CHEAT CODES: WALKTHROUGH TO ACE THE NLE 08/06/2024

CHEAT CODE I: FUNDAMENTALS OF NURSING

Nursing Theorists

Proponent Theory
Callista Roy Adaptation Theory
Dorothea Orem Self- Care and Self Care Deficit
Faye Abdellah Identification of 21 Nursing Problems
Florence Nightingale Environmental Theory
Hildegard Peplau Interpersonal Model
Imogene King Goal Attainment Theory
Jeam Watson Human Caring
Lydia Hall Care, Core, Cure
Madeleine Leninger Transcultural Nursing
Martha Rogers Science of Unitary Human Beings
Myra Levine Four Conservation Principles
Rosemarie Parse Human Becoming
Virginia Henderson Identification of 14 Basic Needs

Nursing Process

A-ssessment

• Get facts. Collect, organize validate and record client data

• Subjective (apparent to the client), Objective (based on the senses of the nurse)
• Primary data (provided by the client), Secondary data (other sources: patient’s chart)

D- iagnosis

• Can be actual or potential

• Make nursing diagnosis

P-lanning

• Determine goals and outcomes

I-mplementation

• Doing, delegating, documenting

E-valuation

• Judging if the plan worked or management has been effective

***Nursing Process is sequential

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Nursing Procedures

Computed Tomography Scanning

• Cross section visualization

• noninvasive and painless
• has a high degree of sensitivity for detecting lesions.

***WITH or WITHOUT CONTRAST

Nursing Responsibilities:

• Assess for claustrophobia – needs sedation

• Assess for iodine/shellfish allergy.
• teaching the client about the need to lie quietly throughout the procedure.
• NPO if with contrast medium, for 4 hrs.
• Inform about warmth feeling and metallic taste during administration
• WOF: flushing, nausea and vomiting.
• EXCRETION

MRI (Magnetic Resonance Imaging)

• Strong magnet + radiofrequency waves

• 3 D images

Nursing Responsibilities:

• Assess for claustrophobia – needs sedation

• Assess for history of metal implants
• Procedure lasts for 30-90 mins
• Painless
• Inform that machine makes drum-like or knocking sound
• Remove metals
• C/I – pacemakers, prosthesis
Cerebral Angiography

• Is an x-ray study of the cerebral circulation with a contrast agent injected into a selected
artery (femoral)
• Visualize aneurysm

Nursing Responsibilities:

• Obtain a signed consent.

• Hydrate the client, clear liquids are usually permitted.
• Instruct the client to void before and after the procedure

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Electroencephalography (EEG)

• Graphic record of the electrical activity generated in the brain.

Nursing Responsibilities:

• Shampoo hair
• Avoid stimulants 24-48 hrs before
• Proper placement of electrodes
• Explain the procedure, assure the client he/she will not receive electrical shock.
• The nurse needs to check doctor’s order regarding the administration of antiseizure
medication prior to testing.
• Inform the client that the standard EEG takes 45 to 60 minutes and 12 hours for sleep EEG.

Lumbar Puncture

• The needle is usually inserted between L4 and L5.

• Queckendstedt’s test- subarachnoid obstruction

Nursing Responsibilities

• Genupectoral position
• Obtain signed consent.
• Void before procedure
• Flat on bed 6-8 hrs reduce the incidence of headache.
• Increase OFI
• Prepare 3 test tubes
▪ microorganisms
▪ nutrients
▪ blood cells

Cardiac Enzymes

Enzyme Indication Result

Myoglobin Tissue Necrosis Increased immediately after MI
attack
CK-MB Most cardiac specific enzyme DEFINITIVE cardiac enzyme
Accurate in myocardial damage

Electrocardiography (ECG)

P wave – atrial contraction

• 0.04 – 0.11 sec

PR interval – time when electrical impulse travel from the SA to AV node

• 0.12 – 0.20 sec

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QRS COMPLEX – ventricular contraction

• 0.05 – 0.10 sec

ST segment - period of slow repolarization of the ventricles.

T wave – ventricular relaxation

ECG Changes

ECG Change Indication Manifestations

Hypokalemia LOW potassium U wave
Depressed ST segment
Flat T wave
Hyperkalemia HIGH potassium Prolonged QRS complex
Elevated ST segment
Peak T wave
Myocardial Infarction Blood obstruction Pathologic Q wave
Elevated ST segment
Inverted T wave

2D ECHO

• Assess cardiac structure and mobility

• Painless
• 30 – 60 minutes
• No special preparation is needed

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Cardiac Catheterization

Purpose:

• Assess heart structures

• Pulmonary flow
• Oxygen level

Nursing Responsibilities:

Pre procedure:

C-onsent

A-nesthesia (local)

R-ecord baseline vs

D-amahin (warm flushing feeling)

I-odine

A-void eating (NPO 4-6 hrs)

C-lean insertion site

Post Procedure:

C-heck area distal to insertion site

A-ssess VS

T-amang position – BR 6-8 hrs

H-ip flexion – no more than 30 degrees

E-nsure pressure application

T-ake fluids (INC OFI)

E-CG - dysrhythmias

R-eport allergic reaction to dye

Pulse Oximetry

A - always check PULSE

B – Blanch test

C – color removal

D – detects O2 sat
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Arterial Blood Gas Analysis

Use of ARTERIAL BLOOD to measure:

• PaO2, PaCo2, pH

Nurse’s Responsibilities:

• Educate the client regarding the need for the test.

• Explain to the client the need to hold still.
• Perform the Allen’s Test.
• Keep the client calm.
• 5 – 10 mL of arterial blood is drawn.
• A needle connected to a heparinized syringe is utilized.
• Most common site for blood withdrawal is the RADIAL ARTERY.
• Apply continuous pressure to the site for 5 minutes and 10 minutes for femoral sites.
• Place specimen on a container with ice & transport immediately to the lab.

Bronchoscopy

• Direct inspection and observation

• DIAGNOSTIC: collect secretion/sputum for biopsy
• THERAPEUTIC: excise lesions, remove foreign objects
• PRE-PROCEDURE
o Informed consent, NPO 6-8 hrs, atropine, valium, local anesthetics, remove dentures,
valuables
• POST-PROCEDURE
o Side-lying, check cough and gag reflex, WOF tachycardia, DOB, cyanosis, hypotension,
arrhythmias

Lung Scan

• Radioisotope + scintillation camera

• Confirms PULMONARY EMBOLISM
• Instruct client to REMAIN STILL during procedure

Thoracentesis

Nursing Responsibilities:

• Pre-procedure:
o Informed consent
o Ask pt. to sit upright while leaning on the tray table.
o Instruct the client to hold still
• Post-procedure:
o Position pt. on the UNAFFECTED SIDE.
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o Apply pressure dressing & assess puncture site for bleeding & crepitus
o Monitor for signs of pneumothorax, air embolism & pulmonary edema

Sputum Collection

• Acid – fast bacillus staining/ sputum culture

• Direct method:
o Obtain early morning specimen (15 ml)
o Instruct client to rinse mouth with water
o Deep breathing
o Cough out sputum in container
• Indirect method:
▪ Sterile suction catheter with an attached sputum trap or transtracheal
aspiration.

Thoracentesis

• aspiration of pleural fluid through a needle

• orthopneic position
• informed consent
• Fluid - 7-8 or 8-9 in intercostal posterior axillary line
• Air - 2-3, 3-4 in intercostals
• Needs chest x-ray
• Positioned lying on unaffected side

Suctioning

Principles:

• Performed to clear airways

• Relieves respiratory distress

Need for suctioning

• Dyspnea, pallor and cyanosis

• Drooling, vomitus in the mouth, bubbling breath sound
• Decreased O2 Saturation
• Decreased breath sounds

Route Oropharyngeal Nasopharyngeal Tracheostomy

Position Semi fowlers Semi fowlers Semi fowlers
Pressure 110-150mmHg 110-150mmHg 90-110mmHg
Length of the tube 3-5 inches 3-5 inches 2-3 inches
Lubricant water Water soluble lubricant Saline solution
Duration of suction 5-15 seconds 5-15 seconds 5-10 seconds
Rest period 20-30 seconds 20-30 seconds 2-3 minutes
Oxygen delivery Face mask Face mask Ambubag

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Artificial Airway/Tracheostomy

Purposes:

• To administer oxygen
• To suction secretions
• To by-pass upper airway obstruction

Tracheostomy

• A curved tube (plastic/metal) is inserted through the opening and into the trachea to keep
airway open
• Inserted using a laryngoscope
• Can be temporary or permanent
• Can be cuffed or cuff less

Parts:

• Outer cannula (Main shaft)-inserted into the trachea. Cloth or tape is tied through the flange
around the neck of the patient to keep it in place
• Inner cannula- it is the part being removed for cleaning (hydrogen peroxide and NSS)
• Obturator- it is inserted into the tube to guide the outer cannula during initial placement. It is
kept in the bedside in case of dislodgement.

Principles:

• Semi fowlers
• Don sterile gloves
• Use hydrogen peroxide and NSS in cleaning the cannula
• Tie should not be too tight which might compress the jugular vein
• KEPT IN THE BED SIDE: Obturator and Suction Machine

Abdominal (diaphragmatic) and purse-lip breathing

• Semi / high fowlers position

• Slow deep breath, hold for a count of 3 then slowly exhale through mouth and pursed lip
• 5 – 10 slow deep breaths every 2 hours on waking hours

Coughing exercise

• Upright position
• Contraindicated: post brain, spinal or eye surgery
• Take two slow deep breaths; on the third breath, hold for few seconds, cough twice without
inhaling in between
• May splint surgical incisions
• Every 2 hours while awake
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Incentive spirometry

A breathing device that provides visual feedback that encourages patient to sustain deep voluntary
breathing and maximum inspiration.

• 10 times every 1 to 2 hours

Chest Physiotherapy

• Postural drainage
• Percussion
• Vibration

Contraindications:

• ICP more than 20mmHg, head and neck injury, active hemorrhage, recent spinal surgery, active

hemoptysis, pulmonary edema, confused or anxious patients, rib fracture

Postural Drainage

• When = morning, at bedtime, 30 minutes – 1 hour before or 1-2 hours after meal
• Each position = assumed for 10 – 15 minutes
• Entire treatment should last only for 30 minutes

Percussion

• Rhythmical force provided by clapping the nurse’s cupped hands against the client’s thorax
• Over affected segment for 1-2 minutes

Vibration

• Perform by contracting all the muscles in the nurse’s upper extremities to cause vibration while
applying pressure to the client’s chest wall
• One hand over the other

Enema

Purpose

• Bowel training program

• Eliminate feces and flatus
• Avoid contamination of the sterile field during surgery
• Treat constipation and impaction
• Support visualization of intestines

Procedure:

• Lubricate insertion tube 3-4 inches

• Position: Left lateral position

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• Deliver slowly to minimize discomfort minimum of 10-15 minutes

• Container height:
o Retention: 12 “above the rectum
o Non- retention: 18 “above the rectum
• Temperature: NOT MORE THAN 42 degree Celsius

Types of Enema

1. Cleansing Enema- height of container is 18 inches from the point of entry. Instruct the patient to hold
the fluid for 10-15 minutes

***WOF: Fluid and electrolyte imbalances

2. Carminative Enema- release gas, it distends the rectum and colon stimulating peristalsis. Uses about
60-80ml of fluid

3. Oil Retention-given to soften feces and lubricate the rectum and anal canal. Uses 90-120ml of oil
(mineral, cotton seed, olive) and kept in place for 1-3 hours

Endoscopy

Pre- procedure:

• NPO 8 – 12 h
• Consent
• Remove dentures
• Conscious sedation
• Anticholinergics
• Local anesthetics

Post Procedure:

• NPO 2 – 4 h
• Check for gag reflex
• WOF fall back of tongue
• Monitor for bradycardia and dysrhythmias

Gastric Analysis

Indication: HCL and pepsin secretion

NPO 12 h

HOW:

• NGT
• Collection of gastric contents every 15 min for 1 hour

RESULT:

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• Increased –Zollinger Ellison Syndrome, Duodenal Ulcer

• Decreased – Gastric Cancer, Pernicious Anemia

Occult Blood Test/ Guaiac’s Test

Aka Guaiac’s Test

Indication – blood in the stool

Pre- procedure:

• High fiber diet 2-3 days

• NO: red meat, poultry, fish, melon, broccoli, cauliflower, iron – FALSE POSITIVE RESULT
• NO: Vit. C – FALSE NEGATIVE RESULT

HOW: hydrogen peroxide

3 stool specimens for 3 cons days

RESULT: blue ring – (+) bleeding

Nasogastric Tube (NGT)

Indications

F-eeding
I-rrigation
D-ecompression

Me-dication

Measurement:

Adult: Nose, earlobe, Xyphoid (NEX)

Assessment BEFORE insertion

a. Swallowing

b. Nasal obstruction

c. Alertness

Position

1. Hyperextend head-during insertion

2. Flex head-after insertion

(+) Resistance

• W - ithdraw

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• R - elubricate

• R – einsert

Watch out for (WOF)

• (-) talking

• Cough, DOB

PLACEMENT:

1. X-ray

2. Aspirate gastric contents

3. Auscultate

Urinalysis

• Color: Amber, tea-colored (biliary d/o), urobilinogen

• Odor: Aromatic/ Ammoniacal (decomposed urine)
• pH: Acidic – does not favor bacterial growth
• Specific gravity: 1.050-1.025, if elevated urine is concentrated, suspect dehydration
• Phosphates/Urates: Normal
• Glycosuria – Diabetes (BS is more than 200mg)
• Hematuria – Stones, BPH, renal diseases, UTI
• Albuminemia – protein in urine, eclampsia
• Pyuria – UTI
• Cyllinduria – cast in urine (stones)
• First voided urine, mid-stream to clean the urethra first
• Sterile specimen
• Indwelling catheter – wait in the end of the catheter for 30 mins
• Indwelling catheter – aspirate from 10ml syringe

Urine Culture & Sensitivity Test

• Exact microbe
• Result is final only after 5-7 days
• Same collection process but less amount

Opthalmoscopy

• Opthalmoscope
• Used in determining cataract
• Dim the light and focus light of opthalmoscope in the eye

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Otoscopy

• Otoscope
• A cannula is inserted in the external auditory canal
• No need for written consent
• 3 y/o above – up & back
• 3 y/o below – down & back

Rhinoscopy

• Rhinoscope
• Hyperextend the neck

Models of Health

Judith Smith

Clinical Model

• Absence of the signs and symptoms of a disease.

• Narrowest

Role Performance Model

• Able to perform job

Adaptive Model

• Capable of adjusting
• Although there is infirmity, he is able to find ways to cope.

Eudemonistic Model

• Individual is able to achieve the apex of Maslow’s Hierarchy of needs (self-actualization).

• Maximization of potential and mission in life
• Fulfillment of his purpose in life

Levell and Clark , Ecologic Model of Health

• Epidemiological triad –agent, host, environment

Multiple Causation Theory of Disease

• health is affected by different factors in the environment

Rosenstoch – Becker’s Health Belief Model

• Individual perception affects modifying factors which may influence likelihood of action

Travis’ Illness-Wellness Continuum

- Health is in a spectrum which moves into polarity of directions

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- Premature of death ->Disability/Disease ->Symptoms ->Signs -> Awareness -> Education

->Growth
- High level wellness

Dunn’s High-Level Wellness Grid

• Health-illness Continuum
• health axis “Favorable/Unfavorable environment”

Quadrants:

1. High level wellness in a favorable environment

2. Emergent high levels in Level Wellness in an unfavorable environment

3. Poor Health in an Unfavorable Environment

4. Poor health in a favorable environment

Schumann’s Stages of Illness Behaviors

1. Symptom experience

2. Assumption of sick role

3. Medical care contact

4. Dependent client role

5. Convalescence/ Rehabilitation

DOCUMENTATION or CHARTING

• STAT – now
• Ad lib – as desired
• PRN – as required
• OD – right eye/ once a day
• OS – left eye
• OU – both
• AD – right ear
• AS – left ear
• AU – both ears
• Ss – half

In case of ERROR: draw a straight line, signature, initials

POSITIONING

• Sitting
• High Fowlers (90%)

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• Orthopneic position (leaning on a table, hands extended)

• Supine, Back Lying, Dorsal, Horizontal Recumbent
• Flat on Bed – no pillow
• Dorsal Recumbent – legs flexed to relax abdominal muscles, abdominal palpation/ exam –
followed by diagonal draping
• Standing/Erect
• Prone/ Face – lying position
• Sim’s Position, Left- lateral, Side-lying
– Rectal exam, suppository insertion, enema administration
• Knee Chest position/ Geno-pectoral position/ Jack Knife position
– Rectal exam, dysmenorrhea
• Lithototomy – stirrups
• Trendelenburg – foot up; head down
• Reverse trendelenburg – head up, foot down
• Modified trendelenburg – only 1 leg up for shock

Methods of taking body temperature

Oral – contraindicated in brain damage, mental illness, retarded, problem with nose and mouth, tooth
extraction, contraption in nose and mouth, altered LOC, dyspnea, seizures, 7 y/o below

***2 mins under the tongue

Rectal – contraindicated in imperforate anus, rectal polyps, Hirschsprung’s disease, diarrhea, increase
ICP, cardiac disease (may cause vagal stimulation)

• Not safe since it can cause rectal trauma

• 1 min

Axillary – 3mins

Tympanic – external ear. contraindicated in otitis, ear surgery; most accurate

Temporal Scanner - done in temporal; most convenient

***Temperature can be checked every 30 mins since hypothalamus can only fluctuate the temperature
every 30 mins

Alterations in body temperature

Hyperpyrexia: 41 ̊ degrees +

Pyrexia: 37.5 ̊ - 38 ̊ degrees +

1. Onset / Chill phase: up HR, up RR, shivering, cold skin, cessation of sweating

2. Course / Plateau phase: absence of chills, feels warm, up HR, RR, thirst

3. Abatement phase: flushed skin, sweating, reduced shivering

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Average: 36 ̊ - 38 ̊ degrees

Hypothermia: 36 ̊ degrees below

Death: 34 ̊ degrees

Types of Fever

• Intermittent – fluctuates from febrile to afebrile

• Remittent – febrile, temperature fluctuation is minimal
• Relapsing – fluctuates in days
• Constant / Continuous – febrile, temperature fluctuation is wide (+2)

*Heat Stroke – depletion of fluid, hypothalamus does not regulate

*Hypothermia – induced (surgery), extreme temperature

Nursing interventions

• Feels chilled – provide extra blankets

• Feels warm – remove excess blankets; loosen clothing
• Adequate nutrition and fluids
• Reduce physical activity
• Oral hygiene
• Tepid Sponge Bath – increase heat loss (conduction, convection, evaporation)

VITAMIN DEFICIENCIES

Vit A (Retinol)

• Healthy eyes, skin, and gums

• Deficiency: Xeropthalmia (night blindness) – Bitot’s spot
• Severe: Keratomalacia (irreversible)

Vit D (Calciferol)

• Not coming from the sun; but sunlight activates it

• Enhances calcium and phosphorus absorption
• Deficiency: Ricketts
• Severe: Osteomalacia

o Bow legged – genu varum

o Knock knee – genu valgum

o Pectus carinatum (Harrison’s groove)

o Spinal deformity

o Stunted growth

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***You can store calcium up to 31 years

Vit E (Tocopherol)

• Antioxidant: remove free radicals

• Amount should not go 400 units because if it exceeds. It becomes prooxidant
• Enhances RBC maturation
• Deficiency: anemia

Vit K (Menadione)

• Anti-hemorrhagic
• Deficiency: hemorrhage, bleeding

B Vitamins – Metabolism since these have enzymatic activity

Vit B1 (Thiamin)

• Deficiency: Beri-beri; Wernicke-Korsakoff Syndrome

• Edema in wet Beri-beri

Vit B2 (Riboflavin)

• Deficiencies: Ariboflavinosis, cheilosis

• Angular stomatitis - mouth fissures

Vit B3 (Niacin)

• Deficiency: Pellagra – butterfly sign, cassel’s collar

Vit B5 (Pantothenic Acid)

• Keeps integrity of hair

• Deficiency: alopecia

Vit B6 (Pyridoxine)

• Deficiency: Neuritis

Vit B12 (Cyanocobalamin)

• Definition: pernicious anemia, neuritis

Vit C (Ascorbic)

• Inc. absorption of iron

• Deficiency: scurvy – easy bruising, gums, perifollicular lesion, hemorrhage

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Types of Diet

Regular

• Has all essentials, no restrictions

• No special diet needed

Clear liquid

• “see-through foods” like broth, tea, strained juices, gelatin

• Recovery from surgery or very ill

Full liquid

• Clear liquids plus milk products, eggs

• Transition from clear to regular diet

Soft diet

• Soft consistency and mild spice

• Difficulty swallowing

Bland

• Chemically and mechanically non stimulating, no spicy food

• Ulcers or colitis

Low residue

• No bulky foods, apples or nuts, fiber, foods having skins and seeds
• Rectal disease

High calorie

• High protein, vitamin and fat

• Malnourished

Low calorie

• Decreased fat, no whole milk, cream, eggs, complex CHO

• Obese

Diabetic

• Balance of protein, CHO and fat

• Insulin-food imbalance

High protein

• Meat, fish, milk, cheese, poultry, eggs

• Tissue repair and underweight

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Low fat

• Little butter, cream, whole milk or eggs

• Gallbladder, liver or heart disease

Low cholesterol

• Little meat or cheese

• Need to decrease fat intake

Low sodium

• No salt added during cooking

• Heart or renal disease

PAIN

• Subjective
• May have psychogenic pain as well
• Acute – less than 6 months
• Chronic – more than 6 months
• Intractable – not relieved

***Wong and Baker Scale – 1-10 rating

***Phantom pain – pain from amputated limb

***Gate Theory of Pain - Substantia gelatinosa

Pain threshold

• May be psychological/ physiological

o Heat and cold

o Imagery and distraction

DEATH

Thanantology – study of death

Post-mortem care

• Must be pronounced dead by physician

Rigor Mortis - stiffening

Algor Mortis - change in temperature

Livor Mortis - color change

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