of failure”

“Usually the threat of death makes people a lot more aware of their lives”

“Stop thinking all the time that you're in the way, that you're bothering the person next to you. If people don't like it, they can complain. And if they don't have courage to complain, that's their problem”

“...there were two things that prevent us from achieving our dreams: believing them to be impossible or seeing those dreams made possible by some sudden turn of the wheel of fortune, when you least expected it. For at that moment, all our fears suddenly surface: the fear of setting off along a road heading who knows where, the fear of a life full of new challenges, the fear of losing for ever everything that is familiar”

“A warrior accepts defeat. He does not treat it as a matter of indifference, nor does he attempt to transform it into a victory. The pain of defeat is bitter to him; he suffers at indifference and becomes desperate with loneliness. After all this has passed, he licks his wounds and begins everything anew. A warrior knows that war is made of many battles: he goes on”

“Tragedies do happen. We can discover the reason, blame others, imagine how different our lives would be had they not occurred. But none of that is important: they did occur, and so be it. From there onward we must put aside the fear that they awoke in us and begin to rebuild”

“You have to take risks. We will only understand the miracle of life fully when we allow the unexpected to happen”

“We can never judge the lives of others, because each person knows only their own pain and renunciation. It's one thing to feel that you are on the right path, but it's another to think that yours is the only path”

“But there is suffering in life, and there are defeats. No one can avoid them. But it's better to lose some of the battles in the struggles for your dreams than to be defeated without ever knowing what you're fighting for”

Hope you read some of his books; it might help us deal with life.

I am Reborn!

2007-11-01T17:11:00.000+08:00

As you can see, I am doing my best to make this blog more interactive and fun... I almost deleted this one because I cannot maintain two blogs at the same time. But when I saw that its PageRank is 2/10, I decided to revive this (It is hard to get Google PageRank, you know...) I was not that aware that this blog has a lot of readers.

Anyways, Thanks to all of you. I invited friends who are in medical fields as co authors. I want them to share their experiences around the world so that we have idea what its like to be in their places.

Bear with me as I am trying my best to make this blog something to look forward to.

Tremendous Increase in H-1B Visa Fee

2007-10-31T23:55:00.000+08:00

While the Bridge Amendment is still for discussion in the House. The Senate and the House will be meeting on November one to discuss some bills which includes the increase 3500 for the H-1B Visa Fee. The Employers are protesting because it will cost them too much to hire and shoulder all the expense for health workers.

I hope everything will turn out right in favor to the foreign health workers.

More latest updates at Hammond Law Group

Ear Drops Administration

2007-08-01T01:38:00.000+08:00

Wash your hands with soap and warm water and dry them thoroughly.
Carefully wash and dry the outside of the ear, taking care not to get any water in the ear canal.
Warm the ear drops to body temperature by holding the container in the palms of hands for a few minutes. Do not warm the container in hot water. Hot ear drops can cause pain, nausea, and dizziness.
Shake the container.
Tilt your head (or have the patient tilt his or her head) to the side or lie down with the affected ear up. Use gentle restraint, if necessary, for an infant or a young child.

Open the container carefully. Position the dropper tip near, but not inside, the ear canal opening. Do not allow the dropper to touch the ear, because it could become contaminated or injure the ear. Ear drops must be kept clean.
Pull your ear (or the patient’s ear) backward and upward to open the ear canal, as shown in the picture above. If the patient is a child younger than three years old, pull the backward and downward, as shown in the picture below.
Place the proper dose of number of drops into the ear canal. Replace the cap on the container.
Gently press the small, flat skin flap over the ear canal opening to force out air bubbles and push the drops down the ear canal.
Stay (or keep the patient) in the same position for at least five minutes. If the patient is a child who cannot sit still, the doctor may tell you to place a clean piece of cotton gently into the child’s ear, to prevent the medication from draining out.
Repeat the procedure for the other ear, if directed to do so.
Gently wipe any excess medication of the outside of the ear, using caution to avoid getting moisture in the ear canal. Wash your hands.

IELTS FAQs

2007-06-29T17:41:00.000+08:00

What can I bring into the examination room?
Only your ID, PENCILS, ERASER.. Correction fluid must not be used. You must leave anything which you do not need, or which is not allowed, either outside the examination room, or as instructed by the supervisor. Mobile phones and pagers must be switched off and placed with personal belongings in the area designated by the supervisor. Any candidate who does not switch off their phone/pager, or who retains one in their possession, will be disqualified.

Is the IELTS test completed in one day?
The Listening, Reading and Writing components of the test are always completed immediately after each other and in this same order. The Speaking test can be taken up to 7 days either before or after the test date. But usually it is done in the afternoon of the test date and on the following day.

Will the listening tape provide me with all the necessary instructions and pauses?
Yes. At the beginning of the test, candidates receive instructions and hear a sample question. Next, candidates read Section One questions and then listen to Section One and answer the questions on the question paper as they listen. The same procedure follows for Sections Two, Three and Four. This takes approximately 30 minutes to complete. In the final ten minutes, candidates transfer their answers onto the answer sheet.

Is there a similar period of ten minutes at the end of the Reading test for the transfer of answers?
No. The Reading test is one hour, and you must write all your answers on the answer sheet in this time.

What is the Speaking test?
The Speaking test is conducted as a one-to-one interview with a certified examiner, which is recorded on an audiocassette.

What should I bring for the Speaking test?
You need to bring the same identification documents you supplied on registration, as these must be checked again against the information on the application form. These documents will be checked by the administrator and the Speaking examiner prior to you entering the interview room.

What happens if I lose my Test Report form?
At any time within two years of the date of the examination, you can apply to the centre which administered the test to be sent 5 copies of the original Test Report Form free of charge. These Test Report Forms will not be sent to you, but will go directly to the university, Embassy or Consulate that require them. For any further copies, there is an administration charge per copy. Please contact us for further details.

Will I receive my results?
Under normal circumstances, you will receive your Test Report Forms approximately three weeks after you complete the test.

Help is available for disabled candidates?
Test centres make every effort to cater for the special needs of any disabled candidates, to enable them to best understand questions and tasks and to give their answers. It is our aim for the language level of all candidates, irrespective of disability, to be assessed fairly and objectively. Candidates with special needs should inform us when applying so that appropriate arrangements can be made.

What happens if I want to postpone or cancel my application?
Check our Cancellation and Postponement pages for full details.

What happens if I am absent on the day of the test without giving prior notice?
You will lose your full test fee. However, if you can provide a medical certificate within 5 days of the test date then 75% of the fee will be refunded or you can register for a later IELTS test date.

What can I do if I am unhappy with my results?
You can apply for your test to be re-marked within four weeks of receiving your results. There is a fee for this which is refunded should your band score change.

Care for a Client with Traction

2007-06-01T09:13:00.000+08:00

A. a pulling force exerted on bones to reduce and / or immobilize
fractures, reduce muscle spasm, correct or prevent deformities

B. nursing care
1. check traction apparatus frequently to ensure that
a. ropes are aligned and weighs are hanging freely
b. bed is in proper position
c. line of traction is within the long axis of the bone
2. maintain client in proper alignment
a. align in center of bed
b. do not rest affected limb against foot of bed
3. perform neurovascular checks to affected extremity
4. observe for and prevent foot drop
a. provide footplate
b. encourage plantarflexion and Dorsiflexion exercises
5. observe for and prevent deep-vein thrombosis ( especially in russel traction due to pressure on popliteal area
6. observe for an prevent skin irritation and breakdown ( especially over body prominences and traction application sites)
7. provide pin care for clients in skeletal traction
a. usually consist of cleansing and applying antibiotic ointment, but individual agency policies may vary
b. observe for any redness, drainage, odor
8. assist with ADL; provide overhead trapeze to facilitate moving, using bedpan, ect
9. prevent complications of immobility
10. encourage active ROM exercises to unaffected extremities
11. Check carefully for orders about turning

Care for a Client with Cast

2007-06-01T09:11:00.000+08:00

A. Types of cast: long arm, short arm, long leg, short leg, walking cast with rubber heel, body cast, shoulder spica, hip spica

B. Casting materials
1. plaster of paris – traditional cast
a. takes 24- 72 hours to dry
b. precautions must be taken until cast is dry to prevent dents, which may cause pressures areas
c. signs of dry cast: shiny white , hard , resistant
d. must be kept dry since water can ruin a plaster cast
2. synthetic cast ( fiberglass)
a. strong, lightweight ;sets in about 20 minutes
b. can be dried using dryer or hair blow-dryer on cool setting; some need special lamp to hardened
c. water-resistant; however, if cast become wet, must be dried thoroughly to prevent skin problems under cast

C. cast drying – plaster cast
1. use palms of hands, not fingertips, to support cast when moving or lifting client
2. support cast on rubber – plastic protected pillows with cloth pillowcase along length of cast until dry
3. turn client every 2 hours to reduce pressure and promote drying
4. do not cover the cast until it is dry ( may use fan to facilitate drying)
5. do not use heat lamp or hair dryer on plaster cast

D. Assessment
1. perform neurovascular checks to area distal to cast
a. report absent or diminished pulse, cyanosis, or blanching, coldness, lack of sensation, inability to move finger or toes, excessive swelling
b. report complains of burning , tingling or numbness
2. note any odor from the cast that may indicate infection
3. note any bleeding on cast in a surgical client
4. check for “hot spots” that may indicate inflammation under cast

E. general care
1. instruct client to wiggle toes or fingers to improve circulation
2. elevate affected extremity above heart level to reduce swelling
3. apply ice bag to each side of the cast if ordered

F. Providing client teaching and discharge planning concerning
1. isometric exercises when cleared with physician
2. reinforcement of instructions given on crutch
3. do not get cast wet; wrap cast in a plastic bag when bathing or take a sponge bath
4. if a cast that has already dried and hardened does become wet, may use blow dryer on low setting over wet spot; if large area of plaster cast becomes wet, call physician
5. do not scratch or insert foreign bodies under cast; may direct cool air from blow dyer under cast for itching
6. recognize and report signs of impaired circulation or of infection
7. cast cleaning
a. clean surface soil on plaster cast with a slightly damp cloth; mild soap may be used for synthetic cast
b. to brighten a plaster cast, apply white shoe polish sparingly

Assistive Devise

2007-06-01T09:07:00.000+08:00

A. Cane
1. types: Single, straight-legged cane, tripod cane
2. nursing care: teach client to hold cane in hand opposite from the affected extremity and to advance cane at the same time the affected leg is move forward

B. Walker
1. mechanical device with four legs for support
2. nursing care: teach client to hold upper bars of walker at each side, then move the walker and step into it

C. Crutches: teaching the client proper use of crutches is an important nursing responsibility
1. ensure proper length
a. when client assumes erect position the top of crutch is 2 inches below the axilla, and 6 inches in front and to the side of the feet
b. client’s elbow should be slightly flexed when hand is on the hand grip
c. weight should not be borne by the axillae
2. crutch gaits
a. four – point gait: used when weight bearing is allowed on both extremities
1. advance right crutch
2. step forward with left foot
3. advance left crutch
4. step forward with right foot
b. two-point gait: typical walking pattern, an acceleration of four – point gait
1. step forward moving both right crutch and left leg simultaneously
2. step forward moving both left crutch and right leg simultaneously.
c. three-point gait: used when weight bearing is permitted on one extremity only
1. advance both crutches and affected extremity several inches, maintaining good balnce
2. advance the unaffected leg to the crutches , supporting the weight of the body on the hands
d. Swing-to( through) : used for clients with paralysis of both lower extremities who are unable to lift feet from floor
1. both crutches are placed forward
2. clients swings forward to the crutches

Crack the NCLEX-RN Exam!

2007-05-17T03:15:00.000+08:00

1. READ, READ, READ. a broader knowledge
in nursing concepts, content areas and
DRUGS makes you prepared to take on
questions on clinical assessment,
interventions and procedures. Do not
focus on how much info you can absorb
but just try to understand and apply the
knowledge you learned in the actual
clinical setup. the big question
is...ARE YOU COMPETENT, SAFE and
EFFECTIVE TO PRACTICE NURSING IN THE US?
(i read Saunders 3rd Ed. twice, the
Davis Reviewer on Drugs, part of Mosby's
and the Kaplan Strategies for Test
taking at least 2x too) Also, take time
to study the Herbal Drugs--saw palmetto,
black cohosh, st.johns wort, hawthorne,
gingko biloba etc. are frequently asked.

2. SIMULATE THE NCLEX EXAM. Take as much
Practice Tests in your computer. Take
time to answer the questions. I take a
100 item exam in the morning, another
100 in the afternoon and another 100
just before going to sleep.

3. LEARN FROM YOUR MISTAKES. Take time
to check on the rationales of the
mistakes you have made. It is better to
make mistakes now and learn from it
rather than on the actual exam.

4. DEVELOP,MASTER and APPLY TEST TAKING
STRATEGIES. In the exam, you don't look
for the answer right away. You need to
eliminate to get to the right answer.
Follow a criteria in eliminating choices
given. Make use of the Maslow's
Heirarchy, ABC, ADPIE, Safety... Never
rely on a hunch---try to eliminate.

5. EXERCISE, SLEEP and EAT WELL. You
don't want to be sick on the week of
your exam.

SPEND ENOUGH TIME WITH YOUR FAMILY or
FRIENDS---you also don't want to be
crying in the day of the exam because
you miss them.

6. SECURE YOUR ATT, ATB (for Saipan),
PLANE TICKETS, HOTEL and MONEY as early
as possible. If you attend to it later,
these things will cause severe anxiety
on your part--and you never would want
that..believe me, i got my ATB the day
i'm leaving for Saipan.

ALERT! ALERT! Make sure that you signed
your Passport. An examinee was not
admitted at Pearsonvue on his exam day
because he forgot to sign his passport.

7. BE CONFIDENT, NEVER DOUBT YOURSELF
and BELIEVE YOU CAN MAKE IT. Our
attitude defines us when we face
adversities.

8. ALWAYS TAKE TIME TO COMMUNE WITH GOD.
Never start a day without talking to God
and gaining strength from Him and His
Word. In exams as NCLEX, we need His
divine intervention above anything
else--at least on my part, it was indeed
the determining factor in my exam.

from goodnurses club

Caring for the Patient on a Ventilator

2007-05-03T14:29:00.000+08:00

The nurse must be able to do the following:

1. Identify the indications for mechanical ventilation.

2. List the steps in preparing a patient for intubation.

3. Determine the FIO2, tidal volume, rate and mode of ventilation on a given ventilator.

4. Describe the various modes of ventilation and their implications.

5. Describe at least two complications associated with patient’s response to mechanical ventilation and their signs and symptoms.

6. Describe the causes and nursing measures taken when trouble-shooting ventilator alarms.

7. Describe preventative measures aimed at preventing selected other complications related to endotracheal intubation.

8. Give rationale for selected nursing interventions in the plan of care for the ventilated patient.

9. Complete the care of the ventilated patient checklist.

10. Complete the suctioning checklist.

11.To review indications for and basic modes of mechanical ventilation, possible complications that can occur, and nursing observations and procedures to detect and/or prevent such complications.

12.To provide a systematic nursing assessment procedure to ensure early detection of complications associated with mechanical ventilation.

Indication for Intubation

1. Acute respiratory failure evidenced by the lungs inability to maintain arterial oxygenation or eliminate carbon dioxide leading to tissue hypoxia in spite of low-flow or high-flow oxygen delivery devices. (Impaired gas exchange, airway obstruction or ventilation-perfusion abnormalities).
2. In a patient with previously normal ABGs, the ABG results will be as follows: PaO2 > 50 mm Hg with pH <> 50 mm Hg : hypertension, irritability, somnolence (late), cyanosis (late), and LOC (late)

3. Neuromuscular or neurogenic loss of respiratory regulation. (Impaired ventilation)4. Usual reasons for intubation: Airway maintenance, Secretion control, Oxygenation and Ventilation.

Types of intubation: Orotracheal, Nasotracheal, TracheostomyPreparing for Intubation

Recognize the need for intubation.

Notify physician and respiratory therapist. Ensure consent obtained if not emergency.

Gather all necessary equipment:

a. Suction canister with regulator and connecting tubing

b. Sterile 14 Fr. suction catheter or closed in-line suction catheter

c. Sterile gloves

d. Normal saline

e. Yankuer suction-tip catheter and nasogastric tube

f. Intubation equipment: Manual resuscitator bag (MRB), Laryngoscope and blade, Wire guide, Water soluble lubricant, Cetacaine sprayg.

g. Endotracheal attachment device (E-tad) or tapeh.

h. Get order for initial ventilator settingsi.

i. Sedation prn

j. Soft wrist restraints prnk.

k. Call for chest x-ray to confirm position of endotracheal tubel.

l. Provide emotional support as needed/ ensure family notified of change in condition.

Intubation

Types of Ventilators

Ventilator Settings, Modes of Mechanical Ventilation, Complications of Mechanical Ventilation

1. Associated with patient’s response to mechanical ventilation:

A. Decreased Cardiac Output

Cause - venous return to the right atrium impeded by the dramatically increased intrathoracic pressures during inspiration from positive pressure ventilation. Also reduced sympatho-adrenal stimulation leading to a decrease in peripheral vascular resistance and reduced blood pressure.

Symptoms – increased heart rate, decreased blood pressure and perfusion to vital organs, decreased CVP, and cool clammy skin.

Treatment – aimed at increasing preload (e.g. fluid administration) and decreasing the airway pressures exerted during mechanical ventilation by decreasing inspiratory flow rates and TV, or using other methods to decrease airway pressures (e.g. different modes of ventilation).

B. Barotrauma

Cause – damage to pulmonary system due to alveolar rupture from excessive airway pressures and/or overdistention of alveoli.

Symptoms – may result in pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema.

Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of high airway pressures resulting in development of auto-PEEP in high risk patients (patients with obstructive lung diseases (asthma, bronchospasm), unevenly distributed lung diseases (lobar pneumonia), or hyperinflated lungs (emphysema).

C. Nosocomial Pneumonia:

Cause – invasive device in critically ill patients becomes colonized with pathological bacteria within 24 hours in almost all patients. 20-60% of these, develop nosocomial pneumonia.

Treatment – aimed at prevention by the following:

Avoid cross-contamination by frequent handwashing.

Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-bore NG tubes)Suction only when clinically indicated, using sterile technique

Maintain closed system setup on ventilator circuitry and avoid pooling of condensation in the tubing.

Ensure adequate nutritionAvoid neutralization of gastric contents with antacids and H2 blockers

D. Positive Water Balance:

1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) – due to vagal stretch receptors in right atrium sensing a decrease in venous return and see it as hypovolemia, leading to a release of ADH from the posterior pituitary gland and retention of sodium and water. Treatment is aimed at decreasing fluid intake.

2. Decrease of normal insensible water loss due to closed ventilator circuit preventing water loss from lungs. This fluid overload evidenced by decreased urine specific gravity, dilutional hyponatremia, increased heart rate and BP.E.

E. Decreased Renal Perfusion – can be treated with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP) – reduce PEEP

G. Hepatic congestion – reduce PEEP

H. Worsening of intracardiac shunts –reduce PEEP

2. Associated with ventilator malfunction:

Alarms turned off or nonfunctional – may lead to apnea and respiratory arrestTroubleshooting

Ventilator AlarmsLow exhaled volume: Cuff leak, Tubing disconnect, Patient disconnectedEvaluate cuff; reinflate prn; if ruptured, tube will need to be replaced. Evaluate connections; tighten or replace as needed; check ETT placement, Reconnect to ventilator.

High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff herniation, Increased airway resistance/decreased lung compliance (caused by bronchospasm, right mainstem bronchus intubation, pneumothorax, pneumonia), Patient coughing and/or fighting the ventilator; anxiety; fear; pain.

Suction patient, Insert bite block, Reposition patient’s head/neck; check all tubing lengths, Deflate and reinflate cuff,

Auscultate breath sounds, Evaluate compliance and tube position; stabilize tube,

Explain all procedures to patient in calm, reassuring manner, Sedate/medicate as necessary.

Low oxygen pressure: Oxygen malfunctionDisconnect patient from ventilator; manually bag with ambu; call R.T

3. Other complications related to endotracheal intubation.

Sinusitis and nasal injury – obstruction of paranasal sinus drainage; pressure necrosis of nares

1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.

2. Treatment: remove all tubes from nasal passages; administer antibiotics.B.

Tracheoesophageal fistula – pressure necrosis of posterior tracheal wall resulting from overinflated cuff and rigid nasogastric tube

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressures q. 8 h.

2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral feedings; place esophageal tube for secretion clearance proximal to fistula.

Mucosal lesions – pressure at tube and mucosal interface

1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8 h.; use appropriate size tube.

2. Treatment: may resolve spontaneously; perform surgical interventions.

Laryngeal or tracheal stenosis – injury to area from end of tube or cuff, resulting in scar tissue formation and narrowing of airway

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8.h.; suction area above cuff frequently.

2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical repair.

Cricoid abcess – mucosal injury with bacterial invasion

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8 h.; suction area above cuff frequently.

2. Treatment: perform incision and drainage of area;

3. administer antibiotics.

Other common potential problems related to mechanical ventilation: Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick secretions, Patient discomfort due to pulling or jarring of ETT or tracheostomy, High PaO2, Low PaO2, Anxiety and fear, Dysrhythmias or vagal reactions during or after suctioning, Incorrect PEEP setting, Inability to tolerate ventilator mode.

PLAN OF CARE FOR THE VENTILATED PATIENT

Patient Goals:

1. Patient will have effective breathing pattern.

2. Patient will have adequate gas exchange.

3. Patient’s nutritional status will be maintained to meet body needs.

4. Patient will not develop a pulmonary infection.

5. Patient will not develop problems related to immobility.

6. Patient and/or family will indicate understanding of the purpose for mechanical ventilation.

courtesy: good nurses club

Drugs and Dosage

2007-04-28T12:44:00.000+08:00

Part H IV DRIP CALCULATIONS

Calculation of Weight Based IV DripsDrugs can be administered to clients in continuous IV drips.

The medication bag/syringe is labeled with the concentration of medication in the solution (i.e. units/ml,mcg/ml, meq/ml).
The medication order will be used to determine the setup of the problem. Ratio and proportions can be set up to solve these problems, and depending upon the complexity of the order several steps may be needed.

The following examples will show you the basis for solving these problems.

A. When the order is written as mg/hr.

ExampleOrder: Fentanyl 5 mg/hr.
The bag is labeled 250 mg in 500 ml of solution.
How fast will the IV need to be infused to give the correct dose?

1. The IV rate will be as an hourly rate, so no conversion needs to be made for time.
If the order was written with a different time, you would need to calculate the mg/hr. (use ratio and proportion)

2. Put the problem in ratio and proportion.
5 mg = 250 mg 5 (500) = 250 x 2500 x = 10 ml/hrx ml 500 ml 250 IV rate

B. The order may be written as unit of measurement/ Kg of weight/ hour.

Example Order: Heparin 100 units/Kg/hr.
The label on the solution reads 10,000 units/50 ml.The patient weighs 70 Kg.

How fast should the solution run to give the correctdosage?
1. First you need the total dosage/hr.Dose (units/hr) x weight in Kg equals the hourly dose.
If the weight isin lbs, that must be converted to Kg first.100 units x 70 Kg = 7,000 units/hr2.

Now put the dose in ratio and proportion with the concentration.7,000 units = 10,000 units

10,000x = 50 (7,000) x= 350,000 x= 35 ml/hrx ml 50 ml 10,000 rate

C. When the order is written as unit of measurement/ Kg of wt/minute.

Example Order: Dopamine 20 mcg/Kg/minute.
The bag is labeled Dopamine 100 mg/50 ml.The patient weighs 88 lbs.

How fast will the IV run to give the dose?

1. First because the weight is in lbs, you must convert lbs. to Kg.(88 lbs = 40 Kg)
2. Find the hourly dose. Because it is written in mcg/K/min you must multiplyby 60 minutes to get the hourly dose.

20mcg x 40 Kg x 60 minutes = 48,000 mcg/hr3.

Note that the concentration is in mg/ml not mcg, so you must convert too btain like units of measure.
100 mg = 1mg x=100,000 mcg/mlx mcg 1000 mcg

4. Lastly set the problem up in ratio and proportion.

100,000 mcg = 48,000 mcg/hr 100,000x = 2,400,000 x = 24 ml / hr IV rate50 ml x ml

Practice Exam #7

1. Order: Morphine 5 mg/hr. The syringe is labeled 100 mg/ 100 ml. How fast will theIV run to deliver the correct dosage? ____________ _______
2. Order: Heparin 50 units/Kg/hr. The solution is labeled 1000 units/ ml. The patient weighs 10 Kg. What is the correct rate? __________
3. Order: Dobutamine 10 mcg/Kg/min. The bag is labeled 1 mg/ ml. The patientweighs 23 Kg. What is the correct rate? ____________ ________
4. Order: Pitocin 5 miliunits/minute. The bag is labeled 10 units/liter. What is the correct rate?_______ _________ ___
5. Order: Ritodrine 0.05 mg/min. The bag is labeled 0.15 gm/500 ml. The patientweighs 198 lbs. What is the correct rate in ml/hrs?_____ _____

PRACTICE EXAM #7 ANSWERS
1. 5 mg = 100 mgx ml 100 ml100x = 500 mlx = 500 = 5 ml/hr. rate100
2. a. 50 units x 10 Kg x 60 min = 30,000 units/hrb. 30,000 units = 1000 unitsx ml 1 ml1000x = 30,000 (1)x = 30,000 = 30 ml/hr IV rate1000
3. a. 10 mcg x 23 kg x 60 min = 13,800 mcg/hrb. 13,800 mcg = 1 mgx ml 1 ml

NOTE: You must have like units of 1mg = 1000 mcgc. 13,800 mcg = 1000 mcgx ml 1 ml1000x = 13,800 (1)x = 13,800 = 13.8 ml/round to 14 ml/hr1000

from: nclex-rn

TRANSMISSION-BASED PRECAUTIONS

2007-04-27T00:39:00.000+08:00

KEY CONCEPTS you will learn include:
· What the reasons for the new Transmission-Based Precautions are
· What Transmission-Based Precautions are designed to do
· What preventive processes and practices are recommended for each
route of infection transmission
· How to effectively use Transmission-Based Precautions

BACKGROUND
Although the spread of infectious diseases in hospitals has been recognized for many years, understanding how to prevent nosocomial infections and implementing policies and practices that are successful has been more difficult. The transmission of nosocomial infections requires
three elements: a source of infecting microorganisms, a susceptible host
and a mode of transmission. The human source of nosocomial infections may be patients, hospital personnel or, less often, visitors. These people may have infectious diseases, be in the incubation period (no symptoms), or may be chronic carriers. Other sources of infecting microorganisms are inanimate objects that become contaminated, (e.g., instruments) and the environment, including air and water. Susceptible hosts are those patients, hospital personnel and, less often, visitors who may become infected. Resistance among people to infecting
microorganisms varies; for example, some are immune, others get infected and become asymptomatic carriers; and still others get infected and develop a clinical disease. Factors such as age, underlying diseases, treatment with certain drugs (e.g., antimicrobials, corticosteroids and other immunosupressive agents) and irradiation play a role in this process. The three main routes of infection transmission in hospitals are airborne, droplet and contact. An infecting microorganism, however, can be transmitted by more than one route. For example, varicella (chicken pox) is transmitted both by the airborne and contact route at different stages of
the disease. The purpose of this is to explain how Transmission-Based Precautions are
used in the hospital to minimize the risk of clients, patients, visitors and staff becoming infected while dealing with the healthcare system. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals

DEFINITIONS
· Airborne transmission. Transfer of particles 5 μm or less in size into the air, either as airborne droplets or dust particles containing the microoganism; can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or suctioning; can remain in the air for up to several hours and be spread widely within a room or over longer distances. Special air handling and ventilation are needed to prevent airborne transmission.

· Droplet transmission. Contact of the mucous membranes of the nose, mouth or conjunctivae of the eye with infectious particles larger than 5μm in size; can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or suctioning. Droplet transmission requires close contact between the source and the susceptible person
because particles remain airborne briefly and travel only about 3 feet
(1 meter) or less.

· Contact transmission. Infectious agent (bacteria, virus or parasite) transmitted directly or indirectly from one infected or colonized person to a susceptible host (patient), often on the contaminated hands of a health worker.

· Colonization. Pathogenic (illness- or disease-causing) organisms are present in a person (i.e., they can be detected by culturing or other tests) but are not causing symptoms or clinical findings (i.e., cellular changes or damage). Coming in contact with and acquiring new organisms, while increasing the risk of infection, usually does not lead to infection because the body’s natural defense mechanism (the immune system) is able to tolerate and/or destroy them. Thus, when organisms are transmitted from one person to another, colonization rather than infection is generally the result. Colonized persons, however, can be a major source of transfer of pathogens to other persons (cross-contamination) especially if the organisms persist in the
person (chronic carrier), such as with HIV, HBV and HCV

TRANSMISSION-BASED PRECAUTIONS
The new isolation guidelines issued by CDC in 1996 involve a two-level approach: Standard Precautions, which apply to all clients and patients attending healthcare facilities, and Transmission-Based Precautions, which apply only to hospitalized patients (Garner and HICPAC 1996). This new system retains the best features of both Universal Precautions
(UP) and Body Substance Isolation (BSI) and replaces the cumbersome disease-specific isolation precautions with three sets of Transmission- Based Precautions (air, droplet or contact).
Note: Protective isolation of immunocompromised patients, such as those with AIDS, is not an effective way to reduce the risk of cross-infection (Mananganet al 2001).

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals

In all situations, whether used alone or in combination, Transmission-Based Precautions must be used in conjunction with the Standard Precautions (Garner and HICPAC 1996).

Airborne Precautions These precautions are designed to reduce the nosocomia transmission of particles 5 μm or less in size that can remain in the air for several hours and be widely dispersed (Table 1). Microorganisms spread wholly or partly by the airborne route include tuberculosis (TB), chicken pox (varicella virus) and measles (rubeola virus). Airborne precautions are recommended for patients with either known or suspected infections with
these agents. For example, an HIV-infected person with a cough, night sweats or fever, and clinical or x-ray findings in the lungs should go on airborne precautions until TB is ruled out.
Where TB is prevalent, it is important to have a mechanism to quickly assess patients with suspected TB because delayed diagnosis, resulting in lack of isolation, has been shown to be an important factor in hospitalbased transmission. In this situation, airborne precautions are the last defense in reducing the risk of TB transmission.

Table 1. Airborne Precautions
Used in addition to Standard Precautions for a patient known or suspected to be infected
with microorganisms transmitted by the airborne route.
PATIENT PLACEMENT
· Private room.
· Door closed.
· Room air is exhausted to the outside (negative air pressure) using fan or other filtration system.
· If private room not available, place patient in room with patient having active infection with the same disease, but with no other infection.
RESPIRATORY PROTECTION
· Wear face shield (or goggles and surgical mask)
· If TB known or suspected, wear particulate respirator (if available).
· If chicken pox or measles:
- Immune persons, no mask required.
- Susceptible persons, do not enter room.
· Remove PPE (face shield) after leaving the room and place in a plastic bag or waste container with tight-fitting lid.
PATIENT TRANSPORT
· Limit transport of patient to essential purposes only.
· During transport, patient must wear surgical mask.
· Notify area receiving patient.
Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications, Chicago, IL. Copyright 2000.

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals

Droplet Precautions These precautions reduce the risks for nosocomial transmission of pathogens spread wholly or partly by droplets larger than 5 μm in size (e.g., H. influenzae and N. meningitides meningitis; M. pneumoniae, flu, mumps and rubella viruses). Other conditions include diphtheria, pertussis (whooping cough), pneumonic plague and strep pharyngitis (scarlet fever in infants and young children). Droplet precautions are simpler than airborne precautions because the particles only remain in the air for a short time and travel only a few feet;
therefore, contact with the source must be close for a susceptible host to become infected.

Table 2. Droplet Precautions
Use in addition to Standard Precautions for a patient known or suspected to be infected
with microorganisms transmitted by large-particle droplets (larger than 5 μm).
PATIENT PLACEMENT
· Private room; door may be left open.
· If private room not available, place patient in room with patient having active infection with the same disease, but with no other infection.
· If neither option is available, maintain separation of at least 3 feet between patients.
RESPIRATORY PROTECTION
· Wear mask if within three feet of patient.
PATIENT TRANSPORT
· Limit transport of patient to essential purposes only.
· During transport, patient must wear surgical mask.
· Notify area receiving patient.
Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications, Chicago, IL. Copyright 2000.

Contact Precautions These precautions reduce the risk of transmission of organisms from an
infected or colonized patient through direct or indirect contact (Table 3). They are indicated for patients infected or colonized with enteric pathogens (hepatitis A or echo viruses), herpes simplex and hemorrhagic fever viruses and multidrug (antibiotic)-resistant bacteria. Interestingly, chicken pox is spread both by the airborne and contact routes at different stages of the illness. Among infants there are a number of viruses transmitted by direct contact. In addition, Contact Precautions should be implemented for patients with skin or eye infections that may be contagious (e.g., draining abscesses, skin infections that are wet and draining, herpes zoster, impetigo, conjunctivitis, scabies, lice and wound infections).

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals

Table 3. Contact Precautions
Use in addition to Standard Precautions for a patient known or suspected to be infected or colonized with microorganisms transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items.
PATIENT PLACEMENT
· Private room; door may be left open.
· If private room not available, place patient in room with patient having active infection with the same microorganism, but with no other infection.
GLOVING
· Wear clean, nonsterile examination gloves when entering room.
· Change gloves after contact with infective material (e.g., fecal materials or wound drainage).
· Remove gloves before leaving patient room.
HANDWASHING
· Wash hands with antibacterial agent or use alcohol-based handrub after removing gloves.
· Do not touch potentially contaminated surfaces or items before leaving the room.
GOWNS AND PROTECTIVE APPAREL
· Wear clean, nonsterile gown when entering patient room if you anticipate contact with patient or if the patient is incontinent, has diarrhea, an ileostomy, colostomy or wound drainage not
contained by a dressing.
· Remove gown before leaving room. Do not allow clothing to contact potentially contaminated surfaces or items before leaving the room.
PATIENT TRANSPORT
· Limit transport of patient to essential purposes only.
· During transport, ensure precautions are maintained to minimize risk of transmission of organisms.
PATIENT CARE EQUIPMENT
· Reserve noncritical patient care equipment for use with a single patient, if possible.
· Clean and disinfect any equipment shared among infected and noninfected patients.
Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications, , IL. Copyright 2000.

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals

Table 4. Empiric Use of Transmission Based Precautions
AIRBORNE DROPLET CONTACT
· rashes (vesicule or pustule)
· cough, fever and upper lobe chest findings
(dullness anddecreased breath sounds)
· cough, fever and chest findings in any area in HIV-infected person or at high-risk for HIV
· meningitis (fever, vomiting and stiff neck)
· hemorrhagic rash with fever
· severe, persistent cough during periods
when pertussis is present in community
· generalized rash of unknown cause
· acute diarrhea in an incontinent or diapered patient
· diarrhea in adult with history of recent antibiotic use
· bronchitis and croup in infants and young children
· history of infection with multi-resistant organisms (except tuberculosis)
· abscess or drainingwound that cannot be covered

The use of Transmission-Based Precautions, including their empiric use in selected circumstances, is designed to reduce the risk of airborne-, dropletand contact-transmitted infections between hospitalized patients andhealthcare staff. To assist health workers in correctly implementing theappropriate precautions, Table 6 provides a summary of the types of
isolation precautions and the illnesses for which each type of precaution is recommended. In addition, Appendix I provides a complete listing of the types and duration of the isolation precautions needed for the vast majorityof infectious diseases.

Empiric Use ofTransmission-BasedPrecautions
In certain circumstances, if there is any question of an infectious process in a patient without a known diagnosis, implementing Transmission-BasedPrecautions should be considered on an empiric basis until a definitive diagnosis is made. Examples of the “empiric use” of Transmission-Based Precautions as they apply to the three routes (air, droplet and contact) are
illustrated in Table 4. In addition, a complete listing of clinical syndromes or conditions warranting the empiric use of Transmission-Based Precautions is shown in Table 5. From time to time and based on local conditions, other important infectious diseases should be considered for addition to this list.
Note: Unfortunately “reminder signs” for isolation patients do not use (compliance) with infection precautions (Manangan et al 2001). Unfortunately,

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals

Table 6. Summary of Types of Precautions and Patients Requiring the Precautions

Standard Precautions
Use Standard Precautions for the care of all patients.

Airborne Precautions
In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmittedby airborne droplet nuclei. Examples of such illnesses include:
Measles
Varicella (including disseminated zoster)a
Tuberculosis b
Droplet Precautions

In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include:
Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis

Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis
Other serious bacterial respiratory infections spread by droplet transmission, including:
Diphtheria (pharyngeal)
Mycoplasma pneumonia
Pertussis
Pneumonic plague
Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children
Serious viral infections spread by droplet transmission, including:
Adenovirusa
Influenza
Mumps
Parvovirus B19
Rubella
Contact Precautions
In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment.

Examples of such illnesses include:
Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance.

Enteric infections with a low infectious dose or prolonged environmental survival, including:
Clostridium difficile
For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus,

Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children
Skin infections that are highly contagious or that may occur on dry skin, including:
Diphtheria (cutaneous)
Herpes simplex virus (neonatal or mucocutaneous)
Impetigo
Major (noncontained) abscesses, cellulitis, or decubiti
Pediculosis
Scabies
Staphylococcal furunculosis in infants and young children
Zoster (disseminated or in the immunocompromised host)†
Viral/hemorrhagic conjunctivitis
Viral hemorrhagic infections (Ebola, Lassa, or Marburg)*

100 item Comprehensive Exam II with Answers and Rationale

2007-04-26T14:02:00.000+08:00

1. In a child with suspected coarctation of the aorta, the nurse would expect to find
The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)

2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by

The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.

3. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.

4. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?

The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.

5. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness. Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.

6. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be

The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.

7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates

The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggests altered thinking processes.

8. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?
The correct answer is B: Flexion of the hip and knees with passive flexion of the neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis.

9. Post-procedure nursing interventions for electroconvulsive therapy include
The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care.

10. The nurse is talking to parents about nutrition in school aged children. Which of the following is the
The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.

11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home

The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.

12. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?

The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.

13. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.

14. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should
The correct answer is C: Give the client simple information about what she will be doing. The distressed disoriented client should be gently oriented to reduce fear and increase the sense of safety and security. Environmental changes provoke stress and fear.

15. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?

The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.

16. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?

The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help you to reinforce the need for daily management of the disease whether or not the patient "feels better".

17. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is
The correct answer is B: "Your child has less red blood cells that carry oxygen." The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.

18. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
The correct answer is B: When the client threatens self-harm and harm to others. Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public.

19. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8 months.

20. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?

The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.

21. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?

The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.

22. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?

The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent''s pregnancies will result in a child with systic fibrosis.

23. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent?
The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.

24. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
The correct answer is C: Clothing has become tight around the waist
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.

25. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

The correct answer is D: Occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.

26. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to

The correct answer is A: Ask the client about the refusal of certain pain medications. Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.

27. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?

The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.

28. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client??"

The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.

29. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?

The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss.

30. Which type of accidental poisoning would the nurse expect to occur in children under age 6?

The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.

31. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.

32. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?

The correct answer is B: Twenty month-old who has just learned to climb stairs. Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.

33. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?

The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.

34. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia. Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.

35. A nurse is caring for a client with multiple myeloma. Which of the following should be included in the plan of care?

The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, client’s are at high risk for pathological fractures.

36. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
A) Reading

The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention.

37. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?

The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture and active and passive range of motion exercises important interventions for maintaining function of affected joints.

38. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?

The correct answer is C: Provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.

39. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?
The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.

40. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
The correct answer is D: Note patterns of increased blood pressure
Hypertension is a key assessment in the course of the disease.

41. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?

The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alchohol intake.

42. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child?
The correct answer is B: Explain the surgery 1 week prior to the procedure
A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.

43. During the evaluation phase for a client, the nurse should focus on

The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation. Evaluation process of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care.

44. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
The correct answer is A: Review the medications the client is receiving
Antibiotics and medications containing sorbitol may induce diarrhea.

45. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?
The correct answer is D: Thiocyanate
Thiocyanate levels rise with the metabolism if nitroprusside and can cause cyanide toxicity.

46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates

The correct answer is C: Flight of ideas
Flight of ideas - defines nearly continuous flow of speech, jumping from 1 topic to another.

47. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?
The correct answer is B: Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood.

48. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to

The correct answer is B: Ask the client what foods are acceptable
Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.

49. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and

The correct answer is B: Decreased colloidal osmotic pressure in the capillaries. The increased glomerular permeability to protein causes a decrease in serum albumin which results in decreased colloidal osmotic pressure.

50. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?

The correct answer is C: Bilirubin
In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.

51. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?

The correct answer is C: 15 minutes
Frequency is the time from the beginning of one contraction to the beginning of the next contraction.

52. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?
The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." Recovery is total abstinence from all drugs.

53. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
The correct answer is A: Measure head circumference
In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.

54. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
The correct answer is B: With fear of rejection causing increased rage toward the victim. The fear of rejection and loss only serve to increase the batterer’s rage at his partner.

55. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?
The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

56. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with

The correct answer is C: Life’s stressors
Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings.

57. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

The correct answer is A: High in carbohydrates and proteins
Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.

58. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?

The correct answer is D: Should be limited to three to four cups of milk daily
More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.

59. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

The correct answer is B: Set time aside to get the mother to express her feelings and concerns.
Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed.

60. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
The correct answer is B: Use oxygen during meals improves gas exchange
Clients with emphysema breathe easier when using oxygen while eating.

61. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

The correct answer is B: Place the client in a sitting position with legs dangling
Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.

62. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?

The correct answer is C: Assessing the client''s learning style
As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.

63. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of

The correct answer is B: Dehydration
Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.

64. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.

65. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?

The correct answer is A: Retractions in the soft tissues of the thorax
Slight intercostal retractions are normal. However in disease states, especially in severe airway obstruction, retractions become extreme.

66. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?

The correct answer is B: Imitation of Sounds
Imitation of sounds such as "da-da" is expected at this time.

67. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"
At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.

68. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?
The correct answer is D: I can switch to a bottle if I need to take a break from breast feeding.
Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.

69. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
The correct answer is C: Mild emesis progressing to projectile vomiting
Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings.

70. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?

The correct answer is B: It assesses a child''s development.
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.

71. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
The correct answer is C: Compile a history of behavior patterns and developmental accomplishments
A complete behavioral, and developmental history plays an important role in determining the diagnosis.

72. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by
The correct answer is B: Minimizing the episode and underestimating the victim’s injuries
Many abusers lack an understanding of the effect of their behavior on the victim and use excessive minimization and denial.

73. The nurse, assisting in applying a cast to a client with a broken arm, knows that
The correct answer is C: The wet cast should be handled with the palms of hands
Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.

74. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to

The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
A toddler with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possible a secondary infection.

75. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

The correct answer is C: Tripled the birth weight
The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.

76. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
A) Age 40 years
The correct answer is D: Uses cocaine on weekends
Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.

77. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?
The correct answer is A: Leave the room and return five minutes later and give the medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.

78. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

The correct answer is C: Riding a tricycle
Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.

79. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?

The correct answer is A: All lesions crusted
The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.

80. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

The correct answer is D: Moist saline dressing
This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.

81. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:

The correct answer is D: Reflects an average blood sugar for several months Glycosolated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 3-4 months and is used to monitor client adherence to the therapeutic regimen.

82. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

The correct answer is C: Assist the client with pursed lip breathing Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.

83. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have

The correct answer is D: Heaviness in the affected testicle
The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.

84. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily

The correct answer is A: Psychological
With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that produces craving and compulsive use.

85. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
The correct answer is A: Separation anxiety
While a toddler will experience all of the stresses, separation from parents is the major stressor.

86. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?

The correct answer is C: Perceived loss of control
For school age children, major fears are loss of control and separation from friends/peers.

87. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
The correct answer is A: Cardizem SR tablet (diltiazem)
Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.

88. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?

The correct answer is B: Drug tolerance
Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.

89. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
The correct answer is A: Acceptance of the pregnancy
During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.

90. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

The correct answer is B: Prescribed use of an MAO inhibitor
SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.

91. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

The correct answer is C: Apply bulky, loose dressing to nose and ears.
Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

92. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

The correct answer is A: "Touching the abdomen could cause cancer cells to spread."
Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.

93. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?

The correct answer is C: Respiratory rate of 32
Clients with deep vein thrombosis are at risk for the development of pulmonary embolism. The most common symptoms are tachypnea, dyspnea, and chest pain.

94. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is

The correct answer is A: Avoid alcohol use during this time
Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided

95. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?

The correct answer is B: Administer the medication with a syringe next to the tongue
Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

96. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

The correct answer is B: Talk with the client to find out about the preferred herbal preparation
Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health-care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death".

97. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating

The correct answer is A: "I will increase sodium and fluids and restrict potassium."
The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.

98. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
The correct answer is A: Promote verbal and nonverbal communication with both the client and the interpreter
The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues

99. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?

The correct answer is D: Color
Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.

100. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
The correct answer is B: Frequent turning
Frequent turning will prevent skin breakdown.

Herbal Medicines

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Herb Medicinal Claim
These are some of the common Herbal Medicines that are included in the NCLEX-RN. I put some pictures for some unfamiliar plants.

1. Alfalfa Source of carotene (vitamin A); contains natural fluoride

2. Aloe Healing agent

Basil leaf Remedy to inhibit vomiting

Bee pollen Renewal of enzymes, hormones, vitamins, amino acids, and others

5. Bilberry leaf Increases night vision, reduces eye fatigue

6. Black cohosh Relieves menstrual cramps; same effects as estrogen

7. Blue cohosh Regulate mens. flow; emergency remedy for bee stings

8. Butternut bark Works well for constipation

Capsicum (Cayenne) Normalizes blood pressure; stops bleeding on contact

10. Cascara sagrada bark Remedies for chronic constipation and gallstones

11. Chamomile flower for a nervous stomach; relieves cramping due to mens. cycle

12. Cranberry Bladder or kidney infection

13. Dandelion leaf and root Detoxify poisons in the liver;beneficial in lowering blood pressure

Echinacea root Treat strep throat, lymph glands

Eucalyptus leaf General medicinal

16. Feverfew herb Migraines; helps reduce inflammation in arthritis joints

17. Garlic capsules “Nature’s antibiotic”

18. Ginger root Remedy for sore throat

Ginkgo biloba Improves blood circulation to the brain

20. Ginseng root,Siberian Resistance against stress; slows the aging process

21. Goldenseal Treatment of bladder inf, cankers, mouth sores, and ulcers

Hawthorn Strengthens and regulates the heart; relieves insomnia

Kava kava root Induce sleep and help calm nervousness

24. Licorice root Mild laxative

25. Oregano leaf Settles the stomach after meals, helps treat colds

26. Rhubarb root Powerful laxative

Saw palmetto berry Mucus in the head and nose

Senna leaf Splendid laxative

St. John’s wort Correct irregular menstruation

30. Thyme leaf Relief of migraine headaches

31. Witch hazel bark and leaf Restores circulation; for stiff joints

THERAPEUTIC PROCEDURES(protocol)

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SELECTED TOPICS ON COMMON NURSING PROCEDURES
UNIVERSAL PRECAUTIONS
HANDWASHING
BARRIER METHOD
STERILIZATION AND DISINFECTION
IMMUNIZATION
ENVIRONMENTAL CONTROL AND SANITATION
ISOLATION
SURGICAL ASEPSIS
MAINTENANCE OF STERILE FIELD
MEDICAL AND SURGICAL ASEPTIC TECHNIQUES
THERAPEUTIC EXERCISES
ISOMETRIC
ISOTONIC
ROM
CHEST PHYSIOTHERAPY
BREATHING
COUGHING\POSTURAL DRAINANGE
PERCUSSION AND VIBRATION
INCENTIVE SPIROMETER
SUCTIONING
TRACHEOSTOMY CARE
OXYGEN THERAPY

Chest Physiotherapy
It is the combination of percussion, vibration, and postural drainage
Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes
Vibration is done during 5 exhalations
Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.
Instruct the client to increase fluid intake to liquefy secretions
This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.
This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy
Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.
Humidify the oxygen first before you administer.
Check for bubbles in the humidifier to promote adequate flow of oxygen
Check for kinks in the tubing
Position: semi-fowlers/ high fowlers position
Place cautionary readings: “NO smoking: Oxygen is in used”
Instruct the client not to use woolen blankets as this may create static electricity
pulmonary function tests
tidal volume- 500
residual volume- 1200
expiratory reserve volume –1200
inspiratory reserve volume – 3100

Vital Capacity- tidal volume + IRV + ERV = 4800
Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000
Forced Residual Capacity – ERV + RV

incentive spirometry – hold 2-6 sec; 4-5 times/H
endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly
visualization –
X ray
Lung Scxan – 20-40mins isotopes in body for 8 H
laryngoscopy
Bronchoscopy
Thoracentesis- consent, VS and baseline X-ray + post Procedural

Tracheostomy Care
tie new trache tie before removing the old tie to prevent accidental dislodgement
use precut gauze and perform care OD at least.
soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well
suction prn, oral care prn
Oxygen Delivery Equipment
cannula – 2-6 LPM – 24-45%
Mask – 5-8 LPM – 40-60%
parial rebreather – 6-10 LPM – 60-90%
non rebreather – 10-15 LPM – 95-100%
tent – 4-8 LPM – 30-50 %
Venturi mask –
2-3 LPM – 24-28%
4 LPM – 30%
6 LPM – 35%
8 LPM – 45%
14LPM – 55%

Suctioning
PURPOSE: To obtain sputum sample.
NURSING ALERT:
Hyperoxygenate the patient before and after the procedure.
Apply intermittent suction on withdrawal of the catheter.
Do not suction the patient for more than 15 seconds.
Thoracentesis
PURPOSE: Aspiration of fluid and /or air from the pleural space.
NURSING ALERT:
Check the consent.
Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder.
Instruct the patient not to cough, breath deeply or move during the procedure.
After the procedure: Position the patient on the unaffected side/puncture site up.
Check for bleeding at the puncture site and monitor the respiratory function.
Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.

ENEMA
They act by distending the intestines that increases peristalsis and expulsion of feces and flatus.
Enemas serve the following purpose:
Relief of constipation
Relief of flatulence
Lowers down body temperature
Evacuates feces in preparation for diagnostic procedures
Administration of medications
Take note of the general principles of Enema:
Tube: lubricate and insert 3-4 inches
Position: adult- left lateral; infants and children- dorsal recumbent
Administration- administer the enema in a minimum of 15 minutes duration.
Conatainer’s Height- 12 inches above the rectum
Temperature- 42°C or less

types:
carminative – expel flatus – 60 –180 ml.
retention oil – 1 –3 hours(LUBRICANTS)
BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI
wetting/stool softeners- Colace(days)
Chemical hypertonic irritant-increases peristalsis-castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN
Saline- Epson salts, milk of mg(rapid)/mg citrate
return flow – haris flushing , colon irrigation
fleet – commercial
oil 1-3 H retention
others – 5 to 10 mins.
cleansing- irritating( hypertonic osmotic))
high 1000 ml
low 500 ml

T = 40-43 ‘ C ( 105 – 110 ‘ F
CHILDREN 37.7 ( 100 ‘ F)
APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.
INSERT 7 – 10 CM ( 3-4 INCH)-ADULT
5 – 7.5 CM. –CHILD
2.5 – 3.5 – INFANT

IF FEELING OF FULLNESS – CLAMP – 30 SECS

amount
18 mos – 50-200 ml
18 mos – 5 y – 200-300 ml
5 – 12 years – 300 – 500 ml
12 – above – 500 – 1000 ml.

rectal tubes
infants-10-12F
toddler – 14 –16F
school age – 16-18F
adult – 22 – 30F
ENEMAS- PRESCRIBED AMOUNT AND TIME
HYPERTONIC – 5-10MINS – VARIES
HYPOTONIC(TAP)-15-20MIN – 500-1000ML
ISOTONIC(SALINE)-15-20MIN- 50ML
SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP
oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.
COLOSTOMY CARE
ostomy – divert and drain fecal material
temporary ( trauma / inflammatory condition)
permanent ( Cancer / congenital or Birth defects
stoma – red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation

parts:
periostomal seal
adhesive square –
solid wafer disk skin barrier
liquid skin sealant
drainable end
pouch ( Can be washable)
pouch belt
face plate

ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full
colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation
avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended
dry skin before applying appliance
karaya – barrier to prevent contamination with excreta
appliance can be up to 2 weeks
broadwell 48 – 72 hours to check for periostomal skin
24-48 hours if eroded / ulcerated
refer to enterostomal therapy nurse
with deodorant ( Charcoal filter Disk)
Catheterization, urinary
PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.

NURSING ALERT:
Know the necessary facts:
Principles Male Female
Position Supine Dorsal recumbent
Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in.
French number or
Circumference #14- 16 #18
Length of tube to
be inserted 2-3 in. 6-9 in.
Balloon size 5-10 ml. (30 ml 5-10 ml
Can be used to
achieve hemostasis
of the prostatic area
following prostatectomy

Place to secure lower abdomen Inner thigh

 The procedure is sterile
 Maintain a close system
 The draining bag must always be below the bladder
 The catheter bag should not be allowed to lie on the floor
 Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it

CATHETER CHANGE
PLASTIC – 1 WEEK
LATEX – 2-3 WEEKS
SILICONE – 2-3 MOS.
PVC – 4-6 WEEKS

CLOSED INTERMITTENT IRRIGATION
ASPIRATE FROM PORT
CBI -3 WAY FOLEY CAHETER
CATHETER IRRIGATION ONLY – 200 ML.
BLADDER IRRIGATION – 1000ML
CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED
URINARY DIVERSIONS-URINARY STOMA
ILEAL CONDUIT- EXTERNAL POUCH
KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN
SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS
NORMAL AMOUNT/ DAY
1-3 / 500-600ML
3-5 / 600-700ML
5-8 / 700-100OML
8-14 / 800 – 1400ML
14 – ADULT / 1500 – 2500

CAN HOLD 500 – 750 ML

Bladder training
Q2 hours and 30 mins void(Trigerring, Credes and valsalva)

NEUROGENIC BLADDER
Intermitent Catheterization – 2-3 hours if <150ml>for incontinence – kegels exercises

HEMODIALYSIS
DONE 3-5 HOURS – 2-3 TIMES A WEEK
AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS
PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H
MONITOR FOR HEMORRHAGE
DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-

COMPLICATIONS
PERITONEAL DIALYSIS
TENCKOFF,GORE-TEX CATHETER
WEIGH BEFORE AND AFTER, WARM DIALYSATE
CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V
PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION

TYPES:
CAPD(4-6H INDWELLING),
AUTOMATED 30MINS EXCHANGES,
INTERMITTENT- 4X A WEEK – 10H/DAY,
CONTINOUS – 1 DAY INDWELLING
DRESSINGS
PROTECT FROM INJURY , BACTERIAL CONTAMINATION
PROVIDE HUMIDITY
INSULATION
ABSORB DRAINAGE
DEBRIDE THE WOUND
PREVENT HEMORRHAGE
SPLINT / IMMOBILIZE
COMFORT

GUAZE, SYNTHETIC , SECURING, TEGADERM
TYPES OF DRESSINGS
DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE
WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE
WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)
WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE
WOUND HEALING
HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS
FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS
MATURATION(PHASE 21 DAYS – 2 YEARS)
pressure ulcer dressings
dry gauze stage II-IV
tegaderm film/ hydrocolloid – SI - SII
Absorptive Dressing III
Hydrogel – II - III
WOUND CARE
PRIMARY
SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)
TERTIARY- ABD. DRAINAGE

EXUDATES – SUPPURATION
PUS – ABCESS( PYOGENIC BACTERIA)
SURGICAL DRAINS
PENROSE – OPEN ENDS
CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR
D/C 3-7 DAYS POST – OP
PACKAGE – FACILITATE GRANULATION
IRRIGATION LAVAGE - STERILE
CHEST TUBES AND DRAINAGE SYSTEMS
1-DRAINAGE
2-WATERSEAL
3-COLLECTION/SUCTION

SEALED PATENCY-AFTER 3 DAYS REEXPANDED
FLUCTUATIONS IN WATER SEAL CHAMBER
RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE

NUTRITIONAL SUPPORT
NGT-GAVAGE AND LAVAGE
TPN
Nasogastric Tube Insertion
Purposes:
Gastric Gavage- gastric feeding
Gastric Lavage- stomach irrigation
For decompression
Medication and supplemental fluid administration
Principles:
Position: High-Fowler’s position
Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.
Lubricate the tip of the tube by a water soluble lubricant before insertion
Secure the NGT by taping to the bridge of the nose

Gastroenteral Feedings
This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall.
Remember these principles:
Position: fowler’s or sitting position
Prior to feeding, assess the bowel sounds and residual content
Assess for tube placement and patency:
Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated.
X-ray most accurate
Aspirate gastric content
Immerse the tip of the tube in water, no bubbles must be produced.
Height of feeding: 12 inches above the patient’s point of insertion
Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube

TOTAL PARENTERAL NUTRITION
peripheral<>Anti-embolism Stocking
Helps prevents thrombophlebitis by promoting venous return from the legs
It usually requires a doctor’s order
The client’s extremeties must be properly measured to assure therapeutic effect
Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes
The stockings must be removed every 8 hours for 20-30 minutes
Assess the skin integrity

DOSAGES AND CALCULATION
CONVERSIONS
MEDICATION DOSAGES
D/A X V = Q
INFUSIONS
TOTAL VOLUME X DROP FACTOR
TIME IN HOUR ( 60 MIN.)
THERAPEUTIC DOSE
CLARKS RULE
BSA COMPUTATION
IV INFUSION FOR BURNS

MEDICATION ADMINISTRATION
RIGHT DRUG
RIGHT DOSAGE
RIGHT ROUTE
RIGHT TIME
RIGHT PATIENT
RIGHT ATTITUDE
RIGHT DOCUMENTATION

PARENTERAL ADMINISTRATION
IM – G 18-21 ; 1 1/2 INCH, Z-TRACK
( RETRACT)
SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN)
INTRADERMAL- 10-15’; G26-27;1\2 INCH BEVEL UP
INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW

IV THERAPY
backflow means patent line
solutions for specific diseases and contraindications of certain solutions
management and troubleshooting
check for phlebitis and infiltration
change line everyday
keep site sterile

BLOOD TRANSFUSION
line – PNSS
vital signs – baseline then Q15 x 4; Q30 x 2; then q h
4 –6 hours
blood typing and crossmatching
watch out for blood transfusion reactions
hemolytic
anaphylactic
febrile
hypervolemic
septic

Hygiene and comfort measures
BEDMAKING- OD
PERINEAL CARE – FRONT TO BACK
OUTER TO INNER, ONE COTTONBALL PER STROKE
BEDBATHING AND ND SHAMPOO
FOOT, HAIR , SKIN AND NAIL CARE
ORAL CARE
EYE AND EAR CARE

THERAPEUTIC BATH
SALINE – 4 ML- 500 ML
OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES
CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION
Na CHO3 – 4 ml. – 500 ml H2O
cooling / relieves irritation
KMnO4 – tablets dissolved in H2O – clears and disinfects

Rotating Tourniquet
APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES
DO NOT RELEASE SIMULTANEOUSLY
PATIENT IN ORTHOPNEIC / FOWLERS POSITION

CPR and ACPLS Protocols
0-1 MINUTE ; CARDIAC IRRITABILITY
0-4 MINUTES; BRAIN DAMAGE NOT LIKELY
4-6 MINUTES; BRAIN DAMAGE POSSIBLE
6-10 MINUTES; BRAIN DAMAGE LIKELY
10 MINUTES-IRREVERSIBLE BRAIN DAMAGE

Management of Care - DELEGATION

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Lesson 1 : Management of care

1. Concepts of Management and Supervision:

a. Review standards / position statements of the following agencies before delegating any nursing tasks
-State board of nursing
-Interpretations / position statements of specific board or nursing
-Standards of nursing organizations: ANA, NLN, and NCSBN
-Policy of health care institutions
b. Use critical thinking in management situations

2.Delegation
a. Definition of delegation: a process by which responsibility and authority for performing tasks are transferred from one individual to another who accepts that authority and responsibility
b. Delegation involves
-Responsibility: an obligation to accomplish a task
-Accountability: accepting ownership for the results or lack of
-Authority: right to act or empower
c. Principles of delegation
-A nurse can only delegate those tasks for which that nurse is responsible according to the specific state's nurse practice act
-The delegator remains accountable for the task
-Along with responsibility for a task, the nurse who delegates must also transfer the authority necessary to complete the task
-The delegator knows well the task to be delegated
-Delegation is a contractual agreement that is entered into voluntarily
-Consider the scope of practices of nursing personnel :

registered nurses:
baccalaureate prepared nurses are equipped to care for individuals, families, groups and communities in both structured and unstructured health settings
2.associate degree prepared nurses are equipped to care for individuals in a structured health care environment
3. RNs cannot delegate to unlicensed personnel:
a. initial assessment of patients
b. evaluation of patient data
c. nursing judgment
d. patient/family education/evaluation
e. nursing diagnosis/nursing care planning
Licensed practical or vocational nurses (LPN/VN) are equipped to assist in implementing a defined plan of care and to perform procedures according to protocol. Assessment skills are directed at differentiating normal from abnormal. Competence is in caring for physiologically stable patients with predictable conditions.

Unlicensed assistive personnel (UAP) have the most limited scope of practice. They can assist in a variety of direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining measurements such as vital signs, height, weight and intake and output. They can also perform indirect activities such as housekeeping, transporting and stocking supplies.

d. Steps to delegation
1. Define the task
2. Determine the delegate
is the task within the scope of practice of the delegate?
the scope of practice is define
-nurse practice acts: each state defines what nurses may do
-standards of practice: the American Nurses Association (ANA)
defines standard of practice
Organizational policies and job descriptions
Does the ability of this caregiver match the needs of the task?
3. Communicate clearly about expectations regarding the task
state clearly who will do what by when and how, where and why it will be done
state clearly the outcomes you expect
4. Reach mutual agreement about the task to be completed
the delegator validates with the delegate that an understanding exists regarding what is to be done and the outcomes that are expected
discuss potential problems and solutions
5. Monitor the task and provide guidance as needed
was the task completed according to specifications?
6. Evaluate results
was the desired outcome obtained?
in the desired time?
7. Provide feedback to individual on outcomes performance
review with the delegate what went right as well as what went wrong with the process
e. Five rights of delegation
1. Right task
2. Right circumstances
3. Right person
4. Right direction/communication
5. Right supervision

Client care assignments
Assign the right task
Assign the task to the right person
The PN may assign tasks to the unlicensed assistive personnel or nursing assistants
Unlicensed assistive personnel (UAP) or nursing assistants cannot delegate to other UAPs or nursing assistants
Performance Improvement / Quality Assurance .

Quality definition: the degree to which client care services increase the probability of desired outcomes and reduce the probability of undesired outcomes given the current state of knowledge
Performance improvement/assurance definition: the process of attaining a new level of performance or quality that is superior to any previous one
Total quality management definition: a management philosophy that emphasizes a commitment to excellence throughout the organization
Six characteristics of total quality management
Customer/client focus
Focus on outcomes
Total organizational involvement
Multidisciplinary approach
Use of quality tools and statistics for measurement
Identification of key areas for improvement