TOP 93 NURSING SKILLS, PROCEDURES and NORMAL VALUES

A
1. ABDOMINAL ASSESSMENT
Procedure: I-A-Pe-Pa
Regular assessment: I-Pa-Pe-A
Sequence: RLQ RUQ LUQ LLQ
Position: dorsal recumbent
AVOID:
A ppendicitis
P heochromocytoma
A bdominal Aortic Aneurysm
W ilms tumor

2. AMNIOCENTESIS vs. ULTRASONOGRAPHY

AMNIOCENTESIS VARIABLES ULTRASONOGRAPHY

aspiration of amniotic fluid inside the amniotic
sac through an outside puncture
1. If more than 20 weeks' gestation (empty
bladder) to prevent confusion between it and
the amniotic sac
2. If less than 20 weeks' gestation (full bladder)
to elevate the uterus and increase
visualization of the fluid pocket
1. If done early in pregnancy: To detect
chromosomal abnormalities
2. If done late in pregnancy:
To detect fetal lung maturity and to resolve
polyhydramnios
visualization of the uterine content including all the
Definition products of conceptus
1. After 20 weeks (empty bladder)
2. Before 20 weeks (full bladder) to increase ultrasonic
resolution and elevate the presenting head for biparietal
Preparation of the diameter measurement
mother
First Trimester
1. Gestational age assessment
2. Evaluation of congenital anomalies;
Purpose (s) 3. Confirm multiple pregnancy
Second Trimester
1. Guidance of procedure (amniocentesis);
2. Assessment of placental location

Third Trimester***
1. Determination of fetal position
2. Estimation of fetal size/ weight

3. ARTERIAL BLOOD GAS (ABG) ANALYSIS

Serum pH 7.35 7.45
CO2 35 45
HCO3 22 26
PaO2 85 95 mmHg
Increased: Polycythemia
Decrease: Anemia

BEFORE:
Allen Test to assess patency of the RADIAL artery***
Avoid suctioning at least 20-30 minutes BEFORE procedure

AFTER: Apply pressure on puncture site for 5 minutes

First step in ABG analysis determine pH***

4. ABDOMINAL PARACENTESIS
Purpose:
Obtain fluid specimen
To relieve pressure on the abdominal organs d/t the excess fluid

BEFORE:
Ask client to void***

DURING:
Position: Sitting position
Common site: midway between the umbilicus and symphysis pubis
Measure abdominal girth at the umbilical level
Maximum amount to be drain is 1500 mL
Strict STERILE technique

5. ASEPSIS
1 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 MEDICAL ASEPSIS SURGICAL ASEPSIS
Purpose To reduce microorganism To destroy microorganism including spores
Indication Routine nursing care Procedure involving sterile areas
Technique Disinfection (clean) Sterilization (sterile)

B
6. BARIUM SWALLOW AND BARIUM ENEMA
BARRIUM SWALLOW BARIUM ENEMA
USE Examination of UGT Examination of LGT
BEFORE NPO 6 8 hours NPO at midnight (6 8 hrs)
DIET: Low residue diet, Clear liquid diet (1 3 days)
Laxatives, Cleansing enema
AFTER Constipation: Increase fluids, Laxative
Stool color: chalky white 1 3 days

7. BENNERs STAGES OF NURSING EXPERTISE***

No experience
Stage 1 Novice Limited performance
Inflexible
Marginally acceptable performance
Stage 2 Advanced beginner
Recognizes the meaningful aspect of a real situation
2 or 3 years of experience
Stage 3 Competent Demonstrates organizational and planning abilities
Coordinates multiple complex care demands
3 to 5 years of experience
Perceives situations as wholes rather in terms of parts, as in Stage 2
Stage 4 Proficient
Has holistic understanding of the client, which improves decision making
Focus on long term goals
Performance is fluid, flexible, and highly proficient
Stage 5 Expert No longer requires rules, guidelines, or maxims
Demonstrates highly skilled intuitive and analytic ability in new situations

8. BLEEDING PRECAUTION (OPEN wounds)

P ressure over the injury
E levate above the heart
C old compress
A rterial pressure
T orniquet

9. BLOOD TRANSFUSION
BEFORE
Check order 2 RNs
o Client name and identification number
o Unit number
o Blood type matching
o Expiration date
o Doctors order/ Informed consent
Obtain baseline VS
warm blood at room temperature for NOT more than 30 minutes

DURING
STAY with the patient and Check every 15 minutes 1st hour
Check every hour succeeding hours

BLOOD COMPONENTS
Blood Component Infusion rate Volume
Whole blood 2 to 4 hours 450 ml
PRBC 2 to 4 hours 250 ml
Cryoprecipitate 30 minutes 10 ml
Platelets Rapid 35 to 50 ml
Fresh frozen plasma Rapid of bleeding; 1 to 2 hours 250 ml

BT REACTION
REACTION CAUSE S/SX MANAGEMENT
C irculatory overload/ too rapid dyspnea, HPN, increased PR Slow down the infusion rate
Congestion
H emolytic incompatibility jaundice, shock HA Stop the infusion
A llergic antigen/ antibody reaction urticaria, wheezing, facial edema Stop the infusion
Antihistamine
P yrogenic bacterial fever, chills Stop the infusion
Paracetamol
Save unit of blood and return
to blood bank for analysis.

BT REACTION MANAGEMENT: (in sequence)***

2 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 B T stop
L et the tubings be changed
O pen NSS
A lways check the VS
D octor, where are you!
S cold the bank

OTHERS:***
Gauge: 18 or 19
Y set filter IV transfusion set
IV fluid: NSS only (other solution like dextrose causes hemolysis)
Start at KVO for 15 minutes
Monitoring: 15 minutes for the 1st hours and hourly thereafter
Time
o 4 hours: WBC, PRBC
o Rapid: Plasma, Platelets, Cryoprecipitate

10. BONE MARROW BIOPSY/ ASPIRATION

Bones commonly used: sternum, iliac crest, iliac spines, or proximal tibia (children)
DURING
Position:
site is iliac crest Prone
site is sternum Supine
About 1 to 2 mL of bone marrow is obtained.

AFTER: PREVENT BLEEDING

Bed rest for 30 minutes
Ice bag on punctured site
Pressure on the puncture site
Position: Lie on operative/biopsied side for 10 to 15 minutes

11. BOWEL DIVERSIONS

TYPES OF OSTOMY
Ileostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity)
Cecostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity)
Ascending colostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity)
Transverse colostomy mushy/ semi-formed
Descending colostomy formed
Sigmoid colostomy formed

STOMA
Color brick red (May turn to pink after several months and years)
Sensation normally no sensation
Protrusion to inches
Drain 1/3 to full
Appliance size (pouch opening) 1/16 to 1/8 inches

COLOSTOMY IRRIGATIONS needed by Descending and sigmoid colostomy

1st stimulate
2nd evacuate
Position: sitting

FOODS
Causes odor Beans
Asparagus
Garlic
Eggs
Spices
Causes gas Celery
Cabbage
Corn
Camote
Cauliflower
Champagne
Cucumbers
Carbonated drinks
Thicken stool Tapioca
Rice
Yogurt
Apple and apple sauce
Banana
Cheese

Permanent colostomy Descending and sigmoid colostomy

Colon cancer sigmoid colostomy

12. BREASTFEEDING
ASSESSMENT OF PROPER LATCHING
3 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 C hin to breast
pen mouth widely
L ips turned outward
A reola is visible above only

Nipple touches the posterior tongue 9to promote swallowing reflex)

Nipple (bottle) always filled with milk 9to prevent colic)

Color of stools:
Breast fed: golden yellow
Formula fed: pale yellow

13. BRONCHOSCOPY
BEFORE: NPO for 6-12 hours prior to procedure; no dentures; maintain good oral hygiene
DURING:
uses local anesthetic spray to minimize gagging while inserting the bronchoscope
supine with head hyperextended
AFTER:
POSITION: semi fowler's
NPO till gag returns then start with ice chips then followed by sips of water soft diet regular diet
ice bags to throat
minimize talking, coughing, laughing; warm saline gargles; assess for respiratory distress

14. CANCER SCREENING
PROCEDURE
Breast Self Exam (BSE)
Testicular Self Exam (TSE)
Mammogram
Paps smear
Digital rectal Exam (DRE)
C
SCHEDULE
Monthly, 3 to 5 days after the onset of menstruation
Monthly, after a warm bath
35 to 40 years 1x (baseline)
41 to 50 years every 2 years
51 and above yearly
Onset 40 every 3 years
41 and above yearly
50 and above yearly
40 and above yearly (if high risk)

15. CHEMOTHERAPY SIDE EFFECTS

SIDE EFFECTS INTERVENTIONS
Nausea and vomiting o Provide antiemetics 30 60 minutes before chemotherapy
Anorexia o AVOID: unpleasant odor, spicy foods, hot
o Small Frequent Feedings
o Diet: soft bland
GATRO-INTESTINAL o Ensure adequate fluid hydration
o Frequent oral hygiene
Oral thrush o Rinse mouth with strength peroxide and NSS
o Brush teeth with soft toothbrush and baking soda
o USE: unwaxed dental floss, cotton-tip applicator for viscous xylocaine over lesions
Neutropenia Neutropenic precaution
(WBC) o Handwashing
o Neutropenic diet/ low-bacteria diet: cooked foods
AVOID: fresh flowers, fruits, vegetables, raw foods, vaccinations
HEMATOPOEITIC o Reverse isolation/ private room
(Bone marrow o Assess vital signs every 4hours
suppression) Thrombocytopenia Thrombocytopenic precaution
(Platelets) o AVOID: aspirin, IM, invasive procedures, punctures, contact sports
o Use soft bristled toothbrush, electric razor, stool softener
Anemia Blood transfusion
(RBC) Bed rest
Alopecia o Discuss potential TEMPORARY hair loss (2 to 4 weeks)
o Use of wigs
INTEGUMENTARY
o If hair grows back color and texture changes
o AVOID: excessive shampooing
Cystitis o Increase fluids
GENITO-URINARY
Sterility/ infertility o Temporary

Nadir lowest point of RBC, WBC and platelets after chemotherapy administration; occurs within 7 to 14 days after

16. CHESTPHYSIOTHERAPY (CPT)

POSTURAL DRAINAGE PERCUSSION VIBRATION
Purpose To drain by GRAVITY To mechanically dislodge To loosen mucus secretions
4 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 Method Positioning Striking by cupped hands Quivering palm on chest wall
Duration 10 to 15 minutes per position 1 to 2 inches/ lung segment 5 exhalation***
Sequence:***
1 postural drainage
2 percussion
3 vibration

done BEFORE meals

ask patient to COUGH after chestphysiotherapy

17. CHEST TUBE

a. DRAINAGE BOTTLE
NURSING CONSIDERATIONS:
Keep at least 2 to 3 feet below the chest (to allow drainage by gravity)
NEVER raise the bottle above the level of the heart (to prevent reflux of air or fluid)
NOTE:
COLOR: bloody drainage during the first 24 hours
OUPUT: 500 1000 ml during the first 24 hours
FLUID DRAINAGE: the tube is inserted at 8th or 9th ICS
AIR DRAINAGE: the tube is inserted 2nd or 3rd ICS

COMMON OBSERVATIONS
NO DRAINAGE
Resolution
Obstruction

b. WATER SEAL BOTTLE

NURSING CONSIDERATIONS:
Immerse tip of the tube in 2- 3 cm of sterile NSS to create water seal

COMMON OBSERVATION:
INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration, fall during
expiration)
NO FLUCTUATIONS
Obstruction check and milk the tubing with CAUTION
Low suction
Re expand lungs do chest X- ray for confirmation
CONTINUOUS BUBBLING
Air leakage (except during suctioning)

c. SUCTION CHAMBER
NURSING CONSIDERATIONS:
Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS (to stabilize the normal negative
pressure in the lungs and protects the pleura from trauma if the suction pressure is inadvertently increased)

COMMON OBSERVATION:
CONTINUOUS GENTLE BUBBLING (indicates adequate suction control)
NORMAL

d. CHEST TUBE REMOVAL

Give analgesics 30 minutes before removal
Clamp on bedside
DURING removal: let the patient EXHALE and hold breath while doing VALSALVA MANEUVER
Maintain dry, sterile, occlusive dressing

e. EMERGENCY SITUATION
DISLODGE (chest tube removal FROM THE CLIENT)
AT BEDSIDE: vaselinized gauze
Palm pressure (for splinting)
DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage)
ATBEDSIDE: Extra bottle immersed in sterile water
Clamp (Hemostat)

f. ALERT! Never clamp the test tubes over an expanded period of time. Clamping the chest tubes IF a client with an air in
the pleural space will cause increased pressure buildup and possible TENSION PHEUMOTHORAX

18. CEREBROSPINAL FLUID (CSF) ANALYSIS

Protects from mechanical trauma
Function of CSF: Carries nutrients to brain
Characteristics
Normal pressure: 5 to 15 mmHg/ 70 to 180 mmH2O
Normal volume: 100 to 200 ml
WBC: 0 - 5 cells/mm
Glucose: 40 to 80 mg/dl (40 to 80 mg/100ml)
Protein: 15 to 45 mg/dl (15 to 45 mg/100 ml)
Meningitis
5 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 Increase protein content
Decrease glucose content
Increase WBC content
Cloudy (bacterial meningitis)
Clear (viral meningitis)

19. COMMUNICATION: ATTENTIVE LISTENING

Absorbing both the CONTENT and the FEELING the person is conveying, without selectivity
Listening actively, using all senses (as opposed to listening passively with just the ear)
Active process that requires energy and concentration
Paying attention to the total message (both verbal and non-verbal) and noting whether these communications are
congruent
Conveys an attitude of caring and interest, thereby encouraging the client to talk

20. COMMUNICATION: PHYSICAL ATTENDING***

1) face the other person squarely
2) adopt an open posture
3) lean towards the person
4) maintain good eye contact
5) try to be relatively relaxed

21. CT SCAN
X-ray
Contrast medium warm sensation
AVOID: pregnant women
Before: NPO
After: increase fluid

22. CVP MONITORING

Measure the pressure of the right atrium
Place the zero level of the manometer at the level if the right atrium (4th ICS)
AVOID: coughing and straining
NORMAL: 2 -12 mmHg

23. CYSTOSCOPY
Direct visualization of the LOWER urinary tract (bladder and urethra)
PURPOSE:
specimen collection
treatment of the interior of the bladder and urethra
Prostate surgery
Local anesthesia commonly used
POSITION: dorsal recumbent
CONTRAINDICATIONS: acute cystitis, bleeding disorders
AFTER:
Assess
VS
urine characteristic (NORMAL: pink tinged or tea-colored urine)
I&O
Encourage fluids
Sitz bath
Observe for fever, dysuria, pain in suprapubic region

D
24. DIALYSIS
Urgent indication for dialysis in patient with CRF is PERICARDIAL FRICTION RUB.
Objectives of hemodialysis:
a. To extract toxic nitrogenous substances from the blood
b. To remove excess water
Principles of hemodialysis:
Diffusion toxic and wastes move from an area of higher concentration in the blood to an area of lower
concentration in the dialysate
Osmosis excess water is removed from the blood by osmosis
Ultrafiltration water moving under high pressure to an area of lower pressure accomplished by negative
pressure (suction)

Before peritoneal dialysis, patient should empty bladder and bowels.

E
25. EAR
Ear bones (Ossicles)
M alleus Hammer

6 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 A nvil Incus
S tapes Stirrups

Position during drug administration:

Below 3 years old down and back
Above 3 years old up and back

Outer ear problem (otitis externa) conductive hearing loss

Middle ear problem (otitis media, otosclerosis) conductive hearing loss
Inner ear problem (labrynthitis, Menieres disease) sensorineural hearing loss

26. ECG
NORMAL
PR 0.12 0.20 seconds
QT 0.32 0.40 seconds
QRS 0.04 0.10 seconds

HYPERKALEMIA Tall T wave

HYPOKALEMIA Flat T wave, presence of u wave
HYPERCALCEMIA Short ST segment and QT interval***
HYPOCALCEMIA Lengthened ST segment and QT interval

Atrial flutter
With P wave (saw tooth)
Regular rhythm
Normal QRS

Atrial fibrillation***
No P wave
Irregular rhythm
Normal QRS

Atrial tachycardia
With P wave (different shape)
Regular rhythm
Normal QRS

Ventricular fibrillation
No P wave
Chaotic rhythm
No QRS

Ventricular tachycardia
No P wave
Regular rhythm
Wide and bizarre QRS

27. ENEMA
TYPES:
Cleansing enema cleansing (3x)
Carminative enema flatus
Return flow/ Harris flush/ Colonel irrigation flatus (5 6x)
Retention soften; lubricate (1 3 hours)
VOLUME-based***
o Small volume (150 to 240 ml) used to cleanse rectum and sigmoid
o Large volume (500 to 1000 ml) used to cleanse entire colon

SOLUTIONS:
Hypertonic sodium biphosphate
Hypotonic tap water
Isotonic NSS
Irritants soapsuds, Bisacodyl/ Fleet
Lubricants oil

Position: left-sidelying/ dorsal recumbent***

Enema tube lubricate first; insert in rotating motion

Infant 1 1.5 inches
Child 2 3 inches
Adult 3 4 inches

Cramping:
Lower the solution
Clamp and wait for 30 seconds***
Restart

7 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 Temperature: 100oF (37.7oC)

4 factors affecting Force of flow of the solution:

(1) Height of the solution container
(2) Size of the tubing
(3) Viscosity of the fluid
(4) Resistance of the rectum

28. E.S.S.R. feeding method of patients with cleft lip and cleft palate
E nlarge the nipple hole
S timulate the sucking
S wallow
R est

29. ESR (Erythrocyte Sedimentation rate) value:

30 to 40 mm/hr indicates mild inflammation
40 to 70 mm/hr indicates moderate inflammation, and
70 to 150 mm/hr indicates severe inflammation.

30. EXERCISES

TYPES OF EXERCISE
CHARACTERISTICS ISOTONIC ISOMETRIC ISOKINETIC
OTHER NAME Dynamic Static/Setting Resistive
JOINT MOVEMENT x
CONTRACTION
Increase strength Increase strength Increase strength
BENEFITS on Increase tone Increase endurance Increase size
MUSCLES Increase mass Increase heart rate and Increase blood pressure and
Joint flexibility cardiac output blood flow to muscles
Use of trapeze
Walking Quadricep setting May be isometric or isotonic with
EXAMPLES Swimming Squeezing on stress ball resistance
Cycling Kegels Weight-lifting
Running

31. FIRE EXTINGUISHER

Type A trash fire paper, woods, leaves (water under pressure)
B fuel fires oil, gasoline, kerosene (CO2)
C electric fire appliances, wire (dry chemicals)
D any kind (graphite)

F
32. FECAL
C-olor -----------brown/yellow stercobilin
O-dor------------aromatic
C-onsistensy-----------solid-semi-formed moist
A-mount ----------------100-400g/day
S-hape------------------cylindrical

33. FOODS rich in IRON***

Liver
Green leafy vegetables
Dried fruits
Scallops, shrimps
Oyster, clams
molasses

34. PROBLEMS IN STOOL ELIMINATION

M elena dark colored stool (upper Gi bleeding)
A cholic stool gray colored stool (bile obstruction)
S teatorrhea fat containing stool (malabsorption)
H ematochezia bright red colored stool (lower GI bleeding)

G
35. GTPALM
G Gravida refers to the number of pregnancies regardless of outcome
P Para refers to the number of deliveries that reached viability (20 weeks gestation)
born dead or alive; multiple births count as 1 delivery regardless of the number
8 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 of newborns delivered

T Term deliveries number of TERM births (infants born after 37 weeks and above)
P Preterm deliveries number of PRETERM births (infants born between 20 to 37 weeks)
A Abortions number of pregnancies that end in spontaneous or therapeutic abortion prior to
age of viability (20 weeks)
L Live number of children currently alive
M Multiple gestations number of pregnancy with more than one newborn
(regardless of the number of neonates delivered)

36. GLOVING***
Open-glove technique used when:
o Gloving another team member
o Changing a glove DURING a procedure (self or team member)***
o A sterile scrub or gown is not required

Closed-glove technique used when:

o Anytime you are initially applying sterile gown and gloves

CHANGING GLOVES DURING A PROCEDURE

1. Ask the Circulating Nurse (CN) to remove contaminated glove
2. CN should wear gloves
CN grasp contaminated glove at palm
Scrubbed person holds onto the sleeve of the gown (to prevent riding over)

3. Using OPEN-GLOVE method, reapply sterile glove***

H
37. COLORS OF HOSPITAL TANKS
Nitrous oxide (laughing gas) Blue
Oxygen Green
Cyclospropane Orange
Nitrogen Black
Carbon dioxide Grey
Helium Brown
Medical air Yellow
Halothane Red

38. HOSPITAL COLOR CODES

Code blue cardiac arrest, medical emergency
Code pink infant abduction
Code red fire
Code yellow bomb threat
Code silver combative person with weapon

I
39. IMMUNIZATION

SENSITIVITY MOST SENSITIVE to heat OPV, measles

LEAST SENSIITVE to heat DPT, Hepa B, BCG, TT

FORM:
Toxoid Diphtheria and Tetanus
killed bacteria Pertusis
live attenuated OPV
freeze dried measles and BCG

40. INFORMED CONSENT

Purpose:
To ensure the clients understanding of the nature of the surgery
To indicate the clients decision
To protect the client against unauthorized procedure
To protect the surgeon and hospital against legal action

9 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 2 TYPES:
1) Express consent may be either an oral or written agreement
2) Implied consent nonverbal behaviour indicates agreement

General guidelines/ content of informed consent:

Diagnosis or condition that requires treatment
Purpose of the treatment
What the client can expect to feel or experience
The intended benefits of the treatment
Possible risks or negative outcomes of the treatment
Advantages and disadvantages of possible alternatives to the treatment (including no treatment)

4 elements of informed consent:***

Voluntary no force, coercion, or manipulation
Comprehension all interior and exterior impediments to comprehension have been assessed and removed
Interior anxiety, pain, sedative medication
Exterior transcultural barrier, terminology, speed of presentation
Competence
Can give consent:
must be at least 18 years old
emancipated minor: a person under 18 who is self supporting or married
Cannot give consent:
Unconscious
Sedated
mentally ill and
judged to be incompetent
Discloure all possible options and outcomes

Circumstances requiring an Informed Consent:

R adiation or cobalt therapy
A nesthesia use
B lood administration
I nvasive procedure
o E ntrance into a body cavity
o S - urgical procedure using scalpel, scissors, suture (Invasive procedures)

Requisites for validity of informed consent

Legal age
Mentally capacitated
Secured within 24 hours before the surgery
Secured before pre-op medication administration
Written permission
Signature
Witness nurse, physician

For minors (under 18), unconscious, psychologically incapacitated permission from responsible family member
For emancipated minors (married, college student living away from home, in military service, any pregnant female or
any who has given birth)

4 Criteria are needed to be met if consent is NOT needed anymore:

There is an immediate threat to life
Experts agree that it is an emergency
Client is unable to consent
A legally authorized person cannot be reached

Surgery without consent-- BATTERY!

Role of the physician: to obtain the informed consent
Role of the nurse:
Witness a clients signature after the physician has explained the procedure
Place informed consent in the clients chart
Respond to any questions the client have about the procedure
Notify the physician if the client appears to have concerns

41. ISOLATION PRECAUTION

Tier 1: Standard Precaution
to all blood and body fluids except for sweat
to all clients regardless of diagnosis
hand washing and PPE (clean)

Tier 2: Transmission-based precaution

10 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 Airborne > 3 feet N95 Measles
Droplet nuclei < 5 microns TB
Varicella (chickenpox)
Droplet < 3 feet Mask Meningitis, mumos
Droplet nuclei > 5 microns Pertussis, pneumonia
German measles, GABHS (Scarlet fever, pharyngitis)
Diptheria
Contact Skin Gloves MRSA (Staph)
Gown Impetigo
Scabies
Herpes Simplex
Hepatitis A
Diarrhea

Immunocompromised first
Infectious - last

42. IV SOLUTIONS
HYPOTONIC ISOTONIC HYPERTONIC
Characteristics Solute < solvent Solute = solvent Solute > solvent
O pressure of solution
Fluid movement from Intravascular TO cells No movement From Intracellular TO Intravascular
Effect to the cell Swell expand the intravascular shrink/ crenation
compartment
Indications Dehydrated patients Hypovolemia Edema
Burns (resuscitative stage)
Examples Distilled water D5W 10% dextrose in water
0.45% NSS LR 5% dextrose in 0.9% saline solution
0.33% NSS NSS 5% dextrose in 0.45%
2.5% dextrose D5 0.225% NSS 5% dextrose in LR
TPN
Dialysate
contraindicated for clients with Avoid D5W if the client is at
increased intracranial pressure, risk of increased intracranial
clients at risk of 3rd space fluid pressure (ICP)
shift Use LR for BURNS

43. IV THERAPY COMPLICATIONS:

COMPLICATIONS MANIFESTATIONS ACTIONS
Circulatory overload Dyspnea slow down
increased BP contact physician
SOB, crackles elevate HOB
give oxygen
Air embolism Dyspnea Discontinue
decreased BP Left sidelying and trendelenburg
Phlebitis Swelling + Heat Discontinue
Cold
Elevate
Restart (another site)
Infiltration Swelling + Cool Discontinue
Decrease infusion rate*** Warm/ Moist heat (due to edema)
Elevate
Restart (another site)
Pyrogenic reaction Fever, chills Discontinue
Retain IV equipment for C&S

METHODS OF IV ADMINISTRATION
1. Large volume infusion safest and easiest
2. IV Bolus fastest effect
3. Intermittent Venous Access (heparin lock/ Saline lock) increase mobility and comfort
Sequence: SASH methods
o S - Saline
A - Antibiotic
S - Saline
H - Heparin
4. Volume controlled infusions
5. Piggy back

SELECTING A VEIN
First verify the order for I.V. therapy unless it is an emergency situation.
Explain the procedure to the patient.
Select a vein suitable for venipuncture.
o Back of hand (metacarpal vein.) Avoid digital veins, if possible. (The advantage of this site is that it permits
arm movement.)
If a vein problem develops later at this site, another vein higher up the arm may be used.
Forearm (basilic or cephalic vein)
11 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 o Inner aspect of elbow, antecubital fossa, median basilic and median cephalic for relatively short-term
infusion. However, use of these veins prevents bending of arm.
Lower extremities.
o Foot - venous plexus of dorsum, dorsal venous arch, medial marginal vein
o Ankle - great saphenous vein
Central veins are used:
o When medications and infusions are hypertonic or highly irritating, requiring rapid, high-volume dilution to
prevent systemic reactions and local venous damage (eg, chemotherapy and hyperalimentation).
o When peripheral blood flow is diminished (eg, shock) or when peripheral vessels are not accessible (eg,
obese patients).
o When CVP monitoring is desired.
o When moderate or long-term fluid therapy is expected.
NURSING ALERT
o The median basilic and cephalic veins are not recommended for chemotherapy administration due to the
potential for extravasation and poor healing resulting in impaired joint movement. In addition, these veins
may be needed for intermediate or long-term indwelling catheters.
o Use lower extremities as a last resort. A patient with diabetes or peripheral vascular disease is not a suitable
candidate. Obtain an order from the health care provider for the I.V. site and monitor lower extremity closely
for signs of phlebitis and thrombosis.

L
44. LASER
a. L ight
A mplification by
S timulated
E mission of
R adiation

b. TYPES
Carbon dioxide gas (clear goggles)
ND:YAG Neodymium: Yttrium Alluminum garnet) bright lamp (green goggles)
Argon gas (orange goggles)

c. HAZARDS
Eyes goggles
Skin gown and gloves
Lungs mask

45. LEVEL OF CONSCIOUSNESS

a. GLASGOW COMA SCALE
GLASGOW COMA SCALE
EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
4 Spontaneous 6 To verbal command
5 Oriented, converses
3 To verbal command 5 To localized pain
4 Disoriented, converses
2 To pain 4 Withdraws
3 Uses inappropriate words
1 No response 3 Flexes abnormally (Decorticate)
2 Makes incomprehensible sounds
2 Extends abnormally (Decerebrate)
1 No response
1 No response

12 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 7 and below - in a comatose state
3 lowest score
15 highest score

b. A.V.P.U. (for Pediatric client)

use to assess neurologic condition (like Glasgow Coma Scale)
Usually used in infants
A Alert and Awake
V Verbal response to stimuli
P Pain response in stimuli
U Unresponsive

c. Level I (conscious) 3 Cs: conscious, cognitive, coherent

Level II (lethargic) drowsy, sleepy, obtunded, confused
Level III (stuporous) responds to strong stimuli only
Level IV (coma) unresponsive; absent protective reflexes

46. LEOPOLDs MANEUVER

BEFORE: patient void first
Nurse warm hands

MANEUVER PURPOSE NURSING CONSIDERATIONS

1. First maneuver

to determine fetal While facing the woman, place the hands on top and side of the uterus
presentation (fundus) and palpate.

HEAD - smooth, hard/firm, and round, freely movable and ballotable.

BREECH - irregular, rounded, softer, and is less mobile.

2. Second maneuver

Still facing the woman, place hands on either side at the middle of the
to determine the fetal abdomen. Determine what fetal body part lies on the side of the abdomen.
position
to determine fetal If firm, smooth, and a hard continuous structure FETAL BACK
back (heart)
If smaller, knobby, irregular, protruding, and moving, EXTREMITIES

3. Third maneuver While facing the woman, grasp the part of the fetus situated in the lower
uterine segment between the thumb and middle finger of one hand.

To determine Using firm, gentle pressure, determine if the head is the presenting part.
engagement
to determine fetal HEAD - will feel firm and globular.
presentation
If immobile, engagement has occurred. This maneuver is also known as
Pallach's maneuver or grip
1. Fourth
2. maneuver
The examiner faces the woman's feet.
to determine fetal
attitude The examiner palpates the abdomen along the side of the uterus below the
umbilicus towards the symphysis pubis (pelvic inlet) to detect heads degree
of flexion, position and even station.

47. LIVER BIOPSY

BEFORE: Note COAGULATION PROFILE (clotting factors, PT, PTT, APTT and platelet count*
DURING: exhale and hold breath
AFTER: Position: Right side-lying position

48. LUMBAR PUNCTURE (LUMBAR TAP)

PURPOSE: To withdraw CSF to determine abnormalities
Measures CSF pressure (normal opening pressure 60-150 mm H2O)
Obtain specimens for lab analysis (protein [normally not present], sugar [normally present], cytology, C&S)
Check color of CSF (normally clear) and check for blood
Inject air, dye, or drugs (anesthesia) into the spinal canal

AREA: Insert needle between L3 L4 or L4 L5 (spinal cord ends in L2)

BEFORE PROCEDURE:
Obtain consent
Empty bladder

13 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 DURING PROCEDURE:
Position of the patient: C-position (flex the shoulders, not the head)
Position of the nurse: infront of the patient
Position of the doctor: at the back of the patient

AFTER PROCEDURE: prevent spinal headache

Position: flat for 6-12 hours (to prevent spinal headache)
Force fluids (to maintain pressure and prevent spinal headache)
Blood patching
label specimen

M
49. MAGNETIC RESONANCE IMAGING (MRI)/ NUCLEAR MAGNETIC RESONANCE (NMR)
Uses radio waves
BEFORE:
remove metals: jewelry, hairpins, glasses, wigs (with metal clips), and other metallic objects.

AVOID:
patients with orthopedic hardware
intrauterine devices
pacemaker
internal surgical clips
or other fixed metallic objects in the body (braces, retainers)
BEFORE:
Have client void before test.

DURING
remain still while completely enclosed in scanner throughout the procedure, which lasts 45-60 minutes.
Teach relaxation techniques to assist client to remain still and to help prevent claustrophobia***
NORMAL: audible humming and thumping noises from the scanner during test.

Sedate client if ordered.

50. MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) Test
Route: ID, 0.1 mL of PPD is injected INTRADERMALLY, creating a wheal or bleb
Read: 48 to 72 hours
Result: (+) to exposure
10 mm and above not immunocompromised
5 mm and above immunocompromised (HIV, with history of TB, pediatric and geriatric clients)
0 - 4 mm= NOT SIGNIFICANT
Erythema without induration is NOT considered significant***

51. MASLOWs HIERARCHY OF NEEDS

Physiologic needs basic survival needs Attaining a place in a group
Air, Food, Water Maintaining the feeling of belonging
Shelter Acceptance by others
Rest, Sleep
Activity Self-esteem needs
Temperature Self-esteem: feelings of independence,
competence, self-respect
Safety and Security needs Esteem from others: recognition, respect,
physical aspects: comfort***, protection from appreciation, feel they are valued and worthwhile
bodily harm
psychological aspects: security and stability Self-actualization
The innate need to develop ones maximum
Love and belonging needs (Social Acceptance)*** potential and realize ones abilities and qualities
Giving and receiving affection the need to function at ones optimal level, and to
be personally fulfilled.

52. MEDICATION
a. Drug interaction
Additive effect 1+1=2
eg. diazepam + alcohol = increase sedation
Synergism/ potentiation 1+1=3
eg. codeine + aspirin = intense pain relief

14 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 Antagonist 1+1=0
eg. Coumadin + Vitamin K
Interference increase or decrease metabolism/ excretion
eg. Probenecid decrease excretion of Penicillin

b. Medication order
STAT (statim) immediate/ once
eg. Magnesium sulfate (preeclampsia)
Single order/ one time once
eg. Anxiolytic (pre-surgery)
Standing / routine carried out indefinitely
eg. antibiotics
PRN (Pro Re Nata) no specific time of administration/ as needed
eg. Pain relievers
Telephone order within 24 hours
Signed
Indicate as Telephone Order
Put decimal number

c. Components of Medication order (Drug prescription)***

Clients name
Date and time of order
Name of drugs
Dose and route
Time of frequency
Signature

d. Drug effects
Therapeutic desired
Side effects 2nd effect, expected
Adverse effects severe side effect, unexpected
Allergic reaction immunologic response

N
53. NAEGELEs RULE
If LMP is from APRIL TO DECEMBER, use the formula:
o - 03 + 07 + 01 (MM, DD, YY)
If LMP is from JANUARY TO MARCH, use the formula:
o + 09 + 07 (MM, DD)

54. NASOGASTRIC TUBE (NGT)

TYPES
Levin - single lumen
Salem sump double lumen

INSERTION
Measurement: adult (N.E.X.), pedia (N.E.M.U.X.)
Position: high-fowlers and neck hyperextended
Instruction: ask to swallow
Placement:
1- X-ray
2- Aspirate and pH test
normal gastric pH = 1 to 4 (acidic)
3- Listen/ auscultate for borborygmi sound after introduction of 10 30 ml of air (20 ml)
4- Listen/ auscultate for breath sounds (to double check)

REMOVAL
Instil 50 ml of air
Take deep breath and hold pinch catheter withdraw
Mouth care and blow nose

FEEDING
Check placement
Position: sitting/ upright/ fowlers
Check for RESIDUAL CONTENT dont discard; above 100ml STOP
Hang: 12 inches from point of insertion
Flush : 50 to 100 ml of water
Remain upright 30 minutes

55. NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST)

NON STRESS TEST vs. CONTRACTION STRESS TEST

Non Stress Test DIFFERENTIATION Contraction Stress Test

15 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 Fetal movement and fetal heart rate Variables compared Uterine contraction and fetal heart rate
NORMAL (Reactive/ Positive) NORMAL (Non-reactive/ Negative)
Increase FM Increase FHR (acceleration) Increase UC Decrease FHR (deceleration)
Decrease FM Decrease FHR (deceleration) Result Decrease UC Increase FHR (acceleration)

ABNORMAL (Nonreactive/ Negative) ABNORMAL (Reactive/ Positive)

Increase FM Decrease FHR (deceleration)
Decrease FM Increase FHR (acceleration)
2 FHR accelerations within a 10min period, each
acceleration increasing to 15bpm and lasting at
least 15 sec
Abnormal or non reactive result needs further
evaluation that same day; usually needs
contraction stress testing
Increase UC Increase FHR (acceleration)
Decrease UC Decrease FHR (deceleration)
Two ways: Nipple Rolling and Intravenous Oxytocin
Delivery
Desired response 3 contractions within 10min, lasting 40 to 60 sec is
needed
Not performed until about 38+week
Management Watch out for Preterm labor

FETAL HEART RATE DECELERATIONS

CAUSE MANAGEMENT
EARLY Head compression Observation
LATE Uteroplacental insufficiency Side-lying position
Oxygenation
Increased IV fluids
Stop Oxytocin (Pitocin)
Call the MD
Caesarean if not corrected
VARIABLE Cord compression Trendelenburg/ Knee-chest/ Side-lying position
Oxygenation
Increased IV fluids
Stop Oxytocin (Pitocin)
Call the MD
Caesarean section if not corrected

56. NORMAL VALUES

serum protein = 6.0 to 8.0 g/dL.
albumin level = 3.4 and 5 g/dL.
BUN: creatinine ration = 10:1 to 20:2
Electrolytes:
K = 3.5 5.5 mEq/L
Na = 135 145 mEq/ L
Ca = 4.5 5.5 mEq/ L
Mg = 1.5 2.5 mEq/ L
Ph = 2.5 4.5 mEq/ L
Cl = 98 108 mEq/ L

serum amylase level = 25 to 151 units/L.

In chronic pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal
value.
In acute pancreatitis, the value may exceed five times the normal value.

Therapeutic serum drug level

Carbamazepine = 3 to 14 mcg/mL
Phenytoin = 10 and 20 mcg/mL
Magnesium sulfate = 4 to 8 mg/dL
Lithium = 0.5 to 1.5 mEq/L***
Digoxin = 0.5 to 2 ng/dl
Acetaminophen = 10 30 mg/dL
Theophylline = 10 20 mcg/ml

57. O.R. TEAM MEMBERS

SCRUB NON SCRUB
Surgeon Anesthesiologist
Surgical assistant Biomed
Scrub nurse Circulating nurse

SCRUB NURSE CIRCULATING NURSE

o Performs complete scrub
o Prepares and hands out instruments
o Hands instruments while maintaining sterile
technique
o Ensures everybody in the scrub team practices
sterile technique
o Partner in OS and instrument counting
o Anticipates the needs of the team
o Patient advocate (act in behalf of the patient);
GUARDIAN OF THE PATIENT; doing something that
o Greets the client upon arrival 1st primary
responsibility of circulating nurse
o Checks client identification
o Sponge counting together with scrub nurse
o Monitors the urine output and blood loss together
with anesthesiologist
o Ensures the consent form is signed
o Documents the entire procedure

16 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 patient cant do
*Scrub and Circulating Nurses best tandem in OR***

58. PACEMAKER: CONTRAINDICATIONS

Strong magnetic fields MRI
Electrical fields high powered instruments (microwave oven, TV, radio, vacuum cleaners)
Cellular phones do not place near chest; place in the ear farthest in the pacemaker implant

59. PAIN
LOCATION:
Referred pain appear to arise in different areas***
Cardiac pain left shoulder, left arm
Gallbladder right shoulder

Visceral pain pain arising from organs or hollow viscera

60. PERSONAL SPACE/ COMMUNICATION ZONES

Intimate Touching to Body contact Cuddling a baby
distance 1.5 feet Heightened sensations of body heat and smell Touching a blind client
Voice tone low Positioning a client
Observing an incision
Restraining a toddler for injection
Lovemaking
Confiding secrets
Sharing confidential information
Personal 1.5 to 4 feet Body heat and smell noticed less Communication between nurse and patient/
distance Voice tone moderate facilitates sharing of thought and feelings
Physical contact is allowed (handshake or touching a (interviewing)
shoulder) Sitting with a client
Giving medications
Establishing IV infusions
Bantering
Physical assessment
Social 4 to 12 feet Body heat and smell re imperceptible Nurses rounds
distance Voice tone loud enough to be overheard by others Wave a greeting
Clear visual perception of the whole person
Public 12 to 15 feet Loud, clear vocal tones with careful enunciation Public talk/ giving speech
distance Gathering of strangers

61. PRESSURE ULCERS

Stage 1 non-blanchable, erythema
2 epidermis and dermis involvement, shallow water blister
3 subcutaneous involvement, deeper crater
4 muscles and bone involvement, tissue necrosis

62. PULSE OXIMETRY/ O2 SATURATION

Measures:
1) Oxygen saturation
2) Pulse rate

Site:
Adult: finger
Pedia: toes
Other sites: nose, earlobe or forehead

Normal: 95 to 100%
70% and below life threatening

SaO2 and SpO2 same***

AVOID:
Sudden movement
Nail polish
Light

R
17 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
63. RADIATION THERAPY
Radiation therapy uses high-energy ionizing rays that destroys the cells ability to reproduce by damaging the cells
DNA

TELETHERAPY BRACHYTHERAPY
External SOURCE Internal
Not radioactive PATIENT Radioactive
Cobalt therapy, Linear Accelerated Radiation EXAMPLE 1. Unsealed oral, IV radioactive iodine 131,
S
Vitamin B12
2. Sealed implant (seeds) cesium, iridium
ALLOW AVOID S hield: lead + Dosimeter badge
Leave markings Sunlight T ime: 5 min/visit; 30 min/ shift; 1 pt/ day
Vitamin A and D Alcohol D istance: 3 feet away
Soap and water and Lotion, powder, cosmetics At bedside: forceps and lead container
pat dry Adhesive tape AVOID: pregnant and children
Tight clothing Aratula: Caution

64. RESTRAINTS
PURPOSE: to prevent injuring self and others

CLASSIFICATION:
1. Physical manual/ physical device
2. Chemical substances/ medications

2 standards for applying restraints:

1. behavioural management standard when the client is a danger to self or others
2. acute medical and surgical care standard temporary immobilization of a client is required to perform a procedure

Guidelines:
1. Obtain consent
o Should be RENEWED DAILY
o PRN order is PROHIBITED

2. Use clove-hitch knot***

3. Tie the free ends of the restraints on MOVABLE part of the bed frame***
4. Assess skin integrity per agency protocol (every 15 to 30 minutes)
Release restraints every 2 hours
Reassess the need for restraints every 8 hours

S
65. SENTINEL EVENT
Is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious
injury specifically includes loss of limb or function. (by The Joint Commission

66. SCHILLINGs TEST

PART 1 PART 2
(CONFIRMATORY) (IDENTIFICATION OF CAUSE)
Vitamin B12 Vitamin B12 and Intrinsic factor
(+) vitamin B12 in urine normal (+) vitamin B12 in urine Pernicious Anemia is stomach in origin
(-) vitamin B12 in urine (+) Pernicious Anemia (-) vitamin B12 in urine Pernicious Anemia is small intestine in origin

67. SLEEP
Promoting Sleep: SLEEP PATTERN
Establish a regular bedtime and wake-up time
Establish regular, relaxing bedtime routine
Provide short daytime nap (15 to 30 minutes)***
Promoting Sleep: ENVIRONMENT
Adequate exercise during the day. Avoid exercise at least 3 hours before bedtime
Associate bed for sleep
Keep noise to minimum. Use white noise from a fan, air conditioner, or white noise machine
Sleep on comfortable mattress and pillow
Promoting Sleep: DIET
AVOID heavy and spicy meals 2 to 3 hours before bedtime
AVOID alcohol and caffeine-containing foods (coffee, tea, chocolates) at least 4 hours before bedtime
Alcohol and caffeine act as DIURETICS
If bedtime snacks are necessary: consume light carbohydrates or a milk drink
Promoting Sleep: MEDICATION
Sleeping pills last resort
Take analgesics before bedtime to relieve pains

68. Specimen collection: STOOL

Defecate in a clean bed pan or bedside commode.
Void before the specimen collection (to prevent urine contamination)
QUANTITY:
SOLID STOOL: About a pea-size or 1 inch (2.5cm)
18 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 LIQUID STOOL: 15 to 30 mL
Refrigerate and label

a. FECAL OCCULT BLOOD TESTING (Guaiac Test)

Occult = hidden
Uses a chemical reagent which detects the presence of the enzyme peroxidase in the hemoglobin molecule.
RESULTS:
Changes in color like blue indicates a guaiac positive result
No change or any other color than blue indicates a negative result.
Avoid contaminating the specimen with urine or toilet tissue.
Label
Avoid specified foods and vitamin C 3 days prior to collection and specified medication 7 days prior to collection.

FALSE POSITIVE FALSE NEGATIVE

RED MEAT (Beef, liver, and processed meats) VITAMIN C
RAW VEGETABLES or FRUITS (Particularly radishes, turnips, horseradish, and melon)
MEDICATIONS (NSAIDs, IRON preparations, and ANTICOAGULANTS)

69. Specimen collection: SPUTUM

Sputum arises from the tissue of the respiratory tract
Saliva excreted by the salivary and mucus glands
BEST TIME: early morning
BEFORE: Mouth care
DURING:
o Deep breaths then cough up 15 to 30 mL (1 to 2 tablespoons).
o Wear gloves when collection.
o Ask the client to expectorate, not spit
o Should be cough directly into the specimen container

70. Specimen collection: URINE

SPECIMEN PURPOSE CONSIDERATIONS WHEN COLLECTING
CLEAN VOIDED For routine examination Usually collected by the client with minimal
assistance
Preferably done on the first voided specimen in the
morning but it can be collected anytime if needed
At least 10 to 30 mL
Clean container is used
CLEAN-CATCH or For urine cultures BEST TIME: early morning concentrated urine
MIDSTREAM URINE Done when a woman has menstrual Sterile specimen container
period Place specimen during midstream flow.
QUANTITY:
30 to 50 ml routine urinalysis
5 to 10 ml C&S
CATHETER Collection of sterile specimen usually Nurse aspirates from the lumen of a latex catheter
done when clients are catheterized for or from a self-sealing port
other reasons
24-HOUR To determine the ability of the kidneys Collection of all urine produced in 24 hours
to concentrate urine The first voided urine is discarded; last urine
To determine disorders of glucose voided included
metabolism Either refrigerated or preservative is added
To determine levels of specific
constituents

71. SPONGE COUNTING

1 Before the operation starts (immediately preceding incision) to establish a baseline
2 Before closure of body cavity
3 Before the skin is closed/ before wound closure starts

The SCRUB and the CIRCULATING nurses should count audibly and concurrently***

72. SUCTIONING
Endotracheal/ tracheostomy Naso-/ oro- pharyngeal
Time per attempt 5 to 10 seconds 5 to 10 seconds
Interval 2 to 3 minutes 20 to 30 seconds
insertion 5 inches and withdraw 1 to 2 cm 4 to 6 inches

Endotracheal
Position: semi-fowlers
Time: 5 to 10 seconds/ 5 minutes
Interval: 20 to 30 seconds
DURING
Lubricate the catheter with water-soluble lubricant (2 to 3 inches)
Insert during INHALATION in CIRCULAR motion***
DO NOT insert during swallowing (it may enter the esophagus)
o But in NGT let the patient swallow to promote entrance in stomach
Apply suction: during withdrawal
GLOVE: dominant hand
19 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 Hyperoxygenate BEFORE and AFTER suctioning
Conscious: DBE
Unconscious: ambubag, 3 to 5 times (12 15 LPM)

73. SUTURES (catgut) a thread, wire, or other material used in the operation of stitching parts of the body together
TYPES OF SUTURES:
Absorbable digested by body enzyme
plain gut (yellow)
chromic gut (brown)
Non-absorbable become encapsulated by tissue and remains unless removed (removed 7 days after)
silk (light blue)
nylon (green)
cotton (pink)
Prolene (royal blue)
Mersilenne (Turquoise)
Vicryl (purple)
Dacron (orange)

T
74. T-TUBE
PURPOSE:
To maintain patency***
To drain
To prevent bile leakage to the peritoneum
DRAINAGE
Color: 1st 24 hours reddish brown
Amount: 1st 24 hours 500 to 1000 ml
Normal color of stool after removal brown
Draining does not need doctors order

75. TELEPHONE ORDER

Only RNs may receive telephone orders
The order should be countersigned by the physician within 24 hours

76. TENSILON TEST

edrophonium chloride (Tensilon) IV
evaluation of muscle strength
USE: To diagnose myasthenia gravis
At bedside:
resuscitation equipment
atropine sulfate on bedside for possible CHOLINERGIC CRISIS
neostigmine for possible MYASTHENIC CRISIS
Results:
(+) diagnosis = improvement on muscle function after administration of drug
(-) diagnosis = muscle fasciculations occur as a result of the drug

77. THORACENTESIS
Purpose: To remove excess fluid or air from the pleural space to ease breathing
POSITION: sitting while leaning forward over a pillow
Chest X-ray identifies best insertion site
Within the first 30 minutes, not more than 1000 mL should be removed
AVOID: coughing , deep breathing
AFTER: Unaffected side with head elevation of 30o for at least 30 minutes

78. THYROIDECTOMY: Complications

Bleeding Feeling of fullness at incision site
Check soiled dressing at nape area, sandbag

Accidental removal of parathyroid Hypocalcemia classic sign tetany

Calcium gluconate, slowly administer- to prevent arrhythmia

Laryngospasm DOB, SOB

tracheostomy at bedside, suction

Accidental damage of the laryngeal nerve Hoarseness of voice

Encourage patient to talk post op asap to determine laryngeal nerve damage

Thyroid storm Fever, Irritability, Agitation, restlessness, Tachycardia

beta blockers

79. TOTAL PARENTERAL NUTRITION (TPN)/ PN/ IV HYPERALIMENTATION

Dextrose content 10 to 50%
Duration of TPN 24 hours
Site: central veins (SVC) subclavian vein (an x-ray is done to confirm its placement)***
20 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 Position during insertion: trendelenburg
Complication:
Thrombophlebitis due to hypertonicity of the solution change access site
Hyperglycemia rapid infusion regulate
Hypoglycemia abrupt discontinuation hyperinsulinism dont stop abruptly
Infection unsterile procedure sterile technique
Fluid overload rapid infusion regulate
Air embolism
Allergy
If empty, give hypertonic solution:
D10W pedia
D50W adult
BEFORE:
check label of solution and rate of infusion with medical order
inspect TPN bottle for precipitates or turbidity
administer via an infusion pump
DURING:
Initially administered at 50 ml/hr*** for the FIRST hour
Monitor glucose
Monitor vital signs every 4 hours
AFTER: Monitor WBC
PRIORITY NURSING DIAGNOSIS: High risk for infection
Do not overcorrect flow rate if too slow or fast
STERILE technique***
Use transparent air-occlusive dressing***

80. TRACHEOSTOMY CARE

1) Position 6) Remove dressing
2) Open sterile packages 7) Clean inner cannula
3) Pour soaking solutions 8) Replace
4) Suction 9) Clean incision site and flange
5) Remove inner cannula and place in soaking 10) Apply dressing
solution 11) Change ties

81. TRACTIONS
TYPES
Skin traction impaired skin integrity
Skeletal traction risk for infection
Counter traction weight of the patient
Bucks not more than 8 to 10 lbs of weight should be applied
Crutchfield tongs (skull tongs) used to immobilize the cervical spine (indicated for unstable fractures or dislocation of
the cervical spine)
Crutchfield tongs/ Gardner-Wells skull tongs
POSITION: supine

82. TRANSFERRING Patient from BED to WHEELCHAIR

1 assist patient into sitting position
2 position chair parallel to the bed (strong side***)
- Client with walking difficulty, angle the chair to 45 degrees***
3 use transfer belt
- NURSE: hold belt
- PATIENT: hold shoulder of nurse
4 pivot towards the wheelchair

83. TRANSFERRING Patient from BED to STRETCHER

1 lower HOB
2 raise bed slightly higher than stretcher
3 stretcher parallel to the bed
4 nurse press own body against stretcher to secure it against the bed
Client flex neck and arms across chest
5 roll both sides of pull sheet towards the patient
6 grasp and pull the pull sheet towards the stretcher

84. TRIAGE
trier- to sort
To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be
addressed

3 CATEGORIES IN TRIAGE in E.R.

EMERGENT URGENT NON-URGENT
Color Red Yellow Green
Urgency Life, limb, eye threatening Needs treatment in 20 minutes Can wait hours or days
Needs immediate attention to 2 hours
Examples Chest pain, cardiac arrest, Fever >40oC, simple fracture, sprain, minor laceration, rash,
severe respiratory distress, abdominal pain, asthma with no simple headache. Toothache,
21 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
 chemicals in the eye, limb respiratory distress sore throat
amputation, penetrating trauma,
severe hemorrhage

4 CATEGORIES IN TRIAGE in DISASTER

IMMEDIATE DELAYED MINIMAL EXPECTANT
Number 1 2 3 4
Color Red Yellow Green Black
Examples Chest wounds, shock, open Stable abdominal wound, eye Minor burns, minor fractures, Unresponsive, high spinal
fractures, 2-3 burns and CNS injuries minor bleeding cord injury

85. TUNNING FORK TEST

b. WEBERS TEST To test for bone conduction by examining lateralization of sound.
Hold and place the base of the tunning fork on top of the clients head; ask the client where he/she hears the
noise.
Results:
Weber negative if sound is heard on both sides or localized at the center of the ear.
Weber positive sound heard better on the impaired ear bone-conductive hearing loss;
sound heard on the normal ear sensorineural disturbance

c. RINNE TEST To compare air conduction from bone conduction.

Ask client to block one ear intermittently (move a fingertip in and out of the ear)
Hold the handle of the activated tuning fork against the mastoid process (until vibrations can no longer be
felt/heard by the client).
Immediately hold the vibrating fork with the prongs in front of the clients ear canal.
Results:
Positive Rinne Air conduction (AC) is greater than bone conducted (BC).
Negative Rinne BC is equal to or longer than air conduction indicating a conductive hearing loss.
Infants: ring a bell or have the parent call the childs name (to assess gross hearing); newborns
may become silent or open their eyes wide; by 3 or 4 months, child will turn his/her head
toward the sound.

VITAL SIGNS
86. BLOOD PRESSURE
a. Systolic contraction depolarization
Diastolic relaxation repolarization

b. DETERMINANTS OF BLOOD PRESSURE***

Pumping action of the heart Blood volume
strong pumping BP increases BV increases BP increases
weak pumping BP decreases BV decreases BP decreases
Peripheral Vascular Resistance (PVR) Blood viscosity
increased vasoconstriction BP increases blood highly viscous BP increases
decreased vasoconstriction BP decreases blood less viscous BP decreas

c. ASSESSING BLOOD PRESSURE***

The cuff should wrap (A) 40% of the arm length and (B) 80% should encircle the adults arm (arm
circumference)/ 100% of the childs arm
The lower border of the cuff should be 2.5 cm above the antecubital space.
Use the bell of the stethoscope low pitched sounds

Pump about 30 mmHg more from the point the pulse has disappeared.
Deflate the cuff at a rate of 2 to 3 mmHg per second.
Rest the arms for 1 to 2 minutes before taking the blood pressure again, in cases reading is not certain.
Calibrate the sphygmomanometer every 6 months
Allow 30 minutes for resting if the client has exercise, smoking or ingested caffeine
Read lower meniscus of the mercury to prevent error of parallax
o error of parallax if the eye level is higher than the level of lower meniscus

A 40%

B 80%

d. KOROTKOFF PHASES***
Phase 1 a sharp thump determines the systole
Phase 2 a blowing or whooshing sound (increasing sound)

22 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

 Phase 3 a crisp, intense tapping (loud tapping)
Phase 4 a softer blowing sound that fades (muffled sound)
Phase 5 Silence determines the diastole

e. Taking BP in thigh
1 Position patient
Prone (best)
Supine with legs flexed
2 Expose thigh
3 Locate popliteal pulse
4 Wrap the cuff

f. Common mistakes
FALSE-LOW FALSE-HIGH
Bladder of cuff too wide Bladder of cuff narrow
Arm above heart level Arm below heart level
Deflating cuff too quickly Deflating cuff too slowly
Inflating too slowly
Smoking, caffeine and exercise for the last 30 minutes

g. Systolic in legs is higher compared to brachial around 10 to 40mmHg

h. 3 years old and above - Start taking BP routinely
i. BP of 120/100/80 phase 1/4/5

87. TEMPERATURE
a. ORAL accessible and convenient c. RECTAL Reliable measurement (Inconvenient
S Smoking* and more unpleasant)
N Newborn R Rectal disease/diarrhea
O Oral surgery I Immunosuppressed
U Ulceration/injury to the mouth C Clotting disorders
T Tremors/convulsions T Turning to the side is difficult
H Hot/cold foods & fluids just ingested wait H Hemorrhoids
for 15 to 30 minutes before taking U Undergone rectal surgery
temperature M Myocardial infarction

b. AXILLARY Safe and non-invasive d. TYMPANIC Readily accessible, reflects the

A Axillary injury core temperature, very fast 9 Risk of injuring the
X eXercise/activity membrane)
I Inadequate circulation E Evident cerumen
L Laging basa (moist pits) A An ear infection is present
A After bathing R Reading may vary between left and right
measurement

88. PULSE the wave of blood created by the contraction of the left ventricle.
Wait for 10 to 15 minutes if he client has been physically active.
Use 2 or 3 middle fingertips lightly over the pulse site.
Doppler ultrasound stethoscope (DUS): transducer probe (gel may be applied) and stethoscope headset; when using a
DUS, hold the probe lightly over the pulse site.
Apical pulse
7 years old and above located at the 5th ICS LMCL
below 7 years old located at the 4th ICS LMCL
PULSE SITES
Infants, palpable: brachial and femoral
Allens test: radial
CPR, infants: brachial
CPR, adults: carotid

89. RESPIRATIONS The act of breathing.

2 Types of breathing
Costal thoracic
Diaphragmatic Abdominal

First to take BEFORE invasive procedures

Physiologic apnea

a. RATE Eupnea (breathing that is normal in rate and depth), bradypnea (abnormally slow), tachypnea (abnormally fast),
C and apnea (absence of breathing).
D
APNEA EUPNEA
BRADYPNEA TACHYPNEA

23 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

EF b. DEPTH Hyperventilation (rapid and deep breaths), hypoventilation (very shallow respirations), and Kussmauls
breathing (hyperventilation associated with metabolic acidosis).
I
H

HYPERVENTILATION
HYPOVENTILATION

c. RHYTHM Cheyne-Stokes breathing (regular rhythm from very deep to very shallow respirations then temporary apnea)
and Biots respiration (shallow breaths interrupted by apnea).

CHEYNE-STOKES

BIOTS

U
90. URINARY CATHETERIZATION: TYPES
TYPES Straight Catheter Indwelling Catheter (Foley or Retention catheter)
NO. OF SINGLE: only for drainage DOUBLE:
LUMENS urine drainage
for inflation of balloon (serves as an anchor)
OR
TRIPLE:
urine drainage
for inflation of balloon (serves as an anchor)
for continuous irrigation
PURPOSE Inserted only as much times as Inserted and stays connected to the bladder for a long time
it takes to drain the bladder or
obtain a urine specimen
SPECIAL Coude catheter is a variation Secure catheter tubing: male - upper thigh or abdomen
CONISDERATIONS of straight catheter which has Female - inner thigh
a curved and tapered tip,
usually used for male patients NO TUB BATHS, shower is preferable
with prostatic hypertrophy
Collection bag should always be below bladder
Position during procedure: FEMALE Dorsal Recumbent
MALE Supine
Lubricate catheter
Catheter accidentally slips into vagina: leave the catheter in vagina, get
new catheter and insert to urethra then remove the catheter from vagina
Increases susceptibility to infection

2 Main Principles observed:

1) Principle of sterility
2) Principle of gravity

Replace urinary catheter every 5 to 10 days

91. URINE ELIMINATION

Color amber/straw, transplant
Order aromatic
pH 4.5 to 8
Amount 1200-1500 ml/day (30-60 ml/hr)
Sp.gr 1.010-10.25

92. PRESENTING UTI

W ash before and after sex
O n time voiding
M ake us of cotton undergarment
A lways wipe from anterior to posterior
N o sprays, harsh soaps, powder.

W
93. WRITING NURSING DIAGNOSIS
INCORRECT CORRECT
1. Write the diagnosis in terms of response Needs assistance with bathing related to bed Self care deficit: bathing related to immobility
rather than need. rest
2. Use related to rather than due to or Noncompliance due to hostility towards Noncompliance related to hostility towards
caused by to link etiology to problem nursing staff nursing staff

24 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES

statement
3. Write diagnosis in legally advisable terms.
AVOID libellous words or would imply
nursing negligence.
4. Include in the problem statement only
client responses that are unhealthy or that
the client wants to change.
5. AVOID including signs and symptoms of
illness in the problem statement.
6. Express the client statement and etiologic
factors in terms that can be changed;
otherwise, nursing energies are being
directed to a hopeless task
7. Express the problem statement in terms of
unhealthy client responses rather than
environmental conditions
8. AVOID reversing the problem statement
and etiologic statement
9. Make sure that the 2 parts of the diagnosis
do not mean the same thing
10. Write diagnosis without value judgments.
WATCH OUT for your ADJECTIVES!
11. DO NOT include medical diagnosis.
Spouse abuse related to husbands
immaturity and violent temper.
Impaired skin integrity related to clients lying
back all night
Mild anxiety related to impending surgery.
Cough related to long history of smoking.
Alterations in Bowel elimination: Permanent
colostomy related to cancer of the bowel
Cluttered home related to inability to discard
anything
Impaired swallowing related to possible
aspiration.
Alteration in comfort related to pain.
Poor home maintenance management
related to laziness.
Impaired home maintenance management
related to arthritis.
25 | TOP NURSING SKILLS, PROCEDURES and NORMAL VALUES
High risk for violence: spouse abuse related
to husbands reported inability to control
behaviour
Impaired skin integrity related to immobility.
---
Ineffective airway clearance related to 20
year history of smoking.
Self-care deficit: Care of colostomy, related to
feeling s of powerlessness
High risk for injury related to cluttered home
(inability to discard anything)
Risk for aspiration related to difficulty
swallowing.
Unrelieved incisional pain related to fear of
drug addiction
Impaired home maintenance management
related to low value ascribed to home safety
and cleanliness
Impaired home maintenance management
related to mobility, endurance and comfort
alterations.