Comprehensive PNLE Nursing Pre-board Study Guide

Clinical Prioritization and Nursing Triage

• Prioritizing Clients after Endorsement:

  • In a clinical setting, a client with a Myocardial Infarction (MI) complaining of nausea must be seen first. Nausea is a critical symptom of impending or worsening MI; immediate assessment allows for rapid treatment to avoid further cardiac muscle damage.

  • Other high-priority assessments incluyen saturations of dressings (e.g., serosanguinous fluid on a 3-day post-op abdominal hysterectomy dressing) and IV infiltrations in dehydrated patients.

• Emergency Triage Categories:

  • Emergent: Life-threatening conditions requiring immediate intervention (e.g., chest pain, diaphoresis, dizziness, or airway obstruction).

  • Urgent: Conditions needing treatment within approximately 2 hours (e.g., kidney stones or moderate abdominal pain).

  • Non-urgent: Conditions where treatment can be delayed for 24-48 hours (e.g., simple ankle twists with intact pulses).

• Primary Trauma Survey Priority Elements:

  • The primary survey focuses on immediate life preservation. A brief neurologic assessment to determine the level of consciousness and pupil reaction is a priority element.

  • Vital signs and detailed abdominal exams are typically part of the secondary survey.

Fundamental Patient Safety and Care Procedures

• Restraint Management:

  • For clients in four-point restraints, the nurse must check circulation every $15-30$ minutes. Because restraints encircle limbs, there is a high risk of restricted blood flow to distal areas; frequent checks allow for adjustments before injury occurs.

• Body Positioning and Spinal Injury:

  • After spinal anesthesia, the client must be positioned flat on their back (supine) for $4-12$ hours to prevent a spinal headache. This headache is caused by the leakage of cerebrospinal fluid (CSF) from the puncture site; a flat position equalizes CSF pressure.

  • For Post-Laminectomy, the nurse must logroll the client to maintain the spinal column in a straight alignment during turning.

  • For Thoracotomy (Partial Pneumonectomy): Position the client on the opposite unoperated side or back in Fowler's position to facilitate ventilation and promote the expansion of the remaining lung tissue.

• Wound and Skin Care:

  • Wound Evisceration: If wound dehiscence with evisceration occurs (e.g., after colon resection), the first response is to place a saline-soaked sterile dressing on the wound to prevent tissue drying and infection.

  • External Rotation Deformity: To prevent hip rotation deformity in bed-bound patients, use a trochanter roll extending from the crest of the ileum to the mid-thigh.

  • Pressure Ulcer Stages:

    • Stage I: Non-blanchable erythema. Management includes normal saline cleansing and protective dressings.

    • Stage III: Ulcer extends into the subcutaneous tissue, often appearing as a deep crater.

  • Wound Healing: "Second intention" healing occurs when wound edges are not surgically approximated and continuity is restored by granulations.

Cardiovascular and Respiratory Nursing

• Myocardial Infarction (MI) and Preload:

  • Nitroglycerin reduces preload and relieves angina by decreasing venous return through vasodilation. This reduces the workload on the heart.

  • Cardiogenic Shock Signs: Low blood pressure (e.g., $80/60$), rapid/weak/irregular pulse (e.g., $110\text{ bpm}$), cold/clammy skin, and decreased urinary output.

• Respiratory Management:

  • COPD Oxygen Administration: Administer oxygen at low rates ($1-2\text{ L/min}$). Chronic $CO_2$ retention renders the medulla insensitive to $CO_2$; therefore, the client’s hypoxic state becomes the primary stimulus for breathing. High oxygen levels can abolish this "hypotic drive."

  • Pneumothorax and Chest Tubes:

    • A tension pneumothorax can be caused by a kinked or obstructed chest tube.

    • To prevent air leaks, check and tape all connections securely.

    • Drainage systems must remain below the level of the chest.

  • Suctioning/Airway: If a neonate gags and turns dusky, the priority is to aspirate the nose and mouth with a bulb syringe to clear the airway.

• Arterial Blood Gas (ABG) Interpretations:

  • Metabolic Acidosis: Low pH (e.g., $7.20$) and low $HCO_3$ (e.g., $19\text{ mEq/L}$).

  • Respiratory Acidosis: Low pH (e.g., $7.30$) and high $PaCO_2$ (e.g., $50\text{ mmHg}$).

Maternal and Child Health Nursing

• Pregnancy Complications:

  • Hydatidiform Mole: Associated with elevated levels of human chorionic gonadotropin (hCG), vaginal bleeding, and a uterus larger than normal for gestational age. It is unassociated with fetal activity (no fetus present).

  • Placenta Previa: Characterized by painless vaginal bleeding in the third trimester. Diagnosis is confirmed via ultrasound; digital exams are contraindicated as they may cause hemorrhage.

  • Ectopic Pregnancy: Focus is on identifying hypovolemic shock. The nurse must monitor the apical pulse (elevated pulse is a sign of shock).

  • Diabetes in Pregnancy: The second half of pregnancy requires increased insulin because placental hormones increase insulin resistance (the diabetogenic effect).

• Induction and Labor:

  • Oxytocin (Pitocin): Discontinue infusion if contractions occur every $1.5$ minutes or last $70-80$ seconds, as this indicates hyperstimulation risks.

  • Magnesium Sulfate: Used to prevent seizures in preeclampsia. The antidote is Calcium Gluconate, which must be administered if patellar reflexes are absent or if respiratory depression occurs. Continuous EKG monitoring is required during Calcium Gluconate administration to check for cardiac arrest.

  • Fetal Station: "Station plus two" means the presenting part is $2\text{ cm}$ below the plane of the ischial spines.

• Neonatal and Pediatric Care:

  • Cleft Lip/Palate Repair: Use soft elbow restraints to prevent the infant from touching the operative site. Avoid placing pacifiers or spoons in the mouth.

  • Congenital Heart Defects:

    • Patent Ductus Arteriosus (PDA): Characterized by a loud, machinery-like murmur.

    • Down Syndrome: Often associated with endocardial cushion defects.

  • SIDS Prevention: Infants should sleep in a supine position (on the back).

Community Health Nursing and Infectious Diseases

• Public Health Nursing (PHN):

  • The primary focus is preventive, not curative, services.

  • Efficiency in programs (like Ligtas Tigdas) is measured by whether goals were attained at the least possible cost.

  • Midwife Ratios: Each rural health midwife is assigned to a population of approximately $5,000$.

• Infectious Diseases:

  • Leprosy (Hansen's Disease): Early signs include thickened, painful nerves and macular lesions with loss of sensation and sweating. Multibacillary leprosy is defined as having a positive slit skin smear and at least $5$ skin lesions.

  • Tuberculosis (TB): Symptoms include low-grade fever, night sweats, chills, and hemoptysis (blood-tinged sputum). A Mantoux test (PPD) is positive if an indurated wheal over $10\text{ mm}$ appears within $48-72$ hours.

  • Leptospirosis: Suspected when a patient has a fever, muscle pain, and yellowish discoloration of the sclera after wading in flood waters.

  • Cholera: Characterized by profuse "rice water" stools.

• Expanded Program on Immunization (EPI):

  • BCG Vaccine: Must be discarded $4$ hours after reconstitution.

  • DPT Vaccine: Sensitive to freezing; must be stored at $2$ to $8^{\circ}C$.

  • Measles (Ligtas Tigdas): Targeted for eradication via Presidential Proclamation No. 4. The pathognomonic sign is Koplik’s spots on the buccal mucosa.

Nursing Research and Management

• Leadership Styles:

  • Autocratic: Task-oriented and directive.

  • Benevolent-Authoritative: Managers show condescending trust and confidence in subordinates.

  • Functional Nursing: Concentrates on tasks and activities (e.g., one nurse for meds, one for treatments) rather than comprehensive patient care.

• Research Principles:

  • Reliability: The ability of an instrument to yield the same results upon repeated administration.

  • Validity: The ability of the instrument to measure what it intends to measure.

  • Hawthorne Effect: Subjects perform differently because they know they are being observed.

  • Anonymity: Ensured by keeping the identities of subjects secret and not linking information to the source.

  • Sampling: "Random sampling" gives every unit an equal chance of being picked. "Judgment sampling" involves selecting samples based on the investigator's existing knowledge of the participants.

Pharmacology and Medical Formulas

• Medication Orders:

  • Zeroes: Always place a zero before a decimal point (e.g., $0.125\text{ mg}$) to prevent dosage errors, but never place a trailing zero after a decimal (e.g., never $0.1250\text{ mg}$).

• Common Medications and Implications:

  • Warfarin (Coumadin): Monitor via PT/INR. Antidote: Vitamin K.

  • Heparin: Monitor via PTT. Therapeutic level is $1.5$ to $2$ times the normal range ($30-45$ seconds).

  • Loop Diuretics (e.g., Furosemide): Can cause Hypokalemia (low potassium).

  • Insulin: An "Unit" is a measure of effect, not a standard weight. Peak for NPH ($7:00\text{ AM}$ dose) is usually around $4:00\text{ PM}$ ($8-12$ hours later).

  • Morphine: Avoid IM route in patients with low platelet counts (e.g., $22,000/\mu\text{l}$) to prevent bleeding; IV is preferred.

• Dosage and IV Calculations:

  • Temperature Conversion:         $\text{Temp in } ^{\circ}C = \frac{(\text{Temp in } ^{\circ}F - 32)}{1.8}$

  • Example: $102^{\circ}F$ is approx $38.9^{\circ}C$.

  • IV Flow Rate:         $\text{Rate (gtt/min)} = \frac{\text{Volume (ml)} \times \text{Drop Factor}}{\text{Time (min)}}$

  • Example: $2\text{ liters}$ over $12\text{ hours}$ with $10\text{ gtt/ml}$ factor:         $\frac{2000 \times 10}{12 \times 60} = 27.77 \approx 28\text{ gtt/min}$.

Psychiatric Nursing

• Disorders and Interventions:

  • Anxiety Attack: Use short sentences, stay with the client, and decrease stimuli.

  • Alcohol Withdrawal: The only effective treatment for addiction is total abstinence. Withdrawal symptoms (tremors, diaphoresis) are managed with benzodiazepines like Lorazepam (Ativan).

  • Schizophrenia: "Loose associations" occur when thoughts are presented without logical connections.

  • Obsessive-Compulsive Disorder (OCD): Rituals are a defense mechanism to control anxiety and guilt. Nurses should designate specific times for the behavior and gradually encourage reduction.

  • Bulimia Nervosa: Management requires monitoring during and after meals to prevent vomiting and identifying anxiety-producing triggers.

  • Post-Traumatic Stress Disorder (PTSD): The distinguishing symptom is re-experiencing the trauma through dreams or flashbacks.