Normal serum phosphorus level is 2.7 to 4.5 mg/dL.
Allen's test is the test to assess for collateral circulation to the
hand by evaluating the patency of the radial and ulnar arteries.
Metabolic acidosis normally results from renal failure, diabetic
ketoacidosis, production of lactic acid, and from the ingestion of toxins, such
as acetylsalicylic acid.
Metabolic alkalosis normally results from the hypovolemia, the loss of
gastric fluid, excessive bicarbonate intake, the massive transfusion of whole
blood, and hyperaldosteronism.
Any condition that causes an obstruction of the airway or depresses
respiratory status can cause respiratory acidosis.
Respiratory alkalosis usually occurs by overstimulation of the
respiratory system.
Hydrogen ions circulate in the body in two forms: (a) Volatile hydrogen of carbonic acid. (b) Non-volatile form of hydrogen and organic acid.
The lungs excrete 13000 to 30000 mEq/day of volatile hydrogen in the
form of carbonic acid as carbon dioxide (CO2).
The kidneys excrete 50 mEq/day of non-volatile acids.
Buffers are reactors that function only to keep the pH within the narrow
limits.
Hemoglobin system maintains acid-base balance by the process called
chloride shift.
Hemoglobin system, plasma protein system, carbonic acid-bicarbonate
system, and phosphate buffer are the primary buffer system in extracellular fluid.
The carbonic acid bicarbonate system maintains a pH 7.4 with a ratio of
20 parts bicarbonate to 1-part carbonic acid (H2CO3).
Carbonic acid concentration is controlled by the excretion of CO2
by the lungs.
The kidneys control the bicarbonate concentration.
In acidosis, the respiratory rate and depth increases in an attempt to
exhale acids.
In alkalosis, the respiratory rate and depth decrease; CO2
is retained to neutralize and decrease the strength of excess bicarbonate.
When the client experiences an acid-base imbalance, monitor the
potassium level closely because the potassium moves in or out of the cells in
an attempt to maintain acid-base balance.
If the client has a condition that causes an obstruction of the airway
or depresses respiratory system, nurse monitor the client for respiratory
acidosis.
Respiratory alkalosis results from conditions that cause
overstimulation of the respiratory system.
Diabetes mellitus or diabetic ketoacidosis, excessive ingestion of acetylsalicylic
acid, high-fat diet, insufficient metabolism of carbohydrates (lactic acid
formation), malnutrition, renal insufficiency or renal failure, and severe
diarrhoea are the causes of metabolic acidosis.
Diuretics, excessive vomiting or gastrointestinal suctioning, hyperaldosteronism,
ingestion of and/ or infusion of excess sodium bicarbonate, and massive
transfusion of whole blood are the causes of metabolic alkalosis.
Normal arterial blood gas valves: (a) pH – 7.35 to 7.45 (b) Pco2 – 35 – 45 mmHg (c) Hco3 – 22- 27 mEq/L (d) Po2 - 80-100 mmHg.
The Allen's test is performed before obtaining an arterial blood
specimen from the radial artery to determine the presence of collateral
circulation and the adequacy of the ulnar artery.
For ABG analysis specimen draw by preparing a heparinized syringe.
In respiratory acidosis the pH is decreased, the Pco2 is elevated.
In respiratory alkalosis the pH is elevated; the Pco2 is decreased.
Bicarbonate ion is the indicator of metabolic function.
In metabolic acidosis the pH is decreased; the bicarbonate ion is
decreased.
In metabolic alkalosis the pH is elevated; the bicarbonate ion is
elevated.
In a respiratory imbalance, the ABG result indicates an opposite
relationship between the pH and the Pco2.
In a metabolic imbalance, the ABG result indicates a corresponding
relationship between the pH and bicarbonate ion.
Normal chloride values in adult is 98-107 mEq/L.
Usually the aPTT (Activated partial thromboplastin time) is used to
monitor heparin therapy and screen for coagulation disorders.
The normal valves of aPTT (Activated partial thromboplastin time) is 20
to 36 seconds, depending on the type of activator used.
The nurse does not draw samples for aPTT from an arm into which heparin
is infusing.
The aPTT should be between 1.5 and 2.5 times normal when the client is
receiving heparin therapy; if the value is longer than 90 seconds, the client
is at risk for bleeding. Nurse initiate bleeding precautions.
Prothrombin time (PT) is a vitamin K-dependent glycoprotein produced by
the liver that is necessary for fibrin clot formation.
Prothrombin time is used to monitor response to warfarin sodium therapy
or to screen for dysfunction of the extrinsic clotting system resulting from
liver disease, vitamin K deficiency, or disseminated intravascular coagulation.
The international normalized ratio (INR) is a frequently used test to
measure the effects of oral anticoagulant.
Normal Prothrombin time value is 9.6 to 11.8 seconds (male adult); 9.5 to 11.3
seconds (female adult).
Normal international normalized ratio is 2 to 3 for standard warfarin therapy, and 3 to 4.5 for
high-dose warfarin therapy.
Diets high in green leafy vegetables can increase the absorption of
vitamin K, which shortens the PT.
If the PT value is longer than 30 seconds in a client receiving warfarin
therapy, initiate bleeding precautions.
Clotting time is the time required for the interaction of all factors
involved in the clotting process. The normal clotting time value is 8 to 15
minutes.
Normal platelet count is 150000 to 400000 cells/mm3.
Nurse monitor the platelet count closely in client receiving
chemotherapy because of the risk for thrombocytopenia.
Erythrocyte sedimentation rate is the rate at which erythrocytes settle
out of anti-coagulated blood in 1 hours.
The normal ESR value is 0 to 30 mm/hr, depending on the age of client.
Normal Hb in male adult 14 to 16.5 g/dL.
Normal Hb level in female adult 12 to 15 g/dL.
Normal iron in male adult 65-175 mcg/dL.
Normal iron in female adult 50 -170 mcg/dL.
Normal RBC count in male adult 4.5-6.2 million/µL
Normal RBC count in female adult 4-5.5 million/µL.
The creatine kinase is an enzyme found in muscle and brain
tissue that reflects tissue catabolism resulting from cell trauma.
The normal serum creatine kinase (CK) 26-174 units/L.
The isoenzyme CK-MB is found mainly in cardiac muscle, CK-BB is found
mainly in brain tissue, and CK-MM is found mainly in skeletal muscle.
Strenuous physical activity, invasive procedures, and intramuscular
injection may falsely elevate CK levels.
The lactate dehydrogenase (LDH) isoenzymes affected by acute myocardial
infraction are LDH1 and LDH2.
Troponin is regulatory protein found in striated muscle (skeletal and
myocardial).
Troponin is two types troponin I, and troponin T.
Myoglobin is an oxygen-binding protein that is found in striated muscle
that releases oxygen at very low tensions.
Normal value of myoglobin is lower than 90 mcg/L; an elevation could
indicate myocardial infraction.
Natriuretic peptides are neuroendocrine peptides that are used to
identify clients with congestive heart failure.
There are three major peptides: (a) Atrial natriuretic peptides (ANP) synthesized in cardiac atrial muscle. (b) Brain natriuretic peptides (BNP) synthesized in cardiac ventricle muscles. (c) C-type natriuretic peptides (CNP) synthesized by endothelial cells.
Brain natriuretic peptides (BNP) is the primary marker for identifying
CHF as the cause of dyspnea.
Normal value of albumin is 3.4 to 5 g/dL.
Normal ammonia value is 10 to 80 mcg/dL.
Alanine aminotransferase (ALT) is used to identify hepatocellular
disease of the liver and to monitor improvement or worsening of the disease.
Normal alanine aminotransferase (ALT) level is 4 to 6 international
units/L.
Aspartate aminotransferase(AST) is used to evaluate a client with
suspected hepatocellular disease.
Normal aspartate aminotransferase (AST) value is 0 to 35 units/L.
Amylase is the enzyme, produced by the pancreas and salivary glands,
aids in the digestion of complex carbohydrates.
In acute pancreatitis, the amylase level is greatly increased.
Normal amylase value 25 to 151 units/L.
Pancreatic enzyme lipase converts fats and triglycerides into fatty
acids and glycerol.
Level of lipase increase in pancreas disease. The normal value is 10 to
140 units/L.
The normal value of direct bilirubin (conjugated) is 0 to 0.3 mg/dL.
The normal value of indirect bilirubin (unconjugated) 0.1 to 1 mg/dL.
The normal value of total bilirubin level is lower than 1.5 mg/dL.
Blood lipids consists primarily of cholesterol, triglycerides, and
phospholipids.
Increased cholesterol levels, Low Density Lipoprotein levels (LDL), and triglyceride levels place
the client at risk for coronary artery disease.
High Density Lipoprotein (HDL) helps protect against the risk of coronary artery disease.
Normal cholesterol level is 140 to 199 mg/dL.
Normal LDL is lower than 130 mg/dL.
The normal HDLs level is 30 to 70 mg/dL.
Normal triglycerides level is lower than 200 mg/dL.
The oral contraceptives may increase the lipid level.
Normal blood protein level is 6 to 8 g/dL.
Uric acid is formed as the purines adenine and guanine are metabolized
continuously during the formation and degeneration of DNA and RNA.
Elevated amounts of the uric acid deposit in joints and soft tissue and
cause gout.
Normal uric acid level in male adult is 4.5 to 8 mg/dL.
Normal uric acid level in female adult is 2.5 to 6.2 mg/dL.
Fasting blood glucose levels are used to help diagnose diabetes
mellitus and hypoglycemia.
Normal fasting blood glucose level is 70 to 110 mg/dL.
To perform oral glucose test nurse, instruct the client too fast for 8
to 12 hours before the test.
To perform oral glucose test nurse, instruct the client with diabetes
mellitus to withhold morning insulin or oral hypoglycemic medication until
after the blood is drawn.
Glycosylated hemoglobin (HbA1c) is blood glucose bound to hemoglobin.
Hyperglycemia in client with diabetes is usually a cause of an increase
in the HbA1c.
The values of glycosylated hemoglobin are expressed as a percentage of
the total hemoglobin.
Glycosylated hemoglobin level in client with good control of diabetes
is 7% or lower. Client with fair control of diabetes is 7% to 8% or poor
control of diabetes client is higher than 8%.
Glycosylated hemoglobin is a reflection of how well blood glucose
levels have been controlled for the past 3 to 4 months.
Glycosylated serum albumin (fructosamine) reflects average serum
glucose levels over a period of 2 to 3 weeks. It is more sensitive to recent
changes than the HbA1c.
The normal value of glycosylated serum albumin in nondiabetic client
1.5 to 2.7 mmol/L; or in diabetic client 2 to 5 mmol/L.
To perform test glycosylated hemoglobin test client fasting is not
required before the test but to perform test glycosylated serum albumin test
the client has needs to fast for 12 hours before the test.
Diabetes mellitus autoantibody panel used to evaluate insulin
resistance and to identify type 1 diabetes and client with a suspected allergy
to insulin.
Diabetes mellitus autoantibody panel value less than 1:4 titer with no
antibody detected.
Serum creatinine is a specific indicator of renal function. The normal
value is 0.6 to 1.3 mg/dL.
The normal blood urea nitrogen level is 8 to 25 mg/dL.
Calcium aids in blood clotting by converting prothrombin to thrombin.
The normal blood calcium level is 8.6 to 10 mg/dL.
Magnesium is used as an index to determine metabolic activity and renal
function.
The normal magnesium level is 1.6 to 2.6 mg/dL.
The normal phosphorus value 2.7 to 4.5 mg/dL.
The normal WBC count is 4500 to 11000 cells/mm3.
A “shift to the left” means that an increased number of immature
neutrophils is present in the blood.
A “shift to the right” means that cells have more than the usual number
of nuclear segments; found in liver disease, down syndrome, and megaloblastic
and pernicious anemia.
A positive western blot or IFA result is considered confirmatory for
HIV.
Normal CD4 T-cell count is between 500 and 1600 cells/L.
Immune system problems occur when the CD4 T-cell count is between 200 and
499 cells/L.
Severe immune system problems occur when the CD4 T-cell count is lower
than 200 cells/L.
Normal CD4-to-CD8 ratio is approximately 2:1.
The p24 antigen assay quantifies the amount of HIV viral core protein
in the client serum.
Normal therapeutic serum Digoxin level is 0.5-2 ng/mL.
Normal therapeutic serum lithium level is 0.5-1.2 mEq/L.
Normal therapeutic serum magnesium sulfate is 4-7 mg/dL.
Normal therapeutic serum salicylate level is 100-250 mcg/mL.
Enteral nutrition is the administration of nutrition with liquefied
foods into the gastrointestinal tract via a tube.
High-quality proteins or complete proteins such as eggs, dairy
products, meat, fish, and poultry contain adequate amount of essential amino
acids.
Vitamin C functions in the production of collagen, a vital component in
wound healing.
High-residue diet provides 20 to 35 g of dietary fiber daily.
High-residue foods are fruits and vegetables and whole-grain products.
Lacto-Ovo Vegetarian client consumes eggs and dairy products, but
excludes meat, poultry, and seafood.
Lacto vegetarian consumes dairy products, but excludes eggs, meat,
poultry, and seafood.
Vegan excludes animal products.
Pesco vegetarian consumes seafood, but excludes meat, poultry, eggs,
and dairy products.
Parenteral nutrition (PN) is the administration of a nutritionally
complete formula through a central or peripheral intravenous catheter. In the
clinical setting, the term PN may be used interchangeably with the term total
parenteral nutrition (TPN) or hyperalimentation.
Parenteral nutrition supplies carbohydrates in the form of dextrose,
fats in an emulsified form, proteins in the form of amino acids, vitamins,
minerals, electrolytes, and water.
Parenteral nutrition is the least desirable form of nutrition and is
used when there is no other nutritional alternative.
PN is given by central vein or by peripheral vein.
The subclavian or internal jugular vein is the central vein normally
used when PN is a short-term intervention (less than 4 weeks).
If PN is longer than 4 weeks, a more permanent catheter, such as a
peripherally inserted central catheter (PICC) line, a tunneled catheter, or an
implanted vascular access device is used.
PN can be administered through a peripheral vein, typically in the arm,
via a PICC line.
The delivery of hypertonic solutions into peripheral veins can cause
sclerosis, phlebitis, or swelling.
For PN the concentration of dextrose ranges from 5% to 70%.
Carbohydrates typically provide 60% to 70% of calorie needs.
For PN the concentration of amino acids from 3.5% to 20%.
In PN about 15% to 20% of total energy needs should come from protein.
Lipids provide up to 30% of calorie needs.
Available concentrations of fat emulsion (lipids) for PN are 10%, 20%,
and 30% providing 1.1, 2, and 3 kcal/mL, respectively.
Most fat emulsions are prepared from soybean or safflower oil, with egg
yolk to provide emulsification; the primary components are linoleic, oleic,
palmitic, linolenic, and stearic acids.
Additives should not be put into the fat emulsion solution.
Fat emulsions contain egg yolk phospholipids and should not be given to
the client with egg allergies.
Heparin may be added to reduce the build-up of a fibrinous clot at the
catheter tip.
Abrupt discontinuation of a PN solution can result in hypoglycemia. The
flow rate should be decreased gradually when the PN is discontinued.
Insulin may be added to control the blood glucose level because of the
high concentration of glucose in the PN solution.
PN is always delivered via an electronic infusion device.
Never increase the infusion rate to “catch up” if the IV infusion gets
behind.
PN is not initiated until correct catheter placement is verified and
the absence of pneumothorax is confirmed.
Infiltration is the seepage of IV fluid out of the vein and into the surrounding
interstitial spaces.
Phlebitis is an inflammation of the vein that can occur from mechanical
or chemical trauma or from a local infection.
Colloids also called plasma expanders. It pulls fluid from the interstitial
compartment into the vascular compartment.
For peripheral fat infusions (lipids), a 20- or 21-gauge lumen or
cannula is used.
For standard IV fluid and clear liquid IV medications, a 22- or 24- gauge
lumen or cannula is used.
Nurse squeeze the plastic bag to ensure intactness and assess the glass
bottle for any cracks before hanging.
Nurse do not write on a plastic IV bag with a marking pen because the ink may
be absorbed through the plastic into the solution. Use a label and a ballpoint
pen for marking the bag, placing the label onto the bag.
Micro drip chambers are used if fluid will be infused at a slow rate
(less than 50 mL/ hr).
Veins in the hand, forearm, and antecubital fossa are suitable sites for
IV lines.
Veins in the lower extremities (legs and feet) are not suitable for an
adult client because of the risk of thrombus formation and the possible pooling
of medication in areas of decreased venous return.
Veins in the scalp and feet may be suitable sites for IV line in infants.
Nurse determine the client's dominant side, and select the opposite
side for a venipuncture site.
Nurse avoid checking the BP on the arm receiving the IV infusion.
Do not place restraints over the venipuncture site.
In an adult, the most frequently used sites for inserting an IV cannula/needle
are the veins of the forearm.
Nurse avoid the peripheral IV sites for infusion: (a) Edematous extremity (b) An arm that is weak, traumatized, or paralyzed (c) The arm on the same side as a
mastectomy (d) An arm that has an arteriovenous fistula or shunt for dialysis (e) A
skin area that is infected.
Heat, redness, tenderness at site, not swollen or hard, and intravenous
infusion sluggish are the signs of phlebitis.
Hard and cordlike vein, heat, redness, tenderness at site, and
intravenous infusion sluggish are the signs of thrombophlebitis.
Nurse ensure that the IV solution is not hanging for more than 24
hours.
Infiltration is a form of tissue damage; it may also call
extravasation.
Central venous catheter position is determined by radiography.
For peripherally inserted central catheter (PICC) the basilic vein
usually is used, but the median cubital and cephalic veins in the antecubital
area also can be used.
Compatibility is the matching of blood from two persons by two
different types of antigen systems, ABO and Rh, present on the membrane surface
of the RBC, to prevent a transfusion reaction.
Designed donor is a compatible donor who has been selected by the
recipient.
The infusion time for 1 unit of packed RBCs usually between 2 to 4
hours.
Each unit of PRBCs increases the hemoglobin level by 1g/dL and hematocrit
by 2% to 3%; the changes in laboratory valves takes 4 to 6 hours after
completion of the blood transfusion.
Platelets are administered immediately upon receipt from the blood bank
and are given rapidly, usually over 15 to 30 minutes.
Fresh-frozen plasma may be used to provide clotting factors or volume
expansion; it contains no platelets.
Cryoprecipitate prepared from fresh-frozen plasma, it can be stored for
1 year.
Cryoprecipitate 1 unit is administered over 15 to 30 minutes.
Cryoprecipitate used to replace clotting factors, especially factor
VIII and fibrinogen.
One unit of WBCs approximately 400 mL is administered over 1 hour.
Autologous donation is not an option for a client with leukaemia and bacteremia.
Blood salvage is an autologous donation that involves suctioning blood
from body cavities, joint spaces, or other closed body sites.
The universal red blood cell donor is O negative; the universal
recipient is AB positive.
Transfusion reactions, circulatory overload, septicemia, iron overload,
disease transmission, hypocalcemia, and hyperkalemia are the complications of a
blood transfusion.
Haemolytic, allergic, febrile, or bacterial reactions, or
transfusion-associated graft-versus-host disease are the types of transfusion
reaction.
Nurse stay with the client for the first 15 minutes of the infusion of
the blood and monitor the client for signs and symptoms of a transfusion
reaction.
If transfusion reaction occurs, nurse stop the transfusion, keep the IV line
open with 0.9% saline, and notify the physician or remain with client and
observe vital signs as every 5 minutes.
Medication are never added to blood components.
Two licensed nurses need to check the physician’s prescription, the
client identity, and the client's identification band or bracelet and number,
verifying that the name and number are identical to those on the blood
component tag.
An 18 to 19-gauge IV needle will be needed to achieve a maximum flow
rate of blood products and prevent damage of RBC.
Nurse begin the blood transfusion slowly under close supervision; if no
reaction is noted within the first 15 minutes, the flow can be increased to the
prescribed rate.
If circulatory overload is suspected, the nurse immediately slows the
rate of blood transfusion infusion and place the client in an upright position,
with the feet in a dependent position.
Iron overload is a delayed transfusion complication that occurs in
clients who receive multiple blood transfusion.
Deferoxamine is administered to treat iron overload. Urine turns red as
iron is excreted after the administration of deferoxamine.
Most commonly disease transmitted by blood transfusion include hepatitis
C.
Hypocalcemia is caused by citrated in transfused blood binds with calcium
and excrete the calcium by body.
Stored blood liberates potassium through haemolysis and it cause
hyperkalemia.
Restraints are two types physical and chemical.
Warfare agent is the biological or chemical substance that can cause
mass destruction or fatality.
Nurse remember the mnemonic RACE to set priorities in the event of a
fire and the mnemonic PASS to use a fire extinguisher.
Action to take in the event of a fire:R-Rescue clients who are in immediate danger; A-Activate the fire
alarm; C-Confine the fire; E- Extinguish the fire: obtain the fire
extinguisher; P- Pull the pin on the fire extinguisher; A-Aim at the base of
the fire; S- Squeeze the extinguisher handle; S- Sweep extinguisher from side to side to
coat the area of the fire evenly.
Dosimeter is used to monitor radiation exposure with a film badge.
Physical restraints restrict client movement through the application of
a device.
Chemical restraints are medications given to inhibit a specific behavior
or movement.
Safety devices (Restraints) are not to be prescribed PRN, that is as
needed.
The poison control centre should be called first before attempting an
intervention during poisoning.
Health care associated infections (nosocomial) also referred to as hospital-acquired
infections.
Milliequivalent is an expression of the number of grams of a medication
contained in 1 mL of a solution.
Each medication has only one generic name.
Trade name also known as the proprietary or brand name.
Unit measures a medication in terms of its action, not its physical
weight.
The nurse should not administer more than 3 mL per intramuscular or 1
mL per subcutaneous injection.
The nurse should never increase the rate of an IV infusion to catch up
if the infusion is running behind schedule.
In a minidrip or microdrip set, 60 gtt is usually equal to 1 mL.
Jaw thrust maneuver is a method to open a victim’s airway if a neck
injury is suspected.
CPR is providing oxygen to the brain, heart, and other vital organs
until help arrives.
CPR is also known as basic life support (BLS).
The compression depth should be 1.5 to 2 inches in adult during CPR.
And 1/3 of anterior-posterior chest diameter in child or infant.
In CPR nurse assess the carotid artery for circulation for child older
than 1 year, and check brachial artery / femoral artery in child younger than 1
year.
The chest compression landmark for a child or in adult is in the centre
of the chest between the nipples. For the infant, the landmark is just below
the nipple line.
In CPR the compression-to-ventilation ratio in adult is 30:2; or in
child or infant 30:2 for a single rescuer; and 15:2 for two rescuers.
The automated external defibrillator (AED)
is used to convert ventricular fibrillation into a perfusing rhythm.
The automated external defibrillator is not recommended for infants
younger than 1 years.
When using the automated external defibrillator on an adult, do not use
the child pads; these pads will not provide an effective shock.
To remove foreign body airway obstruction (FBAO) abdominal thrusts are
used for the adult; back slaps and chest thrusts are used for the child and
infant.
Blind finger sweeps in the mouth of a victim with a foreign body airway
obstruction should not be performed because of the risk of pushing the objects
further into the airway.
Use chest thrusts for the obese or the advanced pregnancy victim.
In an infant, deliver five back slaps and then five chest thrusts to
remove the foreign body from the airway.
Wound dehiscence is the separation of the wound edges.
Wound evisceration is the protrusion of the internal organs through an
incision.
The surgeon is responsible for obtaining the consent for surgery.
Immediate postoperative stage is the period of 1 to 4 hours after
surgery.
Intermediate postoperative stage is the period of 4 to 24 hours after
surgery.
Extended postoperative stage is the period of at least 1 to 4 days
after surgery.
To assess the surgical wound infection, nurse assess the REEDA: redness,
erythema, ecchymosis, drainage, and approximation of the wound edges.
Wound evisceration and dehiscence usually occur 6 to 8 days after
surgery.
Wound evisceration is most common among obese clients and it is an
emergency.
In wound evisceration the client reports feeling a popping sensation
after coughing or turning.
If wound evisceration occur nurse place the client in low Fowler’s
position with the knees bent to prevent abdominal tension on an abdominal
suture line. Cover the wound with a sterile normal saline dressing and keep the
dressing moist
Ergonomic principles are the anatomical, physiological, psychological,
and mechanical principles affecting the efficient and safe use of an individual
energy.
After mastectomy position the client with the head of the bed elevated at
30 degrees (semi-fowler's position), with the affected arm elevated on a pillow
to promote lymphatic fluid return after the removal of axillary lymph nodes.
Turn the client only to the back and unaffected side.
In COPD client, nurse place the client in a sitting position, leaning
forward, with the client’s arms over several pillows, or an overbed table; this
position will assist the client to breathe easier.
Client with GERDs the reverse Trendelenburg’s position may be prescribed.
If automatic dysreflexia occurs, immediately place the client in a high
Fowler’s position.
In cerebral aneurysm bed rest is maintained with the head of the bed
elevated 30 to 45 degrees (semi-fowler's to fowler's position) to prevent pressure
on the aneurysm site.
Do not place a client with a head injury in a flat or Trendelenburg’s
position because of the risk of increased ICP.
The air vent on a Salem sump tube is not to be clamped and is to be
kept above the level of the stomach. If leakage occurs through air vent, instill
30 mL of air into the air vent and irrigate the main lumen with normal saline.
After insertion of NG tube, obtain an abdominal X-ray to confirm
placement of the tube.
For bolus feeding, maintain the client in a high Fowler’s position for
30 minutes after the feeding.
For a continuous NG tube feeding, keep the client in a semi-fowler's
position at all times.
Nurse always assess the placement of a GI tube before instilling
feeding solutions, medications, or any other solution. If the tube is incorrectly
placed the client is at risk for aspiration.
Nurse always assess bowel sounds; do not administer any feeding if
bowel sounds are absent.
Nurse administer the feeding at the prescribed rate or via gravity flow
with a 50 to 60 mL syringe with the plunger removed.
Do not administer the feeding if residual is more than 100 mL. Keep the
head of the bed elevated.
Gently flush with 30 to 50 mL of water or normal saline with the
irrigation syringe after feeding.
If the client vomits, stop the tube feeding and place the client in a
side-lying position; suction the client as needed.
The intestinal tube enters the small intestine through the pyloric
sphincter because of the weight of a small bag containing tungsten at the end.
For small intestine the cantor tube (single lumen) or the Miller-Abbott
tube (double lumen) is used.
Sengstaken-Blackemore tube (triple lumen) and Minnesota tube (four
lumen) are used for esophageal and gastric tubes.
Do not insert the esophageal and gastric tube if the client has ulceration
or necrosis of the esophagus or has had previous esophageal surgery because of
the risk of rupture.
Lavacuator or Ewald tube are used as lavage tube.
The lavacuator is an orogastric tube with a large suction lumen and a smaller
lavage-vent lumen that provides continuous suction.
Ewald tube is a single-lumen large tube used for rapid one-time
irritation and evacuation.
The correct placement of ET tube is confirmed by chest X-ray film.
Nurse monitor cuff pressures at least every 8 hours per agency procedure
to ensure that they do not exceed 20 mmHg. (An aneroid pressure manometer is
used to measure cuff pressures); minimal leak and occlusive techniques are used
for cuff inflation to check cuff pressure.
The Ambu bag needs to be kept at the bedside of a client with an
endotracheal tube or a tracheostomy tube at all times.
A tracheostomy is an opening made surgically directly into the trachea
to establish an airway.
The tracheostomy can be temporary or permanent.
Usually the half strength of hydrogen peroxide is used to clean
tracheostomy tube.
Nurse keep always a resuscitation bag, obturator, clamps, and a spare
tracheostomy tube of the same size at the bedside a client with tracheostomy.
A pilot balloon attached to the outside of the tube indicates the
presence or absence of air in the cuff of tracheostomy tube.
To perform suctioning the tracheostomy tube, nurse hyper oxygenate the
client before suctioning.
The fenestration tracheostomy tube is used to wean the client from a
tracheostomy by ensuring that the client can tolerate breathing through his or
her natural airway before the entire tube is removed. This tube allows the
client to speak.
Tracheomalacia, tracheal stenosis, tracheoesophageal fistula, and
trachea-innominate artery fistula are the complication of tracheostomy tube.
Tracheomalacia is caused by constant pressure exerted by the cuff
causes tracheal dilation and erosion of cartilage.
The tracheostomy tube pulsates in synchrony with the heartbeat it
indicates risk of trachea-innominate artery fistula. Remove the tracheostomy tube immediately.
Never insert a decannulation plug into a tracheostomy tube until the
cuff is deflated and the inner cannula is removed; prior insertion prevents
airflow to the client.
The chest tube drainage system returns negative pressure to the
intrapleural space.
Client with chest drainage system nurse monitor drainage; notify the
physician if drainage is more than 70 to 100 mL/hr or if drainage becomes
bright red or increases suddenly.
Client with chest drainage system fluctuation of the fluid level in the
water seal chamber is normal.
The fluctuation in the water seal chamber stops if the tube is
obstructed, if a dependent loop exists, if the suction is not working properly,
or if the lung has re-expanded.
Continues bubbling in water seal chamber indicates an air leak in the
system and nurse notify the physician.
Gentle bubbling should be noted in the suction control chamber and it
is normal.
Nurse maintain the occlusive sterile dressing at the insertion site
chest drainage system.
Chest radiograph is use to assess the position of the tube and
determines whether the lung has re-expanded.
Nurse always keep the drainage system below the level of the chest and
the tubes free of kinks, dependent loops, or other obstructions.
Frequent change in clients position promote the chest drainage and
ventilation.
Nurse keep a clamp and a sterile occlusive dressing at the bedside at
all times in client with chest drainage system.
Nurse never clamp a chest tube without a written prescription from the
physician.
If the drainage system cracks or breaks, insert the chest tube into a
bottle of sterile water, remove the cracked or broken system, and replace it
with a new system.
When the chest tube is removed, the client is asked to take a deep breath
and hold it, and the tube is removed; a dry sterile dressing, petroleum gauze
dressing, or Telfa dressing is taped in place after removal of the chest tube.
If the chest tube is pulled out of the chest accidentally, pinch the
skin opening together, apply an occlusive sterile dressing, cover the dressing
with overlapping pieces of 2-inch tape, and call the physician immediately.
Before the installation of any substance through the NG tube aspirate
stomach contents and test the pH. If pH of 3.5 or lower indicates that the tip
of the tube is in a gastric location.
The normal respiration is function on negative pressure.
The cardinal vital signs are temperature, pulse, respiration, blood
pressure, and oxygen saturation. A sixth vital sign is pain.
Intrathecal / intraspinal injection given into the spinal cavity.
A blood pressure cuff that’s too narrow can cause a falsely elevated
blood pressure reading.
The diaphragm of the stethoscope is used to hear high-pitched sounds, such
as breath sounds.
A slight difference in blood pressure (5 to 10 mm Hg) between the right
and the left arms is normal.
If a blood pressure cuff is applied too loosely, the reading will be
falsely lowered.
The body metabolizes alcohol at a fixed rate, regardless of serum
concentration.
When lifting a patient, a nurse uses the weight of her body instead of
the strength in her arms.
The nurse should use the bell of the stethoscope to listen for venous
hums and cardiac murmurs.
Laboratory test results are an objective form of assessment data.
An example of a third-party payer is an insurance company.
Romberg’s test is a test for balance or gait.
To perform catheterization, the nurse should place a women in the dorsal recumbent position.
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