NURSING FUNDAMENTALS LATEST STUDY GUIDE WITH DETAILED PROCEDURES 100% CERTIFIED
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NUR FUNDAMENTALS (NURFUNDAMENTALS)
Institution
Chamberlain College Of Nursing
Steam Inhalation
FUNDAMENTALS OF NURSING
NURSING PROCEDURES
a. It is dependent nursing function.
b. Heat application requires physician’s order.
c. Place the spout 12-18 inches away from the client’s nose or adjust the distance as necessary.
2. Suctioning
a. Assess the lungs befor...
nursing fundamentals latest study guide with detai
steam inhalation fundamentals of nursing nursing
suctioning aassess the lungs before the procedur
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NURSING FUNDAMENTALS LATEST STUDY GUIDE WITH
DETAILED PROCEDURES 100% CERTIFIED
FUNDAMENTALS OF NURSING
NURSING PROCEDURES
1. Steam Inhalation
a. It is dependent nursing function.
b. Heat application requires physician’s order.
c. Place the spout 12-18 inches away from the client’s nose or adjust the distance as necessary.
2. Suctioning
a. Assess the lungs before the procedure for baseline information.
b. Position: conscious – semi-Fowler’s
c. Unconscious – lateral position
d. Size of suction catheter- adult- fr 12-18
e. Hyper oxygenate before and after procedure
f. Observe sterile technique
g. Apply suction during withdrawal of the catheter
h. Maximum time per suctioning –15 sec
3. Nasogastric Feeding (gastric gavage)
Insertion:
a. Fowler’s position
b. Tip of the nose to tip of the earlobe to the xyphoid
Tube Feeding
a. Semi-Fowler’s position
b. Assess tube placement
c. Assess residual feeding
d. Height of feeding is 12 inches above the tube’s point of insertion
e. Ask client to remain upright position for at least 30 min.
f. Most common problem of tube feeding is Diarrhea due to lactose intolerance
4. Enema
a. Check MD’s order
b. Provide privacy
c. Position left lateral
d. Size of tube Fr. 22-32
e. Insert 3-4 inches of rectal tube
f. If abdominal cramps occur, temporarily stop the flow until cramps are gone.
g. Height of enema can – 18 inches
5. Urinary Catheterization
a. Verify MD’s order
b. Practice strict asepsis
c. Perineal care before the procedure
d. Catheter size: male-14-16 , female – 12 – 14
e. Length of catheter insertion
male – 6-9 inches ,female – 3-4 inches
For retention catheter:
Male –anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure
Female- inner aspect of the thigh
TYPES OF OSTOMIES
a. Ileostomy
➢ Liquid to semi-formed stool, dependent upon amount of bowel removed
➢ May skew fluid & electrolyte balance, especially potassium & sodium
➢ Digestive enzymes in stool irritate skinDo NOT give laxatives
➢ Ileostomy lavage may be done if needed to clear food blockage
➢ May not require appliance set; if continent ileal reservoir or Koch pouch
b. Colostomy
■ Ascending-must wear appliance--semi-liquid stool
■ Transverse-wear appliance--semi-formed stool
■ Loop stoma
✔ Proximal end-functioning stoma
✔ Distal end-drains mucous
✔ Plastic rod used to keep loop out
✔ Usually temporary
■ Double barrel
,NURSING FUNDAMENTALS LATEST STUDY GUIDE WITH
DETAILED PROCEDURES 100% CERTIFIED
■ Sigmoid
✔ Formed stool
✔ Bowel can be regulated so appliance not needed
✔ May be irrigated
Stoma assessment
a. Color-should be same color as mucous membranes
(normal stoma color- Red not dusky or pale: sign of infection)
b. Edema-common after surgery. Bleeding-slight bleeding common after surgery
6. COLOSTOMY IRRIGATION
✔ Initial colostomy irrigation is done to stimulate peristalsis; subsequent irrigations are done to
promote evacuation of feces at a regular and convenient time
✔ Recommended with sigmoid colostomy
✔ Initiated 5 to 7 days postop
✔ Done in semi – Fowler’s position; then sitting on a toilet bowl once ambulatory.
✔ Use warm normal saline solution
✔ Initially, introduce 200 mls. of NSS then 500 to 1,000 mls. Subsequently
✔ Dilate stoma with lubricated gloved finger before insertion of catheter
✔ Lubricate catheter before insertion.
✔ Insert 3 to 4 inches of the catheter into the stoma
✔ Height of solution 12 inches above the stoma
✔ If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution
until peristalsis relaxes.
✔ Allow the catheter to remain in place for 5 to 10 minutes for better cleansing effect; then
remove catheter to drain for 15 to 20 minutes.
✔ Clean the stoma, apply new pouch
7 . Bed Bath
a. Provide privacy
b. Expose, wash and dry one body part a time
c. Use warm water (110-115 F)
d. Wash from cleanest to dirtiest
e. Wash, rinse, and dry the arms and leg using Long, firm strokes from distal to proximal area – to
increase venous return.
8. Foot Care
a. Soaking the feet of diabetic client is no longer recommended
b. Cut nail straight across
9. Mouth Care
a. Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables
b. Dental check every 6 mounts
10. Oral care for unconscious client
a. Place in side lying position
b. Have the suction apparatus readily available
11. Hair Shampoo
c. Place client diagonally in bed
d. Cover the eyes with wash cloth
e. Plug the ears with cotton balls
f. Massage the scalp with the fatpads of the fingers to promote circulation in the scalp.
11. Restraints
✔ Secure MD’s order for each episode of restraints application.
✔ Check circulation every 15 min
✔ Remove restraints at least every 2 hours for 30 minutes
Types of Restraints
➢ Chemical – sedating antipsychotic drugs to manage or control behavior
➢ Physical – direct application of physical force to a client, with or without the client’s permission.
➢ Seclusion – involuntary confinement of a client in a locked room
Procedure:
✔ Ensure that face-to face assessment is completed on the client
✔ Ensure that the restraint orders are renewed every 24 hours or sooner according to hospital
policy.
✔ Tie the restraints using clove hitch
✔ Secure the tie in a non-movable part of the bed
PRINCIPLES OF MEDICATION ADMINISTRATION
I - “Six Rights” of drug administration
1. The Right Medication – when administering medications, the nurse compares the label of the
, NURSING FUNDAMENTALS LATEST STUDY GUIDE WITH
DETAILED PROCEDURES 100% CERTIFIED
b. As the amount of medication ordered is removed from the container
c. Before returning the container to the storage
2. Right Dose –when performing medication calculation or conversions, the nurse should
have another
qualified nurse check the calculated dose
3. Right Client – an important step in administering medication safely is being sure the medication is
given to the right client.
a. To identify the client correctly:
b. The nurse check the medication administration form against the client’s identification
bracelet and asks the client to state his or her name to ensure the client’s identification
bracelet has the correct information.
4. RIGHT ROUTE – if a prescriber’s order does not designate a route of administration, the nurse
consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the
prescriber immediately.
5. RIGHT TIME
a. the nurse must know why a medication is ordered for certain times of the day and whether
the
time schedule can be altered
b. each institution has are commended time schedule for medications ordered at frequent
interval
c. Medication that must act at certain times are given priority (e.g insulin should be given at a
precise interval before a meal )
6. RIGHT DOCUMENTATION –Documentation is an important part of safe medication administration
a. The documentation for the medication should clearly reflect the client’s name, the name of the
ordered medication,the time, dose, route and frequency
b. Sign medication sheet immediately after administration of the drug
CLIENT’S RIGHT RELATED TO MEDICATION ADMINISTRATION
A client has the following rights:
a. To be informed of the medication’s name, purpose, action, and potential undesired effects.
b. To refuse a medication regardless of the consequences
c. To have a qualified nurses or physicians assess medication history, including allergies
d. To be properly advised of the experimental nature of medication therapy and to give written
consent for its use
e. To received labeled medications safely without discomfort in accordance with the six rights of
medication administration
f. To receive appropriate supportive therapy in relation to medication therapy
g. To not receive unnecessary medications
II – Practice Asepsis – wash hand before and after preparing the medication to reduce transfer
of microorganisms.
III – Nurse who administer the medications are responsible for their own action. Question any order
that you considered incorrect (may be unclear or appropriate)
IV – Be knowledgeable about the medication that you administer
“A FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION IS: “NEVER ADMINISTER AN
UNFAMILIAR MEDICATION”
V – Keep the Narcotics in locked place.
VI– Use only medications that are in clearly labeled containers. Relabelling of drugs are the
responsibility of the pharmacist.
VII – Return liquid that are cloudy in color to the pharmacy.
VIII – Before administering medication, identify the client correctly
IX – Do not leave the medication at the bedside. Stay with the client until he actually takes the
medications.
X – The nurse who prepares the drug administers it.. Only the nurse prepares the drug knows what the
drug is. Do not accept endorsement of medication.
XI – If the client vomits after taking the medication, report this to the nurse in-charge or physician.
XII – Preoperative medications are usually discontinued during the postoperative period unless ordered
to be continued.
XIII- When a medication is omitted for any reason, record the fact together with the reason.
XIV – When the medication error is made, report it immediately to the nurse in-charge or physician. To
implement necessary measures immediately. This may prevent any adverse effects of the drug.
MEDICATION ADMINISTRATION
1. Oral administration
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