FUNDAMENTALS OF NURSING
GLADYS BAUTISTA JAIME 2010
HISTORY OF NURSING Intuitive Period Apprentice Period Educated Nursing Period Page Contemporary Period |1 INTUITIVE PERIOD Nursing was untaught and instructive Beliefs and practices i. Nomads ii. Women iii. iii. Blac Black k magi magic/ c/ evi evill spir spirit its s (voo (voodo doo) o) iv. iv. Whit White e magi magic/ c/ sha shama man/ n/ wit witch ch doc docto tors rs v. Trephining •
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ROME
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Roman Catholic Fabiola – made her home as the first hospital under the Christ Era
APPRENTICE PERIOD TH 11 century – 1836 On the job training period From the rise of religious orders from secular orders up to the dark period of nursing up to the establishment of the 1st training school. RELIGIOUS ORDERS Knights of St. John – ranks and superiority Teutonic Knights – tent hospitals Knights of St. Lazarus – lepers/leprosy •
ANCIENT CITIES AND CONTRIBUTIONS I. BABYLONIA Code of Hammurabi (Law affecting medical practice) RA 9173 – Phil. Nursing Act of 2001 RA 7164 – Old Phil. Nursing Act of 1991 II. EGYPT Art of Embalming (Enhance the knowledge about human anatomy) Recognize 250 diseases III. ISRAEL Moses “Father of Sanitation” Give laws on communicable disease Ritual circumcision IV. CHINA “Materia Medica” (pharmacology) (pharmacology) Used girl clothes for male babies V. INDIA Intuitive Asepsis SUSHURUTU – record of function and responsibility of nurses VI. ANCIENT GREECE Hippocrates – “Father of Scientific Medicine”
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SECULAR ORDERS St. Catherine of Siena – “Lady with a lamp” St. Elizabeth of Hungary – “Patroness of Nurses” Clara Barton – “Founder of American Red Cross” St. Claire – founded the 2 nd order of St. Francis de Asisi • • • •
Dark Period of Nursing Religious upheaval led by Martin Luther Theodore Fliedner st Establish the 1 training school in Germany Kaiserwerth Institute for the Training of the Deaconesses EDUCATED NURSING PERIOD Florence Nightingale – May 12, 1820 in Florence, Italy Crimean War Lady with a lamp St. Thomas School of Nursing Mother of modern nursing •
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Notes: on nursing/ on hospital Environmental Theory (first theorist) Lilian Wald Founder of the Public H ealth Nursing Linda Richards 1st graduate as a nurse in US Initiated the use of white uniforms Use of Nurse’s Notes and Doctor’s Order Mary Mahoney 1st African American Nurse Lavinia Dock Active in Protest Women has privilege to VOTE Margaret Higgins Sanger Founder of the Planned Parenthood (Family Planning)
ROLES AND RESPONSIBILITIES OF NURSES CAREGIVER – providing care COUNSELOR – supporting emotionally CHANGE AGENT – modification of lifestyle CLIENT’S ADVOCATE – protects client’s right CASE MANAGER – collaborates with other member MANAGER – Planning, Organizing, Delegation, Controlling TEACHER – health promotion and teaching LEADER – attaining goals and objectives • • •
RESEARCHER – development of profession
18 THEORIES AND THEORIST 1) FLORENCE NIGHTINGALE “ENVIRONMENTAL THEORY” Cleanliness, Light, Air, Water, Diet, Warm, Noise Free, Drainage 2) LYDIA HALL “CORE, CARE and CURE” Core – person (therapeutic use of self/communication) Care – body (bed bath, oral care, hygiene) Cure – disease (medication, IV Therapy)
CONTEMPORARY PERIOD World War II up to the present Scientific and Technological Advancement Computer, Sophisticated Equipment, Disposable Supplies Own Nursing Law (RA 9173)
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3) VIRGINIA HENDERSON “14 Basic Human Needs” Breath normally, Eat and Drink, Eliminate, Move and Maintain Posture, Sleep and Rest, Dress and Undress, Maintain Body Temperature, Keep Clean, Avoid Danger, Communicate, Worship, Work, Play and Learn 4) HILDEGARD PEPLAU “Psycho dynamic Theory” 4 Phases of Nurse Patient Relationship Orientation – problem identification Identification – feeling of belongingness, trust, Setting GOALS Exploitation – use all resources to resolve problem, IMPLEMENTATION Resolution – goals met, TERMINATION Phase • •
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5) DOROTHEA OREM “Self-care Deficit” Whole Compensatory – 100% nurse Partially Compensatory – 50-50 nurse-patient • •
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GLADYS BAUTISTA JAIME 2010
Supportive-Educative – discharge planning and health teaching
6) MARTHA ROGERS “Science of Unitary Human Beings” Man is a unified whole – inter-related parts 7) IMOGENE KING “Goal Attainment Model” Transaction (Communication Skills) 8) DOROTHY JOHNSON “Behavioral Model” 7 SUBSYSTEMS AGGRESSIVE – self-protective behavior AFFILIATE – security seeking behavior ACHIEVEMENT – master of oneself DEPENDENCY – nurturance seeking ELIMINATIVE – moving out of wastes INGESTIVE – taking-in nutrients SEX – procreation and satisfaction • • • •
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STRUCTURAL INTEGRITY – physical boundaries of human should be intact (skin and mucus membrane)
12) BETTY NEUMAN “Health Care System Model” Origins of Stressors INTRA – within the person/inside INTER – between friends and f amily EXTRA – outside the person • • •
13) SISTER CALLISTA ROY “Adaptation Model” Process of Adaptation INPUT – stressor CONTROL – manage physically and emotionally OUTPUT – outcome and result FEEDBACK – how it affects the next input • • • •
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14) PATRICIA BENNER “Stages of Expertise” NOVICE – bounded with rules and standards, no experience ADVANCE BEGINNER – demonstrate marginally acceptable procedure, real experiences COMPETENT – 2-3yrs. experience, consciously plan the care PROFICIENT – 3-5yrs. Experience, perceive situation as a whole rather than in parts, HOLISTIC VIEW EXPERT – highly fluid and flexible •
9) FAYE GLENN ABDELLAH “21 Nursing Problems” Interrogative = ?
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10) MADELIENE LEININGER “Transcultural Theory” Beliefs and Practice = Respect
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11) MYRA LEVINE “Conservational Model” ENERGY – Input (Food, O2, Water) = Output = Energy PERSONAL INTEGRITY – self-worth/ self-identity SOCIAL INTEGRITY – interpersonal needs •
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15) ROSEMARIE RIZZO PARSE “Human Becoming Theory”
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IDA JEAN ORLANDO
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FUNDAMENTALS OF NURSING
GLADYS BAUTISTA JAIME 2010
“Dynamic Nurse Patient Relationship”
Basic Metabolic Rate Activity Thyroxin Output Epinephrine/NorEpinephrine Fever
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17) JEAN WATSON “Caring Model” Page |4
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18) ERNESTINE WIEDENBACH “Helping Art of Clinical Nursing”
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Conduction Radiation Convection Evaporation
SMITH’S MODEL OF HEALTH Clinical Model Signs/Symptoms Adaptation Model Adapt Role Duties Performance Eudemonistic SelfModel actualization
Healthy X
Illness
X X ROUTE
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STAGES OF EXPERTISE SYMPTOM EXPERIENCE – subjective ASSUMPTION OF SICK ROLE – accept illness and seek advice MEDICAL CARE CONTACT – seek advice from professionals, validation and explanation of disease DEPENDENCY ROLE – healthcare, passive communication REHABILITATION – going back to the pre-illness stage, RECOVERY
RECTAL AXILLARY
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ORAL
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TYMPANIC
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NURSING PROCESS: ASSESSMENT Vital Signs: TEMPERATURE •
HYPOTHALAMUS
THERMOMETER ADVANTAGE NSG.CONSIDERATI ON Most accurate 0.5-1.5 inches Most reliable 1-2 minutes Safest Pat dry before use Non-invasive 5-9 minutes Most 30min rest before convenient 2-3 minutes Most accessible Very fast Prevent puncture of TM Within seconds
N° VALUES 37-38.1 35.8-37 36.537.5 36.837.9
Cleaning – Before Use: bulb to stem After Use: stem to bulb Pyrexia – more than normal temperature Hyperpyrexia – more than 41°C
TYPES OF FEVER INTERMITTENT – fluctuation of temperature bet. normal and abnormal BALANCED BETWEEN HEAT PRODUCTION AND HEAT LOSS REMITTENT – fluctuation of temperature but all above normal HEAT PRODUCTION HEAT LOSS RELAPSING – fever with 1-2 days of normal temperature THE ROYAL PENTAGON REVIEW SPECIALIST, INC. DETERMINED BY METABOLISM
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GLADYS BAUTISTA JAIME 2010
CONSTANT – minimal fluctuation, consistently high
KUSSMAUL’S – deep rapid labored breathing BIOT’S – very shallow with apnea
PULSE Autonomic Nervous System
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Pulse Sites: Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior Tibia, Dorsalis Pedis PULSE RATE: 1 month – 80-180 1 year – 80-140 2 years – 80-130 6 years – 80-120 Adult – 60-100 PULSE FORCE 3 – Full Bounding 2 – Normal 1 – Weak Thready Pulse 0 – No Pulse PULSE Pressure – (Systole-Diastole=PP) N°= 30-40mmHg PULSE Deficit – (Apical-Peripheral Pulse)
Sounds: STRIDOR – harsh, shrill sound on inspiration - Laryngeal obstruction STRETOR – snoring sound on expiration - Obstructed or narrowed airway WHEEZE – squeaky musical sound on expiration - Narrow or constricted bronchus BUBBLING – gurgling sound, air passing through secretions - Heard both on inspiration and expiration Volumes: TIDAL VOLUME – inhalation and exhalation INSPIRATORY RESERVED VOLUME – maximum air that can be inhaled after normal breathing EXPIRATORY RESERVED VOLUME - maximum air that can be exhaled after normal breathing RESIDUAL VOLUME – remaining in the lungs TOTAL LUNG CAPACITY – (T I E R) CHEST INDRAWING – retraction Suprasternal – above the clavicle Subcostal – below the breast bone Intercostal – between the ribs •
RESPIRATION Medulla PONS – Pneumotaxics Center (rhythmic) - Apneustic Center (deep prolonged respiration) - Aortic and Carotid Bodies •
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Rate: APNEA – cessation of breathing ORTHOPNEA – inability to breathe except in upright EUPNEA – normal breathing TACHYPNEA – increased respiratory rate BRADYPNEA – decreased respiratory rate
BLOOD PRESSURE Normal Value: Systole = 100-140 Diastole = 60-90 Nursing Consideration: Rested = 30minutes Position: at the level of heart and supported - Above = false low - Below = false high Palpatory BP (+30mmHg) Bell – low pitch sound (Korotkoff) • •
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Rhythm: CHEYNE’S STOKE – very deep to very shallow then apnea THE ROYAL PENTAGON REVIEW SPECIALIST, INC. •
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BP Cuff – Too narrow = false high - Too wide = false low Inflate 2-3mmHg at a time – Too slow = false high - Too fast = false low Meniscus – lower, at the level of eye to prevent ERROR OF PARALLAX Popliteal Pulse – 10-40mmHg higher than the brachial artery
Wheal – irregular shape, insect bite Vesicle - <.5cm (early chicken pox) Bullae - >.5cm (blister, sign of herpes) Pustule- pus •
HAIR • • • • •
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color and lesion
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Pale – Pallor Blue – Cyanosis Yellow – Jaundice Red – Erythema Virtiligo – Patches or hypopigmented skin Lesion: FLAT – non palpable Macule <1cm - Patch >1cm CIRCUMSIDE – elevated form by solid mass (papule, plaque, nodule, tumor) C/E – formed by free fluid Loose of Skin Surface - Erosion (epidermis, without scar) - Ulcer (epidermis, dermis, subcutaneous with scar) - Fissures (linear crack with sharp edges) Papule - <1cm (warts, acne) Plaque – coalescence of papule (psoriasis) Nodule – 0.5-2cm (squamous and carcinoma) Tumor - >2cm •
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NAILS Normal Angle = 160° angle Flat = 180°angle – indication of early clubbing - Long term lack of oxygen Capillary Refill Test – Blanch Test - Pedia = >2seconds - IMCI = more than 3seconds - Funda = 4seconds •
PHYSICAL EXAMINATION Skin, Hair, Nails
Thickness/Thinness – normal = thick Infection and Infestation Amount of Hair Texture of Hair Growth of Hair
EYES Darken the room (dilate) Pupils – PERRLA Size – 3-7mm Miosis – constricted Mydriasis – dilated Anisocona – unequal Visual Acuity – Snellen’s Chart - Normal = 20/20 - 20/200 = legal blindness Myopia – near = concave Hyperopia – far = convex Presbyopia – loss of elasticity of lens caused by aging Astigmatism – uneven curvature of the cornea • • • • • • •
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EARS 4 years old – up and back •
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3 years old above – up and back 3 years old below – down and back WEBER’S TEST – bone conduction, lateralization of sounds - Bad Bone Conduction = conductive hearing loss - Good = sensory neural hearing loss RINNE’S TEST – conductive hearing loss
THORAX Shape – oval, elliptical (adult), equal or cylindrical (infant) Spinal Alignment Sound – percussion ABDOMEN Palpation – void first Dorsal Recumbent – supine with knees flexed to relaxed abdominal muscle Warm hands during palpation – rub Slow approach Indusperpal – prevent the distortion of abdominal sounds
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LABORATORY EXAMS URINE – routine urinalysis - 24hour urine specimen - Catheterization STOOL – routine fecalysis - Guiac Stool Exam SPUTUM – AFB - Blood specimen •
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URINE Routine urinalysis - First thing in the morning - First voided (collect) - First flow is discarded (midstream catch) - Perineal Care first - Send to laboratory (ideal: add preservatives as protocol of agency) Collect – 30-50ml Culture and Sensitivity – 5-10ml •
STOOL Routine fecalysis - 1inch or 2.5cm/tsp - 15-30ml liquid stool (diarrhea) Guiac Stool Exam - Occult blood exam - Don’t give dark color foods (red meat, Iron Supplement) - Avoid turnips and radishes False Positive for 3days False Negative – vit.C 250mg/day for 3days •
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24hours urine specimen - First void discard - Collect with same container Catheterization - Do’s: clamp below the cord (30-60mins) - Sterile syringe inserted diagonally (self-sealing) - Don’ts: do not collect from bag Acetic Acid Test – protein - Do not heat could explode - (+) cloudiness of solution BENEDICT’S TEST – glucose Result – Blue (-) - Green (+) - Yellow (++) - Orange (+++) - Red (++++)
SPINAL ALIGNMENT Lordosis – lumbar region is affected Kyphosis – thoracic region is affected - Best position when assessing: standing straight Scoliosis – lateral deviation of spine - Best position: bending forward in 90°angle • •
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SOUNDS Bronchial – high pitch sound; hear over the trachea •
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Bronchovesicular – moderate pitch sound; hear over main bronchi Vesicular – low pitch sound; heard over the lung fields Use diaphragm for high pitch sound
Page | 8 PERCUSSION Dull – liver and heart Flat – bones and muscles Resonance – normal lung sound Hyper resonance - hyper inflated lung Tympany – stomach Thorax – Normal Resonance - If dull; solidation of lung tissue - Patient with Pneumonia, Emphysema and Asthma • • • • • •
ACID FAST BACILLI Early AM collection No toothbrush, mouthwash and food Plain water only • • •
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BASIC NURSING SKILLS SUCTIONING POSITION – Conscious: semi-fowlers - Unconscious: Side-lying or lateral to prevent aspiration PRESSURE AGE WALT PORTABLE Adult 120-100mmHg 15-10 Child 110-95mmHg 10-5 Infant 95-50mmHg 5-2 LENGTH – nose to earlobe (13cm or 5inches) •
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BLOOD SPECIMEN FASTING – BUN = triglyceride - CREATININE = serum lipid amylase indicative for kidney function NON-FASTING – CBC, Hemoglobin, Hematocrit, Serum Electrolytes, Clotting Studies
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Lubricant - Nasopharyngeal – water soluble lubricant (KY Jelly) - Oropharyngeal – sterile water TIME – 5-10seconds (15sec. maximum) with 20sec. interval - 30 seconds for hyper oxygenation TECHNIQUE – Never apply suction during the insertion - Apply only during withdrawal; intermittent suctioning (on&off) SIZES - Adult = 18-12 French - Children = 10-8 French - Infant = 8-5 French OXYGENATION Support combustion - No smoking - No faulty electrical devices - No friction - No wool fabrics Emergency: nurse can give 2-3liters/min. (independent) Carbon dioxide – major stimuli for respiration TYPES CONCENTRATION LITERS PER MINUTE Nasal Cannula 24-45 2-6 Simple Face Mask 40-60 5-8 Partial 60-90 6-10 Rebreather 95-100 10-15 Non Rebreather 24-40-50 4-10 Venturi Mask •
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CATHETERIZATION Straight catheterization – common Indwelling – 5-10ml, inflate balloon, sterile balloon SIZES - Male: 18-16 French - Female: 14-12 French LENGTH - Male: 6-9 inches - Female: 3-4 inches THE ROYAL PENTAGON REVIEW SPECIALIST, INC. • • •
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POSITION - Male: supine with legs slightly abducted - Female: dorsal recumbent with knees flexed LUBRICANT – water soluble lubricant LOCATION - Male- tip of glands penis - Female: urethral meatus between clitoris and vagina ANCHOR - Male: lower abdomen - Female: inner aspect of thigh •
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NASOGASTRIC TUBE (NGT) For feeding - Gavage For irrigation – Lavage Decompression – preparation for surgery POSITION – Feeding: high-fowler’s for 30minutes LENGTH – Nose Earlobe Xiphoid (50cm or 20inches) PLACEMENTS – Air: aseptosyringe/stethoscope LUQwhooshing sound - Aspirate: color = greenish or yellowish - pH: Acid = <6 - Lithmus Paper: Blue to Red - X-Ray: most effective RESIDUAL VOLUME – 50ml withhold the fluid (12inches) • • • • • •
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ENEMA RETENTION Oil, Carminative 12 inches 1-3 hours 105-110°F •
COMPARISON SOLUTION HEIGHT TIME TEMPERATURE
SIZES - Adult: 32-22 French - Children: 18-14 French
NON-RETENTION Plain NSS, Soap Suds 18 inches 5-10 minutes 115-125°F
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- Infant: 12 French LENGTH - Lubricate: 2 inches or 5cm - Insert: 3 inches or 7cm POSITION - A: left lateral position to follow the contour - C: dorsal recumbent
MEDICATIONS Traditional Five Rights: - Right Drug - Right Dose - Right Time - Right Patient - Right Route 60mg = 1gram 1tsp = 5ml/cc 1gram = 15 grains 1tbs = 3tsp = 15-30ml 1ml = 15gtts 1 cup = 240ml DRUGS - 3x check the label: - Before removing from shelves - After removing from container - Before returning to the drawer or shelves DOSE – Desired Dose/Stock on Hand X Dilution PATIENT – check for ID band (safest) TIME - AC = before meals - PC = after meals - PRN = as needed - STAT = immediately - BID = twice a day ROUTE - Oral and Sublingual – easy absorbed thru bloodstream - Less expensive, most convenient, safest o Disadvantage – remain under the tongue, if swallowed notify the physician. Dissolved by gastric juice Cause staining of teeth o •
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Contraindicated with Nausea and Vomiting Vaccine (Mantoux test) Tuberculin Test - TOPICAL – dermatologic Gauge: 25, 26, 27 - Only applied at the thin layer Length: 3/8, 5/8, ½ - Patch (Nitroglycerin Patch) – clean, hairless, Degree: 10-15 proximal surface o SUBCUTANEOUS - OPTALMIC – Sitting Position or Lying - OINTMENT – clean, inner to outer canntus Sites: outer upper arm - Instill at the lower canntus – 2drops, wait for 5mins Abdominal (insulin) to absorb Anterior Thigh - Prevent the systemic effect – press nasolacrimal Ventro Gluteal and close eyes Dorso Gluteal - OTIC – side-lying; use cotton tip applicator for Indications: Insulin, Vaccine, Heparin cleaning Gauge: 25, 26, 27 - Instill: allow to flow to side; to change the temp. of Length: 3/8, 5/8, ½ meds to body temp.; absorption for 5minutes Degree: 0-90 (obese); 45 (thin and average) o - INHALATION INTRAMUSCULAR - Position: semi-fowler’s / high fowler’s (for full lung Ventro Gluteal – best site for adult expansion) Position: Prone - Instill: nebulizer – 1-2inches away from the mouth Location: Greater Trochanter Metered dose inhaler – hold breath for Dorso Gluteal – contraindicated for 3years 10seconds; wait for another minute before giving below another dose Position: Prone Bronchodilator – with multiple medications Location: Lateral superior, upper outer Steroid Inhalation – oral hygiene; cause oral fungal quadrant infection Vastus Lateralis – best site for infant - VAGINAL – vaginal suppository, vaginal duche Position: Sitting or Lying - Position: dorsal recumbent, remain free for 5Location: middle third anterior lateral aspect 10minutes of thigh - During irrigation – BL with hips higher than the Rectus Femoris – same with vastus lateralis (NT shoulders LATERAL) - RECTAL – left lateral position/ Sim’s Position, right Deltoid – 0.5-1.5ml leg flexed Position: Sitting - Insert until something has grabbed it away – Location: Acromian Process 2-3 finger 20mins absorption breaths below - PARENTERAL Gauge: 20, 21, 22, 23 INTRADERMAL o Length: 1, 1 ½, 2 Sites: inner lower arm (skin test) Degree: 90 Upper chest and back Beneath the scapula - Z-TRACK Technique Indications: Check for allergy - Used for parenteral IRON preparations THE ROYAL PENTAGON REVIEW SPECIALIST, INC. o
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Retract the skin, inject slowly, hold retraction of the skin until needle is withdrawn, do not massage Principles: Use separate needles for aspiration and injection of medication, Introduce air into the vial before aspirating, Introduce needle in quick twist
INTRAVENOUS THERAPHY TYPES OF SOLUTION - ISOTONIC – plain NSS(green) , LR(dark blue) , D5W(red) - HYPOTONIC – lower concentration; D.45/D.33 (light blue) - HYPERTONIC – higher concentration; D5LR(pink), D5NSS(yellow) GAUGE - 16 – biggest (gray) - 18 – blood transfusion (green) - 20 (pink) - 22 (blue) - 24 – pedia (yellow) Points to remember in IVT - Place in the non-dominant hand, distal side (metacarpal) - Select: large vein, easily palpable and naturally splinted by bone - Avoid highly visible, areas of flexion, damage by previous use and surgically compromised Nursing Consideration - Air Embolism (5ml of air) – prime to remove air - Change IV site and tubing every 72hours, bottle every 24hours regardless how many cc is remaining - Regulate every 15-30 minutes •
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