This document provides an overview of possible topics that may be covered on the fundamentals of nursing portion of the upcoming December 2012 Philippine Nurse Licensure Examination (PNLE). It outlines 14 areas that could be tested, including nursing theorists, the nursing process, health concepts, infection control, nutrition, and common nursing skills. For each area, key concepts and terms are defined to guide students in their preparation for exam questions related to fundamentals of nursing.

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

2. WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 1: FUNDAMENTALS OF NURSING
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
V. HEALTH / DISEASE / ILLNESS
 Health is the complete physical, mental, social (totality)
well-being and not merely the absence of disease or
infirmity.
FOUR MODELS OF HEALTH BY SMITH
1. Clinical Model
 Man is viewed as a Physiologic Being
 If there are no signs and symptoms of a disease, then
you are healthy
2. Role Performance Model
 As long as you are able to perform SOCIETAL
functions and ROLES you are healthy
3. Adaptive Model
 Health is viewed in terms of capacity to ADAPT
 Failure to adapt is disease
4. Eudaemonistic Model
 Because health is viewed in terms of Actualization
 Disease is a pathologic change in the structure or function
of the mind and body
 Illness is a highly subjective feeling of being sick or ill
STAGES OF ILLNESS AND HEALTH-SEEKING BEHAVIOR BY
SUCHMAN
 Symptom Experience
Client realizes there is a problem
Client responds emotionally
 Sick Role Assumption
Self-medication / Self-treatment
Communication to others
 Assuming a Dependent Role
Accepts the diagnosis
Follows prescribed treatment
 Achieving recovery and rehabilitation
Gives up the dependent role and assumes
normal activities and responsibilities
VI. CHAIN OF INFECTION
► MODE OF TRANSMISSION it indicates the potential of the
disease; conveyance of the agent to the host; it can be by
common source transmission, contact source, air-borne
transmission.
There are four main routes of transmission
A. By Contact Transmission
1. Direct contact ( person to person )
2. Indirect contact ( usually an inanimate object)
3. Droplet contact ( from coughing, sneezing, or
talking, or talking by an infected person)
B. By Vehicle Route ( through contaminated items)
1. Food – salmonellosis
2. Water – shigellosis, legionellosis
3. Drugs – bacteremia resulting from infusion of a
contaminated infusion product
4. Blood – hepatitis B,
C. Airborne Transmission
1. Droplet of nuclei
2. Dust particle in the air containing the infectious
agent
3. Organisms shed into environment from skin, hair,
wounds or perineal area.
D. Vector borne Transmission, arthropods such as
flies, mosquitoes, ticks and others.
VII. ISOLATION PRECAUTIONS
 Standard Precautions / Universal Precautions
 Applies to ALL BODY FLUIDS
 Includes:
1. HAND WASHING
2. Personal Protective Equipment
(sequence of removing PPE’s)
gloves-mask-gown-eyewear-cap
3. Safe use of sharps
4. Removing spills of blood and body fluids
5. Cleaning and disinfecting equipment
 Transmission Based Precautions
• Airborne precautions
 A single room under negative pressure
ventilation with a wash hand basin
 The door must be kept closed at all times except
during necessary entrances and exits.
 Disposable paper towels
 A high efficiency mask, if available, should be
worn when entering the room of a patient with
known or suspected tuberculosis.
• Droplet precautions
 Put on a standard mask prior to entering the
isolation room.
 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:
1. AFTER contact with the patient or
potentially contaminated items,
2. AFTER removing gloves, and
3. BEFORE taking care of another patient.
• Contact precautions
 Non-sterile, disposable gloves are needed when
there is contact with an infected site, with
dressings, or with secretions.
 A mask when performing procedures that may
generate aerosols or when performing
suctioning is recommended.
 Hands washing (see droplet precautions)
VIII. NUTRITION
Food Sources
Protein Meat, fish, eggs, milk, poultry, cheese,
beans, mongo
Carbohydrates Grains, Legumes, Potatoes, Cereals,
Breads
Fats / Lipids Saturated: coconut oil, and palm kernel
oil, dairy products (especially butter, ,
cream, and cheese), meat (beef), dark
meat of poultry, and poultry skin,
chocolate
Unsaturated: Avocado, Nuts, Vegetable
oils such as soybean, canola, and olive oils
Vit. A Eggs, carrots, squash, all green leafy
vegetables
Vit. D Fish, liver, egg, milk, margarine
Note: excess vit.D may lead to fetal cardiac
problem
Vit. E Green leafy vegetables, fish, corn

3. WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 1: FUNDAMENTALS OF NURSING
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
Vit.K Leafy green vegetables, particularly the
dark green ones such as: Spinach,
Broccoli, Malunggay, Avocado
Vit. C Tomatoes, guava, papaya, citrus fruits
Folic Acid Asparagus, organ meat, green leafy
vegetables
Vit. B ( foods rich in protein )
Calcium and
Phosphorus
Milk, cheese, green leafy vegetables,
whole grains, seafood, tofu
Iron Pork liver, lean meat, kamote leaves,
soybeans, seaweeds, mongo
Iodine Iodized salt, seafood, milk, egg, bread
IX. NURSING SKILLS
A. Hygiene
 A complete bed bath consists of washing a dependent
client’s entire body in bed; a complete bed bath with
assistance involves helping the client to wash.
 A partial bed bath consists of or buttocks that may cause
discomfort or odor if le washing only parts of the client’s
body such as feet ft unwashed.
 A tub bath or shower provides a more thorough
cleansing than a bed bath; the amount of nursing
assistance is determined by the client’s age and health
and safety consideration.
 A therapeutic bath is ordered by a physician for a
specific purpose.
Therapeutic baths include:
 Sitz bath – to reduce inflammation and clean the
perineal area.
 Tepid sponge bath – to reduce fever.
 Medicated tub bath – to relieve skin irritation.
Nursing Consideration
 Avoid unnecessary exposure and chilling.
Expose, wash, rinse and dry only a part of the
body at one time.
Avoid draft
Use correct temperature of water.
 Observe the patient’s body closely for physical signs
such as rashes, swelling, discoloration, sore, burns etc.
 Give special attention to the following body areas;
behind the ears, axilla, under the breast, umbilicus,
pubic region, groin and spaces between the fingers
and toes.
 Do the bath quickly but unhurriedly, use even, smooth
but firm strokes.
 Use adequate amount of water and change as
frequently as necessary.
 If possible, do such procedure as vaginal douche,
enema, shampoo, oral care etc. before bath.
B. Physical Assessment
 Provide privacy.
 Make sure that all needed instruments are available
before starting the physical assessment
 Be systematic and organized when assessing the client.
Inspection, Palpation, Percussion, Auscultation.
 EYES: Visual acuity is tested using a snellen chart. The
room used for this test should be well lighted
 EARS: Weber’s Test assesses bone conduction, this is a
test of sound lateralization, Rinne Test compares bone
conduction with air condition.
 NECK: Let the client sit on a chair while the examiner
stands behind him.
 THORAX: The client should be sitting upright without
support and uncovered to the waist.
 HEART: Anatomic areas for auscultation of the heart
 Aortic valve – Right 2nd ICS sternal border.
 Pulmonic Valve – Left 2nd ICS sternal border.
 Tricuspid Valve – – Left 5th ICS sternal border.
 Mitral Valve – Left 5th ICS midclavicular line
 BREAST
 ABDOMEN: Place the client in a supine position with the
knees slightly flexed to relax abdominal muscles.
(Inspection,Auscultation,Percussion,Auscultation)
C. Vital Signs
 Temperature (NV 36 – 37.5 C)
 Elderly people are at risk of hypothermia
 Hard work or strenuous exercise can increase
body temperature
 Oral: most accessible 2-3 mins. * 15 minutes
interval after ingestion of hot or cold drinks
 Rectal: most accurate 2-3 mins.
 Axillary: most safest 6-9 mins.
 Pulse (NV 60-100 bpm)
 Wave of blood created by contraction of the left
ventricle of the heart
 Radial: best site for adult
 Brachial: best site for children
 Apical: best site for 3 years old below
 Respiration (NV 12/16-20)
Normal Breath Sound
Vesicular Soft, low pitch Lung periphery
Broncho-
vesicular
Medium pitch Larger airway
blowing
Bronchial Loud, high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random, sudden
reinflation of alveoli
fluids
Rhonchi Trachea, bronchi Fluids, mucus
Wheezes All lung fields Severely narrowed
bronchus
Pleural
Friction Rub
Lateral lung field Inflamed Pleura
 Blood Pressure (NV 120/80 mm/hg)
 This is the force exerted by the blood against a
vessel wall
 The pressure rises with age.
 A rest of 30 minutes is indicated before the blood
pressure can be readily assessed after stressful
activity.
 Interval of 30 minutes is needed after smoking or
drinking caffeine.
 After menopause, women generally have higher
blood pressures than before.
 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

4. WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 1: FUNDAMENTALS OF NURSING
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
Common Errors in Blood Pressure Assessment
Errors Effect
Bladder cuff too narrow Erroneously high
Bladder cuff too wide Erroneously high
Arm unsupported Erroneously high
Insufficient rest before the
assessment
Erroneously high
Repeating assessment too
quickly
Erroneously high
Cuff wrapped too loosely or
unevenly
Erroneously low
Deflating cuff too quickly Erroneously low systolic and
high diastolic reading
Deflating cuff too slowly Erroneously high diastolic
reading
Failure to use the same arm
consistently
Inconsistent measurements
Arm above level of the heart Erroneously low
Assessing immediately after a
meal or while client smokes
Erroneously high
Failure to identify
auscultatory gap pressure
Erroneously low systolic
pressure and erroneously low
diastolic
D. Medication Administration
 FIVE RIGHTS
The Right Drug with
The Right Dose through
The Right Route at
The Right Time to
The Right Patient
 Standard Order, Carried out until cancelled by another
order.
 PRN Order, As needed, or only when necessary.
 Stat Order, Carried out immediately and for one time
only.
 Always clarify doubtful /unclear order
 Do not leave medicine with the client to take by himself
 Do not give drug that shows physical changes or
deterioration
 Report an error in medication immediately to the nurse
in charge.
 Check medication 3 times before taking to the client:
o When taking the medication from the storage area
o Before placing medication into the medicine
rack/glass
o Before placing medicine to the storage area
 The nurse who prepares the medication must be
responsible for administering and recording it. Never
endorse it to another nurse.
 Always observe asepsis in preparing and administering
drugs.
 Ascertain client’s identity before administering
medications. Check room or bed or card, call out client’s
name, check I.D., wrist band
 Care must be taken to prevent instilling medication
directly into cornea.
 ORAL: If patient vomits within 20 – 30 minutes of taking
the drug, notify the physician. Do not re-administer the
drug without doctor’s orders.
SUBLINGUAL ROUTE – drugs that is placed under the
tongue, where it dissolves.
BUCCAL ROUTE – a medication is held in the mouth
against the mucous membranes of the cheek until the drugs
dissolves
 EYES MEDS: Apply ointment along inside edge of the
lower eyelid from inner to outer canthus.
 EAR MEDS:
Infants: draw the auricle gently downward and
backward.
Adults: lift pinna upward and backward
 Intradermal: Parallel to the skin, do not massage
 Subcutaneous: 45 degree above the skin, if obese 90
degree
 Intramuscular: 90 degree above the skin, aspirate to
check if blood vessel was hit.
D. Urinary Catheterization
 Use appropriate size of catheter
Male: Fr 16-18
Female: Fr 12-14
 Place the client in appropriate position:
Male: Supine, legs abducted and extended
Female: Dorsal recumbent
 Locate the urinary meatus properly:
Male: at the tip of the glans penis
Female: between the clitoris and vaginal orifice
 Lubricate catheter with water soluble lubricant before
insertion
Male: 6 – 7 inches
Female: 1 – 2 inches
 Length of catheter insertion:
Male: 6 – 9 inches
Female: 3 -4 inches
 Anchor catheter properly:
Male: laterally or upward over the lower abdomen /
upper thigh
Female: inner aspect of the thigh
Nursing Interventions to Induce Voiding/Urination
 Provide privacy
 Assist the patient in the anatomical position of voiding
 Serve clean, warm and dry bedpan (female) or urinal
(male)
 Allow the client to listen to the sound of running water
 Dangle fingers in warm water
 Pour warm water over the perineum
 Promote relaxation
 Provide adequate time for voiding
 Last resort: URINARY CATHETERIZATION
E. Nasogastric Tube (NGT)
 Gavage (feeding) / Lavage (suctioning)
 Select the nostril that has greater airflow.
 Assist the client to a high fowler’s position
 NEX technique (nose-ear-xiphoid)
 Checking the patency:
 Aspirate stomach contents and check the pH,
which should be acidic
 Introduce 10-30 ml of air into the NGT and
auscultate at the epigastric area, gurgling sound is
heard
 The most accurate method of assessing the
placement of NGT is X-ray study
 Before feeding assess residual feeding contents. To assess
absorption of the last feeding, if 50 ml or more, verify if the
feeding will be given.
 Height of feeding is 12 inches above the point of
insertion.
 Ask the client to remain in position for at least 30 min
 Common Problems of Tube Feedings
Vomiting
Aspiration
Diarrhea
Hyperglycemia
F. Enema Administration
 Position the client:
Adult: Left lateral
Infant/small children: Dorsal recumbent
 Lubricate the tube about 5 cm ( 2 in )
 Insert 7 – 10 cm ( 3 to 4 inches) or rectal tube gently
in rotating motion
 Raise the solution container and open the clamp to
allow fluid to flow
High Enema: 12-18 inches above the rectum
Low Enema: 12 inches above the rectum
 If the client complains of fullness or pain, use the
clamp to stop the flow for 30 sec. and then restart the
flow at a slower rate
 Encourage the client to retain the enema, ask the
client to remain lying down

5. WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 1: FUNDAMENTALS OF NURSING
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
G. Colostomy Care
 Stoma should appear red, similar to the mucosal linin
of the inner cheek
 Slight bleeding initially when the stoma is touched is
normal, but other bleeding should be reported.
 Change colostomy appliance if it is 1/3 full.
 Use warm water, mild soap (optional), and cotton
balls or a washcloth and towel to clean the skin and
stoma.
 Apply skin barrier over the skin around the stoma to
prevent skin breakdown.
 Changing is best in the morning before breakfast.
 Control Odor: (deodorizer, charcoal disk and prevent
odor causing foods)
Type of Discharge
Ileostomy Liquid fecal drainage
Drainage is constant and cannot
be regulated
Contains some digestive enzymes
Odor is minimal bec of fewer
bacteria are present
Ascending Colostomy Liquid fecal drainage
Drainage is constant and cannot
be regulated
Odor is a problem requiring
control
Transverse
Colostomy
Malodorous, mushy drainage
Descending
Colostomy
Solid fecal drainage
Sigmoidostomy Normal fecal characteristics
H. Suctioning
 Suction only when necessary not routinely
 Use the smallest suction catheter if possible
 Client should be in semi or high Fowler’s position
 Use sterile gloves, sterile suction catheter
 Hyperventilate client with 100% oxygen before and
after suctioning
 Insert catheter with gloved hand (3-5“ length of
catheter insertion) without applying suction. Three
passes of the catheter is the maximum, with 10
seconds per pass.
 Apply suction only during withdrawal of catheter
 The suction pressure should be limited to less than
120 mmHg
 When withdrawing catheter rotate while applying
intermittent suction
 Suctioning should take only 10 seconds (maximum of
15 seconds)
I. Tracheostomy Care
 Assist the client to a semi-Fowler’s or Fowlers
position.
 Hydrogen peroxide moisten and loosens dried
secretions
 Rinse the inner cannula thoroughly in the sterile
normal saline.
 When changing the ties: tie one end of the new tie to
the eye of the flange while leaving old ties in place.
 Put two fingers under the tapes before tying it.
J. Blood Transfusion
Compatible Incompatible
A A / O AB / B
B B / O AB / A
AB A / B / AB / O
O O A / B / AB
 Check for cross matching and blood typing. To ensure
compatibility
 Obtain and record baseline VS, Note: If patient has
fever do not transfuse
 Practice strict, ASEPSIS
 At least 2 nurses check the label of the blood
transfusion, Check the following:
- Serial Number
- Blood component
- Blood type
- Rh factor
- Expiration date
- Screening test
 Check the blood for gas bubbles and any unusual color
or cloudiness. Note: Gas bubbles indicate bacterial
growth, Unusual color or cloudiness indicate
hemolysis
 Warm blood at room temperature before transfusion.
 Identify client properly, two nurses check the client’s
identification
 Gauge of needle: #18
 Drop Factor: KVO
 Duration: RBC – 4 hours;
Platelets, FFP – 20 minutes
 When reactions occurs:
 STOP transfusion
 KVO with PNSS
 Send remaining blood, a sample of client blood
and urine sample to the laboratory.
 Notify the physician
 Monitor VS
 Monitor I & O
 Common BT reactions:
 Hemolytic: flank /back pain
 Anaphylactic: rashes, itching, DOB (worst)
 Febrile: fever and chills
 Circulatory Overload: DOB, crackles
 Sepsis: Fever and chills
K. Assistive Device
 Canes
 COAL (cane opposite affected leg)
 Angel is 20-30 degrees
 Walkers
 Hand bar below the client’s waist and the elbow is
slightly flexed.
 Crutches
 Length of the Crutches: Subtract 40 cm or 16
inches to the height of the client obtain the
approximate crutch length.
 20 to 30 degrees of flexion at the elbow.
 Four point gait:
* right crutch, the left foot, the left crutch, right
foot.
 Two point gait:
* left foot and right crutch, right foot and left
crutch
 Three point gait:
* left foot and both crutches, right foot.
 Swing Through Gait: .
* Advance both crutches, Lift both feet and swing
forward, Land the feet in front of crutches.
 Going up the stairs: (good goes to heaven, bad
goes to hell)
L. Chest Physiotheraphy ( CPT )
 Steam Inhalation
 Place the client in Semi-Fowler’s position
 Cover the client’s eyes with washcloth to prevent
irritation
 Place the steam inhalator in a flat, stable surface.
 Place the spout 12 – 18 inches away from the
client’s nose or adjust distance as necessary
 To be effective, render steam inhalation therapy
for 15 – 20 minutes

6. WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 1: FUNDAMENTALS OF NURSING
POSSIBLE TOPICS ON FUNDAMENTALS OF NURSING FOR THE UPCOMING DECEMBER 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the
possible topics that might be part of the upcoming December 2012 PNLE
 Postural drainage
 Use of gravity to aid in the drainage of secretions.
 Patient is placed in various positions to promote
flow of drainage from different lung segments
using gravity.
 Areas with secretions are placed higher than lung
segments to promote drainage.
 Patient should maintain each position for 5-15
minutes depending on tolerability.
M. Closed Chest Drainage ( Thoracostomy Tube )
Types of Bottle Drainage
One-bottle system
 The bottle serves as drainage and water-seal
 Immerse tip of the tube in 2-3 cm of sterile NSS
to create water-seal.
 Keep bottle at least 2-3 feet below the level of
the chest
 Observe for fluctuation of fluid along the tube.
The fluctuation synchronizes with the
respiration.
 Observe for intermittent bubbling of fluid;
continues bubbling means presence of air-leak
In the absence of fluctuation:
Suspect obstruction of the device
 Assess the patient first, then if patient is stable
 Check for kinks along tubing;
 Milk tubing towards the bottle (If the hospital
allows the nurse to milk the tube)
 If there is no obstruction, consider lung re-
expansion; (validated by chest x-ray)
 Air vent should be open to air.
Two-bottle system
 If not connected to the suction apparatus
 The first bottle is drainage bottle;
 The second bottle is water-seal bottle
 Observe for fluctuation of fluid along the tube
(water-seal bottle or the second bottle) and
intermittent bubbling with each respiration.
Three-bottle system
 The first bottle is the drainage bottle;
 The second bottle is water seal bottle
 The third bottle is suction control bottle.
 Observe for intermittent bubbling and
fluctuation with respiration in the water- seal
bottle
 Continuous GENTLE bubbling in the suction
control bottle.
 Suspect a leak if there is continuous bubbling in
the WATER seal bottle or if there is VIGOROUS
bubbling in the suction control bottle.
 The nurse should look for the leak and report
the observation at once. Never clamp the tubing
unnecessarily.
 If there is NO fluctuation in the water seal bottle,
it may mean TWO things
 Either the lungs have expanded or the system
is NOT functioning appropriately.
 In this situation, the nurse refers the
observation to the physician, who will order for
an X-ray to confirm the suspicion.
 In the event that the water seal bottle breaks,
the nurse temporarily kinks the tube and must
obtain a receptacle or container with sterile
water and immerse the tubing.
 She should obtain another set of sterile bottle as
replacement. She should NEVER CLAMP the
tube for a longer time to avoid tension
pneumothorax.
 In the event the tube accidentally is pulled
out, the nurse obtains vaselinized gauze and
covers the stoma.
 She should immediately contact the physician.
N. Oxygen Therapy
 Nasal Cannula (24% - 45% ) at flow rate of 2 – 6 L/min.
 Simple Face Mask (40% - 60%) at liter flows of 5 - 8
L/min
 Partial Rebreather Mask (60% - 90%) at liter flows of
6 – 10 L/min.
 Non-Rebreather Mask (95% - 100%) at liter flows of
10 – 15 L/min.
 Oxygen is colorless, odorless, tasteless and a dry gas that
support combustion, therefore leakage cannot be
detected.
 Place cautionary signs reading “ No SMOKING: Oxygen
in Use”
 Avoid materials that generate static electricity, such as
woolen blankets and synthetic fibers.
 Set up the oxygen equipment and the humidifier filled
with distilled/sterile water.
 CANNULA: Put over the client’s face, with the outlet
prongs fitting into the nares.
 FACE MASK: Fit the mask to the contours of the client’s
face, apply it from the nose downward