Fundamentals of Nursing

Nursing Board Review

Outline of review for the boards

History of Nursing- World and Philippines

The Nursing theories
Concepts of Health and Illness
Human Basic Needs
Stress and Adaptation
Outline of review for the boards

ASSESSING HEALTH STATUS

VITAL SIGNS
PHYSICAL ASSESSMENT
Outline of review for the boards

CLIENT CARE
ASEPSIS
SAFETY
HYGIENE
MEDICATIONS
SKIN INTEGRITY
TERMINAL CARE
Outline of review for the boards

HEATH PROMOTION AND DISEASE

PREVENTION
ACTIVITY and EXERCISE
REST and SLEEP
PAIN management
NUTRITION
FECAL ELIMINATION
URINARY ELIMINATION
OXYGENATION
CIRCULATION
Fluids and Electrolytes
History of Nursing
 Intuitive Nursing

 Apprentice Nursing

 Dark Period of Nursing

 Educated Nursing

 Contemporary Nursing
History of Nursing

Intuitive Nursing
 Primitive and untaught

 Code of HAMMURABI

 Moses- Father of Sanitation

 Hippocrates- Developed standards for client

care, medical standards and need for nurses

History of Nursing
Educated Nursing
 Florence Nightingale- born May 12, 1820 in
Florence ITALY
 Trained: Germany at Kaiserswerth School

 Founded the St. Thomas School of Nursing

in England
 Teachers are devoted clinical instructors solely
for teaching
 The first nurse to exert political pressure on
government
Nursing in the PHILIPPINES

 First School of Nursing= ILOILO MISSION

hospital school of nursing
 Anastacia Giron-Tupas= Founder of the PNA
 Rosario Delgado= first PNA president
Theories in Nursing

Four concepts Central to Nursing:

P-E-H-N
 Person

 Environment

 Health

 Nursing
Theories in Nursing

 ENVIRONMENTAL THEORY
 Relate nature with the bird- Nightingale
 ‘The act of utilizing the environment of the
patient to assist him in his recovery’
Theories in Nursing
 INTER-PERSONAL RELATIONS Model
 Remember “ PEP” talk
 Hildegard PEPLAU

Therapeutic relationship:
 Orientation= assist client to “understand”

problem
 Identification= Client dependence, inde and

inter he recognizes his problems in this phase

 Exploitation/Exploration= Derives “full value”

ini-exploit!!
 Resolution= old and new goals put aside
Theories in Nursing
 Nature of Nursing- Definition of Nursing
 The meaning of Nursing is “VIRGIN”

 Recall the 14 needs!!!!!

 Associate 14 virgin HENS

 Virginia HENDERSON

 She believes that clients need to express their

emotions, remain independent, autonomous

 They must work in such a way that they feel a sense

of accomplishment
Theories in Nursing

 21 nursing problems
 “Faid 21”
 Faye Abdellah
Theories in Nursing
 GENERAL THEORY OF NURSING-
SELF- CARE
 Associate “Self care “ to “ORAL care” or
“per orem”
 Dorothea OREM
 1. WHOLLY compensatory= unable to
control
 2. PARTLY compensatory= unable to
perform SOME self care
 3. SUPPORTIVE- EDUCATIVE= who
needs to learn and needs assistance
Theories in Nursing
 BEHAVIORAL SYSTEM MODEL
 Associate behavior with John (in
John and Marsha)
 “kaya JOHN(son) magsumikap ka “
 Dorothy Johnson
Theories in Nursing
 Conservation Theory
 “the Divine is Conservative”
 “Levin” – levine, divine
Theories in Nursing

 GOAL ATTAINMENT
Recall that the KING of the land has a
GOAL to attain for his kingdom

 IMOGENE KING!
 Her theory is applicable to the child
bearing women and their families
Theories in Nursing

 UNITARY BEING: Man as the

CENTRAL Focus
 “Roger , Roger, let us unite our Man
in the center of the battlefield”
 The whole is greater than its parts
 Martha ROGERS
 She believes in the use of the
principles of NON CONTACT
therapeutic touch
Theories in Nursing
HEALTH CARE SYSTEMS model
 Betty NEUMAN

 Stresses, reactions to stress and

adaptation to stressors
 After overcoming the stresses you will
become a “NEW- Man”
 Intrapersonal stressor= illness

 Extrapersonal stressors= financial

concerns, community resources
 Interpersonal stressor= unrealistic role
expectations
Theories in Nursing

 ADAPTATION MODEL
 Individual is a BIOPSYCHOSOCIAL
ADAPTIVE system with input and
output
 “associate this with a Nun”
 SISTER ROY= nag a adopt ng mga
bata
 Her theory supports the unity
between the client and God
Theories in Nursing

 CULTURAL CARE DIVERSITY

 Transcultural Nursing
 Madeleine LEININGER
Theories in Nursing

 Nursing Process theory and CARE,

CORE and CURE
 The nurse who coined the word
nursing process and stated “ I care, I
core and I cure”
 Hall of Fame award!!!
 LYDIA HALL
Theories in Nursing

 DYNAMIC NURSE-PATIENT
Relationship
 Associate dynamic action to the
team of ORLANDO
 Ida Jean ORLANDO!!!
 Go Orlando, the dynamic team!!!!!
Theories in Nursing

 HUMAN BECOMING THEORY

 Remember to become a ‘rose’ per se ,
you must be a bud first!!!!!!!!!!!!
 Rosemarie Parse
 Her theory emphasizes that clients are
the AUTHORITY figures and decision
makers for their personal health
Theories in Nursing

HUMAN CARING THEORY

 ‘What is caring?”

 Jean WATSON

 Caring for clients during their end-of-

life experiences
Patricia Benner’s Stages of nursing
expertise (NACPE)
Stage 1 = novice No experience, performance is limited,
inflexible

Stage 2= advanced Demonstrates MARGINALLY acceptable

performance, recognizes the meaningful
beginner aspects of a real situation
Stage 3= Has 2-3 years experience, demonstrates
ORGANIZATIONAL and planning abilities
competent
Stage 4= proficient Has 3-5 years of experience, perceives
situations as whole, has HOLISTIC
understanding of patient
Stage 5= expert Performance is FLUID, flexible and HIGHLY
Proficient, No longer requires rules,
maxims.Demonstrates HIGHLY skilled
intuitive and analytic ability
Health Definition

 A state of complete physical,

mental and social well-being and
not merely the absence of disease
or infirmity
 WHO, 1948
Wellness
 State of well-being
 Seven Components- “seven wishing

WELL”
Physical= carry out task
Social= interact with people
Emotional= express feelings
Intellectual= learn and use info
Spiritual= belief in supernatural
Occupational= leisure and work
Environmental= standard of living in
community
Health Theories

 CLINICAL
 Health is absence of disease

 ROLE PERFORMANCE
 Health is ability to fulfill societal

functions
 ADAPTIVE
 Heath is a creative process of

adaptation
Health Theories

 EUDEMONISTIC
 Health is a condition of self-actualization
 ECOLOGIC
 Health is interaction of three elements:
1. Agent
2. Host
3. Environment
Health Theories

 Dunn
 “doon, dito, dine and dire”
 Four quadrants
 HIGH level Wellness is functioning at the BEST
possible level
Illness and Disease

 DISEASE
 Alteration in body functions

 ILLNESS
 A state of physical, social, emotional,

intellectual, developmental or spiritual

functioning is DIMINISHED
Stages of Illness: S-A-M-D-R

 SYMPTOM experiences
 Client believe something is wrong
 ASSUMPTION of the sick role
 Excuse form work and family role
 MEDICAL care contact
 DEPENDENT CLIENT role
 RECOVERY or REHABILITATION
Abraham Maslow’s Hierarchy of needs

 Physiologic needs- oxygen, water, food

 Safety and security
 Love and belonginess
 Self esteem
 Self actualization
Abraham Maslow’s Hierarchy of needs

 Safety and security

 Physical safety
 Psychological safety
 Shelter from harm
Abraham Maslow’s Hierarchy of needs

 Love and belonginess

 Need to love
 Need to belong
 Need for affection
Abraham Maslow’s Hierarchy of needs

 Self esteem
 Self-worth
 Self-identity
 Self-respect
 Self-image
Abraham Maslow’s Hierarchy of needs

 Self actualization
 Self-fulfillment
 Spiritual fulfillment
Man and His needs

Self-
Actualization

Self-Esteem

Love and Belongingness

Safety and Security

Physiologic Needs
Man’s Need
 Need is something desirable and useful
 Needs are UNIVERSAL
 Needs are MET in different WAYS
 Needs are influenced by different
FACTORS
 Priorities may be CHANGED
 Needs may be POSTPONED
 Needs are INTER-RELATED
Man’s Need

 Need is something desirable and

useful
 Prioritization of needs mat be dictated
by the client’s perception
Man’s Need

 Nursing goal is this area is to:

 Meet the PHYSIOLOGICAL needs of the
patient
 Assess the patient's perception of his
other needs
 Employ nursing Interventions according to
the PERCEIVED NEEDS of the patient NOT
of the nurse
Evaluation Parameters of nursing care

 The nurse checks if the desired criteria

dictated by patient’s needs are achieved
 Check which interventions were helpful
 Revise the plan as needed
Man achieves self-actualization

 (Udan)

 A self-actualized person is basically a

MENTALLY healthy person
 And self-actualization is the essence of
mental Health
Cultural care nursing

 It is the provision of nursing care across

cultural boundaries and takes into account
the context in which the client lives

 It is professional nursing that is culturally

sensitive, culturally appropriate, and culturally
competent
Cultural care nursing

The suggested steps for culture care are:

1. Become aware of one’s own culture heritage
2. Become aware of the client’s heritage and health
tradition
3. Identify client’s preference in health practices, diet,
hygiene, etc. These will affect their health
practices
4. Formulate a culture care plan
Stress and Adaptation
 STRESS
 A condition in which the person responds to
changes in the normal balanced state
 Selye: non specific response of the body to any
kind of demand made upon it

 STRESSOR
 Any event or stimulus that causes an individual to
experience stress
Stress and Adaptation

 SOURCES OF STRESS
1. Internal
2. External
3. Developmental
4. Situational
Stress and Adaptation
Physiological indicators of stress: Sympathetic
response
 Dilated pupils
 Diaphoresis
 Tachycardia, tachypnea, HYPERTENSION,
increased blood flow to the muscles
 Increased blood clotting
 Bronchodilation
 Skin pallor
 Water retention, Sodium retention
 Oliguria
 Dry mouth, decrease peristalsis
 Hyperglycemia
Stress and Adaptation

SELYE’S General Adaptation Theory

A-R-E
ALARM: sympathetic system is mobilized!
RESISTANCE: adaptation takes place
EXHAUSTION: adaptation cannot be
maintained
 ANXIETY
CATEGORY MILD MODERAT SEVERE PANIC
E
Perception Increased Narrowed Inability to Distorted
and arousal focus focus perception
attention
Communicati Increased Voice Difficult to Trembling
on questioni tremors understand unpredictab
ng Focus on Easily le response
particular distracted
object
VS changes NONE Slight Tachycardi Palpitation,
Increase a, choking,
Hyperventil chest pain
ation
Anxiety versus fear
ANXIETY FEAR
State of mental uneasiness Emotion of apprehension
Source may not be Source is identifiable
identifiable
Related to the future Related to the present
Vague Definite
Result of psychologic or Result of discrete physical
emotional conflict or psychological entity,
definite and concrete
events
VS

 T
 P
 R
 BP
TEMPERATURE

 Reflects the balance between the heat

produced and the heat lost from the body
 CORE TEMPRATURE: deep tissues of body
Temperature Monitoring

Oral- accessible and convenient

Rectal- very accurate
Axillary- preferred for newborns
Tympanic- reflects core temperature
Body temperature has a diurnal variation

 POINT of Highest body temperature is

BETWEEN 8 pm to 12 midnight

 POINT of Lowest body temperature is

BETWEEN 4 am to 6 am
Temperature Alteration
FEVER, PYREXIA, HYPERTHERMIA
1. Intermittent: Periods of fever and normal
temp
2. Remittent: Fever fluctuates BUT above
normal
3. Relapsing: Fever for few days, then
normal for few days
4. Constant: ALWAYS above normal,
minimal fluctuation
Heat loss
Mechanism Description

Conduction Transfer of heat form one object to

another by direct contact
Convection Movement of air and heat by air current

Evaporation Loss of heat through evaporation of

water/sweat
Radiation Transfer of heat from warm objects to
cool objects in the form of
electromagnetic waves
Pulse

 A wave of blood created by contraction of the

left ventricle of the heart
 Normal range: 60-100 BPM
Pulse
 Pulse pressure:
 Systolic pressure MINUS diastolic pressure
 Pulse deficit
 Apical pulse MINUS peripheral pulse
 Pulsus paradoxus
 Systolic pressure falls by more than 15
mmHg during INHALATION
 Pulsus alternans
 Alternating strong and weak pulses
Liquid Diet Vs Soft diet
Clear liquid Full liquid Soft diet
Coffee Clear liquid All CL and FL
Tea PLUS: plus:
Carbonated Milk/Milk prod Meat
drink Vegetable Vegetables
Bouillon juices Fruits
Clear fruit juice Cream, butter Breads and
Popsicle Yogurt cereals
Gelatin Puddings Pureed foods
Hard candy Custard
Ice cream and
sherbet
Food Guide pyramid

 Bread, cereals, rice and pasta= 6-11 servings

 Fruit and vegetables
 Meat, poultry, fish, dry beans, eggs
 Milk, yogurt, cheese
 Fats, oils and sweets
Primary Prevention Health promotion and
Specific protection

Secondary Prevention Health maintenance

Screening and case
finding
Early diagnosis
Prompt treatment

Tertiary Prevention Rehabilitation

Primary Education, Exercise, Diet and
Prevention Nutrition, Immunization
Secondary Physical Examination, Pap’s
Prevention smear, BSE, TSE
Sputum AFB, DRE
Providing medication and
treatment
Tertiary Physical therapy, Self-monitoring
Prevention of DM, Speech therapy
Levels of Prevention

1. ENCOURAGING MEDICAL
CONSULTATIONS AND DENTAL CHECK-
UPS
Levels of Prevention

1. ENCOURAGING MEDICAL
CONSULTATIONS AND DENTAL
CHECK-UPS

Secondary Prevention
Levels of Prevention

2. Assessing growth and development of

children for nutritional evaluation
Levels of Prevention

2. Assessing growth and development of

children for nutritional evaluation

Secondary Prevention
Levels of Prevention

3. Family Planning and marriage counseling

Levels of Prevention

3. Family Planning and marriage counseling

primary prevention
Levels of Prevention

4. Teaching a client with diabetes self-

monitoring of glucose level
Levels of Prevention

4. Teaching a client with diabetes self-

monitoring of glucose level

Tertiary prevention
DIAGNOSTIC
EXAMINATIONS

Duke J. Trillanes III, RN, MAP

RA Gapuz Review Center
MUST KNOWS
 KNOW NORMAL VALUES FIRST
 DISEASE CONDITIONS AND THE
SIGNIFICANCE OF CERTAIN
LABORATORY DATA
 POSITIONING FOR THIS TESTS
 PURPOSE AND NURSING ALERT
 SPECIMEN COLLECTION AND PATIENT
PREPARATION
 POST TEST RESPOSIBILITIES
SPECIMEN COLLECTION
Urine
 Clean-catch urine specimen
 For routine urinalysis and culture and sensitivity test

 Perineal care before collection

 The best time to collect the specimen is early in the

morning (first voided-specimen)

 Amount needed: 30-50 cc for urinalysis; 5-10 ml for

culture and sensitivity test

 24 Hours urine Specimen

 discard the first voided urine

 Soak specimen in a container of ice

 Add preservative as ordered and indicate in the label

the type of preservative added.
Second voided Urine Specimen
 Ask the patient to urinate and discard the first
urine specimen and offer a glass of water
afterwards
 After few minutes, ask the client to void again and
collect the specimen
Catheterize Urine Specimen
 Clamp the catheter for 45 mins
 Practice aseptic technique
 Do not collect specimen from the urine bag
 Obtain 3-5 ml of specimen for culture and
sensitivity test and 10-15 ml for urinalysis
 Stool Specimen
Routine Fecalysis
 Use to assess gross appearance, and presence of ova
or parasite in the stool
 Sterile specimen container must be secured

 Instruct the client to defecate in the bedpan and obtain

1tbsp or 1 inch long stool specimen using a sterile
tongue depressor
 Label the specimen and bring immediately to the
laboratory
Stool Culture and Sensitivity Test
 This is done to assess for specific microorganisms and
etiologic agents causing gastroenteritis, and bacterial
sensitivity to various antibiotics
 Sterile technique must be employed
 Label the specimen properly and send immediately to
the laboratory
Guiac Stool Exam (Occult Blood)
 It detects bleeding at the GI tract and
cancer of the stomach
 Meatless diet for 3 days prior to the
procedure
 No to red or dark colored foods tom prevent
false positive result
 No to iron: discontinue temporarily for 3
days prior to the procedure
Sputum specimen
 Gross Appearance
 Collect early morning specimen
 Sterile container must be used
 Mouth care before: gargle only with water (no to
mouthwash, or toothpaste)
 Instruct the client to deep breath and hack-up
sputum from the lungs.
Sputum Culture and Sensitivity test
 Used to assess the etiologic agent causing

Respiratory tract infection and bacterial

sensitivity to various antibiotics
Acid Fast Bacillus (AFB) staining
 To determine active PTB
 Sputum specimen is collected in 3
consecutive mornings

Papanicolao or Cytologic Examination of the

sputum
 To assess for cancer cells
Blood Specimen
 Blood Tests that does not require fasting:
 Complete Blood Count
 Hemoglobin
 Hematocrit Level test
 Clotting studies
 Enzyme studies
 Serum electrolyte studies
 Requires Fasting
 Fasting Blood Sugar
 Blood Urea Nitrogen
 Serum Creatinine
 Serum lipids (cholesterol level, glyceride level)
Body Secretions
 Culture and sensitivity test
 To assess causative agent causing infection, and
bacterial sensitivity to various antibiotics
 Practice aseptic technique
Arterial blood gas analysis
 PURPOSE: To monitor the patient’s response to
oxygen therapy and detects the presence of acid-
base balance.
 NURSING KEYPOINTS:

 No to Suctioning prior to obtaining blood specimen

 Assess for bleeding and hematoma at the puncture

site
 Apply firm pressure at the puncture site for 5-10
minutes
 Specimen should be placed in iced-container

 Assess for metabolic alkalosis for patient with

vomiting, and on the other hand, observe for signs and
symptoms of metabolic acidosis for patients with
diarrhea.
Barium enema
 PURPOSE: To assess the large intestines

NURSING KEYPOINTS:
 Provide a Liquid diet before the procedure.

 Ensure that a laxative is given before the

procedure to promote better visualization, and
after the procedure to prevent constipation
 Report to the doctor if bowel movement does
not occur in 2 days
 Instruct the patient to increase fluids and eat
foods rich in fiber
 The patient should also increase intake of
fluids
Friends and Enemas
 What is an ENEMA?
 A solution introduced into the rectum and
large intestine for the purposes of:
1. To relieve constipation
2. To relieve flatulence
3. To administer medication
4. To evacuate feces in diagnostics or surgery
Enema types
1. Cleansing Enema= intended to remove
feces to prevent escape during surgery, for
visualization procedure and constipation
 Purposes To
1. Prevent escape of feces during surgery
2. Prepare intestines for diagnostics and
surgery
3. Remove feces in constipation/impaction
Enema types

2. Carminative enema= to expel flatus, 60-80

mL of fluids instilled
3. Retention enema= oil or medication is
instilled to treat infection
4. Return flow enema= also to expel flatus,
repeated 6 times
Enema Solutions
Hypertonic Draws water into the SE: Retention of sodium
colon

Hypotonic Distends colon, softens SE: F and E imbalance,

feces water intoxication

Isotonic Distends colon SE: possible sodium

retention

Soap suds Irritates colon SE: May damage mucosa

Oil enema Lubricates feces

The Height of the ENEMAS

During MOST enemas For HIGH enema

No higher than 30 cm above rectum Up to 45 cm above rectum

The TIME of the ENEMAS

Cleansing Enema For Oil retention enema

5-10 minutes 30 minutes

The Length of the ENEMA tube
insertion
 The rectal tube is
inserted 3 to 4 inches
Barium swallow
 PURPOSE: To assess for the esophagus,
stomach, and some portion of the small
intestines.
 NURSING ALERT:

 NPO for 6-8 hours before the procedure

 Laxative is administered after the procedure

to counteract the constipating effects of the
barium
 Withhold anticholinergics and narcotics for 24
hours before the test
 Instruct patient to increase fluids and intake
of fiber-rich foods
Cardiac catheterization
 PURPOSES: To measure oxygen concentration, saturation,
tension and pressure in various chambers of the heart. To
determine a need for cardiac surgery.
 NURSING KEYPOINTS:
 Check for informed consent
 Assess allergy to iodine
 NPO for 6-8 hours before the procedure
 Check for distal pulses after the procedure
 Check for bleeding at the arterial puncture site and apply
pressure
 Keep a 20 lbs sandbag at the bedside as a pressure instrument
if bleeding occurs
 Keep the patient flat on bed with the lower extremities
hyperextended for 4-6 hours
 Neurovascular assessment must be performed distal to the
catheter insertion site and report any abnormal findings
Catheterization, urinary
 PURPOSE: To determine residual urine and obtain sterile specimen. It can
be a straight catheter, suprapubic, indwelling catheter, and external device
catheter.
 NURSING ALERT:
 Know the necessary facts:

Principles Male Female
 Position Supine Dorsal recumbent
 Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in.
 French number or
 Circumference #14- 16 #18
 Length of tube to
 be inserted 2-3 in. 6-9 in.
 Balloon size 5-10 ml. 5-10 ml
 (30 ml)Can be used to
 achieve hemostasis
 of the prostatic area
 following prostatectomy

 Place to secure lower abdomen Inner thigh
 The procedure is sterile
 Maintain a close system
 The draining bag must always be below the
bladder
 The catheter bag should not be allowed to lie
on the floor
 Do not allow the drainage spout to touch the
collection receptacle or on the toilet bowl
when draining it
 Chest X-RAY
 PURPOSE: To detect abnormalities of the
organs in the thoracic area
 NURSING KEYPOINTS:
 Remove any metallic object before the
procedure
 Lead shield for women of childbearing age
Computerized Tomography (CT)

Definition
1. Cross-sectional visualization of the brain determined
by computer analysis of relative tissue density as an
x-ray beam passes through; also known as
computerized axial tomography (CAT) scan
2. Provides valuable information about location and
extent of tumors, infarcted areas, atrophy, and
vascular lesions
3. May be done with or without intravenous injection of
dye for contrast enhancement
Computerized Tomography (CT)
Computerized Tomography (CT)
Computerized Tomography (CT)
Nursing care
1. Explain procedure; inform the client that it will be
necessary to lie still and that the equipment is complex
but will cause no pain or discomfort; infants and
cognitively impaired or anxious clients may need to be
sedated
2. If the facility is small, arrange transportation to a larger
facility that has the required equipment
3. Evaluate for possible allergy to iodine, a component of
the contrast material
4. Withhold food for approximately 4 hours prior to testing;
dye may cause nausea in sensitive patients
5. Remove wigs, clips, and pins prior to the test
6. Evaluate client's response to procedure
 NURSING ALERT:
 If contrast medium will be used, assess for any
allergy to iodine and instruct the patient to be
on NPO for 4 hours prior to the procedure
 Assess for any fear of close spaces
(claustrophobia)
 This procedure is contraindicated to patients
who are pregnant and obese (>300 lbs)
 Let the patient lye still during the whole course
of the procedure
 CVP (Central Venous Pressure) monitoring
 PURPOSE: It measures the pressure of the Right
Atrium
 NURSING KEYPOINTS:
 The nurse should place the zero level of the
manometer at the level of the Right atrium at the 4th
intercostals space to get an accurate reading
 Instruct the client to avoid coughing and straining as
it alters the readings
 Normal CVP reading is 2-12 mm Hg ( when the tube
is at the superior vena cava)
Cystoscopy
 PURPOSE: To assess the bladder and urethra

NURSING KEYPOINTS:
 Check for the informed consent.

 If general anesthesia will be used have the client

on NPO; liquid diet if local anesthesia will be used.

 Monitor intake and output.

 After: Force fluids as prescribed.

 Administer sitz bath for abdominal pain.

 Pink-tinged or tea-colored urine is expected.

 Notify the doctor if bright red urine or clots occur.

 Doppler ultrasound
 PURPOSE: Evaluates patency of veins and
arteries in the lower extremities.
 NURSING KEYPOINT:
 Inform the patient that it is painless.
Doppler UTZ
 ECG (Electrocardiogram)
 PURPOSE: Records electrical waves of the
heart.
 NURSING KEYPOINTS:
 Instruct the patient to lie still, breathe
normally during the procedure
 Let the patient refrain from talking during
the test.
 ST segment elevation or T wave inversion,
indicates MI
 EEG (Electroencephalogram)
 PURPOSES: Records the electrical activity of
the brain, detects intracranial hemorrhage and
tumors
 NURSING KEYPOINTS:
 Advise the client to shampoo hair before and
after the procedure
 If the electrode gel is non removed by
shampooing, the patient may use acetone
 Withhold stimulants, antidepressants,
tranquilizers, and anticonvulsants for 24-48
hours prior to the test
 Fasting Blood Sugar level
 PURPOSE: Detects diabetes mellitus
 NURSING KEYPOINTS:
 Normal blood sugar level is 80-120 mg/dl
 A blood sugar level of more than 140 mg./dl
confirms diabetes.
 Gastric analysis
 PURPOSES: This test is used to detect
ulcers, and to rule-out pernicious anemia. It
may also be done to analyze acidity,
appearance and volume of gastric
secretions
 NURSING KEYPOINTS:
 In gastric ulcer, HCL is normal,
 In duodenal ulcer, HCL is elevated.
 Refrigerate gastric samples if NOT tested
within 4 hours.
 IVP (Intravenous pyelography)
 PURPOSE: Visualization of the urinary tract
 NURSING KEYPOINTS:
 Check for the consent.
 NPO for 8-10 hours before the procedure
 Administer laxative to clear bowels before the procedure.
 Check for allergy to iodine, seafoods or shellfish before the
procedure since the procedure requires the use of iodine
based dye.
 Keep epinephrine at the bedside to counteract possible
allergic reaction. IVP requires the use of a contrast medium
while KUB does not.
 Inform the patient about the possible salty taste that may
be experienced during the test.
 Increase fluid intake after the procedure to facilitate excretion
of the dye.
 KUB
 PURPOSE: Determines the size, shape and
position of kidneys, ureters and bladder.
 NURSING KEYPOINT:
 No special preparation needed.
 Liver biopsy
 PURPOSE: To determine liver disorders.
 NURSING KEYPOINTS:
 Check for the consent.
 Obtain the result of blood tests before biopsy since
bleeding may occur
 Let the patient assume left side or supine during
biopsy
 Instruct the patient to inhale, exhale and hold breath
during the insertion of to stabilize position of the liver
and prevent accidental puncture of the diaphragm
 Position the patient on the Right side after liver biopsy
with pillows underneath to prevent bleeding
 Bedrest for 24 hours after the procedure
 Lumbar Puncture
 PURPOSE: To withdraw CSF to determine
abnormalities.
 NURSING KEYPOINTS:
 Before the procedure: empty bladder and bowel.
 Position: C-position. (fetal posistion)
 During the procedure: needle is inserted between L3
-L4 or L4-L5 to prevent accidental puncture to the
spinal cord since the spinal cord ends at L2.
 After: Position the patient flat for 6-12 hours to prevent
spinal headache. Increase fluid intake.
 Mammography
 PURPOSE: Detects the presence of breast tumor.
 NURSING KEYPOINTS:
 Instruct the patient not to use deodorant, talcum
powder, lotion, perfume or any ointment on the day of
exam as these may give false-positive result
 Let the patient know that her breasts will be
compressed between 2 x-ray plates
 Provide teachings related to Self-breast examination
 Done 7 days after menstruation

 Position: lying down with pillow under the shoulder of

the breast being examined or sitting in front of a mirror
while raising the hands of the side of the breast being
examined.
 Mantoux test
 PURPOSE: A test to determine exposure to TB
 NURSING KEYPOINTS:
 A positive test yields an induration of 10 mm. or more for foreign
born children below 4 years old
 An induration of 5 mm or more is considered positive in patients
with HIV, with treated TB, and if he has had a direct exposure TB
Patients.
 BCG may cause false positive reaction.
 Assess for previous history of PTB and report immediately to the
doctor
 Result is read after 48-72 hours
 MRI (Magnetic Resonance Imaging)
 PURPOSE: Provides cross-sectional images of
brain tissues, more detailed than a CT scan.
 NURSING KEYPOINTS:
 Contraindications:
 pregnant women,
 obesity (more than 300 lbs.),
 claustrophobic patients,
 patients with unstable vital signs
 patients with metal implants like pacemaker, hip
replacements and jewelries.
Magnetic Resonance Imaging (MRI)

Definition
1. This procedure utilizes magnetism and radio waves
to produce images of cross-sections of the body
2. The MRI machine registers the existence of odd-
numbered atoms in the cross sections of the body,
yielding data about the chemical makeup of the
tissues
3. MRI can produce accurate images of blood vessels,
bone marrow, gray and white brain matter, the spinal
cord, the globe of the eye, the heart, abdominal
structures, and breast tissue, and can monitor blood
velocity
Magnetic Resonance Imaging (MRI)

Nursing care
1. Assess ability to withstand confining surroundings
because client must remain in the tunnel-like machine
for up to 90 minutes; open MRI may be an option for
clients who cannot tolerate closed spaces
2. Instruct client to toilet prior to test, since this will be
impossible during the procedure
3. Advise client to remove jewelry, clothing with metal
fasteners, dentures, hearing aids, and glasses prior to
entering scanner
Magnetic Resonance Imaging (MRI)

4. Since this procedure is contraindicated for certain

clients, before the test assess for:
a. Metal prostheses, such as orthopedic screws,
since the magnetic force can dislodge the
devices
b. Pacemakers, since the scanner deactivates
pacemaker
c. Dysrhythmias, because the magnetic field can
affect the conduction system of the heart
d. Unstable medical conditions, since monitoring
of the client is limited during the test
5. Evaluate client's response to procedure
 Stool analysis
 PURPOSE: Assessment of bacteria, virus,
malabsorption and blood.
 NURSING KEYPOINT:
 Avoid aspirin, red meat and vitamin C
three days before the test as these may give
a false positive result.
Tonometry
 PURPOSE: Measures intraocular pressure.

 NURSING KEYPOPINTS:

 Normal reading is 12-21 mm Hg

 A reading of 25 mm Hg indicates glaucoma.

Urinalysis
 PURPOSE: To assess characteristics of urine.

 NURSING KEYPOINTS:

 First voided morning sample preferred: 15 ml.

 Use clean container

 Decreased specific gravity: diabetes insipidus

 Increased specific gravity: diabetes mellitus,

dehydration, SIADH
 (+) Protein: PIH, nephrotic syndrome.

 (+) Glucose: Diabetes mellitus, Infection

Urine Collection

 As fresh as possible
 Mid stream clean
catch
 First morning
specimen best, but for
most purposes
doesn’t make much
difference
Hematuria
Even small amounts of blood are visible
1 part per 1000 is easily seen
Urine collection, 24 hour
 PURPOSE: Determines the excretion of substances

from the kidneys, adrenal glands and the stomach.

 NURSING KEYPOINT:

 Required for ACTH test and schilling’s test (B12

absorption),
 Discard the first voided urine

 Place urine output in a clean container preserved in

ice chest
Thank
You!