Fundamentals of Nursing Practice (RLE)

• Duration of handwashing: 40-60 seconds
• In handwashing, assess that nail tips should be less than ¼ inch long and free of artificial nails or extenders.
• Sequence for putting on PPE

  1. Gown
  2. Mask
  3. Goggles
  4. Gloves
• Sequence for removal of PPE

  1. Gloves
  2. Goggles
  3. Gown
  4. Mask
  5. Wash hands
• Range of Motion - used in positioning, bedridden patients, post surgery or post operative/operation and to promote ABC
• Types of ROM

  1. active - independent (patient can move freely)
  2. passive - pass (has to be with a RN)
  3. active-assisted - kaya niya, iaassist mo siya
• Therapeutic Positioning - to promote comfort and maintain body alignment of patient
• Abduction - the act of drawing away from the median line or center of the body   
• Adduction - the act of drawing toward the median line or center of the body
• Circumduction - a circular movement of the body part
• Dorsiflexion - bending or moving a part toward the dorsum or back
• Extension - the act of straightening or extending the joint
• Flexion - bending of a joint
• Hyperextension - extension of the joint beyond the straight position
• Lateral Flexion - bending a joint toward the side or away from the midline of the body
• Opposition - positioned opposite one another; for example, the thumb to the fingers
• Plantar Flexion - bending the foot so that the toes point downward
• Rotation - a circular movement around a fixed axis
• Supine - maintains proper alignment of the spine
• Fowler's Position - prevents posterior flexion of

  lumbar curvature.

  Fowler's - 45 degrees

  Semi-fowler's - 30 degrees

  High-fowler's - 90 degrees
• Orthopneic - helps in respiration, allowing greater lung expansion
• Lateral (Side Lying) - helps to relieve pressure on the sacrum and heels. Placing pillows prevents lateral flexion of the neck and fatigue of sternocleidomastoid muscles. It also provide good alignment.
• Sim's - The pillow supports the head. It prevents lateral flexion of the neck, and cushions the cranial and bones.
• Prone - promotes drainage from the mouth and is useful for unconscious clients. During respiration, the pressure on the chest could interfere with chest expansion.
• Knee Chest (genupectoral) - position assumed for gynecologic or rectal examination.
• Dorsal Recumbent - used to provide comfort and to facilitate healing following certain surgeries or anesthetics. (e.g. spinal).
• Lithotomy - often used for vaginal examinations and childbirth.
• Trendelenburg - helps clients in shock in order to increase blood flow to heart and cerebral tissues.
• Layers in bed making:

  • bottom sheet

  • draw sheet

  • underpad/protective pad

  • top sheet

  • blanket

  • pillowcase
• An effective back massage should take 4 to 6 minutes to provide cutaneous stimulation.
• before ABC, check for:

  • infection

  • lab values

  • pain
• In Oral Care, review medical record and identify presence of common oral hygiene problem:

  • dental carries - chalky white discoloration of tooth or presence of brown or black discoloration.
  • gingivitis - inflammation of gums
  • periodontitis - receding gum line, inflammation, gasp between teeth
  • halitosis - bad breath
  • cheilitis - cracked lips, dry, cracked and coated tongue
• In Oral Care, place toothbrush at a 45-degree angle to gum line and brush from gum line to crown of each tooth.
• In bed bath, if the patient has a weak or paralyzed side, undress the unaffected side first.
• In bed bath, if an extremity is injured or immobilized, dress affected side first.
• A nurse is preparing to administer Cefuroxime IV to a client. The nurse gathers supplies and the medication before giving the drug. Which action of the nurse demonstrates that she is considering the right drug as one of the rights of medication administration?

  1. The nurse checks the clock before scanning the medication.
  2. The nurse checks the client's armband and asks the client their date of birth
  3. The nurse reads the drug label
  4. The nurse double checks the administration route on the order
• A nurse is preparing a client's daily oral medication. When the nurse brings the client his medication. he says, "What happened to the pink pill? I've never seen this one before!" Which of the following responses from the nurse is most appropriate?

  1. Is your medicine usually a pink pill? Let me check before you take this one
  2. You do not have a pink pill today. You need to take this one
  3. I know you haven't seen it before but this is what has been ordered for you
  4. I don't know. Let me check with the pharmacy
• The nursing student is preparing several medications during RLE retdem. Which medication is considered a liquid form?

  1. Elixir
  2. Lozenges
  3. Gummies
  4. Inhaler
• Routes of Medication Administration

  1. Parenteral
  2. Oral
  3. Sublingual and Buccal
  4. Topical
  5. Transdermal
  6. Mucous Membrane
• PO - per orem