10/19/23, 10:09 AM Midterm Nursing Integration (2023)
MIDTERM NURSING INTEGRATION (2023)
1. TPN care: IV pump required, change tubing and bag every 24h, do not add medications,
Lipids piggybacked in TPN
• COMPLICATIONS: hyperglycemia, infection. Monitor weight, I&O, and electrolytes.
2. BENEFICENCE: to do good, to prevent or remove harm or evil = best interests of the client.
3. INFORMED CONSENT: Client’s acknowledgment and acceptance of medical treatment.
• REQUIRES explanation, alternatives, and risk factors of the procedure.
• INFORMED CONSENT IS VALID: 18 years or emancipated minor, mental capacity to
consent.
• ROLE OF NURSING: The client signs the consent voluntarily.
• The client understand the procedure
• The client does not have further questions
4. LIVING WILL: this is a legal document that expresses the client's wishes regarding
medical treatment in the event the client becomes incapacitated and is facing end-of-
life issues.
5. POWER OF ATTORNEY: A legal document that appoints a person or persons chosen by the
client to carry out his or her wishes about health care, or to make decisions on the client’s
behalf when he or she is no longer able to do so.
6. DELEGATION OF LPN: Stable patient with a predictable outcome.
• Monitoring client findings (as input to the RN’s ongoing assessment of the client).
• Reinforcing client teaching from a standard care plan.
• Performing tracheostomy care and suctioning.
• Suctioning.
• Checking nasogastric tube patency.
• Administrating enteral feedings.
• Inserting a urinary catheter.
• Administrating medication (excluding intravenous medications in several states)
• Wound care.
7. DELEGATION OF UAP: Activities of daily living (ADLs)
• Bathing
• Grooming
• Dressing
• Toileting
• Ambulating (never a first time after surgery)
• Feeding (without swallowing precautions)
• Positioning
• Bed making
• Specimen collection
• Intake and output (I&O)
• Vital signs (for stable clients)
• BLOOD TRANSFUSION STEPS: informed consent, 18-19 G catheter, Y set with filter
primed with NS, verify with other RN, initiate within 30 min received blood, not add
medication, begin at 2ml/h, check BS every 5 min for 15-30 min, administer within less
than 4h.
8. MRSA PRECAUTIONS: contact: wear gloves and a gown.
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, 10/19/23, 10:09 AM Midterm Nursing Integration (2023)
9. RESTRAINS PROTOCOLS: needs physician order, PRN prescriptions are not allowed, informed
consent is required, renew every 24h.
10. TRACHEOSTOMY CARE: observe for excess secretions, air obstruction, and coughing,
remove thesoiled dressing, after disconnecting remove the inner tube for cleaning, clean
exposed parts of the outer tube, without removing the trach tube install new ties and
removed the old ones.
11. Thrombophlebitis Nursing Interventions: warm compresses
12. Chemotherapy and certain foods to avoid:
• Hot, spicy (hot pepper, curry, Cajun)
• High fiber (raw fruit and vegetables, coarse whole grain)
• Fatty, greasy, or fried foods
• Rich deserts
• Nuts, seeds, or dried fruits.
13. Endotracheal Tube (Care and measurement): Observe for right bronchi mono-intubation,
Mark incisor tooth or lip line, reposition side to side, Check cuff pressure frequently: 15 -
20 mmHg, Drain condensate water in the tubing.
14. Steven Johnson Syndrome signs and symptoms/Precautions: tiredness, lethargy, headache,
fever, rash, blisters, flu-like
• Prevention: avoid the medications that trigger it.
15. Placenta Previa: bright red and painless bleeding
16. PLACENTA ABRUPTIA: dark red, painful bleeding
17. NONSTRESS TEST: fetal heart rate monitoring.
• REACTIVE: two or more decelerations of 15 bpm lasting 15 seconds over 20 min
• NON-REACTIVE: test does not meet the criteria after 40 min (if the baby is sleeping try
the testfor 20 min more).
18. Variable Decelerations: the shapes vary V, U, or W. Can be not necessarily be associated
withthe mother’s contractions, abrupt <30 sec from onset to nadir
• ETIOLOGY: cord compression, oligohydramnios, cord prolapse.
19. Mastitis Nursing Interventions: Instruct the mother in breast hygiene measures.
• Apply heat or cold to the site as prescribed.
• Maintain lactation in a breastfeeding mother.
• Encourage manual expression of breast milk or use of a breast pump every 4 hours.
• Support her breasts with a supportive bra.
• Administer analgesics or antibiotics as prescribed
20. G- GRAVITY
a. T- TERM BIRTHS (PAST 38 WEEKS)
b. P- PRETERM (20-37 WEEKS)
c. A-ABORTIONS
d. L- CURRENT LIVING CHILDREN
21. FUNDUS LOCATION: 12-14 weeks: slightly above the symphysis pubis.
• 16 weeks: between the symphysis pubis and umbilicus
• 20-22 weeks: level of the umbilicus
• 36 weeks: at the xiphoid process
22. Subinvolution: Incomplete involution or failure of the uterus to return to its normal size and
condition after delivery.
about:blank 2/13
MIDTERM NURSING INTEGRATION (2023)
1. TPN care: IV pump required, change tubing and bag every 24h, do not add medications,
Lipids piggybacked in TPN
• COMPLICATIONS: hyperglycemia, infection. Monitor weight, I&O, and electrolytes.
2. BENEFICENCE: to do good, to prevent or remove harm or evil = best interests of the client.
3. INFORMED CONSENT: Client’s acknowledgment and acceptance of medical treatment.
• REQUIRES explanation, alternatives, and risk factors of the procedure.
• INFORMED CONSENT IS VALID: 18 years or emancipated minor, mental capacity to
consent.
• ROLE OF NURSING: The client signs the consent voluntarily.
• The client understand the procedure
• The client does not have further questions
4. LIVING WILL: this is a legal document that expresses the client's wishes regarding
medical treatment in the event the client becomes incapacitated and is facing end-of-
life issues.
5. POWER OF ATTORNEY: A legal document that appoints a person or persons chosen by the
client to carry out his or her wishes about health care, or to make decisions on the client’s
behalf when he or she is no longer able to do so.
6. DELEGATION OF LPN: Stable patient with a predictable outcome.
• Monitoring client findings (as input to the RN’s ongoing assessment of the client).
• Reinforcing client teaching from a standard care plan.
• Performing tracheostomy care and suctioning.
• Suctioning.
• Checking nasogastric tube patency.
• Administrating enteral feedings.
• Inserting a urinary catheter.
• Administrating medication (excluding intravenous medications in several states)
• Wound care.
7. DELEGATION OF UAP: Activities of daily living (ADLs)
• Bathing
• Grooming
• Dressing
• Toileting
• Ambulating (never a first time after surgery)
• Feeding (without swallowing precautions)
• Positioning
• Bed making
• Specimen collection
• Intake and output (I&O)
• Vital signs (for stable clients)
• BLOOD TRANSFUSION STEPS: informed consent, 18-19 G catheter, Y set with filter
primed with NS, verify with other RN, initiate within 30 min received blood, not add
medication, begin at 2ml/h, check BS every 5 min for 15-30 min, administer within less
than 4h.
8. MRSA PRECAUTIONS: contact: wear gloves and a gown.
about:blank 1/13
, 10/19/23, 10:09 AM Midterm Nursing Integration (2023)
9. RESTRAINS PROTOCOLS: needs physician order, PRN prescriptions are not allowed, informed
consent is required, renew every 24h.
10. TRACHEOSTOMY CARE: observe for excess secretions, air obstruction, and coughing,
remove thesoiled dressing, after disconnecting remove the inner tube for cleaning, clean
exposed parts of the outer tube, without removing the trach tube install new ties and
removed the old ones.
11. Thrombophlebitis Nursing Interventions: warm compresses
12. Chemotherapy and certain foods to avoid:
• Hot, spicy (hot pepper, curry, Cajun)
• High fiber (raw fruit and vegetables, coarse whole grain)
• Fatty, greasy, or fried foods
• Rich deserts
• Nuts, seeds, or dried fruits.
13. Endotracheal Tube (Care and measurement): Observe for right bronchi mono-intubation,
Mark incisor tooth or lip line, reposition side to side, Check cuff pressure frequently: 15 -
20 mmHg, Drain condensate water in the tubing.
14. Steven Johnson Syndrome signs and symptoms/Precautions: tiredness, lethargy, headache,
fever, rash, blisters, flu-like
• Prevention: avoid the medications that trigger it.
15. Placenta Previa: bright red and painless bleeding
16. PLACENTA ABRUPTIA: dark red, painful bleeding
17. NONSTRESS TEST: fetal heart rate monitoring.
• REACTIVE: two or more decelerations of 15 bpm lasting 15 seconds over 20 min
• NON-REACTIVE: test does not meet the criteria after 40 min (if the baby is sleeping try
the testfor 20 min more).
18. Variable Decelerations: the shapes vary V, U, or W. Can be not necessarily be associated
withthe mother’s contractions, abrupt <30 sec from onset to nadir
• ETIOLOGY: cord compression, oligohydramnios, cord prolapse.
19. Mastitis Nursing Interventions: Instruct the mother in breast hygiene measures.
• Apply heat or cold to the site as prescribed.
• Maintain lactation in a breastfeeding mother.
• Encourage manual expression of breast milk or use of a breast pump every 4 hours.
• Support her breasts with a supportive bra.
• Administer analgesics or antibiotics as prescribed
20. G- GRAVITY
a. T- TERM BIRTHS (PAST 38 WEEKS)
b. P- PRETERM (20-37 WEEKS)
c. A-ABORTIONS
d. L- CURRENT LIVING CHILDREN
21. FUNDUS LOCATION: 12-14 weeks: slightly above the symphysis pubis.
• 16 weeks: between the symphysis pubis and umbilicus
• 20-22 weeks: level of the umbilicus
• 36 weeks: at the xiphoid process
22. Subinvolution: Incomplete involution or failure of the uterus to return to its normal size and
condition after delivery.
about:blank 2/13
