MEQ
Always remember to put rational
definition dont put it too short
make it eligibile to read
usually point form
ADMISSION
- prepare the bed (how, call bell, side rail,)
- if not arive yet (prepare to receive the patient)
- identify patient
- oriented patient (meal time, dr, visit time, how to use, toilet)
- iv, information
- HW, physical assesment, allergies
- documentation
IO CHART
- totaling(end of shift)
- maintaning (in shift)
- fluid
- clear fluid (no dairy product)
- DESCRIBE IT CLEAR
- blood (moderate amnt of red clor fluid)
NURSING DIAGNOSIS (NANDA) ( SOAP/I)
sub, obj,
S- "im feel cold" said the patient
O - t' 40 C , shivering, body warm to touch
A - altered body temp related to diesease process
P/i - remove extra blanket to (evaluation)
-
bed sore
-wound assestment
- ripple mattress
- high protein diet to improve healing process
- perform doc for the wound
to monitor the progress
help n encourage patient do deep breathing to bring out the
PLEASE DONT WRITE THE LEVEL U CANNOT DO
Nursing process
o An organize/rational method of planning and providing nursing care
Purpose of nursing process
o Client receive quality care in minimal time with maximal efficiency
Etiology
o The cause of origin disease
Subjective data
o Consist of information that only the client feel n describe and are called symptoms
o Eg: pain
Objective data
o Measurable observable data that are obtained thru observation, lab report, physical
assessment, clinical manifestations, vital signs
type or nursing process
1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation
Assessment
o Collect data/identify actual problem
o Comprehensive assessment (physical assessment, health history)
o Focused assessment
o Collect data ( primary – client) ( secondary – fam, health care, medic record,
rounds, result test)
o Verbal, non verbal
Nursing diagnosis
o a clinical judgment about individual, family, or community responses to actual or
potential health problems/life processes.
Nursing goal
o A specific expected outcome of nursing intervention as related to the established
nursing diagnosis
Plan
o Process of prioritizing nursing diagnosis n collaborative problem, identifying
Measurable goals or outcome, selecting appropriate intervention n documenting the
plan of care.
Intervention
o Nursing interventions are actions a nurse takes to implement their patient care
plan, including any treatments, procedures, or teaching moments intended to
improve the patient’s comfort and health
Purpose of evaluation
o Determine the effectiveness of nursing care.
Different medical n nursing diagnosis
o Nursing diagnosis ( terminology used by nurses to identify the client actual risk,
wellness, problem or condition )
o Medical diagnosis (terminology used for clinical judgement by the physician that
identify or determine a specific disease n condition)
How to identify which nursing diagnosis need to attend first
o Any nursing diagnoses that directly relate to survival or a threat to the
patient’s mortality should be prioritized first. This may be related to the
patient’s access to air, water, or food, defined as the necessities of survival
Nurse role
o Caregiver
o Communicator
o Teacher
o Client advocate
o Change agent
o Counselor
o Manager
o Leader
o Research consumer
Nursing theory
o Environmental theory
o Theory of interpersonal relations
o Nursing need theory
o Nursing process theory
o Theory of human caring
o Self-care theory
Nursing practice
o Nursing practice involves four areas, namely, promoting health and wellness,
preventing illness, restoring health, and care of the dying. Promoting health and
wellness means the client receiving the health services may not be sick and is just
enhancing the quality of life. These health services include, but not limited to
improving nutrition and physical fitness, preventing drug and alcohol misuse,
restricting smoking, and preventing accidents and injury in the home and workplace.
Primary prevention
o focuses on preventing disease before it develops
Secondary prevention
o attempts to detect a disease early and intervene early
Tertiary prevention
o Directed at managing established disease in someone and avoiding further
complications.
Primary source
o Data from client
Pulse pressure
o Pulse pressure is the difference between systolic and diastolic blood pressure. It is
measured in millimeters of mercury. It represents the force that the heart
generates each time it contracts. Resting blood pressure is normally approximately
120/80 mmHg, which yields a pulse pressure of approximately 40 mmHg
Pulse used during emergency for adults
o carotid artery
Decide method checking temp/pulse
o Baby n children 3 years
o Unconscious client
o Client breath through oral
o Breathless
o Injury in mouth
Reduce fever
o Reduce physical activity
o Oral hygiene
o Tepid sponge
o Thin clothing
o Remove extra blanket
o Keep environment cool
o Apply cool pack
o Antipyretic
Convert 38°C to F
o (9/5 x c) + 32 = F
(9/5x 38) + 32 = F
(1.8 x 38) + 32 = 100.4 F
Locate the apical pulse
o Above apex heart
Indication of checking apical pulse n how to check
o During assessment
o Use finger locate pulse, apply stethoscope to chest, listen,
Term to use describe pulse type, respiratory, BP problem
o Pulse (normal, Tachycardia (fast), bradycardia (slow) )
o RR ( costal breathing -up&out) (diaphragm breathing – downward movement)
o Bp problem ( hypertension) (hypotension )
Characteristics pulse
o Rhythm,rate, force, equality
o 60-80 bpm
Characteristics respiration
o 12-20 normal
Factor affect bp reading , pulse, respiratory, temp
o Bp ( age, stress, gender, race, medication, exercise , diurnal variation, obesity,
disease process,)
o Pulse (age, gender, exercise, temp, drugs, body built, pathology, stress)
o Respiratory (exercise, acute pain, anxiety, smoking,body position, medication, brain
stem injury)
o Temp (age , exercise, circadian rhythm, stress, food intake, drugs, climate, gender,
illness)
Purpose hot therapy
o Provide warm n comfort
o Blood circulation
o Reduce pain
o Suppuration
o Decrease joint stiffness
o Reduce muscle tension
o Healing tissue swealing
o Relieve bladder
What to consider when checking bp
1. Explain the procedure to the patient
2. Select appropriate arm
What is the correct step when assessing the abdominal
o Inspect
o Auscultation
o Precussion
o Palpation
What position is the nurse should place the patient during physical assessment?
o Supine position
Instruction need to provide when auscultate clients lungs
1. Instruct client to take low deep breath through mouth
2. Listen for full breath using sthethoscope
Different type of physical assessment
o Comprehensive assessment
o Focus assessment
o Ongoing assessment
Which finding might lead the nurse to suspect a nutritional altered?
o Abnormal bmi
o Excessive weight loss
o Refusal to ingest food
o Abnormal vital sign
How to ensure the safety of client?
o Side rail up
o Keep small object
o Keep plasrtic bag away
o Electrical outlet covered
o Never leave a child alone in a bathtub
• Decreased sensory acuity
• Protects from drafs
• Provide adequate lighthing
• Keep personal item within reach
The purpose of restraint
o To prevent the client from injuring self and other
Nurse need to do prior apply the restrainer
o Understand the purpose
o As little as possible
o X interfere health/treatment
o X abstruct the blood circulation
o Change frequently
o Less embarrassed
Before restrain the client
o Assses client behavior
o Get written order
o Communicate with client and family
o Explain
Who is at risk to fall when to initial fall risk assessment
o Age, gender, musculoskeletel disorder, patients imbalance n using drugs
• Identify age,health history
• Observe level of consciouness, orientation, mobility
Safety hazard eldery client
o Latex sensitization
o Burns
o Electrical shock
o Poisoning
o Falls
Precaution when caring clients at all time
o Hand hygiene,glove,maskk,gown,
Type of isolation in hospital
o Contact isolation
o Droplet isolation
o Airbone isolation
Effective method to control the spread of infection
o Immunise against infectious diseases
o Hand hygiene
o Stay at home when sick
o Cover cough n sneeze
o Clean surface regulary
o Ventilate home
o Food safety
When positive pressure room?
o Air preasure is higher than that in the adjoining area
o To avoid the air become contaminated
o Use for patients with immuno-compromised condition
When negative pressure room
o Air pressure is lower than the outside air
o Prevent patogen frpm flowing to adjoining, non contaminated areas when the door
opened
o Used when caring patient with highly infectious disease
Act when trasporting client with respiratory isolation
o Use ppe
o Use disposable or dedicated patientcare equipment
o Prioritize cleaning and disinfection of the room
How to prevent pressure sore?
o Positioning
o Lift rather drag the client
o Massage bony prominrnces
o Avoid plastic cover pillow
o Keep skin clean n dry
o Use ripple matrress
o Provide balance diet
o Keep bed wrinkle free
Cause pressure sore
o Caused by unrelieved pressure that compromises blood flow to an area
Part body prone tp have pressure ulcer
o Side of head
o Ear
o Shoulder
o Greater trochanter
o Kee
o Malleolus
o Back of head
o Scapulae
o Elbow
o Sacrum
o Heels
o Vertabrea
o Pelvis
o Cheek
o Breast
o Genitalia
o Toes
Who need help in oral care?
o Client with paralysis
o Ill/sick/weak fracture bone
o Unconscious
o Oral dieases
Position for unconscious
no chocking
o Side lying position lateral
How to perform perineal care
front to the back
o Gather supplies
o Provide privacy
o Wash hand put glove
o Instruct patient to bend the knee n open the leg
o Cleanse the perineum usinf front to back motions
How to decide what type of bath of the client
o unconcious patient
post op
o
o stimulate
o circulation
Why need to clean from distal to proximal
o Increase venous blood return
clean to dirty
Type of position
o Recumbent
o Supine
o Lateral
o Semiprone
o Prone
o Fowlers
o Dorsal
Body mechanic prinsiple
o Facing the direction of movement
o Divide balance between arms n leg
o Reduce friction
o Hold object close to body
o Reduce force of work
o Use laverage,rolling,turning,pivoting
o Avoid bending the waist
o Adjust bed height
o Carry object close to the midline of body
o Avoid streatching
o Never lift alone
Why body mechanic is important
o Minimize clients injury
o Minimize nurse work related musculoskeletal injury
o Minimize nurse fatigue
Action take during transferring client from bed to chair
o Make sure the chair in good condition
o Assist client sitting on the bed with leg hanging over the side of the bed
o Assist client to stand up
o Let client place their arm on your shoulder while u put your hand around theor
waist
o Turn patient around with his back to the chair and seat him gently
Who need to be fed?
o Weak n helpless
o Paralyze
o Mental problem and not sensible
o Mental retarded
o Handicap
o Children
o Blind
Observe during feeding client
o
o 1. swallow reflex
o 2. remove all the bone in food
3.
o
Food not appropriate for HPT client
o Processed food
o Saturated fats
o Salt
o Fried
o Excessive alcohol intake
Food for diarrhoea client
o Clear broths
whatever with milk product
o Banana apple
oily
o Rice spicy
o Toast
Food for dysphagia client
o Pureed food very thick
o Moistened sticky a bit
o Mashed
Food for fever client
soft diet
o Fluid-rich foods
Types of food pyramid that will be used more
o At the base (food vegetable)
Lifestyle choice
o A choice a person makes about how to live and behave according to their
attitudes,taste, and values
How to feed client who hjust had eye surgery
o Help client sit using clock
o Tell client what the food is
o Put small amount of food on the tip of spoon and instruct client to open his
mouth
o Allow client to eat at her own pace
o Stop feeding if they tell or show u they have enough
Common use to describe urination problem
incontinent
o Dysuria
dan lain2
Common disorder of bowel elimination
o Irritable bowel syndrom
what type of mroorganism inside the feces/urine
How to collect specimen C&S
Urine what type of mroorganism inside the feces/urine
o Use sterile urine container
o Remove the lid . do not touch the inner surface
o Take the mid stream
o Fill half container
o Close tightly
o Label the container and send it to the lab
Stool
o Make sure the poo doesn’t touch the inside of toilet
o Use spoon or spatula to collect the poo
o Screw the lid shut
Sputum
o Instruct patient to take 3 deep breaths
o Then force a deep cough
o Expectorate into sterile screwtop cointaner
What position when giving fleet enema
o Left lateral position
Condition could cause dark amber concentrated urine
o Dehydration
o Food/drink/meds
o Hemolytic tract infection
o UTI
o Hepatitis C
o Liver n kidney disorder
Should a constipated client take laxative everyday?
o No
Assesment indicate a client is dehydrated due to diarrhoea
o Dry skin, thirst,
o Less frequent urination than normal
o Dark colored urine
o Fatigue
o Inability to sweat
Goal for client with diarrhea related to ingestion of an antibiotic for an upper respiratory
infection
o Client understanding causes and rationale for treatment
o Client consume atleast 1.5 to 2 l of water
o Client reestablishes n maintain a normal pattern of bowel functioning
Admission
1. orientation
o Prepare to receive client 2, physival asses
o Welcoming the client 3. interview
4. help client change
o Orientation
5. remain patient to simpan brg kemas
o Safeguard valuable n clothing 6. collect dat
o Compiling nursing data base HW
o Help client undress
o Documentation
How and whom u should collect data during admission
o Subjective n objective data
o Perform physical assessment
Discharge
o Written medical order
o Discharge instruction/teaching
o Notify billing office explain how to take med
o Report notyf housekeeping staff
to clean the room
o Room cleaning
When to sign AMA/AOR
o Client want to leave hospital without dr permission
How to adress client during admission
o Use term mr ms miss mdm or last name
When client has absconded from the ward
o Notify nurse manager, security
o Contact patients emergency contact 1.check first
2.inform primary
o Contact the police
nurse
o 3. inform dt
4.call famil
How to promote sleep at night
o Darkness
o Consisten sleep schedule
o Familiar sleep environment
o Good ventilation
o Sleep ritual
o Comfort quiet
Define health and illness
Health
o A state of complete physical, mental n social well being, not merely the absence of
disease physically and mentaly stable and healthy
Illness
o Abnormal process in which the persons level of functioning is changed compared with
previous level
What is insomnia
o Difficulty falling asleep. Awakening frequently during the night, awakening early
Purpose of deep breathing
o Muscle relaxation
o Facilitate lung aeration
Person need deep breathing
o Immobilize client
o Respiratory disease
o Pre n post op
o Heart problem
o Eldery
How to teach
o Inhale slowly until the greatest chest expansion is achieved
o Hold 2 to 3 sec
o Exhale slowly from mouth
o Repeat 5 times
