SUPPLEMENTS SUPPLEMENTS FOR FOR

THEORETICAL THEORETICAL FOUNDATIONSFOUNDATIONSSAFE AND EFFECTIVE CARE ENVIRONMENTSAFE AND EFFECTIVE CARE ENVIRONMENTHEALTH PROMOTION AND MAINTENANCEHEALTH PROMOTION AND MAINTENANCE

FUNDAMENTAL CONCEPTSFUNDAMENTAL CONCEPTSREDUCTION OF RISK POTENTIALREDUCTION OF RISK POTENTIALTHERAPIES AND PROCEDURESTHERAPIES AND PROCEDURES

MANAGEMENT OF CAREMANAGEMENT OF CARE

CCOMPETENCE,CONFIDENTIALITY OMPETENCE,CONFIDENTIALITY AND PRIVACYAND PRIVACY

AADVOCACY AND ACCOUNTABILITYDVOCACY AND ACCOUNTABILITY RRESPECTFUL CARE AND ESPECTFUL CARE AND

RESPONSIBILITYRESPONSIBILITY PPROTECTED RELATIONSHIP AND ROTECTED RELATIONSHIP AND

PROMOTION OF PUBLIC HEALTHPROMOTION OF PUBLIC HEALTH EETHICAL STANDARDS OF CARETHICAL STANDARDS OF CARE

INFORMED CONSENTINFORMED CONSENT

CAPACITY AND COMPETENCECAPACITY AND COMPETENCE INCLUDES EXPLANATION OFINCLUDES EXPLANATION OF

BBENEFITS, ENEFITS, EEXPECTED XPECTED RRESULTS,ALTERNATIVES AND ESULTS,ALTERNATIVES AND RRISKISK

VOLUNTARYVOLUNTARY INFORMATION UNDERSTOODINFORMATION UNDERSTOOD CANNOT SIGN IF UNDER CANNOT SIGN IF UNDER

ALCOHOL OR PREMEDICATEDALCOHOL OR PREMEDICATED

Which statement about Which statement about consent is not accurate:consent is not accurate:

It includes explanation of benefits It includes explanation of benefits and disadvantagesand disadvantages

It states that consent cannot be It states that consent cannot be withdrawn anytimewithdrawn anytime

It requires a competent adult who It requires a competent adult who can make voluntary choicescan make voluntary choices

Married minors and pregnant minors Married minors and pregnant minors can sign own consent for treatmentcan sign own consent for treatment

MANAGED CAREMANAGED CARE WORK ALLOCATIONWORK ALLOCATION

PATIENT NEEDS AND CONDITIONSPATIENT NEEDS AND CONDITIONS ABILITIES OF STAFFABILITIES OF STAFF CONTINUITY OF CARECONTINUITY OF CARE KNOWLEDGE OF STAFF AND KNOWLEDGE OF STAFF AND

QUALIFICATIONS\QUALIFICATIONS\ RIGHT TASK- FUNCTION , ACTIVITY , RIGHT TASK- FUNCTION , ACTIVITY ,

DECISION…….INFORMATION , DECISION…….INFORMATION , SUPERVISION , FOLLOW-UPSUPERVISION , FOLLOW-UP

DON’T DELEGATE DON’T DELEGATE ASSESSMENT,TEACHING ASSESSMENT,TEACHING EVALUATION,PLANNINGEVALUATION,PLANNING

DELEGATIONDELEGATION

BUILDS TRUSTBUILDS TRUST EMPOWERS OTHERSEMPOWERS OTHERS TEACHES AN MOTIVATESTEACHES AN MOTIVATES TEAMWORK DEVELOPSTEAMWORK DEVELOPS ENHANCE COMMUNICATIONENHANCE COMMUNICATION RAPID PRODUCTIVITY AND RAPID PRODUCTIVITY AND

RAISED SKILLRAISED SKILL

WHICH OF THE WHICH OF THE FOLLOWING IS NOT TRUE FOLLOWING IS NOT TRUE ABOUT MANAGED CARE?ABOUT MANAGED CARE?

In delegation , responsibility is transferred, In delegation , responsibility is transferred, accountability is sharedaccountability is shared

Responsibility is determined by Nurse practice Responsibility is determined by Nurse practice acts, standards of care, job description and acts, standards of care, job description and policy statementpolicy statement

In delegating identify variables nevertheless this In delegating identify variables nevertheless this would not change authority and responsibilitywould not change authority and responsibility

Delegate to the lowest person on heirarchy that Delegate to the lowest person on heirarchy that has the required skills and abilities who is has the required skills and abilities who is allowed to do the task legally and according to allowed to do the task legally and according to the organizationthe organization

Example: “ feed client if Example: “ feed client if coherent and awake, if coherent and awake, if

confused do not feed and confused do not feed and notify me asap.notify me asap.

IN PLANNING FOR STAFFING IN PLANNING FOR STAFFING ALWAYS TAKE INTO ALWAYS TAKE INTO CONSIDERATION CAPACITY / CONSIDERATION CAPACITY / ABILITY OF THE STAFF.ABILITY OF THE STAFF.

SCOPESCOPE R.N.-R.N.-

PLANNING AND HEALTH TEACHINGPLANNING AND HEALTH TEACHING LICENSURE REQUIREMENTSLICENSURE REQUIREMENTS ASSESSMENT AND EVALUATIONASSESSMENT AND EVALUATION NEED FOR KNOWLEDGE AND SKILLNEED FOR KNOWLEDGE AND SKILL

LPN/LVN-LPN/LVN- STABLE PATIENTSSTABLE PATIENTS STANDARD UNCHANGING PROCEDURESSTANDARD UNCHANGING PROCEDURES SIMPLE MONITORING AND IMPLEMENTATIONSIMPLE MONITORING AND IMPLEMENTATION SEQUENCED/PREDICTABLE OUTCOMESSEQUENCED/PREDICTABLE OUTCOMES STATE PRACTICE ACT INCLUSIONSTATE PRACTICE ACT INCLUSION

UAPUAP-DIRECT PATIENT CARE ACTIVITY AND -DIRECT PATIENT CARE ACTIVITY AND STANDARD OPERATING UNCHANGING STANDARD OPERATING UNCHANGING PROCEDURESPROCEDURES

INCIDENT REPORTSINCIDENT REPORTS

SEQUENCE-UNEXPECTED OR SEQUENCE-UNEXPECTED OR UNPLANNED OCCURENCEUNPLANNED OCCURENCE

RISK MANAGERRISK MANAGER SITUATIONS-STATEMENT OF FACTS SITUATIONS-STATEMENT OF FACTS

AND PATIENT PHYSICAL RESPONSEAND PATIENT PHYSICAL RESPONSE

ACTUAL AND POTENTIAL-REPORT ACTUAL AND POTENTIAL-REPORT WITHIN 24 HOURS-INVESTIGATION OF WITHIN 24 HOURS-INVESTIGATION OF REFERRING TEAM MANAGEMENT(RISK REFERRING TEAM MANAGEMENT(RISK MANAGER)MANAGER)

In writing an incident report In writing an incident report the nurse manager should the nurse manager should

state the following state the following guidelines on charting guidelines on charting

exceptexcept Don’t include words such as error or Don’t include words such as error or inappropriateinappropriate

Don’t include judgemental statementsDon’t include judgemental statements Only actual risks should be reported Only actual risks should be reported

within 24 hours to the risk managerwithin 24 hours to the risk manager Documentation of clients status Documentation of clients status

should be continuous should be continuous

RESTRAINTSRESTRAINTS LIABLE FOR FALSE IMPRISONMENTLIABLE FOR FALSE IMPRISONMENT

LLAST RESORTAST RESORT IINFORMED CONSENT(PROXY)NFORMED CONSENT(PROXY) AALTERNATIVE MEASURES FIRSTLTERNATIVE MEASURES FIRST BBENEFITS> RISKSENEFITS> RISKS LLENGTH OF TIME AND ENGTH OF TIME AND

CIRCUMSTANCES SPECIFIEDCIRCUMSTANCES SPECIFIED EENSURE SAFETY – CIRCULATION NSURE SAFETY – CIRCULATION

CHECKS,SKIN CARE, ROM AND CHECKS,SKIN CARE, ROM AND REMOVE Q2HREMOVE Q2H

RESTRAINTS IS USED RESTRAINTS IS USED FOR:FOR:

THE PURPOSE OF DISCIPLINETHE PURPOSE OF DISCIPLINE COMFORT AND CONVENIENCE OF COMFORT AND CONVENIENCE OF

PROVIDERPROVIDER REQUIRED TO TREAT MEDICAL SYMPTOMSREQUIRED TO TREAT MEDICAL SYMPTOMS MEASURE USED TO CONTROL BEHAVIORMEASURE USED TO CONTROL BEHAVIOR PREVENT BREACH IN SAFE AND PREVENT BREACH IN SAFE AND

EFFECTIVE DELIVERY OF MEDICAL EFFECTIVE DELIVERY OF MEDICAL THERAPY.THERAPY.

ENSURE SAFETY OF OTHER PATIENTSENSURE SAFETY OF OTHER PATIENTS MEDIUM OF LIMIT SETTING AND MEDIUM OF LIMIT SETTING AND

PROVISION OF EXTERNAL CONTROLSPROVISION OF EXTERNAL CONTROLS

COMPLAINTSCOMPLAINTS

CCOMPROMISE / COLLABORATIVE OMPROMISE / COLLABORATIVE AGREEMENTAGREEMENT

LLISTEN ATTENTIVELYISTEN ATTENTIVELY EEXPLAIN SCOPES AND XPLAIN SCOPES AND

LIMITATIONSLIMITATIONS AASK AND RELAY EXPECTED SK AND RELAY EXPECTED

SOLUTIONS AND TERMSSOLUTIONS AND TERMS NNON-DEFENSIVEON-DEFENSIVE

A CLIENT WHO IS ABOUT TO BE BATHED BY A CLIENT WHO IS ABOUT TO BE BATHED BY A NURSE STATES;”You are too young to know A NURSE STATES;”You are too young to know

how to do this, get me someone who knows how to do this, get me someone who knows what they are doing”.the nurse best response what they are doing”.the nurse best response

is:is: We do this procedure daily, I have done We do this procedure daily, I have done this several times, tell me what are you this several times, tell me what are you afraid of?afraid of?

I can see you are upset , can we talk I can see you are upset , can we talk about it?about it?

You’re concerns show you are upset, we You’re concerns show you are upset, we will talk about this after I have will talk about this after I have demonstrated the procedure.demonstrated the procedure.

Can you be more specific about you’re Can you be more specific about you’re concerns?concerns?

Health teachingHealth teaching

C-CONSIDER SUPPORT SYSTEMS / C-CONSIDER SUPPORT SYSTEMS / COMPLIANCECOMPLIANCE

H- olds MOTIVATION AND INSIGHTH- olds MOTIVATION AND INSIGHT A- ALLOW FEEDBACKA- ALLOW FEEDBACK N-NEEDS MET AND ASSUREDN-NEEDS MET AND ASSURED G- GOALS AND PRIORITIES SET w/ G- GOALS AND PRIORITIES SET w/

pnt.pnt. E- EMPATHETIC AND ENSURES E- EMPATHETIC AND ENSURES

COLLABORATIONCOLLABORATION

Patient EducationPatient EducationType of learning:Type of learning:

CognitiveCognitivePsychomotorPsychomotorAffectiveAffective

Patients Patients motivationmotivation –PRIORITY –PRIORITYFACTORS – DURATION , COMPLEXITY AND SIDE EFFECTSFACTORS – DURATION , COMPLEXITY AND SIDE EFFECTS

Discharge planningDischarge planning Begins with first encounterBegins with first encounter

Functional level consideredFunctional level consideredReferrals and preferrencesReferrals and preferrences Compromised planCompromised plan

WHAT IS THE BEST GAUGE WHAT IS THE BEST GAUGE THAT THE CLIENT THAT THE CLIENT

UNDERSTANDS DISCHARGE UNDERSTANDS DISCHARGE TEACHING?TEACHING? PATIENT VERBALIZES INTERESTPATIENT VERBALIZES INTEREST

PATIENT ASKS QUESTIONS RELATED PATIENT ASKS QUESTIONS RELATED TO ADAPTATION TO NEEDED CHANGE TO ADAPTATION TO NEEDED CHANGE IN BEHAVIORIN BEHAVIOR

ACCURATE DEMONSTRATION OF ACCURATE DEMONSTRATION OF PROCEDUREPROCEDURE

PLANS FOR PRACTICE SESSIONS PLANS FOR PRACTICE SESSIONS RELATED TO HEALTH CARE RELATED TO HEALTH CARE SUGGESTIONS TAUGHT BY THE R.N.SUGGESTIONS TAUGHT BY THE R.N.

SAFETY AND INFECTION SAFETY AND INFECTION CONTROL pg.27-49CONTROL pg.27-49

UNIVERSAL PRECAUTIONS UNIVERSAL PRECAUTIONS STANDARD PRECAUTIONS – BARRIERSTANDARD PRECAUTIONS – BARRIER

COMMUNICABLE DISEASE CONCEPTSCOMMUNICABLE DISEASE CONCEPTS CLINICAL MANIFESTATIONS-CLINICAL MANIFESTATIONS-

INITIAL,PATHOGNOMONIC/OUTSTANDINGINITIAL,PATHOGNOMONIC/OUTSTANDING DIAGNOSTIC TESTS AND ETIOLOGYDIAGNOSTIC TESTS AND ETIOLOGY CARE ESSENTIALS AND IMPLICATIONSCARE ESSENTIALS AND IMPLICATIONS

MANAGEMENTMANAGEMENT SEQUELAESEQUELAE

category-specific category-specific isolation isolation

strict- prevents transmission of highly contagious strict- prevents transmission of highly contagious or virulent infections spread by air or direct or virulent infections spread by air or direct contact(diptheria and chickenpox)contact(diptheria and chickenpox)

Contact-prevents transmission of highly Contact-prevents transmission of highly transmissible infections spread by close or direct transmissible infections spread by close or direct contact to skin and mucous membranes that do contact to skin and mucous membranes that do not warrant strict precautionsnot warrant strict precautions

respiratory – prevents trans mission of infectious respiratory – prevents trans mission of infectious diseases over short distances through air diseases over short distances through air droplets(measles, meningitis,mumps, pneumonia droplets(measles, meningitis,mumps, pneumonia and H. Influenza)and H. Influenza) airborneairborne dropletdroplet

enteric precautions – prevents enteric precautions – prevents transmission of infections by direct or transmission of infections by direct or indirect contact with feces(oral-fecal)indirect contact with feces(oral-fecal)( cholera,infectious diarrhea , hepa A , ( cholera,infectious diarrhea , hepa A , infectious AGE)infectious AGE)

AFB isolation-prevents spread of AFB isolation-prevents spread of pulmonary tuberculosis( laryngeal TB)pulmonary tuberculosis( laryngeal TB)

drainage and secretion precautions- drainage and secretion precautions- prevents transmission by direct or indirect prevents transmission by direct or indirect contact with purulent material or drainage contact with purulent material or drainage from an infected body site(abcess, burn from an infected body site(abcess, burn infection,and infected wound)infection,and infected wound)

Universal blood and body fluid Universal blood and body fluid precautions- prevents contact with precautions- prevents contact with pathogens transmitted by pathogens transmitted by direct/indirect contact with infective direct/indirect contact with infective blood or body fluids containing blood or body fluids containing blood( AIDS, HEPA-B,SYPHILIS)blood( AIDS, HEPA-B,SYPHILIS)

care of severely immunocompromised care of severely immunocompromised clients- protects client with lowered clients- protects client with lowered immunity and resistance from immunity and resistance from acquiring infectious acquiring infectious organism( LEUKEMIA, LYMPHOMA, organism( LEUKEMIA, LYMPHOMA, APLASTIC ANEMIA)APLASTIC ANEMIA)

WHICH OF THE FOLLOWING IS WHICH OF THE FOLLOWING IS AN INCORRECT STATEMENT AN INCORRECT STATEMENT

MADE BY THE STUDENT NURSE MADE BY THE STUDENT NURSE ABOUT INFECTION CONTROLABOUT INFECTION CONTROL

HANDWASHING IS THE SINGLE MOST HANDWASHING IS THE SINGLE MOST EFFECTIVE WAY OF PREVENTING THE EFFECTIVE WAY OF PREVENTING THE SPREAD OF INFECTIONSPREAD OF INFECTION

AUTOCLAVING KILLS ALL PATHOGENIC AUTOCLAVING KILLS ALL PATHOGENIC MICROORGANISMS INCLUDING SPORESMICROORGANISMS INCLUDING SPORES

AUTOCLAVED ITEMS IS CONSIDERED AUTOCLAVED ITEMS IS CONSIDERED STERILE UNTIL 6 MOS. ONLYSTERILE UNTIL 6 MOS. ONLY

THE SKIN CAN NEVER BE STERILETHE SKIN CAN NEVER BE STERILE

THE FOLLOWING THE FOLLOWING PATIENTS ARE PATIENTS ARE

INCLUDED IN REVERSE INCLUDED IN REVERSE ISOLATION ISOLATION

PRECAUTIONS EXCEPT:PRECAUTIONS EXCEPT: BURN PATIENTSBURN PATIENTS PATIENTS WITH APLASTIC ANEMIAPATIENTS WITH APLASTIC ANEMIA PATIENT WHO ARE ON STEROID THERAPYPATIENT WHO ARE ON STEROID THERAPY PATIENTS WHO ARE ON CHEMOTHERAPYPATIENTS WHO ARE ON CHEMOTHERAPY PATIENTS WHO ARE ON RADIATION PATIENTS WHO ARE ON RADIATION

THERAPYTHERAPY PATIENTS WITH LEUKEMIAPATIENTS WITH LEUKEMIA PATIENTS WITH LYMPHOMAPATIENTS WITH LYMPHOMA

POISONINGPOISONING

CHILD PROOFCHILD PROOF REFER - POISON CONTROL CENTERREFER - POISON CONTROL CENTER IDENTIFY AND BRING AGENTIDENTIFY AND BRING AGENT SECURE SAFETY AND ABC’SSECURE SAFETY AND ABC’S INDUCE VOMITING W/ IPECACINDUCE VOMITING W/ IPECAC STOP/DELAY ABSORPTION W/ STOP/DELAY ABSORPTION W/

WATER/MILK/ACTIVATED CHARCOALWATER/MILK/ACTIVATED CHARCOAL

THE NURSE SHOULD INTERVENE THE NURSE SHOULD INTERVENE IF A MOTHER OF A VICTIM OF IF A MOTHER OF A VICTIM OF

POISONING VERBALIZES TO DO POISONING VERBALIZES TO DO THE FOLLOWING:THE FOLLOWING:

PLANS TO INDUCE VOMITING FOR PLANS TO INDUCE VOMITING FOR PATIENT WITH ASPIRIN POISONINGPATIENT WITH ASPIRIN POISONING

PLANS TO INDUCE VOMITING WHEN PLANS TO INDUCE VOMITING WHEN SHE IS CERTAIN THAT HER CHILD’S SHE IS CERTAIN THAT HER CHILD’S GAG REFLEX AND LOC ARE INTACTGAG REFLEX AND LOC ARE INTACT

WILL NOT GIVE IPECAC IF CHILD IS WILL NOT GIVE IPECAC IF CHILD IS EXHIBITING NARROWED PULSE EXHIBITING NARROWED PULSE PRESSUREPRESSURE

WILL WAIT FOR THE SEIZURE TO END WILL WAIT FOR THE SEIZURE TO END BEFORE ADMINISTERING IPECACBEFORE ADMINISTERING IPECAC

CONTRAINDICATIONS OF CONTRAINDICATIONS OF IPECAC / INDUCTION OF IPECAC / INDUCTION OF

VOMITINGVOMITING SEIZURESEIZURE SUBNORMAL LOC AND GAG SUBNORMAL LOC AND GAG

REFLEXREFLEX SUBSTANCE SUBSTANCE

CORROSIVE/PETROLEUM CORROSIVE/PETROLEUM DISTILATEDISTILATE

SHOCK-SEVERESHOCK-SEVERE

DISASTER PLANNINGDISASTER PLANNING TRIAGE-GREATEST GOOD FOR THE TRIAGE-GREATEST GOOD FOR THE

GREATEST NUMBER OF PEOPLEGREATEST NUMBER OF PEOPLE PRINCIPLES- ABCD , MASLOWS PRINCIPLES- ABCD , MASLOWS

RED-UNSTABLE – IMMEDIATE CARERED-UNSTABLE – IMMEDIATE CARE YELLOW- STABLE – CAN WAIT 30-60 MINYELLOW- STABLE – CAN WAIT 30-60 MIN GREEN –STABLE- CAN WAIT LONGERGREEN –STABLE- CAN WAIT LONGER BLACK- UNSTABLE – FATAL, LAST SEENBLACK- UNSTABLE – FATAL, LAST SEEN DOA – SUPPORTIVE COMFORT DOA – SUPPORTIVE COMFORT

MEASURESMEASURES

DURING FIRE WHICH SET DURING FIRE WHICH SET OF PATIENTS WILL THE OF PATIENTS WILL THE NURSE MOBILIZE FIRSTNURSE MOBILIZE FIRST

AMBULATORYAMBULATORY BEDRIDDENBEDRIDDEN CRITICALCRITICAL TERMINALTERMINAL

WHICH STEP IN FIRE WHICH STEP IN FIRE MANAGEMENT COMES MANAGEMENT COMES

LAST?LAST? ALARMALARM CONTAINCONTAIN MOBILIZEMOBILIZE EXTINGUISHEXTINGUISH

PREVENTION AND PREVENTION AND EARLY DETECTION OF EARLY DETECTION OF

DISEASEDISEASE

Medical Asepsis/ Clean Medical Asepsis/ Clean TechniqueTechnique

Principles:Principles:             Pathogens move through spaces or air currentPathogens move through spaces or air current             Pathogens are transferred from one surface to Pathogens are transferred from one surface to

another whenever objects touch.another whenever objects touch.             Hand washing removes microorganismHand washing removes microorganism             Pathogens are released into the air on droplet Pathogens are released into the air on droplet

nuclei when person speaks, breaths, and sneeze. nuclei when person speaks, breaths, and sneeze.             Pathogens are transferred by virtue of gravityPathogens are transferred by virtue of gravity             Pathogens move slowly on dry surface but very Pathogens move slowly on dry surface but very

quickly through moisture.quickly through moisture.

Surgical Asepsis/ Sterile Surgical Asepsis/ Sterile TechniqueTechnique

            Areas of the body considered sterile are:Areas of the body considered sterile are: oo              Blood streamBlood stream oo              Spinal FluidSpinal Fluid oo              Peritoneal CavityPeritoneal Cavity oo              Urinary TractUrinary Tract oo              MusclesMuscles oo              BonesBones oo              Chamber of the EyesChamber of the Eyes

    Sterile object remains sterile when touched by Sterile object remains sterile when touched by another sterile objectanother sterile object

            Sterile objects or fields, which falls out of Sterile objects or fields, which falls out of the range of vision or below one’s waist, are the range of vision or below one’s waist, are considered contaminated.considered contaminated.

            Sterile items become contaminated when Sterile items become contaminated when they come in contact with microorganism they come in contact with microorganism transported through the air.transported through the air.

            When sterile object/ field come in contact When sterile object/ field come in contact with another surface, it becomes contaminated.with another surface, it becomes contaminated.

            Fluids flows in the direction of gravity.Fluids flows in the direction of gravity. The edges of the sterile field are considered The edges of the sterile field are considered

unsterileunsterile

Isolation PracticesIsolation Practices             Strict Isolation- prevents transmission of highly Strict Isolation- prevents transmission of highly

communicable disease by contact and airborne communicable disease by contact and airborne transmissiontransmission

            Respiratory isolation- prevents transmission by Respiratory isolation- prevents transmission by dropletdroplet

            Enteric precaution- prevents transmission through Enteric precaution- prevents transmission through ingestioningestion

            Wound and skin precaution- prevents cross-Wound and skin precaution- prevents cross-infection by direct contact with wounds and infection by direct contact with wounds and contaminated articlescontaminated articles

            Discharge precaution- prevent cross-infection by Discharge precaution- prevent cross-infection by secretions-contaminated articlessecretions-contaminated articles

Blood precaution- prevent transmission by contact with Blood precaution- prevent transmission by contact with blood or items contaminated with bloodblood or items contaminated with blood

GROWTH AND GROWTH AND DEVELOPMENTDEVELOPMENT

DEVELOPMENTAL TASKS---MILESTONES DEVELOPMENTAL TASKS---MILESTONES ----DELAYS(FIXATIONS/LAG)----DELAYS(FIXATIONS/LAG)

IQ = MA / CA X 100IQ = MA / CA X 100 JUDGEMENT , COMPREHENSION AND JUDGEMENT , COMPREHENSION AND

LISTENINGLISTENING

DDST – BIRTH TO 6 YEARS DDST – BIRTH TO 6 YEARS PERSONAL SOCIAL, FINE , GROSS MOTOR PERSONAL SOCIAL, FINE , GROSS MOTOR

AND LANGUAGE SKILL AREASAND LANGUAGE SKILL AREAS

HEALTH SCREENINGHEALTH SCREENING OB – GYNE / REPRODUCTIVE TESTSOB – GYNE / REPRODUCTIVE TESTS

UTZ-5 WKS CONFIRM PREGNANCY AND AOGUTZ-5 WKS CONFIRM PREGNANCY AND AOG AMNIOCENTESIS – 16 WKS-DETECT GENETIC AMNIOCENTESIS – 16 WKS-DETECT GENETIC

DISORDERS – 30 WEEKS – L/S RATIO ( 2-4 WKS DISORDERS – 30 WEEKS – L/S RATIO ( 2-4 WKS RESULT)(EMPTY Bladder)RESULT)(EMPTY Bladder)

OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN OCT – (28 WKS)FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN 10 MINUTES- REACTIVE10 MINUTES- REACTIVE

NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE NST – FHR ACCELERATIONS (32-34 WKS) – 2-MORE FHR ACCELERATION OF 15BPM/MORE LASTING 15 FHR ACCELERATION OF 15BPM/MORE LASTING 15 SECS -20 MINS. AND RETURN OF FHR TO SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE – REACTIVENORMAL/BASELINE – REACTIVE

DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION)DOPTONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION) AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE AFPT-FETAL SERUM CHON , -DETECT NEURAL TUBE

DEFECTS – 16-18 WKSDEFECTS – 16-18 WKS CHORIONIC VILLI SAMPLING –FETAL CHORIONIC VILLI SAMPLING –FETAL

ABNORMALITIES- 10-12 WKSABNORMALITIES- 10-12 WKS

NEWBORN/INFANT NEWBORN/INFANT HEALTH SCREENINGHEALTH SCREENING

PKU – GUTHRINE BLOOD TEST-EAT PKU – GUTHRINE BLOOD TEST-EAT CHON FOR 2 DAYS MIN.CHON FOR 2 DAYS MIN.(PHEONISTICS – DIAPER)(PHEONISTICS – DIAPER)

SICKLE CELL DISEASE –SICKLE CELL DISEASE –ABNORMALLY SHAPED Hg ,ABNORMALLY SHAPED Hg ,

ELISA AND WESTERN BLOTELISA AND WESTERN BLOT CARRIER SCREENING FOR CYSTIC CARRIER SCREENING FOR CYSTIC

FIBROSIS AND SWEAT CHLORIDE FIBROSIS AND SWEAT CHLORIDE TESTTEST

SCHOOL AGESCHOOL AGE

HEARING AND VISION TESTSHEARING AND VISION TESTS ALLEN PICTURE CARDSALLEN PICTURE CARDS SNELLEN CHART-20/40 AT TODDLER SNELLEN CHART-20/40 AT TODDLER

AND 20/20 AT SCHOOL AGEAND 20/20 AT SCHOOL AGE WEBER’S-SENSORINEURAL AND WEBER’S-SENSORINEURAL AND

CONDUCTIVECONDUCTIVE RINNE’S- CONDUCTIVERINNE’S- CONDUCTIVE DENTAL EXAM – STARTS AT 2 YEARSDENTAL EXAM – STARTS AT 2 YEARS

ADOLESCENTADOLESCENT

PPD – INDURATION – 72 HOURSPPD – INDURATION – 72 HOURS BSE – (18-20 YRS.) POST BSE – (18-20 YRS.) POST

MENSTRATION/MONTHLYMENSTRATION/MONTHLY TSE – MONTHLY (18-20 YRS)TSE – MONTHLY (18-20 YRS) PELVIC EXAM WITH PAP SMEAR – PELVIC EXAM WITH PAP SMEAR –

IF SEXUALLY ACTIVE OR 18 Y.O. IF SEXUALLY ACTIVE OR 18 Y.O. ANNUALLYANNUALLY

IN TEACHING AN ADOLESCENT IN TEACHING AN ADOLESCENT PROPER BSE TECHNIQUE THE PROPER BSE TECHNIQUE THE

NURSE SHOULD INSTRUCT THE NURSE SHOULD INSTRUCT THE CLIENT TO PERFORM BSE IN THE CLIENT TO PERFORM BSE IN THE FOLLOWING POSITIONS EXCEPT:FOLLOWING POSITIONS EXCEPT:

STANDING WITH ARMS ON THE HIPS STANDING WITH ARMS ON THE HIPS FACING THE MIRRORFACING THE MIRROR

LYING DOWN WITH PILLOW UNDER LYING DOWN WITH PILLOW UNDER THE SHOULDERS ARMS AT THE BACK THE SHOULDERS ARMS AT THE BACK OF THE HEADOF THE HEAD

RAISE THE ARM OF THE SIDE TO RAISE THE ARM OF THE SIDE TO EXAMINED ABOVE THE HEADEXAMINED ABOVE THE HEAD

POSITION THE ARMS WITH THE BODY POSITION THE ARMS WITH THE BODY IN ANATOMICAL POSITIONIN ANATOMICAL POSITION

ADULT/ELDERLYADULT/ELDERLY HPN , DM, HEARING AND VISIONHPN , DM, HEARING AND VISION PROSTATE –ANNUALLY@40PROSTATE –ANNUALLY@40 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YOCa CHECK-UPS-Q3Y-20YO ; QY – 40 YO SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRSSIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS FECAL OCCULT BLOOD TEST- > 50 = FECAL OCCULT BLOOD TEST- > 50 =

ANNUALLYANNUALLY DIGITAL RECTAL EXAM - > 40 Y.O. = DIGITAL RECTAL EXAM - > 40 Y.O. =

YEARLYYEARLY PELVIC EXAM – 18-40 Y.O. =PERFORMED PELVIC EXAM – 18-40 Y.O. =PERFORMED

Q 1 – 3 YEARS WITH PAP TESTQ 1 – 3 YEARS WITH PAP TEST MAMMOGRAM – MAMMOGRAM – 35-39 = BASELINE35-39 = BASELINE

40-49 = Q2Y40-49 = Q2Y50 AND OLDER = QYEAR50 AND OLDER = QYEAR

BP SCREENING(mmHg)BP SCREENING(mmHg)SYSTOLICSYSTOLIC DIASTOLICDIASTOLIC FOLLOW-UPFOLLOW-UP

< 130< 130 <85<85 2 YEARS2 YEARS

130-139130-139 85-8985-89 1 YEAR1 YEAR

140-159140-159 90-9990-99 2 MOS.2 MOS.

160-179160-179 100-109100-109 EVALUATE AND EVALUATE AND REFER 1 MOS.REFER 1 MOS.

180-209180-209 110-119110-119 1 WEEK1 WEEK

>210>210 120120 IMMEDIATELIMMEDIATELYY

UPON INITIAL ASSESSMENT THE UPON INITIAL ASSESSMENT THE PATIENT HAS A BLOOD PRESSURE OF PATIENT HAS A BLOOD PRESSURE OF 170/90 mmHg. WHAT IS THE FOLLOW-170/90 mmHg. WHAT IS THE FOLLOW-

UP REFERRAL FOR THIS PATIENT?UP REFERRAL FOR THIS PATIENT?

REFER AFTER 1 WEEKREFER AFTER 1 WEEK EVALUATE AND REFER FOR EVALUATE AND REFER FOR

FOLLOW-UP AFTER 2 WEEKSFOLLOW-UP AFTER 2 WEEKS EVALUATE AND REFER FOR EVALUATE AND REFER FOR

FOLLOW-UP IN 2 MONTHSFOLLOW-UP IN 2 MONTHS EVALUATE AND REFER FOR EVALUATE AND REFER FOR

FOLLOW-UP IN 1 MONTHFOLLOW-UP IN 1 MONTH

IMMUNITY pg 127-130IMMUNITY pg 127-130 CONTRAINDICATIONS:CONTRAINDICATIONS:

SEVERE FEBRILE ILLNESSSEVERE FEBRILE ILLNESS LIVE VIRUSES C/I FOR LIVE VIRUSES C/I FOR

IMMUNOCOMPROMISEDIMMUNOCOMPROMISED ALLERGIESALLERGIES RECENTLY ACQUIRED PASSIVE RECENTLY ACQUIRED PASSIVE

IMMUNITY(BLOOD TRANSFUSION AND IMMUNITY(BLOOD TRANSFUSION AND IMMUNOGLOBULINS)IMMUNOGLOBULINS)

if child –no evidence of immunization <7 if child –no evidence of immunization <7 y.o.y.o. Give DPT,TOPV,TINEGive DPT,TOPV,TINE 4-6 WKS LATER MMR4-6 WKS LATER MMR 1 MONTH AFTER DPT AND TOPV1 MONTH AFTER DPT AND TOPV REPEATED IN ANOTHER MONTHREPEATED IN ANOTHER MONTH AGAIN IN 10-16 MOS.AGAIN IN 10-16 MOS.

CAN GIVE DPT,MMR,TOPV, AND TINE CAN GIVE DPT,MMR,TOPV, AND TINE SIMULTANEOUSLYSIMULTANEOUSLY

TD- 2 DOSES 4-8 WKS APART;3TD- 2 DOSES 4-8 WKS APART;3RDRD DOSE DOSE 6-12 MOS;BOOSTER AT 10 YRS FO LIFE6-12 MOS;BOOSTER AT 10 YRS FO LIFE

OPV/IPV – 2 DOSES AT 4-8 WKS APART ; OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 33RDRD DOSE 2 -12 MOS AFTER 2 DOSE 2 -12 MOS AFTER 2NDND(OPV (OPV NOT USED IN US)NOT USED IN US)

MMR-ONE DOSE – 12 MOSMMR-ONE DOSE – 12 MOS VARICELLA – TWO DOSES 4-8 WEEKS VARICELLA – TWO DOSES 4-8 WEEKS

APART STARTS AT 12 MOS.APART STARTS AT 12 MOS. HEPA B – 3 DOSES;2HEPA B – 3 DOSES;2NDND 1-2 MOS 1-2 MOS

AFTER;3AFTER;3RDRD 4-6 MS AFTER 4-6 MS AFTER PPV- ONE DOSE ;IF 65 AND RECEIVED > PPV- ONE DOSE ;IF 65 AND RECEIVED >

5YEARS – ADMINISTER5YEARS – ADMINISTER INFLUENZA –ANNUALLY EACH FALLINFLUENZA –ANNUALLY EACH FALL

ALLERGY ALLERGY CONTRAINDICATIONSCONTRAINDICATIONS

EGGS – INFLUENZA , MMR EGGS – INFLUENZA , MMR NEOMYCIN – VARICELLA,IPV,MMRNEOMYCIN – VARICELLA,IPV,MMR YEAST – HEPA-BYEAST – HEPA-B GELATIN – VARICELLAGELATIN – VARICELLA

PREGNANCY C/I: MMR AND VARICELLAPREGNANCY C/I: MMR AND VARICELLA IMMUNOSUPPRESSED; VARICELLAIMMUNOSUPPRESSED; VARICELLA WITH Ig or BT PREVIOUS 3-11 MOS – WITH Ig or BT PREVIOUS 3-11 MOS –

MMR AND VARICELLAMMR AND VARICELLA

CONSIDERATIONS-CONSIDERATIONS-IMMUNIZATIONIMMUNIZATION

DPT - IM – ANTERIOR OR LATERAL THIGHDPT - IM – ANTERIOR OR LATERAL THIGH FEVER AND SWELLING 24-48 H POTENTIALFEVER AND SWELLING 24-48 H POTENTIAL SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC SERIOUS-CONVULSIONS,HYPERPYREXIA,LOC

AND SCREAMINGAND SCREAMING MMR – SC – ANTERIOR OR LATERAL THIGHMMR – SC – ANTERIOR OR LATERAL THIGH

RASH, FEVER ARTHRITIS-10DAYS-2 WKSRASH, FEVER ARTHRITIS-10DAYS-2 WKS TRIVALENT OPV – POTRIVALENT OPV – PO

PPD-ID- 4-6/11-16YRS.OLD IN HIGH PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE AREAS – EVALUATED 48-72 PREVALENCE AREAS – EVALUATED 48-72 HOURSHOURS

A PATIENT WITH HIV-AIDS A PATIENT WITH HIV-AIDS IS POSITIVE FOR PPD IS POSITIVE FOR PPD

WHEN THERE IS:WHEN THERE IS: PRESENCE OF INDURATION OF 10 PRESENCE OF INDURATION OF 10

MMMM PRESENCE OF INDURATION OF 15 PRESENCE OF INDURATION OF 15

MMMM PRESENCE OF INDURATION OF 5 PRESENCE OF INDURATION OF 5

MMMM WHEAL FORMATION OF 10MM OR WHEAL FORMATION OF 10MM OR

VESCICULAR PROLIFERATIONVESCICULAR PROLIFERATION

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT TEACHING OPPURTUNITYTEACHING OPPURTUNITY INSPECTION –VISUALLYINSPECTION –VISUALLY PALPATION-WARM HANDSPALPATION-WARM HANDS

DORSUM OF FINGERS FOR TEMPDORSUM OF FINGERS FOR TEMP PERCUSSION-DIRECT,INDIRECT,BLUNTPERCUSSION-DIRECT,INDIRECT,BLUNT

RESONANCE-MODERATE LOW PITCHED CLEAR RESONANCE-MODERATE LOW PITCHED CLEAR HOLLOW(LUNG)HOLLOW(LUNG)

HYPERRESONANCE-OVERINFLATED(EMPHYSEMA)HYPERRESONANCE-OVERINFLATED(EMPHYSEMA) TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL)TYMPANY-HIGH PITCHED,LOUD DRUMLIKE(BOWEL) DULL-SOFT MUFFLED,DENSE FLUID FILLED DULL-SOFT MUFFLED,DENSE FLUID FILLED

TISSUE(LIVER)TISSUE(LIVER) FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-FLAT – SOFT HIGH PITCHED,VERY DENSE TISSUE-

(MUSCLE/BONE)(MUSCLE/BONE) AUSCULTATION-DIAPHRAGM-AUSCULTATION-DIAPHRAGM-

HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT HIGH PITCHED(LUNG,BOWEL,HEART); BELL – SOFT LOW PITCHED(HEART MURMURS) LOW PITCHED(HEART MURMURS)

VITAL SIGNSVITAL SIGNS

TEMPERATURE:TEMPERATURE: ORAL – 98.6 ‘F / 37 ‘CORAL – 98.6 ‘F / 37 ‘C RECTAL – 99.6 ‘F / 37.6’CRECTAL – 99.6 ‘F / 37.6’C AXILLARY – 97.6’F / 36.5’CAXILLARY – 97.6’F / 36.5’C

Body TemperatureBody Temperature             The balance between heat produce by the The balance between heat produce by the

body and heat loss from the bodybody and heat loss from the body             Types of body temperatureTypes of body temperature                 Core temperature- deep tissue temperature Core temperature- deep tissue temperature

of the bodyof the body                 Surface temperature- temperature of the Surface temperature- temperature of the

skin, subcutaneous tissue, and fatsskin, subcutaneous tissue, and fats             The normal core body temperature is The normal core body temperature is

between 36.7between 36.7°C (98.7°F)- 37°C (98.6°F).°C (98.7°F)- 37°C (98.6°F).             The thermoregulation center of the body is The thermoregulation center of the body is

the hypothalamus the hypothalamus

            Types of fever:Types of fever:                 Constant- temperature is constantly Constant- temperature is constantly

highhigh                 Intermittent- the temperature Intermittent- the temperature

fluctuates between periods of fever and fluctuates between periods of fever and periods of normal temperatureperiods of normal temperature

                Relapsing- increase in temperature Relapsing- increase in temperature alternated with 1 or 2 days normal alternated with 1 or 2 days normal temperaturetemperatureo Remittent fever- the temperature fluctuates Remittent fever- the temperature fluctuates

with in a wide range over 24 hours period but with in a wide range over 24 hours period but remains above normal temperatureremains above normal temperature

            Routes of Temperature –TakingRoutes of Temperature –Taking                 OralOral oo              Most accessible and most convenientMost accessible and most convenient oo              Temperature is taken in 2-3 minutes timeTemperature is taken in 2-3 minutes time oo              15 minutes before taking the oral 15 minutes before taking the oral

temperature, don’t allow the client to take hot or temperature, don’t allow the client to take hot or cold foods and fluidscold foods and fluids

                RectalRectal oo              Most accurate measurementMost accurate measurement oo              Thermometer is inserted 0.5-1.5 inchesThermometer is inserted 0.5-1.5 inches oo              Temperature is taken in 2 two minutes Temperature is taken in 2 two minutes

time.time.   

AxillaryAxillary oo              The most non-invasive and the most safestThe most non-invasive and the most safest oo              Temperature is taken in 5-9 minutes timeTemperature is taken in 5-9 minutes time             If the body temperature declines suddenly, If the body temperature declines suddenly,

it is termed as crisis and this indicates it is termed as crisis and this indicates hypothalamic disturbances; while if there is a hypothalamic disturbances; while if there is a gradual decline of fever, we term that as lysis gradual decline of fever, we term that as lysis that indicates normal functioning of the that indicates normal functioning of the hypothalamushypothalamus

            Antipyretic is the drug of choice for patients Antipyretic is the drug of choice for patients with feverwith fever

PulsePulse             It is the wave of blood created by the It is the wave of blood created by the

contraction of the left ventriclecontraction of the left ventricle             Pulse rate is regulated by the Pulse rate is regulated by the

autonomic nervous system (ANS)autonomic nervous system (ANS)             The normal pulse rate of an adult The normal pulse rate of an adult

ranges from 60-100 beats per minuteranges from 60-100 beats per minute             Pulse amplitute describes the quality Pulse amplitute describes the quality

of the pulse in terms of its fullnessof the pulse in terms of its fullness

NumberNumber DefinitionDefinitionDescriptionDescription

00 absentabsent no pulsationno pulsation 11 threadythready not easily feltnot easily felt 22 weakweak stronger thanstronger than

threadythready 33 normalnormal easily felteasily felt 44               boundingbounding strongerstronger

pulsationpulsation

          Pulse deficit is the difference between Pulse deficit is the difference between the apical pulse and radial pulsthe apical pulse and radial puls

          Pulse rate vary in different age levels:Pulse rate vary in different age levels:                 1 year old- 80-180 beats per min 1 year old- 80-180 beats per min

(BPM)(BPM)                 2 years old- 80-140 BPM2 years old- 80-140 BPM                 6 years old- 75-120 BPM6 years old- 75-120 BPM                 10 years old – 50-90 BPM10 years old – 50-90 BPM                 Adult - 60-100Adult - 60-100           When palpating for the pulse, use two When palpating for the pulse, use two

to three finger tips. Don’t use the thumbto three finger tips. Don’t use the thumb

          Pulse sites and reasons for use:Pulse sites and reasons for use:                 Temporal- used when radical pulse is not accessibleTemporal- used when radical pulse is not accessible                 Carotid- used for infants, in cases of cardiac arrest, to Carotid- used for infants, in cases of cardiac arrest, to

determine the circulation of the braindetermine the circulation of the brain                 Apical- routinely used for infants and children up to three years Apical- routinely used for infants and children up to three years

old; to determine discrepancies with radial pulse; used in old; to determine discrepancies with radial pulse; used in conjunction with some medications.conjunction with some medications.

                Brachial- used to measure blood pressure; during cardiac Brachial- used to measure blood pressure; during cardiac arrests of infantsarrests of infants

                Radial- readily accessible and routinely usedRadial- readily accessible and routinely used                 Femoral- used in cases of cardiac arrest, infants children, Femoral- used in cases of cardiac arrest, infants children,

determine the circulation of the legsdetermine the circulation of the legs                 Popliteal- to determine circulation of the lower leg and the site Popliteal- to determine circulation of the lower leg and the site

for the measurement of BP in the lower extremitiesfor the measurement of BP in the lower extremities                 Posterior Tibial- to assess for the circulation of the footPosterior Tibial- to assess for the circulation of the foot                 Pedal- to assess for the circulation of the foot Pedal- to assess for the circulation of the foot

RespirationRespiration           It is the act of breathing: breathing in It is the act of breathing: breathing in

(Inhalation), breathing out (Exhalation)(Inhalation), breathing out (Exhalation)           Types of Respiration:Types of Respiration:                 External Respiration- exchanges of External Respiration- exchanges of

gasses (oxygen and Carbon Dioxide) that gasses (oxygen and Carbon Dioxide) that happens in the alveoli of the lungshappens in the alveoli of the lungs

Internal Respiration- exchange of gasses Internal Respiration- exchange of gasses that happens in the cellthat happens in the cell

Types of breathing:Types of breathing:                 Costal (thoracic) breathing-involves the movement Costal (thoracic) breathing-involves the movement

of the chest of the chest                 Diaphragmatic (abdominal)- involves the movement Diaphragmatic (abdominal)- involves the movement

of the abdomenof the abdomen           The medulla oblongata is the primary respiratory The medulla oblongata is the primary respiratory

center of the bodycenter of the body           There are three(3) processes involved in respirationThere are three(3) processes involved in respiration                 Ventilation- the movement of gasses in and out of the Ventilation- the movement of gasses in and out of the

lungslungs                 Diffusion- exchange of gasses from an area of Diffusion- exchange of gasses from an area of

greater pressure to an area of lower pressure. It occurs at greater pressure to an area of lower pressure. It occurs at the alveolo-capillary membrane.the alveolo-capillary membrane.

                Perfusion- movement of blood for transport of Perfusion- movement of blood for transport of gasses, nutrients, and metabolic wastes productsgasses, nutrients, and metabolic wastes products

          Normal adult breathes 16-20 times per minuteNormal adult breathes 16-20 times per minute

Blood PressureBlood Pressure           It is the pressure exerted by the blood in the arteriesIt is the pressure exerted by the blood in the arteries           Normal adult’s BP is 120/80Normal adult’s BP is 120/80           Systolic Pressure is the pressure resulting from the Systolic Pressure is the pressure resulting from the

contraction of the ventriclescontraction of the ventricles           Diastolic pressure is the pressure when the Diastolic pressure is the pressure when the

ventricles are at rest. (Normal: 60-90 mm Hg)ventricles are at rest. (Normal: 60-90 mm Hg)           Pulse pressure is the difference between the systolic Pulse pressure is the difference between the systolic

and diastolic pressure (Normal: 30-40)and diastolic pressure (Normal: 30-40)           Hypertension – abnormally high blood pressure over Hypertension – abnormally high blood pressure over

140/90 mm Hg for at least two consecutive readings140/90 mm Hg for at least two consecutive readings           Hypotension- abnormally low blood pressure, Hypotension- abnormally low blood pressure,

systolic pressure below 100mm Hgsystolic pressure below 100mm Hg           Postural/ orthostatic hypotension is a sudden drop in Postural/ orthostatic hypotension is a sudden drop in

blood pressure caused by a sudden changed in positionblood pressure caused by a sudden changed in position

          If the BP cuff is too small for a patient, the If the BP cuff is too small for a patient, the BP reading may result to false high BP reading may result to false high measurement; if the BP cuff is too big for a measurement; if the BP cuff is too big for a patient, the BP reading may result I false low patient, the BP reading may result I false low measurementmeasurement

          Women usually have lower BP than menWomen usually have lower BP than men           The series of sounds that the nurse listens The series of sounds that the nurse listens

during BP reading is called Korotkoff soundsduring BP reading is called Korotkoff sounds           In assessing the BP, use the bell-shaped In assessing the BP, use the bell-shaped

diaphragm of the stetoscope since BP is a low diaphragm of the stetoscope since BP is a low frequency soundfrequency sound

Always read the lower meniscus of the mercury Always read the lower meniscus of the mercury of the BP apparatus at eye level to prevent errorof the BP apparatus at eye level to prevent error

NORMAL VITAL SIGNSNORMAL VITAL SIGNSNEWBORN=30 – 50 / MIN; 120 – 140 / NEWBORN=30 – 50 / MIN; 120 – 140 /

MIN; 60/40 – 80/50 mmHgMIN; 60/40 – 80/50 mmHg

1 – 4 YEARS=20 – 40 / MIN; 80 – 140 1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN; 90/60 – 99/65 mmHg/MIN; 90/60 – 99/65 mmHg

5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / 5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN; 100/56 – 110/60 mmHgMIN; 100/56 – 110/60 mmHg

ADULT=12 – 20 / MIN;60 – 100 / MIN ; ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –140 / 90 mmHg90 / 60 –140 / 90 mmHg

BREATHING PATTERNSBREATHING PATTERNS CHEYNE STOKES – PERIODIC BREATHING CHEYNE STOKES – PERIODIC BREATHING

CHARACTERIZED BY RHYTMIC WAXING AND CHARACTERIZED BY RHYTMIC WAXING AND WANINGWANING

DYSPNEA - LABORED PAINFUL BREATHINGDYSPNEA - LABORED PAINFUL BREATHING HYPERVENTILATION – ABNORMALLY RAPID HYPERVENTILATION – ABNORMALLY RAPID

DEEP PROLONGED BREATHINGDEEP PROLONGED BREATHING KUSSMAULS – AIR HUNGER , MARKED KUSSMAULS – AIR HUNGER , MARKED

INCREASE IN DEPTH AND RATEINCREASE IN DEPTH AND RATE TACHYPNEA – FAST SHALLOW BREATHINGTACHYPNEA – FAST SHALLOW BREATHING PARADOXICAL – FLAIL CHEST , DEFLATES PARADOXICAL – FLAIL CHEST , DEFLATES

DURING INHALATIONDURING INHALATION BIOT’S – SHALLOW BREATHS INTERRUPTED BIOT’S – SHALLOW BREATHS INTERRUPTED

BY APNEABY APNEA

NORMAL FINDINGSNORMAL FINDINGS PULSE PRESSURE – 30-40 mmHgPULSE PRESSURE – 30-40 mmHg Intracranial pressure – 10 mmHgIntracranial pressure – 10 mmHg PULSE DEFICIT – MINIMAL(3-5 PULSE DEFICIT – MINIMAL(3-5

ACCEPTABLE)ACCEPTABLE)

IDEAL BODY WEIGHT –IDEAL BODY WEIGHT – MALES -106 LBS FOR 1MALES -106 LBS FOR 1STST 5FT THEN ADD 5FT THEN ADD

6LBS/INCH6LBS/INCH FEMALE – 100LBS FOR 1FEMALE – 100LBS FOR 1STST 5 FT THEN ADD 5 FT THEN ADD

5LBS/INCH5LBS/INCH ADD OR SUBTRACT 10% DEPENDING ON BODY ADD OR SUBTRACT 10% DEPENDING ON BODY

FRAME.FRAME. OBESE AND UNDERWEIGHT IF DEVIATION IS > OBESE AND UNDERWEIGHT IF DEVIATION IS >

20%20%

SKINSKIN SCARS,BRUISES AND SCARS,BRUISES AND LESIONSLESIONS CHECK COLORCHECK COLOR EDEMA – GRADINGEDEMA – GRADING

0-NO EDEMA0-NO EDEMA 1-BARELY DETECTABLE1-BARELY DETECTABLE 2-INDENTATION<5MM2-INDENTATION<5MM 3-INDENTATION 5-10MM3-INDENTATION 5-10MM 4-INDENTATION >10MM4-INDENTATION >10MM

PRESSURE SORE –GRADINGPRESSURE SORE –GRADING 1-NONBLANCHABLE ERYTHEMA1-NONBLANCHABLE ERYTHEMA 2-EPIDERMIS,PARTIAL THICKNESS2-EPIDERMIS,PARTIAL THICKNESS 3-FULL DERMIS AND SQ3-FULL DERMIS AND SQ 4- SUPPORTING TISSUES AND BONES4- SUPPORTING TISSUES AND BONES

TURGOR-PINCH SKIN TENTED 3 SECS TURGOR-PINCH SKIN TENTED 3 SECS NORMAL(ELDERLY-OVER STERNUM)NORMAL(ELDERLY-OVER STERNUM)

skin lesionsskin lesions maculemacule patchespatches papulepapule plaqueplaque nodulenodule tumortumor vesciclevescicle bullaebullae puspus

HAIR AND NAILSHAIR AND NAILS

HIRSUTISM-EXCESSHIRSUTISM-EXCESS ALOPECIA-THINNINGALOPECIA-THINNING

SHAPE – NORMALANGLE OF NAIL SHAPE – NORMALANGLE OF NAIL BED-160’; CLUBBING ANGLE > 180 BED-160’; CLUBBING ANGLE > 180 DUE TO PROLONGED DECREASED DUE TO PROLONGED DECREASED OXYGENATIONOXYGENATION

BLANCHING =< 3 SECS-NORMALBLANCHING =< 3 SECS-NORMAL

HEADHEAD SYMMETRY, SIZE AND SHAPESYMMETRY, SIZE AND SHAPE CRANIAL NERVE ASSESSMENTSCRANIAL NERVE ASSESSMENTS

OPTIC-SNELLENOPTIC-SNELLEN OCULOMOTOR- PERRLAOCULOMOTOR- PERRLA TRIGEMINAL – BITE DOWN AND STROKES TRIGEMINAL – BITE DOWN AND STROKES

WITH COTTONWITH COTTON FACIAL – FACIAL MOVEMENT AND TASTEFACIAL – FACIAL MOVEMENT AND TASTE ACCOUSTIC – HEARING AND ACCOUSTIC – HEARING AND

BALANCE(WATCH TICK TEST,OTOSCOPIC BALANCE(WATCH TICK TEST,OTOSCOPIC EXAMS AND POSTURE TESTS)EXAMS AND POSTURE TESTS)

GLOSSOPHARYGEAL-GAG AND SWALLOWGLOSSOPHARYGEAL-GAG AND SWALLOW VAGUS- SWALLOWING AND SPEAKINGVAGUS- SWALLOWING AND SPEAKING

EYESEYES PTOSIS-DROOPING OF THE UPPER EYELIDPTOSIS-DROOPING OF THE UPPER EYELID ASTIGMATISM – UNEVEN CURVATURE OF ASTIGMATISM – UNEVEN CURVATURE OF

CORNEA LEADING TO REFRACTION ERRORSCORNEA LEADING TO REFRACTION ERRORS NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE NYSTAGMUS- ABNORMAL, INVOLUNTARY EYE

MOVEMENTSMOVEMENTS STRABISMUS-ASSYMETRICAL LIGHT STRABISMUS-ASSYMETRICAL LIGHT

EFLECTION ON EACH CORNEAEFLECTION ON EACH CORNEA RED REFLEX FROM RETINA-NORMALRED REFLEX FROM RETINA-NORMAL COVER UNCOVER TEST – DET.EYE ALIGNMENTCOVER UNCOVER TEST – DET.EYE ALIGNMENT SNELLEN – FAR DISTANCE VISION/VISUAL SNELLEN – FAR DISTANCE VISION/VISUAL

ACUITYACUITY IOP-TONOMETRY TESTS INDENTATION(6-12)IOP-TONOMETRY TESTS INDENTATION(6-12)

EARSEARS

PINNA BACK-UP-ADULT;DOWN-BACK-PINNA BACK-UP-ADULT;DOWN-BACK-CHILDCHILD

RINNE TEST – COMPARES AIR RINNE TEST – COMPARES AIR CONDUCTION WITH BONE CONDUCTION WITH BONE CONDUCTION,VIBRATING FORK PLACED CONDUCTION,VIBRATING FORK PLACED ON THE MASTOID IF SOUND NO LONGER ON THE MASTOID IF SOUND NO LONGER HEARD POSITIONED IN FRONT OF EAR HEARD POSITIONED IN FRONT OF EAR CANNAL. SHOULD HEAR A SOUND= 2:1 ; CANNAL. SHOULD HEAR A SOUND= 2:1 ; AIR CONDUCTION > THAN BONE AIR CONDUCTION > THAN BONE CONDUCTION ;= POSITIVE RINNECONDUCTION ;= POSITIVE RINNE ASSESS CONDUCTIVE HEARING LOSSASSESS CONDUCTIVE HEARING LOSS

EARSEARS

WEBER – SENSORINEURAL AND WEBER – SENSORINEURAL AND CONDUCTIVE HEARING LOSSCONDUCTIVE HEARING LOSS FORK PLACED MIDDLE OF FORE FORK PLACED MIDDLE OF FORE

HEAD,SHOULD BE HEARD HEAD,SHOULD BE HEARD EQUALLY=WEBER NEGATIVEEQUALLY=WEBER NEGATIVE

IF NOT EQUAL=SENSORINEURAL IF NOT EQUAL=SENSORINEURAL HEARING LOSS.HEARING LOSS.

SOUND HEARD BETTER IN THE IMPAIRED SOUND HEARD BETTER IN THE IMPAIRED EAR=BONE CONDUCTIVE HEARING LOSS, EAR=BONE CONDUCTIVE HEARING LOSS, IF VICE VERSA = SENSORINEURAL IF VICE VERSA = SENSORINEURAL DISTURBANCEDISTURBANCE

NECK,MOUTH AND NECK,MOUTH AND PHARYNXPHARYNX

TEETH-32TEETH-32 TONSILS – NO TPC , + GAG REFLEXTONSILS – NO TPC , + GAG REFLEX CERVICAL LYMPH NODES=<1CM CERVICAL LYMPH NODES=<1CM CAROTID – PALPATE THRILL,LISTEN CAROTID – PALPATE THRILL,LISTEN

BRUITBRUIT JUGULAR VEINS – NOT DISTENDEDJUGULAR VEINS – NOT DISTENDED TRACHEA-MIDLINETRACHEA-MIDLINE

THORAX AND LUNGSTHORAX AND LUNGS APL DIAMETER-1:2 – 5:7APL DIAMETER-1:2 – 5:7

1:1 = BARREL CHEST1:1 = BARREL CHEST TACTILE FREMITUS NORMAL-TACTILE FREMITUS NORMAL-

BRONCHOPHONY,EGOPHONY AND WHISPERED BRONCHOPHONY,EGOPHONY AND WHISPERED PECTORILOQUY-CONSOLIDATION OF LUNGSPECTORILOQUY-CONSOLIDATION OF LUNGS

BREATH SOUNDSBREATH SOUNDS VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –VESICULAR – SOFT-LOW PITCHED BREEZY SOUNDS –

PERIPHERAL LUNG SURFACESPERIPHERAL LUNG SURFACES BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM BRONCHOVESCICULAR-HARSH SOUNDS-MAINSTREAM

BRONCHIBRONCHI BRONCHIAL- LOUD COARSE - TRACHEABRONCHIAL- LOUD COARSE - TRACHEA

ADVENTITIOUS BREATH SOUNDSADVENTITIOUS BREATH SOUNDS RALES-FINE SHORT,CRACKLING OR HIGH PITCHED RALES-FINE SHORT,CRACKLING OR HIGH PITCHED

SOUNDS-INSPIRATIONSOUNDS-INSPIRATION RHONCHI-CONTINOUS LOW PITCHED RHONCHI-CONTINOUS LOW PITCHED

COARSEGURGLING HARSH SNORING BEST HEARD ON COARSEGURGLING HARSH SNORING BEST HEARD ON EXHALATIONEXHALATION

WHEEZES- SQUEAKY SOUNDS HEARD – EXHALATIONWHEEZES- SQUEAKY SOUNDS HEARD – EXHALATION STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON STRIDOR – HARSH , MUSICAL SQUEAK HEARD UPON

INHALATIONINHALATION FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ FRICTION RUB-GRATING , CREAKING SOUNDS, FIZZ

LIKE VIBRATIONS – BOTH INHALATION AND LIKE VIBRATIONS – BOTH INHALATION AND EXHALATION EXHALATION

HEART SOUNDSHEART SOUNDS AORTIC AND PULMONIC VALVE AREAS- AORTIC AND PULMONIC VALVE AREAS-

22NDND ICS, R AND L RESPECTIVEY ICS, R AND L RESPECTIVEY ERBS POINT 3ERBS POINT 3RDRD ICS ICS TRICUSPID AREA-4TRICUSPID AREA-4THTH / 5 / 5THTH ICS ICS MITRAL AREA – 5MITRAL AREA – 5THTH ICS , LEFT MCL ICS , LEFT MCL PMI-5PMI-5THTH ICS MCL –(INFANTS-LATERAL TO ICS MCL –(INFANTS-LATERAL TO

LEFT NIPPLE-4LEFT NIPPLE-4THTH ICS) ICS) S1LUBB-CLOSURE OFAV VALVESS1LUBB-CLOSURE OFAV VALVES S2DUBB-CLOSURE OF SEMILUNAR S2DUBB-CLOSURE OF SEMILUNAR

VALVESVALVES MURMURS , GALLOP-ABNORMAL HEART MURMURS , GALLOP-ABNORMAL HEART

SOUNDSSOUNDS

PERIPHERAL VASCULAR PERIPHERAL VASCULAR SYSTEMSYSTEM

ASSESS ASSESS PAIN,PALLOR,PARALYSIS,PARESTPAIN,PALLOR,PARALYSIS,PARESTHESIASAND PULSES.HESIASAND PULSES.

ASSESS HOMAN’S SIGNASSESS HOMAN’S SIGN PULSE DEFICITPULSE DEFICIT

BREASTSBREASTS

START – UPPER OUTER START – UPPER OUTER CLOCKWISECLOCKWISE

ASSESS FOR ASSESS FOR SIZE,SHAPE,SYMMETRY AND SIZE,SHAPE,SYMMETRY AND NODESNODES

ABDOMENABDOMEN DORSAL RECUMBENTDORSAL RECUMBENT INSPECT,AUSCULTATE,PERCUSS AND INSPECT,AUSCULTATE,PERCUSS AND

PALPATEPALPATE BOWEL SOUNDS-HIGH PITCHED BOWEL SOUNDS-HIGH PITCHED

GURGLES HEARD AT 5 – 20 SECOND GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 5-25/MIN NORMAL)INTERVALS( 5-25/MIN NORMAL)

IF NOT HEARD IN 1 MINUTE STAY FOR 3 IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS. MORE. SEQUENCE IS -5 MINS. MORE. SEQUENCE IS CLOCKWISE FROM RLQCLOCKWISE FROM RLQ HYPOACTIVE < 3HYPOACTIVE < 3 HYPERACTIVE HYPERACTIVE

=CONTINOUS,LOUD,FREQUENT=CONTINOUS,LOUD,FREQUENT TINKLING SOUND – BOWEL OBSTRUCTIONTINKLING SOUND – BOWEL OBSTRUCTION

ABDOMENABDOMEN

REBOUND TENDERNESS- REBOUND TENDERNESS- INFLAMMATION OF PERITONEUMINFLAMMATION OF PERITONEUM

KIDNEYS- DORSAL LUMBAR AREA – KIDNEYS- DORSAL LUMBAR AREA – COSTOVERTEBRAL ANGLECOSTOVERTEBRAL ANGLE

KIDNEY PUNCH TESTKIDNEY PUNCH TEST

MUSCULOSKELETAL MUSCULOSKELETAL SYSTEMSYSTEM MUSCLE TONE AND STRENGTHMUSCLE TONE AND STRENGTH

0=COMPLETE PARALYSIS0=COMPLETE PARALYSIS 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE

PALPABLE/VISIBLEPALPABLE/VISIBLE 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH 2=25% - FULL MOVEMENT AGAINST GRAVITY WITH

SUPPORTSUPPORT 3=50% - NORMAL MOVEMENT AGAINST GRAVITY3=50% - NORMAL MOVEMENT AGAINST GRAVITY 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY 4= 75%- NORMAL MOVEMENT AGAINST GRAVITY

WITH MINIMAL RESISTANCEWITH MINIMAL RESISTANCE 5=100%-NORMAL FULL MOVEMENT WITH FULL 5=100%-NORMAL FULL MOVEMENT WITH FULL

RESISTANCERESISTANCE

JOINT MOVEMENTS-CREPITUS=GRATING JOINT MOVEMENTS-CREPITUS=GRATING SOUNDS ARE ABNORMALSOUNDS ARE ABNORMAL

FASCICULATION ABNORMAL CONTRACTIONS FASCICULATION ABNORMAL CONTRACTIONS AND SHORTENING OF MUSCLE FIBERSAND SHORTENING OF MUSCLE FIBERS

TREMOR-INVOLUNTARY TREMBLINGTREMOR-INVOLUNTARY TREMBLING TEST FOR ROM AND ASSESS FOR TEST FOR ROM AND ASSESS FOR

ATROPHY/HYPERTROPHY/CONTRACTURESATROPHY/HYPERTROPHY/CONTRACTURES

NEUROLOGIC TESTSNEUROLOGIC TESTS MENTAL STATUS-MENTAL STATUS-

LANGUAGE-CEREBRAL CORTEX-APHASIALANGUAGE-CEREBRAL CORTEX-APHASIA ORIENTATION(TIME,PLACE,PERSON)(CONFUSION)ORIENTATION(TIME,PLACE,PERSON)(CONFUSION) MEMORY- IMMEDIATE RECALL, RECENT MEMORY MEMORY- IMMEDIATE RECALL, RECENT MEMORY

AND REMOTE MEMORYAND REMOTE MEMORY ATTENTION SPAN AND CALCULATIONATTENTION SPAN AND CALCULATION JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL JUDGEMENT – EXPLAIN/INTERPRET / PERSONAL

VIEWSVIEWS PERCEPTION – SENSORY ANALYSIS AND INTEGRATIONPERCEPTION – SENSORY ANALYSIS AND INTEGRATION

CEREBELLAR FUNCTION- COORDINATION , CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING POINT TO POINT TOUCHING,ALTERNATING MOVEMENTS,GAITMOVEMENTS,GAIT

CRANIAL NERVE FUNCTIONSCRANIAL NERVE FUNCTIONS SENSORY FUNCTION(e.g. PROPRIOCEPTION-SENSORY FUNCTION(e.g. PROPRIOCEPTION-

POSITION SENSE- RHOMBERG’S TEST) POSITION SENSE- RHOMBERG’S TEST)

NEUROLOGIC TESTSNEUROLOGIC TESTS

DEEP TENDON REFLEXDEEP TENDON REFLEX 0-NO REFLEX0-NO REFLEX +1 – MINIMAL ACTIVITY(HYPOACTIVE)+1 – MINIMAL ACTIVITY(HYPOACTIVE) +2 – NORMAL RESPONSE+2 – NORMAL RESPONSE +3 – MORE ACTIVE THAN NORMAL+3 – MORE ACTIVE THAN NORMAL +4 – MAXIMUM ACTIVITY +4 – MAXIMUM ACTIVITY

( HYPERACTIVE)( HYPERACTIVE) PRESENCE OF INFANTILE PRESENCE OF INFANTILE

REFLEXES(BABINSKI) IN AN ADULT REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY SIGNIFIES CNS PATHOLOGY

LEVEL OF LEVEL OF CONSCIOUSNESSCONSCIOUSNESS GLASGOW COMA SCALE=15 POINTS, 7 COMAGLASGOW COMA SCALE=15 POINTS, 7 COMA

EYE OPENINGEYE OPENING SPONTANEOUS=4SPONTANEOUS=4 TO VERBAL COMMAND=3TO VERBAL COMMAND=3 TO PAIN=2TO PAIN=2 NO RESPONSE=1NO RESPONSE=1

MOTOR RESPONSEMOTOR RESPONSE TO VERBAL COMMAND=6TO VERBAL COMMAND=6 TO PAINFUL STIMULI/LOCALIZES PAIN=5TO PAINFUL STIMULI/LOCALIZES PAIN=5 FLEXES AND WITHDRAWS=4FLEXES AND WITHDRAWS=4 DECORTICATE=3DECORTICATE=3 DECEREBRATE=2DECEREBRATE=2 NO RESPONSE=1NO RESPONSE=1

VERBAL RESPONSEVERBAL RESPONSE ORIENTED,CONVERSES=5ORIENTED,CONVERSES=5 DISORIENTED,CONVERSES=4DISORIENTED,CONVERSES=4 USES INAPPROPRIATE WORDS=3USES INAPPROPRIATE WORDS=3 USES INCOMPREHENSIBLE SOUNDS=2USES INCOMPREHENSIBLE SOUNDS=2 NO RESPONSE=1NO RESPONSE=1

ASSESSING MOTOR ASSESSING MOTOR FUNCTIONFUNCTION WALKING GAITSWALKING GAITS

ROMBERGS TEST- STAND FEET TOGETHER ROMBERGS TEST- STAND FEET TOGETHER ARMS RESTING AT THE SIDES,EYES OPEN ARMS RESTING AT THE SIDES,EYES OPEN THEN CLOSED. NEG. ROMBERG – MAY SWAY THEN CLOSED. NEG. ROMBERG – MAY SWAY BUT KEEPS BALANCE.BUT KEEPS BALANCE. SENSORY ATAXIA-CANNOT BALANCE EYES SHUTSENSORY ATAXIA-CANNOT BALANCE EYES SHUT CEREBELLAR ATAXIA-CANNOT BALANCE EYES CEREBELLAR ATAXIA-CANNOT BALANCE EYES

SHUT OR EPONSHUT OR EPON HEEL-TOE WALKING AND VICE VERSAHEEL-TOE WALKING AND VICE VERSA FINGER TO NOSE TEST AND OTHER FINGER TO NOSE TEST AND OTHER

SENSORY FUNCTION TEST (ONE AND TWO SENSORY FUNCTION TEST (ONE AND TWO POINT DISCRIMINATION)POINT DISCRIMINATION)

EXTINCTION PHENOMENON-SYMMETRICAL EXTINCTION PHENOMENON-SYMMETRICAL AREAS ARE TOUCHED BUT SENSATION ON AREAS ARE TOUCHED BUT SENSATION ON ONE SIDE CANNOT BE FELT INDICATES ONE SIDE CANNOT BE FELT INDICATES LESIONS OF SENSORY CORTEXLESIONS OF SENSORY CORTEX

GENITALIA , ANUS AND GENITALIA , ANUS AND RECTUMRECTUM

ASSESS APPEARANCE AND ORIFICES AND ASSESS APPEARANCE AND ORIFICES AND INGUINAL LYMPH NODESINGUINAL LYMPH NODES

INSPECT CERVICAL OS AND VAGINA-SPECULUMINSPECT CERVICAL OS AND VAGINA-SPECULUM DEVIATIONSDEVIATIONS

CYSTOCELE, RECTOCELE,ENTEROCELECYSTOCELE, RECTOCELE,ENTEROCELE HYPO AND EPISPADIAS-URETHRAL OPENING HYPO AND EPISPADIAS-URETHRAL OPENING

DISPLACEDDISPLACED HERNIAS-DIRECT,INDIRECT , FEMORALHERNIAS-DIRECT,INDIRECT , FEMORAL INSTRUCT PNT TO BEAR DOWN-PALPABLE BULGEINSTRUCT PNT TO BEAR DOWN-PALPABLE BULGE

DIGITAL RECTAL EXAM –INSPECTION AND DIGITAL RECTAL EXAM –INSPECTION AND PALPATION –POSITION BOTH=SIM’S , FEMALES – PALPATION –POSITION BOTH=SIM’S , FEMALES – LITHOTOMY;MALES =STAND AND BEND LITHOTOMY;MALES =STAND AND BEND FORWARDFORWARD

PROSTATE GLAND-4 CM ;CERVIX = 2-3 CMPROSTATE GLAND-4 CM ;CERVIX = 2-3 CM HEMORRHOIDS =DILATED VEINSHEMORRHOIDS =DILATED VEINS

ADDITIONAL ADDITIONAL SUPPLEMENTALSSUPPLEMENTALS

NORMAL VALUES - PG 25NORMAL VALUES - PG 25 SIGNIFICANCE OF DIAGNOSTICS SIGNIFICANCE OF DIAGNOSTICS

AND LABORATORY EXAMS –PG 26AND LABORATORY EXAMS –PG 26 HISTORY SIGNIFICANCE – PG.28HISTORY SIGNIFICANCE – PG.28 INITIAL MANIFESTATIONS PG 29-30INITIAL MANIFESTATIONS PG 29-30 UNIVERSAL PRECAUTIONS PG48-51UNIVERSAL PRECAUTIONS PG48-51 THE REST IN “ must knows” AND THE REST IN “ must knows” AND

COMPARISONS OF SIGNS AND COMPARISONS OF SIGNS AND SYMPTOMSSYMPTOMS

MOBILITY AND MOBILITY AND IMMOBILITYIMMOBILITY

POSTURE AND BODY ALIGNMENT-ERECTPOSTURE AND BODY ALIGNMENT-ERECT JOINT MOVEMENTS=RANGE OF MOTIONJOINT MOVEMENTS=RANGE OF MOTION CONNECTIVE TISSUECONNECTIVE TISSUE

BONE TO BONE-LIGAMENTBONE TO BONE-LIGAMENT BONE TO MUSCLE – TENDONBONE TO MUSCLE – TENDON COVERS BONES/JOINTS - CARTILAGECOVERS BONES/JOINTS - CARTILAGE

TYPES OF JOINTTYPES OF JOINT SYNARTHROSES(CARTILAGENOUS)SYNARTHROSES(CARTILAGENOUS) DIARTHROSES( SYNOVIAL)DIARTHROSES( SYNOVIAL) AMPIARTHROSES(FIBROUS)AMPIARTHROSES(FIBROUS)

ERGONOMICS-BODY ERGONOMICS-BODY POSITIONING AND MECHANICSPOSITIONING AND MECHANICS

PRIORITY-ASSESS PERSONAL CAPACITY 1PRIORITY-ASSESS PERSONAL CAPACITY 1STST USE PROTECTIVE DEVICES/ TRANSFER AIDSUSE PROTECTIVE DEVICES/ TRANSFER AIDS CHANGE POSITION SLOWLY-ORTHOSTATIC CHANGE POSITION SLOWLY-ORTHOSTATIC

HYPOTENSION(DANGLE LEGS FIRST)HYPOTENSION(DANGLE LEGS FIRST) PIVOT ON THE STRONGER SIDE,MOVE PNT PIVOT ON THE STRONGER SIDE,MOVE PNT

TOWARDS STRONGER SIDETOWARDS STRONGER SIDE USE LARGER MUSCLES OF THE BODY AND FACE USE LARGER MUSCLES OF THE BODY AND FACE

THE DIRECTION OF THE MOVEMENTTHE DIRECTION OF THE MOVEMENT PULL SHEETS ARE BETTER METHOD THAN PULL SHEETS ARE BETTER METHOD THAN

SLIDINGSLIDING ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE ALWAYS MOBILZE MAXIMUM MANPOWER/HAVE

AN ASSISTANT STANDING BY.AN ASSISTANT STANDING BY. ROCK FROM FRONT TO BACK/VICE VERSA.WIDE ROCK FROM FRONT TO BACK/VICE VERSA.WIDE

BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF BASE OF SUPPORT, WEIGHT NEAR MIDLINE OF THE BODY.USE APPROPRIATE TRANSFER AND THE BODY.USE APPROPRIATE TRANSFER AND AMBULATION AIDS. (TRAPEZE, HOYER LIFT, AMBULATION AIDS. (TRAPEZE, HOYER LIFT, SLIDE BOARD, DRAW SHEET AND TRANSFER SLIDE BOARD, DRAW SHEET AND TRANSFER BELTBELT

Body MechanicsBody Mechanics             It is the efficient, coordinated, and safe use of It is the efficient, coordinated, and safe use of

the body to produce motion and maintain balance the body to produce motion and maintain balance during activity.during activity.

Principles of Body MechanicsPrinciples of Body Mechanics1.1. When the line of gravity passes through the base When the line of gravity passes through the base

support, balance is maintained and stability can be support, balance is maintained and stability can be maintained with the least amount of effort.maintained with the least amount of effort.

2.2. A wider base support increases stability of the body.A wider base support increases stability of the body.3.3. When then center of gravity is close to the base of When then center of gravity is close to the base of

support, a person and an object is more stable.support, a person and an object is more stable.4.4. Enlarging the base of support in the direction of Enlarging the base of support in the direction of

force to be applied maintains stability with minimal force to be applied maintains stability with minimal effort.effort.

5.5. Tightening the abdominal muscles upward and Tightening the abdominal muscles upward and contracting the gluteal muscle downward requires contracting the gluteal muscle downward requires less energy to move something and the less less energy to move something and the less likelihood of musculoskeletal injury.likelihood of musculoskeletal injury.

1.1. Synchronize use of muscle groups’ decreases Synchronize use of muscle groups’ decreases muscle fatigue.muscle fatigue.

2.2. Objects can be moved easily on a flat surface rather Objects can be moved easily on a flat surface rather than on an inclined surface against gravity.than on an inclined surface against gravity.

3.3. It is easier to lift when the larger leg muscles are It is easier to lift when the larger leg muscles are used, rather than using the smaller back muscles.used, rather than using the smaller back muscles.

4.4. The lesser friction when moving objects facilitates The lesser friction when moving objects facilitates motion.motion.

5.5. It is better to pull than to push because pulling It is better to pull than to push because pulling creates lesser friction, hence movement.creates lesser friction, hence movement.

  6.6. In lifting and moving objects, the body’s weight In lifting and moving objects, the body’s weight

must be used to assist.must be used to assist.7.7. Alternate rest periods with periods of muscle Alternate rest periods with periods of muscle

exertion may be used to prevent muscle fatigue.exertion may be used to prevent muscle fatigue. Greater force is required to move a heavy object. Greater force is required to move a heavy object.

THERAPEUTIC THERAPEUTIC EXERCISESEXERCISES

PASSIVE ROM-RETENTION OF ROM AND PASSIVE ROM-RETENTION OF ROM AND MAINTENANCE OF CIRCULATIONMAINTENANCE OF CIRCULATION

ASSISTIVE- INCREASES MOTION , ASSISTIVE- INCREASES MOTION , MAINTAINS MUSCLE TONEMAINTAINS MUSCLE TONE

ACTIVE – MAINTAINS MOBILITY OF THE ACTIVE – MAINTAINS MOBILITY OF THE JOINT AND MAINTAINS MUSCLE STRENGTHJOINT AND MAINTAINS MUSCLE STRENGTH

RESISTIVE – INCREASES MUSCLE POWERRESISTIVE – INCREASES MUSCLE POWER ISOMETRICS- MAINTENANCE OF STRENGTH ISOMETRICS- MAINTENANCE OF STRENGTH

AND PREVENTS MUSCULAR ATROPHYAND PREVENTS MUSCULAR ATROPHY

DANGERS OF DANGERS OF IMMOBILITYIMMOBILITY

DECUBITUS ULCER-OSTEOMYELITISDECUBITUS ULCER-OSTEOMYELITIS OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND OSTEOPOROSIS-PATHOLOGICAL FRACTURES AND

RENAL CALCULIRENAL CALCULI INCREASED CARDIAC WORKLOAD- TACHYCARDIAINCREASED CARDIAC WORKLOAD- TACHYCARDIA CONTRACTURES- DEFORMITIESCONTRACTURES- DEFORMITIES THROMBUS FORMATION-PULMONARY EMBOLISMTHROMBUS FORMATION-PULMONARY EMBOLISM ORTHOSTATIC HYPOTENSION-ORTHOSTATIC HYPOTENSION-

WEAKNESS,FAINTNESS AND DIZZINESSWEAKNESS,FAINTNESS AND DIZZINESS RESPIRATORY STASIS – HYPOSTATIC PNEUMONIARESPIRATORY STASIS – HYPOSTATIC PNEUMONIA CONSTIPATION – FECAL IMPACTIONCONSTIPATION – FECAL IMPACTION URINARY STASIS-URINARY RETENTIONURINARY STASIS-URINARY RETENTION NEGATIVE NITROGEN BALANCE-WEIGHT NEGATIVE NITROGEN BALANCE-WEIGHT

LOSS/DEBILITATIONLOSS/DEBILITATION

A COMPLICATION OF IMMOBILITY IN A COMPLICATION OF IMMOBILITY IN WHICH THE BLOOD VESSELS FAIL TO WHICH THE BLOOD VESSELS FAIL TO

IMMEDIATELY ACCOMMODATE TO THE IMMEDIATELY ACCOMMODATE TO THE CHANGES IN POSITION LEADING TO CHANGES IN POSITION LEADING TO

DIZZINESS,FAINTNESS AND DIZZINESS,FAINTNESS AND WEAKNESS. THE NURSE KNOWS THAT WEAKNESS. THE NURSE KNOWS THAT

THIS IS DUE TO:THIS IS DUE TO: VENOUS STASIS IN THE LOWER VENOUS STASIS IN THE LOWER

EXTREMITIESEXTREMITIES VENOUS POOLING OF BLOOD IN THE LEGSVENOUS POOLING OF BLOOD IN THE LEGS INCREASED VASOCONSTRICTION OF THE INCREASED VASOCONSTRICTION OF THE

PERIPHERAL BLOOD VESSELSPERIPHERAL BLOOD VESSELS ACTIVATION OF THE PARASYMPATHETIC ACTIVATION OF THE PARASYMPATHETIC

NERVOUS SYSTEMNERVOUS SYSTEM

SPECIFIC THERAPEUTIC SPECIFIC THERAPEUTIC POSITIONPOSITION

HIGH FOWLERS-60-90’HIGH FOWLERS-60-90’ FOWLER-45-60’FOWLER-45-60’ SEMI-FOWLERS-30-45’SEMI-FOWLERS-30-45’ LOW-FOWLERS-15-30’LOW-FOWLERS-15-30’ SUPINESUPINE DORSAL RECUMBENTDORSAL RECUMBENT LITHOTOMYLITHOTOMY TRENDELENBURGTRENDELENBURG SIMS LATERALSIMS LATERAL MODIFIED TRENDELENBURGMODIFIED TRENDELENBURG PRONEPRONE KNEE-CHESTKNEE-CHEST SIDE-LATERALSIDE-LATERAL ORTHOPNEICORTHOPNEIC

FOR PATIENTS POST SUBTOTAL FOR PATIENTS POST SUBTOTAL GASTRECTOMY WHICH POSITION GASTRECTOMY WHICH POSITION SHOULD THE NURSE PLACE THE SHOULD THE NURSE PLACE THE

CLIENT IN AFTER MEALS?CLIENT IN AFTER MEALS?

UPRIGHT POSITIONUPRIGHT POSITION LEFT SIDELYING POSITIONLEFT SIDELYING POSITION HIGH FOWLERS POSITIONHIGH FOWLERS POSITION DORSAL RECUMBENT POSITIONDORSAL RECUMBENT POSITION

ASSISTIVE DEVICESASSISTIVE DEVICES CRUTCHES CRUTCHES

CRUTCH HEIGHT-CRUTCH HEIGHT- STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA STANDING ;2 -3 (1-2 INCHES)FINGERS BELOW AXILLA

OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF OR SUPINE ;MEASURE FROM THE ANTERIOR FOLD OF THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 THE AXILLA TO THE HEEL OF THE FOOT AND ADD 2.5 CMCM

TEACH MUSCLE STRENGTHENING EXERCISES TEACH MUSCLE STRENGTHENING EXERCISES PRIOR TO AMBULATION.WEIGHT ON THE HAND PRIOR TO AMBULATION.WEIGHT ON THE HAND GRIP (TO AVOID CRUTCH PALSY)GRIP (TO AVOID CRUTCH PALSY)

ELBOWS SHOULD BE FLEXED 20-30’ AND ELBOWS SHOULD BE FLEXED 20-30’ AND CRUTCHES SHOULD BE KEPT 6 INCHES CRUTCHES SHOULD BE KEPT 6 INCHES LATERALLY AND 6 INCHES TO THE LATERALLY AND 6 INCHES TO THE FRONT=TRIPOD POSITION(8-10 INCHES-OK)FRONT=TRIPOD POSITION(8-10 INCHES-OK)

INSTRUCT CLIENT TO MAINTAIN AN ERECT INSTRUCT CLIENT TO MAINTAIN AN ERECT POSTUREPOSTURE

CRUTCH WALKING GAITSCRUTCH WALKING GAITS FOUR POINT-SLOW SAFE-WEIGHT BEARING FOUR POINT-SLOW SAFE-WEIGHT BEARING

ALLOWED FOR BOTH LEGSALLOWED FOR BOTH LEGS TWO POINT- FASTER SAFE-WEIGHT TWO POINT- FASTER SAFE-WEIGHT

BEARING ALLOWED FOR BOTH LEGSBEARING ALLOWED FOR BOTH LEGS THREE-POINT-NON WEIGHT BEARING OF THREE-POINT-NON WEIGHT BEARING OF

ONE LEGONE LEG SWINGTO/SWINGTHROUGH-PARTIAL SWINGTO/SWINGTHROUGH-PARTIAL

WEIGHT BEARING ALLOWED FOR BOTH WEIGHT BEARING ALLOWED FOR BOTH LEGSLEGS

GETTING INTO A CHAIR –BOTH CRUCHES GETTING INTO A CHAIR –BOTH CRUCHES TO THE WEAK SIDE , STRONGER ARM TO THE WEAK SIDE , STRONGER ARM HOLDS THE ARMRESTHOLDS THE ARMREST

GOING UP AND DOWN THE STAIRS- GOOD GOING UP AND DOWN THE STAIRS- GOOD GOES UP 1GOES UP 1STST AND BAD GOES DOWN 1 AND BAD GOES DOWN 1STST..

WALKERWALKER-- PROVIDES STABILITY AND BALANCEPROVIDES STABILITY AND BALANCE MOVE WALKER AHEAD 15 CM MOVE WALKER AHEAD 15 CM

(6INCHES-8-10 INCHES)WHILE (6INCHES-8-10 INCHES)WHILE WEIGHT IS BORNE BY BOTH WEIGHT IS BORNE BY BOTH LEGS.THEN ALTERNATE WEIGHT LEGS.THEN ALTERNATE WEIGHT BEARING ASSISTED BY THE ARMSBEARING ASSISTED BY THE ARMS

ELBOWS SHOULD BE FLEXED-20-30’ELBOWS SHOULD BE FLEXED-20-30’ IF ONE LEG IS WEAKER MOVE THAT IF ONE LEG IS WEAKER MOVE THAT

LEG TOGETHER WITH THE WALKERLEG TOGETHER WITH THE WALKER

CANECANE HOLD CANE ON THE STRONGER SIDEHOLD CANE ON THE STRONGER SIDE FLEX ELBOW 30’ AND TIP OF CANE 15 FLEX ELBOW 30’ AND TIP OF CANE 15

CM LATERAL TO THE SIDE OF THE 5CM LATERAL TO THE SIDE OF THE 5THTH TOE.TOE.

ADVANCE CANE AND AFFECTED ADVANCE CANE AND AFFECTED LEG ,WEIGHT ON CANE WHEN MOVING LEG ,WEIGHT ON CANE WHEN MOVING THE GOOD LEGTHE GOOD LEG

BUT FOR MAXIMUM SUPPORT ADVANCE BUT FOR MAXIMUM SUPPORT ADVANCE CANE 1 FEET ,MOVE AFFECTED LEG CANE 1 FEET ,MOVE AFFECTED LEG THEN THE STRONGER LEGTHEN THE STRONGER LEG

GOING UP AND DOWN THE STAIRS –GOING UP AND DOWN THE STAIRS –SAME WITH CRUTCHESSAME WITH CRUTCHES

IN TRANSFERRING A HEMIPLEGIC IN TRANSFERRING A HEMIPLEGIC CLIENT WITH RIGHT HEMISPHERE CLIENT WITH RIGHT HEMISPHERE

LESION FROM BED TO THE LESION FROM BED TO THE WHEELCHAIR, THE NURSE SHOULD WHEELCHAIR, THE NURSE SHOULD

POSITION THE WHEELCHAIR:POSITION THE WHEELCHAIR: ON THE RIGHT SIDE 90’ FROM ON THE RIGHT SIDE 90’ FROM

THE BEDTHE BED ON THE LEFT SIDE ON THE LEFT SIDE

PERPENDICULAR TO THE BEDPERPENDICULAR TO THE BED ON THE LEFT SIDE 45’ FROM THE ON THE LEFT SIDE 45’ FROM THE

BEDBED ON THE AFFECTED SIDEON THE AFFECTED SIDE

TRACTIONSTRACTIONS TRAPEZE BAR OVER HEADTRAPEZE BAR OVER HEAD REQUIRES FREE HANGING WEIGHTSREQUIRES FREE HANGING WEIGHTS ANALGESIC GIVEN TO RELIEVE PAINANALGESIC GIVEN TO RELIEVE PAIN CHECK PATIENTS CIRCULATION( 5p’S)CHECK PATIENTS CIRCULATION( 5p’S) TEMPERATURE MONITORINGTEMPERATURE MONITORING INFECTION PREVENTIONINFECTION PREVENTION OUTPUT AND INTAKE MONITORINGOUTPUT AND INTAKE MONITORING Nutrition needsNutrition needs Skin must be frquently checkedSkin must be frquently checked

TYPES OF TRACTIONSTYPES OF TRACTIONS

SKIN TRACTIONSKIN TRACTION SKELETAL TRACTIONSKELETAL TRACTION

BUCKSBUCKS BRYANTSBRYANTS RUSSELSRUSSELS CRUTCHFIELD TONGSCRUTCHFIELD TONGS PELVICPELVIC HALO VESTHALO VEST

NUTRITIONNUTRITION

PREMATURE INFANTS-LESS PREMATURE INFANTS-LESS THAN37WKS/2,500G-100-200 THAN37WKS/2,500G-100-200 CAL/KG/DAY AND HIGHER Na,Ca CAL/KG/DAY AND HIGHER Na,Ca AND CHONAND CHON

FULL TERM-120 CAL/KG/DAYFULL TERM-120 CAL/KG/DAY PREGNANCY + 300CAL/DAYPREGNANCY + 300CAL/DAY LACTATION+ 500CAL/DAY LACTATION+ 500CAL/DAY

ENTERAL FEEDINGSENTERAL FEEDINGS CONDITIONSCONDITIONS

PREOPERATIVE NEED FOR NUTRITIONAL SUPPORTPREOPERATIVE NEED FOR NUTRITIONAL SUPPORT GI PROBLEMSGI PROBLEMS ONCOLOGY THERAPYONCOLOGY THERAPY ALCOHOLISM,CHRONIC DEPRESSION AND EATING ALCOHOLISM,CHRONIC DEPRESSION AND EATING

DISORDERSDISORDERS HEAD,NECK DISORDERS OR SURGERYHEAD,NECK DISORDERS OR SURGERY

COMPLICATIONSCOMPLICATIONS ASPIRATIONTUBE DISPLACEMENTASPIRATIONTUBE DISPLACEMENT CRAMPING,VOMITING,DIARRHEACRAMPING,VOMITING,DIARRHEA HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE HYPEROSMOLAR NONKETOTIC COMA/GLUCOSE

INTOLERANCEINTOLERANCE

TOTAL PARENTERAL TOTAL PARENTERAL NUTRITIONNUTRITION

TYPES OF SOLUTIONSTYPES OF SOLUTIONS TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE

BACTERIAL FILTER USEDBACTERIAL FILTER USED TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID, TNA-TOTAL NUTRIENT ADMIXTURE- AMINO ACID,

DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTERFILTER

PERIPHERAL=NO >10% DEXTROSE AND 2 WKS PERIPHERAL=NO >10% DEXTROSE AND 2 WKS ONLYONLY

CENTRAL – INCOMPATIBLE WITH MEDS AND CENTRAL – INCOMPATIBLE WITH MEDS AND BLOOD IF SINGLE LUMEN USEDBLOOD IF SINGLE LUMEN USED

ATRIAL-HICKMAN/BIOVAC AND GROSHONG- ATRIAL-HICKMAN/BIOVAC AND GROSHONG- HUBBER NEEDLE USED TO ACCESS PORT HUBBER NEEDLE USED TO ACCESS PORT THROUGH SKINTHROUGH SKIN

TPNTPN INITIAL RATE OF INFUSION 50 ML/HR THEN 100-INITIAL RATE OF INFUSION 50 ML/HR THEN 100-

125/HR.125/HR. COMPLICATIONS-HYPEROSMOLAR COMA, COMPLICATIONS-HYPEROSMOLAR COMA,

SEPSIS, PNEUMOTHORAXSEPSIS, PNEUMOTHORAX FAST RATE=HYPEROSMOLAR FAST RATE=HYPEROSMOLAR

STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS)STATE(HEADACHE,NAUSEA,MALAISE,FEVER,CHILLS) SLOWED RATE=REBOUND HYPOGLYCEMIASLOWED RATE=REBOUND HYPOGLYCEMIA

X-RAY CONFIRMS PLACEMENT ATTACH TO PUMPX-RAY CONFIRMS PLACEMENT ATTACH TO PUMP IV TUBING AND FILTER CHANGED Q24 HOURSIV TUBING AND FILTER CHANGED Q24 HOURS ALLOW SOLUTION TO WARM IMMEDIATELY ALLOW SOLUTION TO WARM IMMEDIATELY

BEFORE USEBEFORE USE IF NO SOLUTION USE DEXTROSE 10% W IF NO SOLUTION USE DEXTROSE 10% W

SOLUTIONSOLUTION CHECK DAILY CBG,WEIGHT,TEMP. I AND O ,CHECK DAILY CBG,WEIGHT,TEMP. I AND O , CHECK 3X A WEEK BUN, ELECT,CHECK 3X A WEEK BUN, ELECT, ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND ONCE A WEEK – LFT’S, CBC, SERUM ALBUMIN AND

PT,PTTPT,PTT

OSTOMIESOSTOMIES PERMANENT/TEMPORARYPERMANENT/TEMPORARY STOMA RED AND SLIGHT BLEEDING WHEN STOMA RED AND SLIGHT BLEEDING WHEN

TOUCHEDBURNING SENSATION UNDER TOUCHEDBURNING SENSATION UNDER FACEPLATE INDICATES SKIN FACEPLATE INDICATES SKIN BREAKDOWN,REFER ABDL BREAKDOWN,REFER ABDL DISTENTION/DISCOMFORT, DISTENTION/DISCOMFORT,

KARAYA POWDER(DEC.IRRITATION), KARAYA POWDER(DEC.IRRITATION), CHARCOAL/BISMUTH CARBONATE-DEODORIZERCHARCOAL/BISMUTH CARBONATE-DEODORIZER

APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-APPLIANCE CAN LAST 7 DAYS BUT CHANGE Q48-72H AND 24-48H IFPERIOSTOMAL SKIN 72H AND 24-48H IFPERIOSTOMAL SKIN ERYTHEMATOUS, ERODEDERYTHEMATOUS, ERODED

ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO ILEOSTOMY-LIQUID,CONSTANT,IRRITATING TO THE SKIN,APPLIANCE CONTINOUS,MINIMAL THE SKIN,APPLIANCE CONTINOUS,MINIMAL ODORODOR

COLOSTOMY-FORMED , CAN BE IRRIGATED 300-COLOSTOMY-FORMED , CAN BE IRRIGATED 300-500ML AND REGULATED,MAY NOT HAVE TO 500ML AND REGULATED,MAY NOT HAVE TO WEAR AN APPLIANCEWEAR AN APPLIANCE

URINARY ELIMINATIONURINARY ELIMINATION

BUN – 10-20 MG/DLBUN – 10-20 MG/DL CREA – 0.7 – 1.4 MG/DLCREA – 0.7 – 1.4 MG/DL 24 HOUR URINE PRODUCTION-24 HOUR URINE PRODUCTION-

1000-1500CC1000-1500CC

ANURIA<100ML/24HANURIA<100ML/24H OLIGURIA< 400 ML/24HOLIGURIA< 400 ML/24H POLYURIA > 2000 ML/24HPOLYURIA > 2000 ML/24H

KEGELS –STRENGTHEN MUSCLES OF THE KEGELS –STRENGTHEN MUSCLES OF THE PELVIC FLOOR-TIGHTEN FOR 3 SECS THEN PELVIC FLOOR-TIGHTEN FOR 3 SECS THEN RELAX FOR 3 SECS PERFORM LYING RELAX FOR 3 SECS PERFORM LYING DOWN, SITTING AND STANDING FOR DOWN, SITTING AND STANDING FOR TOTAL OF 45TOTAL OF 45

BLADDER RETRAININGBLADDER RETRAINING INTERMITTENT CATHETERIZATION AFTER INTERMITTENT CATHETERIZATION AFTER

ATTEMPTING TO VOID Q 2-3H, TIME INCREASES ATTEMPTING TO VOID Q 2-3H, TIME INCREASES GRADUALLY BUT NO MORE THAN 8 HOURSGRADUALLY BUT NO MORE THAN 8 HOURS

BLADDER TRAINING – DRINK A MEASURED BLADDER TRAINING – DRINK A MEASURED AMOUNT Q2H THEN ATTEMP TO VOID 30 MINS AMOUNT Q2H THEN ATTEMP TO VOID 30 MINS LATER-TIME GRADUALLY INCREASEDLATER-TIME GRADUALLY INCREASED

TRIGGERING TECHNIQUES-CREDES MANEUVER TRIGGERING TECHNIQUES-CREDES MANEUVER AND VALSALVAAND VALSALVA

CLAMP INDWELLING CATH BEFORE REMOVAL. CLAMP INDWELLING CATH BEFORE REMOVAL. THEN DUE TO VOID 3-4 HOURS AFTER THEN DUE TO VOID 3-4 HOURS AFTER REMOVALREMOVAL

4 HOURS AFTER FOLEY CATHETER 4 HOURS AFTER FOLEY CATHETER REMOVAL THE PATIENT STILL HASN’T REMOVAL THE PATIENT STILL HASN’T

VOIDED. THE NURSE IS EFFICIENT IF SHE VOIDED. THE NURSE IS EFFICIENT IF SHE DID WHICH OF THE FOLLOWING NURSING DID WHICH OF THE FOLLOWING NURSING

ACTIONS FIRST?ACTIONS FIRST? PREPARE FOR STRAIGHT PREPARE FOR STRAIGHT

CATHETER INSERTIONCATHETER INSERTION ASK THE PATIENT INCREASE ASK THE PATIENT INCREASE

ORAL FLUID INTAKEORAL FLUID INTAKE POUR WARM WATER OVER POUR WARM WATER OVER

PERENIUM OR TURN ON FAUCET.PERENIUM OR TURN ON FAUCET. INSPECT THE PATIENTS INSPECT THE PATIENTS

SYMPHYSIS PUBISSYMPHYSIS PUBIS

HEMODIALYSISHEMODIALYSIS DONE 3-5 HOURS – 2-3 TIMES A WEEKDONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR AV FISTULA-NO BP,VENIPUNCTURE OR

CONSTRICTIONSCONSTRICTIONS PALPATE FOR A THRILL AND LISTEN PALPATE FOR A THRILL AND LISTEN

FOR BRUIT Q8HFOR BRUIT Q8H MONITOR FOR HEMORRHAGEMONITOR FOR HEMORRHAGE DISEQUILIBRIUM DISEQUILIBRIUM

SYNDROME,HEPATITIS,HEMORRHAGE,SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONSSEPSIS-COMPLICATIONS

PERITONEAL DIALYSISPERITONEAL DIALYSIS TENCKOFF,GORE-TEX CATHETERTENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM WEIGH BEFORE AND AFTER, WARM

DIALYSATEDIALYSATE CHON LOSS, INFECTION, -CHON LOSS, INFECTION, -

PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & VFEVER , ABDL TENDERNESS AND N & V

PREVENT CONSTIPATION BY INCREASING PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITIONFLOW –REPOSITION

TYPES:TYPES: CAPD(4-6H INDWELLING),CAPD(4-6H INDWELLING), AUTOMATED 30MINS EXCHANGES, AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLINGCONTINOUS – 1 DAY INDWELLING

COMFORT AND PAINCOMFORT AND PAIN

PainPain             The noxious stimilation of threatened or The noxious stimilation of threatened or

actual tissue damage (Geach, 1987)actual tissue damage (Geach, 1987)             Whatever the experiencing person says it Whatever the experiencing person says it

is, existing whenever he or she says it does is, existing whenever he or she says it does (McCaferry, 1979)(McCaferry, 1979)

            It is highly subjective and individual and It is highly subjective and individual and that is one of the body’s defense mechanism that is one of the body’s defense mechanism indicating that there is a problem.indicating that there is a problem.

            It is protective as it gives warning or signal It is protective as it gives warning or signal for tissue injuryfor tissue injury

Classifications of PainClassifications of Pain             Superficial Pain- in the surface of the skinSuperficial Pain- in the surface of the skin             Radiating Pain- pain that extends in the surrounding Radiating Pain- pain that extends in the surrounding

tissuestissues             Somatic Pain- pain that occurs in the muscles, joints, and Somatic Pain- pain that occurs in the muscles, joints, and

bonesbones             Visceral pain- pain that occurs internally (abdominal cavity Visceral pain- pain that occurs internally (abdominal cavity

and thoracic cavity)and thoracic cavity)             Referred pain- pain that is felt on the other part of the Referred pain- pain that is felt on the other part of the

body other than the source of injurybody other than the source of injury             Intractable pain- pain that is resistant to interventionIntractable pain- pain that is resistant to intervention             Psychogenic Pain- emotional painsPsychogenic Pain- emotional pains             Intermittent pain- pain that stops and recurs again and Intermittent pain- pain that stops and recurs again and

again.again.             Phantom pain- pain is felt in the absence of a part of the Phantom pain- pain is felt in the absence of a part of the

body causing the pain.body causing the pain.

Assessment of PainAssessment of Pain             Precipitating Factors- “ What triggers the Precipitating Factors- “ What triggers the

pain or makes it worse?”pain or makes it worse?”             Quality of Pain- “Tell me what the pain feels Quality of Pain- “Tell me what the pain feels

like”like”             Alleviating Factors- “What measures relieve Alleviating Factors- “What measures relieve

your pain”your pain”             Meaning of pain- “ How do you interpret the Meaning of pain- “ How do you interpret the

pain?”pain?”             PatternPattern             Location Pain- “Where is your pain”Location Pain- “Where is your pain” Periodicity- “How long have you felt the pain Periodicity- “How long have you felt the pain

sensationsensation

PREOP CAREPREOP CARE INFANT-DISTRACTINFANT-DISTRACT TODDLER-ALLOW REGRESSION AND TODDLER-ALLOW REGRESSION AND

INVOLVE PARENTS,CONSISTENT INVOLVE PARENTS,CONSISTENT CAREGIVERCAREGIVER

PRE-SCHOOL-LET CHILD HANDLE PRE-SCHOOL-LET CHILD HANDLE EQUIPMENT,EXPRESSION OF EQUIPMENT,EXPRESSION OF FEELINGS THROUGH PLAY FEELINGS THROUGH PLAY DEMOFAMILIAR SORROUNDINGSDEMOFAMILIAR SORROUNDINGS

SCHOOL AGE- EXPLAIN SIMPLY AND SCHOOL AGE- EXPLAIN SIMPLY AND ALLOW CHOICESALLOW CHOICES

ADOLESCENTS- INVOLVE AND POINT ADOLESCENTS- INVOLVE AND POINT OUT STRENGTHS AND OUT STRENGTHS AND BENEFITS,EXPECT RESISTANCEBENEFITS,EXPECT RESISTANCE

PREOP CHECKLISTPREOP CHECKLIST CONSENTCONSENT HEALTH TEACHING (SPEC. POST OP HEALTH TEACHING (SPEC. POST OP

PROCEDURES)PROCEDURES) LAB TESTS,ECG,X-RAYLAB TESTS,ECG,X-RAY SKIN PREPSKIN PREP BOWEL PREPBOWEL PREP IV’SIV’S NPONPO PREOP MEDS,SEDATION AND ANTIBIOTICSPREOP MEDS,SEDATION AND ANTIBIOTICS REMOVAL OF DENTURES,NAILPOLISH AND REMOVAL OF DENTURES,NAILPOLISH AND

JEWELRYJEWELRY NUTRITION-TPN OR ENTERAL FEEDINGS NUTRITION-TPN OR ENTERAL FEEDINGS

PREOPPREOP

WHICH OF THE FOLLOWING INTERVENTIONS BY THE WHICH OF THE FOLLOWING INTERVENTIONS BY THE NURSE CARING FOR A PATIENT WHO IS SCHEDULED NURSE CARING FOR A PATIENT WHO IS SCHEDULED TO HAVE EXPLORATORY LAPAROTOMY IN 8 HOURS IS TO HAVE EXPLORATORY LAPAROTOMY IN 8 HOURS IS

CORRECT?CORRECT?

PLACING THE PATIENT ON NPO 4 HOURS PLACING THE PATIENT ON NPO 4 HOURS PRIOR TO THE TEST AND REMOVING PRIOR TO THE TEST AND REMOVING JEWELRY,DENTURES AND NAIL POLISH.JEWELRY,DENTURES AND NAIL POLISH.

INSERTING AN 18G IV CATHETER INSERTING AN 18G IV CATHETER CONNECTED TO PNSS OPPOSITE THE CONNECTED TO PNSS OPPOSITE THE ARM WITH A 22 G IV CATHETER ARM WITH A 22 G IV CATHETER CONNECTED TO A TPN SOLUTION.CONNECTED TO A TPN SOLUTION.

TEACH THE PATIENT DEEP BREATHING TEACH THE PATIENT DEEP BREATHING EXERCISES AND EXPLAIN THE EXERCISES AND EXPLAIN THE PROCEDURE TO BE DONE ON THE PROCEDURE TO BE DONE ON THE PATIENT INCLUDING RISKS AND PATIENT INCLUDING RISKS AND BENEFITS.BENEFITS.

HAVE THE PATIENT SIGN THE CONSENT HAVE THE PATIENT SIGN THE CONSENT AFTER EXPLAINING THE CONSEQUENCES AFTER EXPLAINING THE CONSEQUENCES AND RISKS AS WELL AS THE BENEFITS.AND RISKS AS WELL AS THE BENEFITS.

INTRAOP- MAINTAIN SURGICAL INTRAOP- MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT STATUS,, ASEPSIS, MONITOR CLIENT STATUS,, APPROPRIATE GROUNDING DEVICES, APPROPRIATE GROUNDING DEVICES,

FLUID BALANCE AND FLUID BALANCE AND SPONGE/INSTRUMENT COUNTSPONGE/INSTRUMENT COUNT

SCRUB NURSE – HANDLES EQUIPMENT , SCRUB NURSE – HANDLES EQUIPMENT , MATERIALS TO THJE SURGEON, MATERIALS TO THJE SURGEON, SPONGE AND INSTRUMENT COUNTSPONGE AND INSTRUMENT COUNT

( STERILE)( STERILE)

CIRCULATING NURSE- ENSURES CIRCULATING NURSE- ENSURES ADEQUACY OF SUPPLIES, SKIN PREP , ADEQUACY OF SUPPLIES, SKIN PREP , DOCUMENTATION , HANDLES STERILE DOCUMENTATION , HANDLES STERILE EQUIPMENTS BY FORCEPSEQUIPMENTS BY FORCEPS

POST OPPOST OP POST OP- MONITOR VSPOST OP- MONITOR VS Q15X4;Q30X2;Q1HX2 THEN PRNQ15X4;Q30X2;Q1HX2 THEN PRN

MONITOR I AND O , K LEVEL , CVP, BOWEL MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC SOUNDS, BREATH SOUNDS AND LOC

RESPIRATORY PHYSIOTHERAPY,TCBDRESPIRATORY PHYSIOTHERAPY,TCBD INCENTIVE SPIROMETRY-20 SECS INHALATIONINCENTIVE SPIROMETRY-20 SECS INHALATION ENCOURAGE AMBULATIONENCOURAGE AMBULATION REFER IF UNABLE TO VOID IN 8 HOURSREFER IF UNABLE TO VOID IN 8 HOURS APPLY TED HOSE AND PNEUMATIC APPLY TED HOSE AND PNEUMATIC

COMPRESSION DEVICE,CHECK FOR HOMAN’S COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGNSIGN

WOUNDSWOUNDS NOTE DRESSING AND INCISIONNOTE DRESSING AND INCISION FEVER 1-2 DAYS POST OP-ATELECTASIS/ FEVER 1-2 DAYS POST OP-ATELECTASIS/

DEHYDRATIONDEHYDRATION 3-7 DAYS – INFECTION3-7 DAYS – INFECTION UPPER GI TUBES-GASTRIC UPPER GI TUBES-GASTRIC

DECOMPRESSIONDECOMPRESSION LOWER GI TUBES – BOWEL LOWER GI TUBES – BOWEL

DECOMPRESSIONDECOMPRESSION WOUND HEALING BY 1WOUND HEALING BY 1STST INTENTION- INTENTION-

SUTURED AND APPROXIMATED ; 3SUTURED AND APPROXIMATED ; 3RDRD INTENTION-NOT CLOSED,W/ PURPOSE EX: INTENTION-NOT CLOSED,W/ PURPOSE EX: DRAINSDRAINS

WOUND HEALING BY 2WOUND HEALING BY 2NDND INTENTION- INTENTION-INCREASED INCIDENCE OF INFECTION , INCREASED INCIDENCE OF INFECTION , INCREASED SCARRING AND LONGER INCREASED SCARRING AND LONGER HEALING TIMEHEALING TIME

POST-OP POST-OP COMPLICATIONSCOMPLICATIONS

SHOCKSHOCK PARALYTIC ILEUSPARALYTIC ILEUS ATELECTASIS AND PNEUMONIA - 2ND DAYATELECTASIS AND PNEUMONIA - 2ND DAY EMBOLISM- 2ND DAYEMBOLISM- 2ND DAY WOUND INFECTION-3-5DWOUND INFECTION-3-5D DEHISCENCE AND EVISCERATION-5-6DDEHISCENCE AND EVISCERATION-5-6D PSYCHOSISPSYCHOSIS CARDIOVASCULAR COMPROMISECARDIOVASCULAR COMPROMISE URINARY RETENTION-8-12HURINARY RETENTION-8-12H URINARY INFECTION -5-8 DURINARY INFECTION -5-8 D DVT-6-14 DAYS-1 YEARDVT-6-14 DAYS-1 YEAR

anesthesiaanesthesia Halothane-respiratory and cardiovascular Halothane-respiratory and cardiovascular

depression-monitor VS, open IV site-ABC’s depression-monitor VS, open IV site-ABC’s prevent aspirationprevent aspiration

Nitrous Oxide- Hypotension and nausea and Nitrous Oxide- Hypotension and nausea and vomiting- adequate O2vomiting- adequate O2

IV thiopental Na- decreased BP , respiratory IV thiopental Na- decreased BP , respiratory depression, laryngospasm- ABCdepression, laryngospasm- ABC

spinal and saddle – hypotension and HA- spinal and saddle – hypotension and HA- increased OFIincreased OFI

conduction block/epidural block- hypotension conduction block/epidural block- hypotension and respiratory depression-HA not experiencedand respiratory depression-HA not experienced

local – excitability and hypersensitivity;no local – excitability and hypersensitivity;no epinephrine on fingersepinephrine on fingers

WHICH OF THE FOLLOWING WHICH OF THE FOLLOWING STATEMENTS IS NOT TRUE STATEMENTS IS NOT TRUE

REGARDING POST OPERATIVE REGARDING POST OPERATIVE

COMPLICATIONSCOMPLICATIONS OBESITY OR MALNUTRITION INCREASES OBESITY OR MALNUTRITION INCREASES

THE INCIDENCE OF POST-OPERATIVE THE INCIDENCE OF POST-OPERATIVE COMPLICATIONSCOMPLICATIONS

THE MAIN PURPOSE OF PRE-OPERATIVE THE MAIN PURPOSE OF PRE-OPERATIVE TEACHING IS TO PREVENT POST-OP TEACHING IS TO PREVENT POST-OP COMPLICATIONSCOMPLICATIONS

high pitched tympany is abnormal in the high pitched tympany is abnormal in the abdominal quadrantsabdominal quadrants

put on TED or pneumatic compresion devices put on TED or pneumatic compresion devices to prevent venous stasisto prevent venous stasis

notify physician if unable to void in 10 hoursnotify physician if unable to void in 10 hours 11stst dressing should be done by RN dressing should be done by RN