1. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
I.
NURSING
THEORIST
PLANNING
PHASE
Types
of
Planning
Florence
Nightingale
Environmental
Theory
-­‐ Prioritize
problems
Initial
planning,
admission
Virginia
Henderson
14
Basic
Needs
-­‐ Formulate
goals
assessment.
Faye
Abdellah
Patient
–
Centered
Approaches
to
-­‐ Select
actions
Ongoing
planning
Nursing
Model
/
21
Nursing
Problems
-­‐ Write
nursing
orders
Discharge
planning:
Dorothy
Johnson
Behavioral
System
Model
M
edications
Imogene
King
Goal
Attainment
Theory
E
xercise
Madeleine
Leininger
Transcultural
Nursing
Model
T
reatment/therapy
Myra
Levin
Four
Conservation
Principles
H
ygiene
Betty
Neuman
Health
care
System
Model
O
ut-­‐patient
follow
up
Dorotheo
Orem
Self-­‐Care
and
Self-­‐Care
Deficit
Theory
D
iet/nutrition
Hildegard
Peplau
Interpersonal
Model
S
exual
activity/spirituality
INTERVENTION
/
Types
of
Intervention
Martha
Rogers
Science
of
Unitary
Human
Beings
IMPLEMENTATION
• Independent
Sister
Callista
Roy
Adaptation
Model
• Dependent
Lydia
Hall
Care,Core,Cure
-­‐ Determining
needs
• Collaborative
Jean
Watson
Human
Caring
Model
for
assistance
Rosemarie
Rizzo
Human
Becoming
-­‐ Putting
into
action
Cognitive
or
Intellectual
Skills
Parse
the
plan
Such
as
analyzing
the
problem,
-­‐ Supervising
problem
solving,
critical
II.
NURSING
PROCESS
delegated
care
thinking
and
making
judgments
-­‐ Documenting
regarding
the
patient's
needs.
ASSESSMENT
PHASE
Subjective
Data
also
referred
to
nursing
activities
Interpersonal
Skills
as
symptoms
or
covert
data
Which
includes
therapeutic
-­‐ Data
Collection
Objective
Data
also
referred
to
communication,
active
listening,
-­‐ Organize
Data
as
signs
or
overt
data,
are
conveying
knowledge
and
-­‐ Validate
Data
detectable
by
an
observer
information,
developing
trust
or
-­‐ Document
Data
Primary
source
is
the
client
rapport-­‐building
with
the
Secondary
source
is
family
or
patient
anyone
else
that
is
not
the
client
Technical
Skills
Which
includes
knowledge
and
skills
needed
to
Methods
of
Data
Collection
properly
and
safely
done
the
Observing
To
observe
is
to
procedure
gather
data
by
using
the
sense.
Interviewing
Is
a
planned
EVALUATION
PHASE
Collecting
data
related
to
communication
or
a
outcome
conversation
with
purpose
Comparing
data
Examining
Is
a
systematic
data-­‐
Drawing
conclusion
collection
method
that
uses
Continuing,
modifying
or
observation
(i.e.,
the
senses
of
terminating
the
nursing
care
sight,
hearing,
smell,
and
touch)
plan
to
detect
health
problems.
III.
ROLES
AND
FUNCTIONS
OF
THE
PROFESSIONAL
DIAGNOSIS
PHASE
Types
of
Nursing
Diagnosis
-­‐ Analyze
Data
NURSE
-­‐ Identify
Health
Actual
diagnosis
is
a
client
Problem
problem
that
is
present
at
the
• Direct
Care
Provider
-­‐
provides
total
care
using
the
-­‐ Formulate
time
of
the
nursing
assessment.
nursing
process
.
Diagnostic
Risk
nursing
diagnosis
is
a
• Communicator
–
communicates
with
clients,
support
Statements
clinical
judgment
that
a
problem
person
and
colleagues
to
facilitate
all
nursing
action.
does
not
exist,
but
the
presence
Diagnostic
Statements
of
risk
factors
• Teacher
–
provides
health
teaching
Problem
(P):
statement
Wellness
diagnosis
• Counselor
–
helps
the
client
to
recognize
and
cope
with
of
the
client’s
response.
Possible
nursing
diagnosis
is
stressful
pyschological
or
social
problem,
Etiology
(E):
factors
one
in
which
evidence
about
a
• Client
Advocate
–
the
nurse
becomes
an
activist
contributing
health
problem
is
incomplete
or
speaking
up
for
the
client
who
cannot
or
will
not
speak
Signs
and
Symptoms
unclear.
for
self.
(S):
defining
Syndrome
diagnosis
is
a
characteristics
diagnosis
that
is
associated
with
• Change
Agent
–
initiates
changes
and
assists
the
client
manifested
by
the
client
a
cluster
of
other
diagnoses.
make
modifications
in
the
lifestyle
to
promote
health.
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE

2. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
• Leader
–
nurse
through
the
process
of
interpersonal
IV.
ISOLATION
PRECAUTIONS
influence
.
• Manager
–
the
nurse
plans,
gives
directions,
develops
Ø Standard
Precautions
/
Universal
Precautions
ü Applies
to
ALL
BODY
FLUIDS
staff,
monitors
operation.
ü Includes:
• Case
Manager
–
coordinates
the
activities
of
other
1. HAND
WASHING
member
of
the
health
care
team.
2. Personal
Protective
Equipment
• Researcher
–
participates
in
scientific
investigation
and
(sequence
of
removing
PPE’s)
uses
research
findings
in
practice.
gloves-­‐mask-­‐gown-­‐eyewear-­‐cap
3. Safe
use
of
sharps
• Collaborator
–
works
in
a
combined
effort
with
all
those
4. Removing
spills
of
blood
and
body
fluids
involved
in
care
delivery.
5. Cleaning
and
disinfecting
equipment
Ø Transmission
Based
Precautions
III.
CHAIN
OF
INFECTION
•
Airborne
precautions
ü A
single
room
under
negative
pressure
ventilation
with
a
wash
hand
basin
ü The
door
must
be
kept
closed
at
all
times
except
during
necessary
entrances
and
exits.
ü Disposable
paper
towels
ü A
high
efficiency
mask,
if
available,
should
be
worn
when
entering
the
room
of
a
patient
with
known
or
suspected
tuberculosis.
•
Droplet
precautions
ü Put
on
a
standard
mask
prior
to
entering
the
isolation
room.
ü Hands
must
be
washed
with
an
antiseptic
preparation
and
must
be
dried
thoroughly
with
a
disposable
paper
towel
or
washed
with
a
waterless
alcohol
hand
rub/gel:
► MODE
OF
TRANSMISSION
it
indicates
the
potential
of
1. AFTER
contact
with
the
patient
or
the
disease;
conveyance
of
the
agent
to
the
host;
it
can
be
potentially
contaminated
items,
by
common
source
transmission,
contact
source,
air-­‐ 2. AFTER
removing
gloves,
and
borne
transmission.
3. BEFORE
taking
care
of
another
patient.
There
are
four
main
routes
of
transmission
•
Contact
precautions
A. By
Contact
Transmission
ü Non-­‐sterile,
disposable
gloves
are
needed
1.
Direct
contact
(
person
to
person
)
when
there
is
contact
with
an
infected
site,
2.
Indirect
contact
(
usually
an
inanimate
object)
with
dressings,
or
with
secretions.
3.
Droplet
contact
(
from
coughing,
sneezing,
or
ü A
mask
when
performing
procedures
that
talking,
or
talking
by
an
infected
person)
may
generate
aerosols
or
when
performing
suctioning
is
recommended.
B. By
Vehicle
Route
(
through
contaminated
items)
ü Hands
washing
(see
droplet
precautions)
1.
Food
–
salmonellosis
2.
Water
–
shigellosis,
legionellosis
3.
Drugs
–
bacteremia
resulting
from
infusion
of
a
V.
NURSING
SKILLS
contaminated
infusion
product
4.
Blood
–
hepatitis
B,
A.
Physical
Assessment
Ø Provide
privacy.
C.
Airborne
Transmission
Ø Make
sure
that
all
needed
instruments
are
available
1.
Droplet
of
nuclei
before
starting
the
physical
assessment
2.
Dust
particle
in
the
air
containing
the
infectious
Ø Be
systematic
and
organized
when
assessing
the
client.
agent
Inspection,
Palpation,
Percussion,
Auscultation.
3.
Organisms
shed
into
environment
from
skin,
hair,
Ø EYES:
Visual
acuity
is
tested
using
a
snellen
chart.
The
wounds
or
perineal
area.
room
used
for
this
test
should
be
well
lighted
Ø EARS:
Weber’s
Test
assesses
bone
conduction,
this
is
D.
Vector
borne
Transmission,
arthropods
such
as
a
test
of
sound
lateralization,
Rinne
Test
compares
flies,
mosquitoes,
ticks
and
others.
bone
conduction
with
air
condition.
Ø NECK:
Let
the
client
sit
on
a
chair
while
the
examiner
stands
behind
him.
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE

3. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
Ø THORAX:
The
client
should
be
sitting
upright
without
Ø Blood Pressure (NV 120/80 mm/hg)
support
and
uncovered
to
the
waist.
ü This
is
the
force
exerted
by
the
blood
against
a
Ø HEART:
Anatomic
areas
for
auscultation
of
the
heart
vessel
wall
ü Aortic
valve
–
Right
2nd
ICS
sternal
border.
ü The
pressure
rises
with
age.
ü Pulmonic
Valve
–
Left
2nd
ICS
sternal
border.
ü A
rest
of
30
minutes
is
indicated
before
the
blood
ü Tricuspid
Valve
–
–
Left
5th
ICS
sternal
border.
pressure
can
be
readily
assessed
after
stressful
ü Mitral
Valve
–
Left
5th
ICS
midclavicular
line
activity.
Ø BREAST
ü Interval
of
30
minutes
is
needed
after
smoking
or
drinking
caffeine.
ü After
menopause,
women
generally
have
higher
blood
pressures
than
before.
ü Pressure
is
usually
lowest
early
in
the
morning,
when
the
metabolic
rate
is
lowest,
then
rises
throughout
the
day
and
peaks
in
the
late
afternoon
or
early
evening
Common
Errors
in
Blood
Pressure
Assessment
Errors
Effect
Ø ABDOMEN:
Place
the
client
in
a
supine
position
with
Bladder
cuff
too
narrow
Erroneously
high
the
knees
slightly
flexed
to
relax
abdominal
muscles.
Bladder
cuff
too
wide
Erroneously
low
(Inspection,Auscultation,Percussion,Auscultation)
Arm
unsupported
Erroneously
high
Insufficient
rest
before
the
Erroneously
high
B.
Vital
Signs
assessment
Repeating
assessment
too
Erroneously
high
Ø Temperature
(NV
36
–
37.5
C)
quickly
ü Elderly
people
are
at
risk
of
hypothermia
Cuff
wrapped
too
loosely
or
Erroneously
low
ü Hard
work
or
strenuous
exercise
can
increase
unevenly
body
temperature
Deflating
cuff
too
quickly
Erroneously
low
systolic
and
ü Oral:
most
accessible
2-­‐3
mins.
*
15
minutes
high
diastolic
reading
interval
after
ingestion
of
hot
or
cold
drinks
Deflating
cuff
too
slowly
Erroneously
high
diastolic
ü Rectal:
most
accurate
2-­‐3
mins.
reading
ü Axillary:
most
safest
6-­‐9
mins.
Failure
to
use
the
same
arm
Inconsistent
measurements
consistently
Ø Pulse
(NV
60-­‐100
bpm)
Arm
above
level
of
the
heart
Erroneously
low
ü Wave
of
blood
created
by
contraction
of
the
left
Assessing
immediately
after
Erroneously
high
ventricle
of
the
heart
a
meal
or
while
client
ü Radial:
best
site
for
adult
smokes
ü Brachial:
best
site
for
children
Failure
to
identify
Erroneously
low
systolic
ü Apical:
best
site
for
3
years
old
below
auscultatory
gap
pressure
pressure
and
erroneously
low
diastolic
Ø Respiration
(NV
12/16-­‐20)
Normal
Breath
Sound
C.
Medication
Administration
Vesicular
Soft,
low
pitch
Lung
periphery
Ø FIVE
RIGHTS
Broncho-­‐ Medium
pitch
Larger
airway
The
Right
Drug
with
vesicular
blowing
The
Right
Dose
through
Bronchial
Loud,
high
pitch
Trachea
The
Right
Route
at
The
Right
Time
to
Abnormal
Breath
Sound
The
Right
Patient
Ø Standard
Order,
Carried
out
until
cancelled
by
another
order.
Crackles
Dependent
lobes
Random,
sudden
Ø PRN
Order,
As
needed,
or
only
when
necessary.
reinflation
of
alveoli
Ø Stat
Order,
Carried
out
immediately
and
for
one
time
fluids
only.
Rhonchi
Trachea,
bronchi
Fluids,
mucus
Ø Always
clarify
doubtful
/unclear
order
Wheezes
All
lung
fields
Severely
narrowed
Ø Do
not
leave
medicine
with
the
client
to
take
by
bronchus
himself
Pleural
Lateral
lung
field
Inflamed
Pleura
Ø Do
not
give
drug
that
shows
physical
changes
or
Friction
Rub
deterioration
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE

4. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
Ø Report
an
error
in
medication
immediately
to
the
E.
Nasogastric
Tube
(NGT)
nurse
in
charge.
Ø The
nurse
who
prepares
the
medication
must
be
Ø Gavage
(feeding)
/
Lavage
(suctioning)
responsible
for
administering
and
recording
it.
Never
Ø Select
the
nostril
that
has
greater
airflow.
endorse
it
to
another
nurse.
Ø Assist
the
client
to
a
high
fowler’s
position
Ø Always
observe
asepsis
in
preparing
and
Ø NEX
technique
(nose-­‐ear-­‐xiphoid)
administering
drugs.
Ø Checking
the
patency:
Ø Ascertain
client’s
identity
before
administering
ü Aspirate
stomach
contents
and
check
the
pH,
medications.
Check
room
or
bed
or
card,
call
out
which
should
be
acidic
client’s
name,
check
I.D.,
wrist
band
ü Introduce
10-­‐30
ml
of
air
into
the
NGT
and
Ø Care
must
be
taken
to
prevent
instilling
medication
auscultate
at
the
epigastric
area,
gurgling
sound
directly
into
cornea.
is
heard
Ø Apply
ointment
along
inside
edge
of
the
lower
eyelid
ü The
most
accurate
method
of
assessing
the
from
inner
to
outer
canthus.
placement
of
NGT
is
X-­‐ray
study
Ø EAR
MEDS:
Infants:
draw
the
auricle
gently
downward
and
Ø Before
feeding
assess
residual
feeding
contents.
To
backward.
assess
absorption
of
the
last
feeding,
if
50
ml
or
Adults:
lift
pinna
upward
and
backward
more,
verify
if
the
feeding
will
be
given.
Ø Intradermal:
Parallel
to
the
skin,
do
not
massage
Ø Height
of
feeding
is
12
inches
above
the
point
of
Ø Subcutaneous:
45
degree
above
the
skin,
if
obese
90
insertion.
degree
Ø Ask
the
client
to
remain
in
position
for
at
least
30
Ø Intramuscular:
90
degree
above
the
skin,
aspirate
to
min
check
if
blood
vessel
was
hit.
Ø Common
Problems
of
Tube
Feedings
• Vomiting
D.
Urinary
Catheterization
• Aspiration
Ø Use
appropriate
size
of
catheter
• Diarrhea
Male:
Fr
16-­‐18
• Hyperglycemia
Female:
Fr
12-­‐14
Ø Place
the
client
in
appropriate
position:
F.
Enema
Administration
Male:
Supine,
legs
abducted
and
extended
Female:
Dorsal
recumbent
Ø Position
the
client:
Ø Locate
the
urinary
meatus
properly:
Adult:
Left
lateral
Male:
at
the
tip
of
the
glans
penis
Infant/small
children:
Dorsal
recumbent
Female:
between
the
clitoris
and
vaginal
orifice
Ø Lubricate
the
tube
about
5
cm
(
2
in
)
Ø Lubricate
catheter
with
water
soluble
lubricant
before
Ø Insert
7
–
10
cm
(
3
to
4
inches)
or
rectal
tube
gently
insertion
in
rotating
motion
Male:
6
–
7
inches
Ø Raise
the
solution
container
and
open
the
clamp
to
Female:
1
–
2
inches
allow
fluid
to
flow
Ø Length
of
catheter
insertion:
High
Enema:
12-­‐18
inches
above
the
rectum
Male:
6
–
9
inches
Low
Enema:
12
inches
above
the
rectum
Female:
3
-­‐4
inches
Ø If
the
client
complains
of
fullness
or
pain,
use
the
Ø Anchor
catheter
properly:
clamp
to
stop
the
flow
for
30
sec.
and
then
restart
Male:
laterally
or
upward
over
the
lower
abdomen
/
the
flow
at
a
slower
rate
upper
thigh
Ø Encourage
the
client
to
retain
the
enema,
ask
the
Female:
inner
aspect
of
the
thigh
client
to
remain
lying
down
Nursing
Interventions
to
Induce
Voiding/Urination
G.
Colostomy
Care
v Provide
privacy
Ø Stoma
should
appear
red,
similar
to
the
mucosal
v Assist
the
patient
in
the
anatomical
position
of
voiding
linin
of
the
inner
cheek
v Serve
clean,
warm
and
dry
bedpan
(female)
or
urinal
Ø Slight
bleeding
initially
when
the
stoma
is
touched
(male)
is
normal,
but
other
bleeding
should
be
reported.
v Allow
the
client
to
listen
to
the
sound
of
running
water
Ø Change
colostomy
appliance
if
it
is
1/3
full.
v Dangle
fingers
in
warm
water
Ø Use
warm
water,
mild
soap
(optional),
and
cotton
v Pour
warm
water
over
the
perineum
balls
or
a
washcloth
and
towel
to
clean
the
skin
and
v Promote
relaxation
stoma.
v Provide
adequate
time
for
voiding
Ø Apply
skin
barrier
over
the
skin
around
the
stoma
v Last
resort:
URINARY
CATHETERIZATION
to
prevent
skin
breakdown.
Ø Changing
is
best
in
the
morning
before
breakfast.
Ø Control
Odor:
(deodorizer,
charcoal
disk
and
prevent
odor
causing
foods)
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE

5. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
Type
of
Discharge
Ileostomy
• Liquid
fecal
drainage
Ø Check
for
cross
matching
and
blood
typing.
To
• Drainage
is
constant
and
cannot
ensure
compatibility
be
regulated
Ø Obtain
and
record
baseline
VS,
Note:
If
patient
has
• Contains
some
digestive
fever
do
not
transfuse
enzymes
Ø Practice
strict,
ASEPSIS
• Odor
is
minimal
bec
of
fewer
Ø At
least
2
nurses
check
the
label
of
the
blood
bacteria
are
present
transfusion,
Check
the
following:
Ascending
• Liquid
fecal
drainage
-­‐
Serial
Number
Colostomy
-­‐
Blood
component
• Drainage
is
constant
and
cannot
be
regulated
-­‐
Blood
type
-­‐
Rh
factor
• Odor
is
a
problem
requiring
-­‐
Expiration
date
control
-­‐
Screening
test
Transverse
Malodorous,
mushy
drainage
•
Ø Check
the
blood
for
gas
bubbles
and
any
unusual
Colostomy
color
or
cloudiness.
Note:
Gas
bubbles
indicate
Descending
• Solid
fecal
drainage
bacterial
growth,
Unusual
color
or
cloudiness
Colostomy
indicate
hemolysis
Sigmoidostomy
• Normal
fecal
characteristics
Ø Warm
blood
at
room
temperature
before
transfusion.
Ø Identify
client
properly,
two
nurses
check
the
H.
Suctioning
client’s
identification
Ø Gauge
of
needle:
#18
Ø Suction
only
when
necessary
not
routinely
Ø Drop
Factor:
KVO
Ø Use
the
smallest
suction
catheter
if
possible
Ø Duration:
RBC
–
4
hours;
Ø Client
should
be
in
semi
or
high
Fowler’s
position
Platelets,
FFP
–
20
minutes
Ø Use
sterile
gloves,
sterile
suction
catheter
Ø When
reactions
occurs:
Ø Hyperventilate
client
with
100%
oxygen
before
ü STOP
transfusion
and
after
suctioning
ü KVO
with
PNSS
Ø Insert
catheter
with
gloved
hand
(3-­‐5“
length
of
ü Send
remaining
blood,
a
sample
of
client
blood
catheter
insertion)
without
applying
suction.
Three
and
urine
sample
to
the
laboratory.
passes
of
the
catheter
is
the
maximum,
with
10
ü Notify
the
physician
seconds
per
pass.
ü Monitor
VS
Ø Apply
suction
only
during
withdrawal
of
catheter
ü Monitor
I
&
O
Ø The
suction
pressure
should
be
limited
to
less
than
Ø Common
BT
reactions:
120
mmHg
ü Hemolytic:
flank
/back
pain
Ø When
withdrawing
catheter
rotate
while
applying
ü Anaphylactic:
rashes,
itching,
DOB
(worst)
intermittent
suction
ü Febrile:
fever
and
chills
Ø Suctioning
should
take
only
10
seconds
(maximum
ü Circulatory
Overload:
DOB,
crackles
of
15
seconds)
ü Sepsis:
Fever
and
chills
K.
Assistive
Device
I.
Tracheostomy
Care
Ø Canes
Ø Assist
the
client
to
a
semi-­‐Fowler’s
or
Fowlers
ü COAL
(cane
opposite
affected
leg)
position.
ü Angel
is
20-­‐30
degrees
Ø Hydrogen
peroxide
moisten
and
loosens
dried
Ø Walkers
secretions
ü Hand
bar
below
the
client’s
waist
and
the
elbow
Ø Rinse
the
inner
cannula
thoroughly
in
the
sterile
is
slightly
flexed.
normal
saline.
Ø Crutches
Ø When
changing
the
ties:
tie
one
end
of
the
new
tie
to
ü Length
of
the
Crutches:
Subtract
40
cm
or
16
the
eye
of
the
flange
while
leaving
old
ties
in
place.
inches
to
the
height
of
the
client
obtain
the
Ø Put
two
fingers
under
the
tapes
before
tying
it.
approximate
crutch
length.
ü 20
to
30
degrees
of
flexion
at
the
elbow.
ü Four
point
gait:
J.
Blood
Transfusion
*
right
crutch,
the
left
foot,
the
left
crutch,
right
foot.
Compatible
Incompatible
ü Two
point
gait:
A
A
/
O
AB
/
B
*
left
foot
and
right
crutch,
right
foot
and
left
B
B
/
O
AB
/
A
crutch
AB
A
/
B
/
AB
/
O
ü Three
point
gait:
O
O
A
/
B
/
AB
*
left
foot
and
both
crutches,
right
foot.
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE

6. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
ü Swing
Through
Gait:
.
ü Observe
for
fluctuation
of
fluid
along
the
tube
*
Advance
both
crutches,
Lift
both
feet
and
swing
(water-­‐seal
bottle
or
the
second
bottle)
and
forward,
Land
the
feet
in
front
of
crutches.
intermittent
bubbling
with
each
respiration.
• Three-­‐bottle
system
ü Going
up
the
stairs:
(good
goes
to
heaven,
bad
goes
to
hell)
L.
Chest
Physiotheraphy
(
CPT
)
Ø Steam
Inhalation
ü Place
the
client
in
Semi-­‐Fowler’s
position
ü Cover
the
client’s
eyes
with
washcloth
to
prevent
irritation
ü Place
the
steam
inhalator
in
a
flat,
stable
surface.
ü Place
the
spout
12
–
18
inches
away
from
the
client’s
nose
or
adjust
distance
as
necessary
ü To
be
effective,
render
steam
inhalation
therapy
for
15
–
20
minutes
Ø Postural
drainage
ü Use
of
gravity
to
aid
in
the
drainage
of
ü The
first
bottle
is
the
drainage
bottle;
secretions.
ü The
second
bottle
is
water
seal
bottle
ü Patient
is
placed
in
various
positions
to
ü The
third
bottle
is
suction
control
bottle.
promote
flow
of
drainage
from
different
lung
segments
using
gravity.
ü Observe
for
intermittent
bubbling
and
ü Areas
with
secretions
are
placed
higher
than
fluctuation
with
respiration
in
the
water-­‐
lung
segments
to
promote
drainage.
seal
bottle
ü Patient
should
maintain
each
position
for
5-­‐15
ü Continuous
GENTLE
bubbling
in
the
suction
minutes
depending
on
tolerability.
control
bottle.
ü Suspect
a
leak
if
there
is
continuous
bubbling
in
the
WATER
seal
bottle
or
if
there
is
M.
Closed
Chest
Drainage
(
Thoracostomy
Tube
)
VIGOROUS
bubbling
in
the
suction
control
bottle.
Types
of
Bottle
Drainage
ü The
nurse
should
look
for
the
leak
and
report
the
observation
at
once.
Never
clamp
the
• One-­‐bottle
system
tubing
unnecessarily.
ü The
bottle
serves
as
drainage
and
water-­‐seal
ü If
there
is
NO
fluctuation
in
the
water
seal
ü Immerse
tip
of
the
tube
in
2-­‐3
cm
of
sterile
bottle,
it
may
mean
TWO
things
NSS
to
create
water-­‐seal.
ü Either
the
lungs
have
expanded
or
the
ü Keep
bottle
at
least
2-­‐3
feet
below
the
level
of
system
is
NOT
functioning
appropriately.
the
chest
ü In
this
situation,
the
nurse
refers
the
ü Observe
for
fluctuation
of
fluid
along
the
tube.
observation
to
the
physician,
who
will
order
The
fluctuation
synchronizes
with
the
for
an
X-­‐ray
to
confirm
the
suspicion.
respiration.
ü In
the
event
that
the
water
seal
bottle
ü Observe
for
intermittent
bubbling
of
fluid;
breaks,
the
nurse
temporarily
kinks
the
tube
continues
bubbling
means
presence
of
air-­‐leak
and
must
obtain
a
receptacle
or
container
with
sterile
water
and
immerse
the
tubing.
In
the
absence
of
fluctuation:
ü She
should
obtain
another
set
of
sterile
bottle
Suspect
obstruction
of
the
device
as
replacement.
She
should
NEVER
CLAMP
v Assess
the
patient
first,
then
if
patient
is
stable
the
tube
for
a
longer
time
to
avoid
tension
v Check
for
kinks
along
tubing;
pneumothorax.
v Milk
tubing
towards
the
bottle
(If
the
hospital
ü In
the
event
the
tube
accidentally
is
pulled
allows
the
nurse
to
milk
the
tube)
out,
the
nurse
obtains
vaselinized
gauze
and
v If
there
is
no
obstruction,
consider
lung
re-­‐
covers
the
stoma.
expansion;
(validated
by
chest
x-­‐ray)
ü She
should
immediately
contact
the
v Air
vent
should
be
open
to
air.
physician.
• Two-­‐bottle
system
ü If
not
connected
to
the
suction
apparatus
ü The
first
bottle
is
drainage
bottle;
ü The
second
bottle
is
water-­‐seal
bottle
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE

7. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY
2012
PNLE
PEARLS
OF
SUCCESS
PART
1:
FUNDAMENTALS
OF
NURSING
N.
Oxygen
Therapy
Ø Nasal
Cannula
(24%
-­‐
45%
)
at
flow
rate
of
2
–
6
L/min.
Ø Simple
Face
Mask
(40%
-­‐
60%)
at
liter
flows
of
5
-­‐
8
L/min
Ø Partial
Rebreather
Mask
(60%
-­‐
90%)
at
liter
flows
of
6
–
10
L/min.
Ø Non-­‐Rebreather
Mask
(95%
-­‐
100%)
at
liter
flows
of
10
–
15
L/min.
Ø Oxygen
is
colorless,
odorless,
tasteless
and
a
dry
gas
that
support
combustion,
therefore
leakage
cannot
be
detected.
Ø Place
cautionary
signs
reading
“
No
SMOKING:
Oxygen
in
Use”
Ø Avoid
materials
that
generate
static
electricity,
such
as
woolen
blankets
and
synthetic
fibers.
Ø Set
up
the
oxygen
equipment
and
the
humidifier
filled
with
distilled/sterile
water.
Ø CANNULA:
Put
over
the
client’s
face,
with
the
outlet
prongs
fitting
into
the
nares.
Ø FACE
MASK:
Fit
the
mask
to
the
contours
of
the
client’s
face,
apply
it
from
the
nose
downward
POSSIBLE
TOPICS
ON
FUNDAMENTALS
OF
NURSING
FOR
THE
UPCOMING
JULY
2012
PNLE
*Patterned
on
the
previous
board
exams
from
December
2006
–
December
2011…
the
purpose
of
this
note
is
to
GUIDE
students
on
the
possible
topics
that
might
be
part
of
the
upcoming
July
2012
PNLE