ATI FUNDAMENTALS EXAM
VERSION 5
1. CHAPTER 1: HEALTH CARE DELIVERY SYSTEMS
A. Components of Health care systems
a.
Participants
1. Consumers- clients
2. Providers
a. Licensed providers: registered nurses, license practical (or
vocational) nurses (LPN), advanced practice nurses (APN), medical
doctors, pharmacists, dentists, dietitians,
physical/respiratory/occupational therapists, etc
b. Unlicensed providers: assistive personal
b.
Settings
1. Hospitals, homes, skilled nursing, assisted living, schools, etc
c.
Regulatory Agencies
1. US department of Health and Human Services
2. US Food and Drug Administration (FDA)
3. State and local public health agencies
4. State licensing boards
a. Determines laws/regulations that govern nursing in their state
b.
ensure health care providers and agencies comply with state
regulations
c.
Issue/revoke nursing license
i.
Nurses need a license in every state they practice in
5. Joint Commission (JCAHO)
a. Set quality standards for accreditation of health care facilities
6. Professional Standards Review Organizations- monitor health care services
provided
d.
Healthcare financing Mechanisms
1. Public federally funded programs
a. Affordable Care Act (Obamacare)
i.
ii.
iii.
Increases access to healthcare for all individuals
Decreasing healthcare costs
Providing opportunities for uninsured to become insured at an
affordable cost
b. States Children’s Health Insurance
i.
Covers uninsured children up to 19 years old at a low cost to
parents
Don’t stop until you are proud
c.
MEDICARE
MEDICAID
Eligibility: >65 years old OR on
disability for more than 2 years OR
have ALS OR on dialysis
Eligibility: low socioeconomic
Part A: inpatient hospital,
limited skilled
nursing
care, home health care
Individual states determine
status, no
insurance
Federally and state funded
eligibility requirements
(hospital insurance) Part
B: outpatient care,
diagnostic services, OT/PT
(medical insurance)
Part C: combination of parts
A and B, optional private insurance
(Medicare advantage
plan)
Part D: prescription drugs
(medications)
e.
Levels of Health Care
Preventativ
e
Focuses on educating and equipping clients to
reduce or control risk factors for disease
Primary
Secondary
Emphasizes health promotion and includes prenatal,
well-baby care, family planning, nutrition
counseling, disease control
Diagnosis and treatment of acute illness and injury
Tertiary
Provision of specialized and highly technical care
Restorative
Intermediate follow-up care for restoring health and
promoting self-care
Continuing
Addresses long-term or chronic health care needs
over a period of time
2. CHAPTER 2: THE INTERPROFESSIONAL TEAM
A. Interprofessional Personnel (non-nursing)
Spiritual Support
Staff
Provides spiritual care (pastors, rabbis, priests)
Registered
Dietitian
Assess/plans for/educates regarding nutrition needs
Laboratory
technician
Obtains specimens of body fluids, and performs
diagnostic tests
Occupational
therapist
Focuses on patient’s independence and regain
activities of daily living (ADL) skills
Pharmacist
Provides and monitors meds
Physical Therapist
Focuses on increasing musculoskeletal function
(especially lower extremities), to maintain mobility
Provider
Assess/diagnose/treat diseases or injury, includes
doctors, APNs, physician’s assistant
Stay Positive, work hard, make it happen
therapist
respiratory treatments including oxygen including
oxygen therapy, chest physiotherapy, inhalation
therapy, and mechanical ventilation
Social worker
Works with clients and families by coordinating inpatient
and community resources to meet psychosocial and
environmental needs that are
necessary for recovery and discharge
Evaluates and makes recommendations regarding the
impact of disorders or injuries on speech, languages, and
swallowing
Speech-language
pathologist
Ex: patient with dysphagia
pathologist for consult
call speech
3. CHAPTER 3: ETHICAL RESPONSIBILITIES
A. Ethical Decision Making In Nursing
a.
Basic principles of ethics
1. Advocacy- support of client’s health, wellness, safety, privacy, and personal
rights
2. Responsibility- willingness to respect obligations and follow through on
promises
3. Accountability- ability to answer for one’s own actions
4. Confidentiality- protection of privacy without diminishing access to highquality care
b.
Ethical Principles for client care
Autonomy
Beneficence
c.
The right to make one’s own personal decisions, even when
those decisions might not be in that person’s best interest
(ex: Jehovah’s witness- blood
transfusion)
Action that promotes good for others, without any self
interest
Fidelity
Fulfillment of promises
Justice
Fairness in care delivery and use of resources
Nonmaleficence
A commitment to do no harm
Veracity
Commitment to tell the truth
Ethical Dilemma
1. Problems that involve more than one choice and stem from
differences in values and beliefs of the decision maker
a. A problem is an ethical dilemma when:
i.
ii.
iii.
There is not enough scientific data to solve it
It conflicts between 2 moral imperatives
Answer will have a profound effect on the situation and the
client
2. When making an ethical decision:
a. Identify if the issue is an ethical dilemma, gather as much relevant info as
possible, reflect on own values, list and analyze all possible options, select
correct option, apply it to situation
Don’t stress. Do your best.
Forget the rest.
4. LEGAL RESPONSIBILITIES
A. Sources of Law
a.
Federal regulations
1. Health Insurance Portability and Accountability Act (HIPPA)
2. Americans with Disabilities Act (ADA)
3. Mental Health Parity Act (MHPA)
4. Patient Self-Determination Act (PSDA)
b.
Criminal and civil laws
1. Criminal law- relates to the relationship between an individual and the
government
2. Civil law- protect individual rights (ex: tort law)
c.
d.
State laws
Licensure
B. Types of Torts
a.
Unintentional torts
1. Negligence
a. nurse fails to implements safety measured for a client at risk for falls (ex:
bed alarm)
b. 5 elements necessary to prove negligence
i.
ii.
Duty to provide care as defined by a standard
Breach of duty by failure to meet standard
iii.
Foreseeability of harm
iv.
Breach of duty has potential to cause harm
v.
Harm occurs
2. malpractice
a. nurse admins a large dose of meds due to a calculation error and
client gets hurt
b.
Intentional torts
1. Assault- threat
2. Battery- acting on the threat
3. False imprisonment
a. A person is confined or restrained against his will; inappropriate use of
restraints and sedatives
C. Informed consent
a.
b.
Legal process by which a client or the client legally appointed designee has
given written permission for a procedure or treatment
Provide should explain (needs to be in clients primary languageinterpreter may be needed):
1. Reason the patient needs procedure or treatment
2. How the procedure/treatment will benefit the client
3. The risks involved if the client receives the procedure/treatment
4. Other options to treat the problem
c.
Nurses role:
1. Witness patient’s informed consent signature
2. Notify provider if they have more questions
d.
Individuals may grant consent for another person if they are:
1. Parent of a minor
2. legal guardian
3. court specified representative
4.
e.
individual has durable power of attorney authority for health care
Refusal of treatment
1. Notify provider, patient signs a document indicating understanding of risks
D. Advanced Directives
a.
Living will- legal document that expresses client’s wishes regarding medical
treatment in the event the client becomes incapacitated and is facing end of life
issues
b.
c.
E.
Durable power of attorney for health care- document in which clients
designates health care proxy to make health care decisions for them if they are
unable to do so
Providers orders- unless there is DNR or AND in the clients medical record, the
nurse will initiate CPR
Mandatory reporting
a.
b.
c.
Abuse- nurses must report any suspicion of abuse (child, elderly, or
domestic abuse)
Communicable disease
Impaired coworker (drinking, drugs)
1. Do not talk directly to them
2. Do not gather more information
3. Report the suspicion
5. INFORMATION TECHNOLOGY
A. Documentation
a.
Elements of documentation
1. Subjective data- direct quotes or summarize information as the client’s
statement
2. Objective data- what the nurse sees, hears, feels, and smells; NO
OPINIONS
b.
Legal guidelines
1. Begin with date and time; write legibly, do not leave blank spaces; do not
use correction fluid, erase, scratch out or blacken out errors, sign all documents
with name and title
B. Reporting formats
a.
b.
Change of shift report
Telephone reports
1. Try to have another RN there to listen in on phone call
2. Read back order to the provider
3. Provider signs order off within 24 hours
c.
d.
Transfer (hand off) reports
Incident reports
1. Document facts without judgement or opinion
2. Do not refer to an incident report in a client’s medical record
C. Information security
a.
HIPPA (health insurance portability and accountability act of 1996
1. Only health care team members directly responsible for a client’s care may
access that client’s record
2. Clients have a right to read and obtain a copy of their medical record
3. Staff must keep medical records in a secure area to prevent
inappropriate access to the info
4. Electronic records are password-protected
5. Nurses must not disclose unauthorized individuals or family
members
6. Nurses must not disclose client’s info to unauthorized individuals or family
members
a. Many hospitals use a code system
6. DELEGATION AND SUPERVISION
A. Delegation
a.
RN cannot delegate
1. Patient education
2.
task that needs nursing judgement
3. Nursing assessment
RN to LPN
Monitoring findings Reinforce
Activities of Daily Living (ADLs)
patient teaching
- Bathing, grooming, dressing,
toileting, ambulating, feeding
(without swallowing
precautions), positioning
Routine tasks
Tracheostomy care Suctioning
Checking NG tube patency
Administering enteral feedings
Inserting a urinary catheter
Administering medication
b.
RN to CNA
- Bed making, specimen
collection, intake and output,
vital signs (for stable clients)
5 rights of delegation
1. Right task
a. Right task is repetitive, requires little supervision, and is
noninvasive for the client
2. Right circumstance
a. Determine the health status and complexity of care the client requires
3. Right person
a. Task is within the delegatee’s scope of practice
4. Right direction and communication
a. Provide a method and timeline for reporting
b. Communicate specific tasks and detail expected results.
Timeline, and expectations for follow-up communication
5. Right supervision and evaluation
a. Provide supervision and provide feedback
7. NURSING PROCESS
A. Assessment/Data collection
a.
Subjective data (symptoms)- during nursing history
1. client’s feelings, perceptions, and descriptions of health status
b.
Objective data (signs)- during physical examination
1. Feel, see, hear, and smell objective data through observation or physical
assessment of the client
c.
Sources of data collection
1. Primary sources
a. Subjective: what the client tells the nurse
b. Objective: data the nurse obtains through observation and
examination
2. Secondary sources
a. Subjective: what others tell the nurse (family, friends)
b. Objective: data the nurse collects from their sources
B. Analysis/Data collection
a.
Requires nurses to look at the data and
1. Recognize patterns or trends
2. Compare the data with expected standards or reference ranges
C. Planning
a.
Prioritize outcomes of care they can readily measure and evaluate
D. Implementation
a.
E.
a.
Nurses base the care they provide on assessment data, analyses and then
Evaluation
Nurses evaluate the client’s responses to nursing interventions and form a clinical
judgement about the extent to which clients have met the goals and outcomes
8. CRITICAL THINKING
A. Don’t know specifics and know how to use critical thinking skills
9. ADMISSIONS, TRANSFERS, AND DISCHARGE
A. Admission process
a.
Document client’s advance directive status (DNR, full code, etc), Base line data
(vital signs, height, weight, allergies), Health history, swallowing
problems (get evaluation from speech pathologist), spiritual health/quality of life
concerns, safety assessments (risk for falls)
b.
c.
Discharge planning starts at admission
Inventory personal items
1. Assistive items: glasses, hearing aids, dentures
2. Medications
3. Discourage keeping valuables at the bedside
B. Transfer
a.
Best thing to use:
1. Situation
2. Background
3. Assessment
4. Recommendation
C. Discharge Education
a.
b.
c.
d.
e.
f.
10.
Review symptoms of potential complications and when to contact provider
Provide names and numbers of community resources
Step by step instructions for continuing treatments (dressing changes, etc)
Dietary restrictions and guidelines
Directions how to take medications
Follow up appointments
MEDICAL AND SURGICAL ASEPSIS
A. Hand Hygiene
a.
Hand wash with antimicrobial or alcohol-based products
1. Antimicrobial: wash for 15 seconds, dry hands with clean paper towel
before turning off faucet
a. Use antimicrobial soap over alcohol based when:
i.
ii.
Hands are visibly soiled
Before eating a meal
iii.
After using the bathroom
iv.
After contact with any bodily fluids
2. Alcohol based: use 3-5 mL, continue to rub until both hands are
completely dry
B. Physical environment
a.
Cover mouth and nose when coughing or sneezing, using and disposing of facial
tissues
1. Ensure 3 spatial separation of 3 ft from a cough
b.
c.
Keep nails short, clean, and no artificial nails; remove jewelry from hands and
wrists
Do not put items on flood, do not shake linens
C. Sterile Field
a.
b.
c.
d.
Do not cough, sneeze, talk over the sterile field
Outer 1 inch wrapping of package is not sterile
Objects below waist/above chest contaminated
Do not reach across/above sterile field, turn back on sterile field
1. To add item drop form 6 inches above the field
e.
11.
Any sterile, nonwaterproofed wrapper that encounters moisture becomes
nonsterile
INFECTION CONTROL
A.
Immune Defenses
a.
Nonspecific innate- barriers respond immediately to all antigens
1. Ex: skin, mucus membrane, stomach acid
b.
Specific adaptive immunity – allows the body to make antibodies in
response to a foreign organism (antigen)
1. Involves B ant T lymphocytes; takes more time
c.
Types of immunity
1. Active natural immunity- body produces antibodies in response to
exposure to a live pathogen
2. Active artificial immunity- body produces antibodies in response to a
vaccine
3. Passive natural immunity- antibodies passed down form a mom to a baby
through breastmilk or the placenta
4. Passive artificial immunity- patient’s immunoglobins administered to them
after exposure to pathogen
B. Infection Processes
a.
Chain of infection
1. Causative agent (bacteria, virus, fungus, prion, parasites)
2. Reservoir- where it lives (human, animal, food, organic matter on
inanimate surfaces, water, soil, insects)
3. Portal of exit- where it leaves the host (respiratory tract,
gastrointestinal trac, etc)
4. Mode of transmission
a. Contact- direct physical contact (person to person)
b. Droplet- sneezing, coughing, and talking
c. Airborne- sneezing and coughing
5. Portal of entry- how it enters the host (may be the same as the portal of
exit)
6. Susceptible host- compromised defense mechanisms
(immunocompromised, breaks in skin) leave the host more
susceptible to infections
b.
Stages of infection
1. Incubation- pathogen enters the body to first symptom
2. Prodromal stage- onset of general symptoms to more distinct
symptoms
3. Illness stage- specific symptoms to infection occur
4. Convalescence- acute symptoms disappear to total recovery
c.
Virulence- ability of pathogen to produce disease
C. Assessment/Data collection
a.
Risk factors:
1. Inadequate hand hygiene, compromised health/defense, chronic or acute
disease, poor personal hygiene, crowded environment, use of IV drugs,
unprotected sex, poor sanitation
b.
Inflammation
1. Body’s local response to injury or infection
2. First stage: redness, edema, pain
3. Second stage: fluid containing dead tissue cells and WBCs
accumulates and exudate appears at the site
a. Types of exudate
i.
Serious (clear), sanguineous (blood), serosanguineous
(pinkish tint), Purulent (leukocytes and bacteria)
4. Third stage: scar tissue
D. Laboratory tests
a.
Leukocytosis- WBC level greater than 10,000/uL indicates infection
1. Normal range: 5,000-10,000/uL
2. Left shift: increase in neutrophils
b.
c.
d.
Elevated erythrocyte sedimentation rate (ESR)- over 20 mm/hr indicates
infection
Presence of micro-organisms on culture of the specific fluid/area
Diagnostic procedures
1. Gallium scan, radioactive gallium citrate
2. X rays, CT scan, MRI
E.
Isolation Guidelines
a.
Standard precautions- for everyone
1. Hand hygiene- use alcohol based waterless product when hands are not
visibly soiled
2. Masks, eye protection, face shields when splashing or spraying of bodily
fluids may occur
3. Clean gloves
b.
Airborne precautions
1. Used for measles, varicella, pulmonary, or laryngeal tuberculosis
2. Private room
3. N95 masks for visitors and caregivers
4. Negative air flow in the room
c.
Droplet Precautions
1. Used for pneumonia, influenza, rubella, mumps, sepsis
2. Private room or room with someone with the same thing
3. Masks for providers and visitors
d.
Contact Precautions
1. Used for respiratory syncytial virus (RSV), shigella, wound
infections, scabies
2. Private room or room with other patient that has the same infection
3. Gloves and gowns worn by caregivers
F.
Herpes Zoster (shingles)
a.
b.
Chickenpox
shingles
Risk factors
1. Concurrent illness, stress, compromise immune system, fatigue, poor
nutritional status
c.
Symptoms: paresthesia, unilateral rash, low grade fever
1. Rash is erythematous, vesicular, pustular, or crusting
d.
Nursing care
1. Isolate the client until the vesicles have crusted
2. Avoid exposing to infants, pregnant women, and those who not had the
chicken pox
e.
Medications:
1.
analgesics- enhance client comfort
2. Antiviral agents- acyclovir
f.
Complications
1. Postherpetic neuralgia- pain more than 1 month after shingles is gone
g.
12.
Prevention: Zoster vaccine and chicken pox vaccine
CLIENT SAFETY
A. Preventing falls
a.
Patient with orthostatic hypotension should avoid getting up too quickly
1. Sit on side of bed for few seconds, stand up for a few seconds, then walk
b.
c.
d.
e.
f.
g.
h.
Provide regular toileting
Place clients at risk for falls close to nurses’ station
Provide hourly rounding
Keep bed in low position and lock breaks
Avoid using all side rails
Provide nonskid footwear
Use gait belts
B. Seizures
a.
Sudden surge of electrical activity in the brain
b.
c.
C.
Do not restrain
Lower them to the floor put them on their side don’t put anything in their
mouth
Fire Safety
Fire Response
R-rescue by moving
people to a safer location
A-alarm- activate facility’s
alarm system
Fire Extinguishers
P- pull the pin
A-aim at base of fire
C-contain- close doors/windows, S- squeeze the handle
turn off
S- sweep the extinguisher side
sources of oxygen
to side
E- extinguish the fire
13.
HOME SAFETY
A. Infants and Toddlers
a.
b.
c.
d.
e.
f.
g.
h.
Do not feed the infant ad hard foods that could be choking hazard
Always place infants on their back to rest
Keep plastic bags to reach
Make sure crib slats are no more than 2 3/8 inches apart
Do not place anything in the crib with the infant
Place toddlers in rear facing car seat in the back seat until 2 years old
Use car seat with 5-point harness for infants and children
Place pots on back burner and turn handle away from front of stove
B. Preschool age children
a.
b.
Place locked fences around pools and provide supervision around pools or water
Use booster seats for children who are less than 4 feet 9 in tall and weigh less
than 40 lbs
c.
d.
e.
If passenger seat has an air bag, place children under 12 years in the back seat
Use of protective equipment in sports
Keep firearms unloaded, locked up, and out of reach
1. Store bullets in different location
f.
Reduce setting on water heater to no higher than 120 degrees F
C. Adolescents
a.
Educate on the hazards of smoking, alcohol, legal, and illegal drugs, and
unprotected sex
b.
c.
Educate on the hazards of driving while distracted
Be alert ot signs of depression, anxiety, or other behavioral changes
D. Older adults
a.
b.
c.
d.
e.
E.
Remove items that could cause the client to trip, such as throw rugs and loose
carpets
Place electrical cords and extension cords against a wall behind furniture
Place grab bars near the toilet and in the tub or shower, and install a stool riser
Use nonskid mat in the tub or shower
Place shower chair in the shower
Fire Safety
a.
use and store oxygen equipment according to the manufacturer’s
recommendation
b.
c.
d.
e.
F.
place a no smoking sign near front of the door
ensure that electrical equipment is in a good repair and well grounded
replace bedding that can generate static electricity (wool, nylon,
synthetics) with items made from cotton.
Keep flammable materials such as heating oil and nail polish remover away
from the client when oxygen is in use
Carbon Monoxide
a.
b.
c.
d.
e.
Very dangerous gas because it binds with hemoglobin and reduces the oxygen
supplied to the tissues in the body
Carbon monoxide cannot be seen, smelled, or tasted
Symptoms: nausea, vomiting, headache, weakness, unconsciousness
Gas burning furnaces, water heaters, and appliances should be inspected annually
Carbon monoxide detectors should be installed and inspected regularly
G. Food Poisoning
a.
b.
c.
d.
Young, old, immunocompromised, and pregnant women are at risk
complications
Perform hand hygiene
Ensure meet and fish are cooked at correct temperature
Handling raw and fresh food separately to avoid cross contamination,
refrigerated perishable items
H. ABCDE principle
a.
b.
Airway/cervical spine- need patent airway, stabilize cervical spine
Breathing
1. Exception: COPD patients- O2 saturation is low 90s—expected
a. NOT PRIORITY
c.
d.
e.
I.
Circulation- assess BP, HR, capillary refill
Disability- determine level of consciousness
Exposure
First Aid
a.
Bleeding
1. Direct pressure to wound site
2. Do not remove impaling objects- instead stabilize them
b.
Fractures
1. Apply a splint
2. Reassess neurovascular status below the injury
c.
Sprains
1. RICE
a. Rest, ice, compression, elevate
d.
Frostbite
1. Warm the affected area to 37-42 degrees C (98.6-108 F) water bath
2. Admin tetanus vaccine
e.
Burns
1. Remove burning agent
2. Elevate clients extremity
3. Admin fluids and tetanus toxoid
14.
ERGONOMIC PRINCIPLES
A. Body Mechanics
a.
Spread feet apart to lower center of gravity and broaden base of support
1. Results in greater balance
b.
c.
d.
e.
f.
g.
Use the major muscle groups to prevent back strain
Distribute weight between the large muscles of arms and legs
Hold object as close as possible
Have a staff member help with positioning clients
Use smooth movements
Gurnee bed
1. Bed should be slightly lower
2. Patient’s arms crossed, chin tilted in
3. Put board against feet to prevent foot drop
B. Client positions
a.
Semi-Fowlers- head of the bed elevated 15-45 degrees
1. Prevents regurgitation and aspiration
2. Promotes lung expansion and ventilation
b.
Fowlers- head of bed elevated 45-60 degrees
1. Useful during nasogastric tube insertion and suctioning
2. Promotes lung expansion and ventilation
c.
High Fowlers- head of bed elevated 60-90 degrees
1. Promotes lung expansion and ventilation
2. Relieves severe dyspnea
3. Prevents aspiration during meals
d.
Supine- client lies on back
e.
Prone- client lies on abdomen
1. Helps prevent hip flexion contractures after a lower extremity
amputation
f.
Sims- client lays on left side and both legs in flexion
1. comfortable sleeping position for many clients
2. used for enema or rectal exams
g.
Orthopneic- sits at the side of bed with arms on bedside table
1. Promotes lung expansion and ventilation
2. Beneficial for COPD patients
h.
i.
Trendelenburg- head of bed lower than the foot of the bed
Reverse Trendelenburg- foot of the bed lower than the head of the bed
1. Promotes gastric emptying for GERD
j.
Modified Trendelenburg- flat with legs about the level of the heart
1. Prevent and treat hypovolemia or hypovolemic shock
15.
SECURITY AND DISASTER PLANS
A. Triage
a.
Class 1: Emergent category (red tag)
1. Highest priority- life threatening injuries
b.
Class 2: Urgent Category (Yellow tag)
1. Second highest priority- major injuries (ex: bone fracture)
c.
Class 3: Nonurgent Category (Green tag)
1. Minor injuries (ex: sprain, cut)
d.
Class 4: Expectant category (black tag)
1. Not expected to live and allowed to die naturally (ex: chest is crushed)
B. Tornado
a.
Close drapes, lower bed to lowest position and move away from windows, place
blanket over clients who are confined to bed
C. Chemical Incident
a.
b.
Undress the client
Irrigate skin with running water
1. Except dry chemicals- then brush the agent off clothes and skin
D. Hazardous material
a.
b.
E.
Use water
Bomb threat
a.
b.
16.
Identify hazardous material
Extend conversation for as long as possible
Listen for distinguishing background noises to help police
HEALTH PROMOTION AND DISEASE PREVENTION
A. Tests
a.
Colorectal screening
1. Every year beginning at age 50 for fecal occult blood testing
2. sigmoidoscopy every 5 years
3.
b.
colonoscopy ever 10 years
Pap Smear (Papanicolaou test)
1. Every 3 years starting at age 21
c.
Mammogram
1. Every year starting at age 40
d.
Testicular Examination
1. Starting at age 20
e.
Prostate exam
1. Starting at age 50
B. Prevention
a.
Primary Prevention
1. Helps prevent initial occurrence of disease
a. Ex: immunization programs, client teaching
b.
Secondary Prevention
1. Early detection of illness, limiting severity
a. Ex: screening
c.
Tertiary Prevention
1. Maximizing recovery after illness
a. Ex: support groups, rehab
17.
CLIENT EDUCATION
A. Domains of Learning
a.
Cognitive Learning
1. Thinking, knowledge, comprehension
b.
Affective learning
1. Feelings, beliefs, values
c.
Psychomotor learning
1.
mental and physical activity
B. Assessment
a.
Assess learning needs
b.
c.
identifying learning style (auditory, visual, kinesthetic)
identify available resources
C. Planning
a.
Identify mutually agreeable outcomes
D. Implementation
a.
b.
E.
a.
No medical jargon
6th grade level or lower
Evaluation
Observe demonstrations
18.
SKIP
19.
SKIP
20.
SKIP
21.
SKIP
22.
SKIP
23.
SKIP
24.
SKIP
25.
SKIP
26.
DATA COLLECTION AND GENERAL SURVEY
A. Therapeutic communication
a.
b.
c.
d.
Don’t do one long assessment try to break it up
Allow more time for responses for older adults
Make sure client is comfortable
Reduce environmental noises
1. Ex: tv, visitors
B. Assessments
a.
Normal order: Inspection, palpation, percussion, auscultation
1. *Exception is abdomen: inspection, auscultation, percussion,
palpation
b.
Inspection
1. Size, shape, color, symmetry, position
c.
Palpation
1. Size, consistency, texture, temperature, location, tenderness
a. Palpate tender areas last
2. Dorsal surface: most sensitive to temperature
3. Palmar surface: sensitive to vibration
d.
Percussion
1. Size, location, tenderness, density
e.
Auscultation
1. Amplitude/intensity, pitch/frequency, duration, quality
2. Used for heart sounds, bowel sounds, lung sounds
C. General Survey
a.
Physical Appearance
1. Age, gender race, level of consciousness, signs of distress, signs of
substance abuse
b.
Body structure
1. Height and weight, Nutritional status, posture, abnormalities
(amputation, skin lesions)
c.
Mobility
1. Gait, movements, range of motion
d.
Behavior
1. Mood, speech
e.
Vital signs
1. Temperature, pulse, respiration, blood pressure, oxygen saturation
27.
VITAL SIGNS
A. Temperature
a.
Ways to take temp
1. Oral: 36-38 C or 96.8 to 100.4 F
2. Rectal: 0.5 C or 0.9 F higher than oral
a. 36.5-38.5 or 97.7- 101.1 F
b. Patient in sim’s position, lubricate thermometer, place in about11.5 in for adult
3. Axillary: 0.5 C or 0.9 F lower than oral
a. 35.5-37.5 C or 95.9-99.3 F
4. Temporal: 0.5 C or 0.9 F higher than oral
a. 36.5-38.5 or 97.7- 101.1 F
b. Move gently from forehead over the temporal artery and then to skin
behind earlobe
5. Tympanic
a. Adult: pull ear up and back
b. Child younger than 3: pull down and back
b.
Considerations
1. Newborns:
36.5-37.5 C or 97.7 and 99.5 F
2. Older adults: average temp: 36 C (96.8 F)
3. Hormonal Changes- temp rises with ovulation, menses, and
menopause
4. Exercise, activity, and dehydration: development of hyperthermia
5. Recent food, drink, or smoking: wait 20-30 min to take temp
c.
Complications
1. Hyperthermia- greater than 39 C
a. Obtain specimens
b. Admin antibiotics
c.
Provide fluids
d. Provide antipyretics
e. Prevent shivering- offer blankets
2. Hypothermia- less than 35 C
a. Provide warm environmental temperature
i.
Warming blanket, warmed IV fluids
b. Keep head covered
B. Pulse
a.
Rate
1. Normal adult: 60-100 bpm
2. Normal infant: 120-160 bpm
b.
c.
Rhythm- regularity
Strength (amplitude)
1. 0= absent
2. 1+= diminished
3. 2+= normal, expected
4. 3+= increased, strong
5. 4+= bounding
d.
Locate radial pulse
1. If pulse is regular: count rate for 30 sec and multiply by 2
2. If pulse is irregular: count for full min and compare to apical pulse
e.
Locate apical pulse
1. Fifth intercostal space, left midclavicular line
f.
g.
Tachycardia- greater than 100 bpm
Bradycardia- less than 60 bpm
C. Respirations
a.
Physiological responses
1. Chemoreceptors in carotid arteries and the aorta monitor CO2 levels
of the blood
a. Rising CO2 levels trigger respiratory centers of the brain to increase
respiratory rate
b.
Process of respiration
1. Ventilation- exchange of CO2 between
environment and lungs
2. Diffusion- exchange of O2 and CO2 between alveoli and RBC
3. Perfusion- flow of RBC to and from pulmonary capillaries (tissues)
c.
Assessment
1. Rate
a.
Normal rate:
i.
adults= 12-20/min
ii.
infants= 35-40/min
iii.
school age kids= 20-30
2. Depth- deep or shallow
3. Rhythm
d.
Pulse Oximetry
1.
Normal 95-100%
2. COPD normal: 91-100%
e.
Considerations
1. Increased respiratory rate
a. Anxiety, smoking, illnesses, anemia, high altitude
2. Decreased respiratory rate
a. Opioids, sedative meds, increasing old age
D. Blood Pressure
a.
b.
c.
hypertension
Systolic BP
Diastolic BP
normal
100
Hypotension- Systolic is less than 90 mmHg
Pulse pressure=systolic- diastolic
1. Increase pulse pressure can indicate cardiovascular disease
d.
Orthostatic hypertension- blood pressure that decreases when a client
changes position from lying to sitting/standing
1. Take clients BP and HR while lying in supine
2. Then have them sit, wait 1-3 min, take BP again
3. The client has orthostatic hypotension if the Systolic decreases more
than 20 mmHg and/or Diastolic decreases more than 10 mmHg with a
10-20% increase in HR
e.
Auscultatory method
1. Width of a cuff should be 40% of arm circumference
2. The inside of the cuff should surround 80% of the arm
circumference
a. Too large of cuff: falsely low readings
b. Too small of cuff: falsely high readings
f.
Nursing implications
1. Don’t measure BP:
a. in an arm with IV infusion in progress
b. side where the client has had a mastectomy
28.
HEAD AND NECK
A. Cranial Nerves
Numb
er
Name
Function
1
Olfactory
Sensory: Smell
2
Optic
Sensory: vision
Snellen chart
3
Oculomotor
Motor: pupil constriction,
eye movements
Follow the
finger, penlight
4
Trochlear
Motor: eye movements
(up/down)
5
Trigeminal
6
Abducens
Sensory + motor: face, chewing Close eyestouch face- pt
explains what
they feel
Motor: eye movement
laterally
7
Facial
Sensory + Motor: Facial
muscles, taste (ant),
parotid/lacrimal glands
How to test
Smile/Frown
8
Vestibulocochl
Sensory: hearing and
ear
balance
9
Glossopharyn
geal
Sensory + Motor: parotid gland,
gag reflex, taste (posterior)
10
Vagus
Sensory + Motor: voice,
pharyngeal/laryngeal muscles,
thoracic/abdominal sense
11
Accessory
Motor: sternocleidomastoid
and trapezius muscle
12
Hypoglossal
Motor: tongue
Gag reflex
Shrug, turning
head
B. Assess
a.
Thyroid glands
1. Take sip of water and feeling the thyroid gland as it moves up the trachea
a. Sizes, masses, and smoothness
b.
Eyes
1. 20/30 vision means a client can read a line from 20 ft away that a person
who has unimpaired vision can read from 30 ft away
2. Tests:
a. Snellen chart- used to screen myopia (nearsightedness)
b. Rosenbaum eye chart- used to screen for presbyopia
(farsightedness)
c. Ishihara Test- color vision
d. Corneal light reflex
e. Uncover/cover test- Strabismus (misalignment)
f. 6 cardinal positions of gaze- wide H pattern
3. PERRLA
a. P- pupils clear
b. E- equal and between 3-7 mm
c. R- round
d. RL- reactive to light
e. A- accommodation of pupils
4. 2 arteries for every 3 veins
c.
Ears
1. Check alignment
2. Pull auricle
a. Adults: Up and back
b. Young children: down and back
3. Insert otoscope 1-1.5 cm bur do not touch ear canal
a. Expect to see: pearly gray and intact tympanic membranes
i.
ii.
Light reflex is visible
Normal amount of cerumen
4. Tests:
a. Whisper test
b. Rinne test
c. Weber test
i.
Negative is normal
C. Changes with aging
a.
b.
c.
d.
e.
29.
Eyes: decreased visual acuity, glare/darkness, yellowing of the lens
Ears: hearing loss, thickening of the tympanic membrane
Mouth: decreased sense of taste, tooth loss, pale gums, gum disease,
decreased salivation
Voice: rise in pitch
Nose: decreased sense of smell
THORAX, HEART, AND ABDOMEN
A. Breasts
a.
Monthly self-exams after menstruation
B. Lungs
a.
Percussion
1. Dullness: indicates pneumonia
2. Hyperresonance: pneumothorax, emphysema
b.
Auscultation
1. Expected: bronchial, bronchovesicular, vesicular
2. Unexpected: crackles (fluid), wheezes, rhonchi, pleural friction rub
C. Heart
a.
b.
c.
d.
e.
S1 sound: mitral and tricuspid close
S2 sound; aortic and pulmonic close
Thrills: vibration murmurs
Bruits: swishing sound obstructed blood flow
Auscultatory sites:
1. Aortic, Pulmonic, Erbs’ point, Tricuspid, Apical
D. Abdomen
a.
Bowel sounds
1. Expected: high pitched clicks and gurgles
2. Unexpected: loud, growling sounds
b.
Percussion
1. Expect to hear tympany
2. Expect dullness over liver
a. Liver size: 6-12 cm
c.
E.
Palpate tender areas last
Expected Changes with Aging
a.
Breasts
1. Nipples can invert
b.
Lungs
1. AP diameter similar to transverse diameter (barrel chest)
2. Alveoli dwindle
3. Kyphosis becomes presen
c.
Cardiovascular
1. Systolic
hypertension
2. Blood vessels thicken
3. Increase pulse pressure
d.
Abdomen
1. More adipose tissue
2. Decrease saliva, gastric secretions, pancreatic enzymes
3. Decrease motility
30.
INTEGUMENTARY AND PERIPHERAL VASCULAR SYSTEMS
A. Skin
a.
Pallor- loss of color
1. Indicates: anemia, shock, or lack of blood flow
b.
Cyanosis- turning blue
1. Indicates: hypoxia
c.
Jaundice- yellow tint
1. Indicates: liver dysfunction, RBC destruction
d.
Erythema – redness
1. Indicates: inflammation, sun exposure, rash
e.
f.
Brown pigmentation indicates venous insufficiency
Skin turgor can indicate dehydration or aging
B. Nails
a.
Capillary refill- normal return of color within 3 seconds
C. Edema
a.
Evaluate pitting by compressing the skin for at least 5 seconds over a bony
prominence
1. + trace, 2 mm, rapid skin response
2. + mild, 4 mm, 10-15 seconds skin response
3. + moderate, 6 mm, prolonged, skin response
4. + severe, 8 mm, prolonged skin response
D. Lesions
Primary Lesions
Macul
e
Flat, skin color change, < 1 cm
Papule
Solid elevation of skin, < 1 cm
Ex: freckle, petechiae
Ex: mole
Nodul
e
Deep, firm, 1-2 cm
Vesicl
e
Serous fluid- filled, 2 cm
Ex: epithelioma, neoplasm
Wheal
Palpable, irregular borders, edematous
Ex: insect bite
E.
Expected changes with aging
a.
b.
c.
d.
e.
f.
g.
31.
Dry, flaky skin
Loss of elasticity
Thinning of hair
Less moisture and sweat
Uneven pigmentation
Slow wound healing
Little subcutaneous tissue over bony prominences
MUSCULOSKELETAL AND NEUROSENSORY SYSTEMS
A. Expected range of motion of joint movement
Flexion
Decreases the angle between 2 adjacent
bones
Extension
Increases the angle between 2 adjacent
bones
Supination
Ventral (front) surface faces up
Pronation
Ventral (front) surfaces faces down
Abduction
Moving extremity away from midline
Adduction
Moving extremity towards the midline
Dorsiflexion
Foot and toes upward
Plantar flexion
Foot and toes downward
Eversion
Turning body part away from midline
Inversion
Turning body part toward the midline
External
Rotation
Rotating a joint outward
Internal
Rotation
Rotating a joint inward
B. Curvatures of the Spine
a.
b.
Expected: concave cervical spine, convex thoracic spine, concave lumbar spine,
convex sacral spine
Unexpected:
1. Kyphosis- hunchback (in older adults)
2. Lordosis- exaggerated curvature of lumbar spine (toddler years and
pregnancy)
3. Scoliosis- S shape
C. Mental Status
a.
Alert
1. Client is responsive and can open eyes and respond spontaneously and
appropriately
b.
Lethargic
1. Client can open eyes but falls asleep readily
c.
Obtunded
1. Responds to light shaking and can be confused and slow to respond
d.
Stuporous
1. Requires painful stimuli (rubbing the sternum)
e.
Comatose- no response
1. Decorticate rigidity- flexion and internal rotation of upper extremity joints and
legs(arms-chin)
2. Decerebrate rigidity- neck and elbow extension, with wrists and fingers
flexed (arms extended)
a. Worse than decorticate
D. Glasgow Coma Scale- baseline of level of consciousness
a.
Looks at eye, verbal, and motor
1. Highest value possible is 15
2. <8 indicates severe head injury
3. 8-12 indicates mild head injury
E.
Motor Function
a.
Assessing balance
1. Romberg’s Test
a. Ask the client to stand with feet together, his arms at his sides and his
eyes closed
i.
Expected findings: client stands with minimal swaying for at least
5 seconds
2. Heel-to-toe walk: heel to tow and walk in straight line
F.
Sensory Function
a.
b.
Stereognosis- place familiar object in the client’s hand and ask them to identify
it
Graphesthesia- trace number on clients hand
G. Grade DTR Response
a.
b.
c.
d.
e.
4+ very brisk with clonus
3+ brisker than average
2+ expected
1+ diminished
0 no response
H. Expected changes with aging
a.
Musculoskeletal system
1. Reduced muscle mass
2. Osteoporosis, loss of bone mass
3. Degenerative alterations in joints
4. Limited range of motion
b.
Neurological system
1. Short term memory decline
2. Diminished, slowed reflex
3. Altered hearing, vision, smell, and deep pain
32.
THERAPEUTIC COMMUNICATION
What to do:
Do not
- Use open ended questions -ask why
(“tell me more”)
-offer opinion
-false reassurance
-closed ended question(yes/no)
-offer personal information
-change subject
but quickly return focus
onto the patient
-minimize patient’s feelings
- say “I know how you feel”
33.
COPING
A. General Adaptation Syndrome
a.
Alarm Reaction- heightened response to stressors
1. Increased blood pressure and heart rate
2. Cortisol released
b.
Resistance Stage- body functions normalize while responding to the stressor
1. Body returns to homeostasis
c.
Exhaustion Stage- body functions are no longer able to maintain a
response to the stressor
1. Can result in fatigue, depression
34.
SELF CONCEPT AND SEXUALITY
A. Impaired body image
a.
b.
35.
Due to amputation, mastectomy, hysterectomy
loss of body function due to arthritis, spinal cord injury, or stroke
CULTURAL AND SPIRITUAL NURSING CARE
A. Spirituality
a.
Christianity
1. may fast during lent
b.
Islam
1. Women must be cared for by female providers
2. May pray 5 times a day
3. Avoid alcohol and pork
4. Fast during Ramadan
c.
Jehovah’s Witness
1. Might night accept blood transfusions
d.
Judaism
1. Some practice a kosher diet
a. No shellfish, pork, or meat with dairy
e.
Mormonism
1. Avoid alcohol, tobacco and caffeine
B. Ethnocentrism
a.
Belief one’s own culture is superior to all other cultures
1. Nurses should avoid this
C. Interpreter
a.
Use facility approved medical interpreter
1. Do not use family/ friends of patient or non-designated employee to interpret
b.
c.
d.
36.
Only ask one question at a time
Direct the questions to the client
Use lay terminology
GRIEF, LOSS, AND PALLIATIVE CARE
A. Types of Loss
a.
Maturational loss
1. Loss that is expected, it is associated with normal life transitions
a. Ex: child leaving home for college
b.
Situational Loss
1. Unanticipated loss caused by an external event
a. Ex: car accident
B. Stages of Grief
a.
b.
c.
d.
e.
Denial- patient has difficulty believing a terminal diagnosis or loss
Anger- client lashes out at other people or things
Bargaining- client negotiates for more time or a cure
Depression- client is overwhelmingly sad
Acceptance- client moves forward
C. Types of grief
a.
b.
Anticipatory grief- grief before having a loss (ex: terminal illness)
Complicated grief- prolonged, severe grief
1. No acceptance of the loss after 6 months
D. Palliative Care vs hospice care
a.
b.
Palliative care- symptom relief and cure
Hospice care- includes palliative care but down not look for cure
1. Patients are not expected to live longer than 6 months]
E.
Manifestations of approaching death
a.
Decreased level of consciousness, labored breathing, mottling (cyanosis),
slow/weak pulse, dropping blood pressure, decreased urine output
b.
F.
Hearing is not diminished
Preparing the body for viewing
a.
b.
c.
37.
Remove all tubes and personal belongings and excess supplies
Lay the body supine with pillow under the bed
Apply fresh linens, put dentures in, dim the lights
HYGIENE
A. Foot care
a.
Important for diabetic patients
1. May experience decreased sensations
a. Variations in temperature
b. Can’t tell if something is in shoe (Ex: nail in foot)
2. Inspect feet daily, cut nails straight across, check shoes for objects, wear
cotton socks
3. Test water temperature for bath
4. Dry feet thoroughly- especially in between toes
5. Apply moisturizer on feet (not in between toes)
6. Do not use over the counter products- go to podiatrist
7. Do not use heating pad on feet
B. Oral Care for unconscious patient
a.
b.
c.
Have suction apparatus ready- prevent aspiration
Position client on his side with his head turned toward you to allow oral
secretions to collect
Denture care:
1. Top denture: pull down and out
2. Bottom denture: pull up and out
3. Store dentures in denture cup
38.
REST AND SLEEP
A. Sleep Cycle
NREM Stage 1
NREM Stage
2
NREM Stage
3
NREM Stage 4
REM
Very light
-Deeper
sleep
-initial
stages of
deep sleep
-deepest
sleep
- vivid dreaming
sleep Only a
few
minutes long
Vital signs and
metabolism
beginning to
decrease
-10-20 min
long
-15-20 min
-Vital signs and long
-difficult to
metabolism
awaken
beginning to
decrease
-15-30 min long
-vital signs low
- very difficult
to awaken
- physiologic
rest and
restoration
-longer with each
sleep cycle
-average length 20
min
-varying vital signs
-very difficult to
awaken
-cognitive restoration
-sleep walking,
sleep talking
B. Sleep Apnea
a.
b.
More than 5 breathing cessations lasting longer than 10 seconds per hour during
sleep
CPAP mask
C. Factors that interfere with sleep
a.
b.
39.
Caffeine consumption, heavy meals before bedtime
Exercise promotes sleep if at least 2 hours before bedtime
NUTRITION AND ORAL HYDRATION
A. Basic Nutrients the body requires
a.
Carbohydrates
1. Provide most of the body’s energy
2. Each gram produces 4 kcal
b.
Fats
1. Provides energy and vitamins
2. No more than 35% of caloric intake should be from fat
3. Each gram produces 9 kcal
c.
Proteins
1. Repairs body tissues
2. Each gram produces 4 kcal
3. Important for wound healing
d.
Vitamins
1. Fat soluble vitamins A, D, E, K
2. Water soluble vitamins C and B complex
B. Age
a.
Newborn
1. Breast milk and formula used during the first full year of life
2. Solid food starting at 4-6 months
a. No cows milk or honey for the first year
b.
Older adults
1. Slower metabolic rate requires fewer calories
2. Thirst sensations diminish
3. Calcium is important for both men and women
C. BMI
a.
b.
Weight (kg) divided by height (m2)
Scale:
1. = obese
D. Diets
a.
b.
c.
Clear liquid- water, tea, coffee, broth, clear juices, gelatin, ginger ale
Full liquid- milk, pudding, fruit, ice cream, juice
Pureed- pureed meats, fruits, scrambled eggs
1. used if jaw is wired shut or after oral surgery
d.
Mechanical soft- diced or ground foods
1. Used if patient does not have teeth
e.
Low residue- low in fiver and easy to digest
1. Used for IBS or other GI disorders
E.
Dysphagia
a.
b.
c.
d.
e.
See Speech pathologist
Semi fowlers position
Thickened liquids
Check for food pockets
Tuck chin to chest when swallowing
f.
g.
h.
40.
Monitor patient during meals
Suction equipment ready
Avoid straws
MOBILITY AND IMMOBILITY
A. Respiratory
a.
Nursing interventions
1. Reposition every 1-2 hours
2. Instruct clients to turn, cough, and breathe deeply every 1-2 hours while
awake
3. Instruct clients to use an incentive spirometer while awake
4. Instruct clients to consume at least 2000 mL fluid per day, unless intake is
restricted
B. Instructions
a.
Cane
1. maintain 2 points of support on the ground at all times
2. Keep the cane on the stronger side of the body
3. Support body weight on both legs move cane forward 6-10 in
4. Move weaker leg forward, then move stronger leg past the cane
b.
Crutches
1. Do not alter crutches after fitting
a. 3 finger widths between axilla and the top of the crutch
2. Support body weight at the hand grips with elbows flexed (20-30
degrees)
3. Stairs- hold rail with one hand and crutches in the other
C. DVT
a.
b.
Symptoms: pain, edema, warmth, and erythema
Nursing actions
1. Notify provider immediately
2. Position client with leg elevated, give anticoagulants
c.
Anti-embolic stockings
1. Remove the stockings every 8 hours to assess redness, warmth, or
tenderness
D. Pulmonary Embolism
a.
b.
Symptoms: shortness of breath, chest pain, decreased BP, increase HR
Nursing actions
1. Give anticoagulants
2. Position client in high fowlers
3. Obtain pulse ox and monitor vital signs
4. Admin oxygen and prepare blood gas analysis
41.
PAIN MANAGEMENT
A. Pain Categories
a.
Acute Pain
1. Protective, temporary, and resolves with tissue healing
2. Tachycardia, hypertension, anxiety, diaphoresis
b.
Chronic pain
1. Lasts longer than 6 months
2. Do not usually alter vital signs—but can have depression, fatigue
3. Idiopathic pain- chronic pain without a known cause (ex:
depression)
c.
Nociceptive pain
1. Inflammation of tissue
2. Throbbing, aching, localized
3. Responds to opioids and nonopioid medications
4. 3 types:
a. Somatic- bones, joints, muscles, skin, connective tissues
b. Visceral- internal organs
c. Cutaneous- skin or subcutaneous tissue
d.
Neuropathic pain
1. Damaged pain nerves
2. Includes phantom limb pain, diabetic neuropathy
3. Shooting, burning, pins and needles
4. Responds to antidepressants, muscle relaxers
B. Symptom analysis
a.
b.
c.
d.
e.
f.
g.
Location- superficial, radiating
How the pain feels- shooting, burning, pins and needles….
Intensity- scale 0-10
Timing- onset, duration, frequency
Setting- how it affects ADLs
Associated findings- fatigue, depression, nausea
Aggravating/relieving factors-
C. Pain care
a.
Nonopioid analgesics
1. Mild to moderate pain
2. No more than 4 g/day
3. Monitor for salicylism (tinnitus, vertigo)
4. Prevent gastric upset by admin with food
5. Long term use- monitor for bleeding
b.
Opioid analgesics
1. Moderate-severe pain
2. Around the clock administration
3. Sedation, respiratory depression, orthostatic hypotension, urinary retention,
nausea/vomiting, constipation
4.
Nolocsone- antidote for opioids
42.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
A. Types of CAM
a.
Acupuncture- needles or pressure along meridians to alter body function or
produce analgesia
b.
c.
d.
e.
B.
Chiropractic medicine- spinal manipulation for healing
Massage therapy- stretching and loosening muscles and connective tissue for
relaxation and circulation
Biofeedback- using tech to increase awareness of various neurological body
responses to minimize extremes
Therapeutic touch – using hands to help bring energy fields into balance
Natural products and Herbal Remedies
a.
Garlic, ginger, ginseng increase bleeding
C. Therapies
a.
Guided imagery- encourage healing and relaxation of the body by having the
mind focus on images
b.
43.
Relaxation techniques- promotes relaxation using breathing techniques while
thinking peaceful thoughts or while tensing and relaxing specific muscle
groups
BOWEL ELIMINATION
A. Constipation
a.
Help constipation
1. Increase fluid intake
2. Increase fiber intake (25-30 g/day)
3. Decrease laxatives
4. Increase activity
b.
Fecal Occult Blood test
1. Collect stool 3 times from 3 different defecations
2. Blue color indicates the stool is positive for blood
B. Enema
a.
b.
c.
d.
e.
f.
g.
Warm the enema solution
Position the client on the left side with the right leg flexed forward
Lubricate the rectal tube or nozzle
Insert the rectal tube 7.5-10 cm (3-4 in)
Bag level with the client’s hip, open the clamp
Raise the bag 30-45 cm (12-18 in) above the anus
Slow the flow by lowering the container if the client reports cramping
C. Ostomy Care
a.
b.
c.
Remove the pouch
Inspect the stoma- should appear moist and pink, peristomal area should be
intact
Use mild soap and water to cleanse the skin and dry it gently and
completely
1. NO MOISTURIZING SOAPS
d.
e.
Cut the opening 0.15-0.3 cm (1/18 to 1/8 in) larger
Fold the bottom of the pouch and clamp it
D. Diarrhea
a.
Fluid and electrolyte disturbances: metabolic acidosis
1. Monitor for dehydration
a. Weak/rapid pulse, hypotension, poor skin turgor, elevated body
temperature
b.
44.
Skin breakdown around the anal area—zinc oxide
URINARY ELIMINATION
A. Input and Output
a.
b.
Input should be about the same as the output
Output less than 30 mL/hr for more than 2 hours is a cause for concern
B. Timed Urine Specimens
a.
b.
Collect for 24 hours
Discard the first voiding and then collect all other urine
1. Refrigerate, label, and transport specimen
C. Catheter Care
a.
b.
c.
d.
Use soap and water at the insertion site
Cleanse the catheter at least 3 times a day
Check for kinks in the tubing
Make sure collection bag is below the bladder level to avoid reflux
D. Urinary Tract Infections
a.
Risk factors
1. Urethral meatus close to the anus, Frequent sexual intercourse, menopausedecreasing estrogen levels, uncircumcised males, use of indwelling
catheters
b.
Nursing considerations
1. Female: cleanse from front to back
2. Male: cleanse beneath foreskin
3. Provide catheter care regularly
4. Drink cranberry juice- treat/prevents UTI
E.
Urinary Incontinence
a.
Types
1. Stress- loss of small amounts of urine form increased abdominal
pressure while laughing, sneezing, or lifting
2. Urge- inability to stop urine flow long enough to reach the
bathroom
b.
Nursing care
1. Establish a toileting schedule
2. Perform kegel exercises
3. Avoid caffeine and alcohol consumption
4. Vaginal cone therapy
45.
SENSORY PERCEPTION
A. Clients with hearing loss
a.
b.
c.
d.
e.
Sit and face the client
Avoid covering your mouth while speaking
Speak slowly and clearly
Do not shout, try lowering vocal pitch
Ask for a sign language interpreter if necessary
B. Clients with Aphasia
a.
b.
Only one person speaking at a time
Speak clearly and slowly using short sentences and simple words
c.
d.
Allow time for clients to understand
Allow plenty of time for clients to respond
C. Hearing loss
a.
Conductive hearing loss
1. Alteration in middle ear that blocks sounds waves before they reach the
inner ear
2. Risk factors: history of middle ear infections, older age
3. Expected findings
a. Rinne test- air conduction of sound less than bone conduction
b. Weber test- lateralizes the affected ear
b.
Sensorineural hearing loss
1. Alteration in the inner ear and auditory nerve
2. Risk factors: prolonged exposure to loud noises, ototoxic
medications, older age
3. Expected findings
a. Rinne test- air conduction of sound greater than bone
conduction
b. Weber test- lateralizing unaffected ear
D. Hearing aids
a.
Client education
1. Use the lowest setting that allows hearing without feedback
2. When not in use: turn it off and remove battery, avoid corrosion of the
hearing aid
46.
PHARMACOKINETICS AND ROUTES OF ADMINISTRATION
A. Absorption
a.
Oral
1. Must pass through the GI tract
2. Absorption varies greatly due to
a. Stability and solubility of the meds
b. Gastrointestinal pH
c. Presence of food in the stomach
d. Forms of meds
B. Distribution
a.
Circulation- inhibit of blood flow or perfusion such as peripheral vascular or
cardiac disease
b.
c.
Permeability of the cell membrane
Plasma protein binding- medication to bind to a protein can affect how much
of the medication will leave and travel to target tissues
C. Metabolism
a.
Factors influencing medication metabolism rate
1. Age- older adults require smaller doses of medication
2. First -pass effect
a. Liver inactivates some medications on their pass through the liver
i.
Require non-enteral route
3. Similar metabolic pathways
a. Same pathway metabolize two medications, can alter the
metabolism of one or both
4. Nutritional status
a. Malnourished can be deficient in the factors that are necessary
D. Excretion
a.
Elimination of medications from the body, primarily through the kidneys
1. Other areas: liver, lungs, intestines
E.
Therapeutic Index (TI)
a.
b.
F.
a.
Meds with high TI have a wide safety margin
Meds with low TI need to be closely monitored
Half Life
The time for the medication in the body to drop by 50%
b.
c.
Short half-life- meds leave the body quickly, 4-8 hours
Long half-life1. meds leave the body more slowly:
a. over more than 24 hours
2. with a greater risk for meds accumulation and toxicity
G. Pharmacodynamics (mechanism of action)
a.
Agonist- medication that can mimic the receptors activity
1. Morphine is an agonist because it activates the receptors that
produce analgesia, sedation, and constipation
b.
Antagonist- medication that can block the usual receptors activity
H. Routes and Administration
a.
Oral
1. Vomiting, decreased GI motility, absence of a gag reflex, difficulty
swallowing, and decreased level of consciousness
2. Have clients sit upright at a 90 degrees angle
3. Do not mix with large amounts of food or beverages
4. Clients Swallow enteric coated or time released meds whole
b.
Sublingual
1. Sublingual: under the tongue
2. Buccal: between the cheek and the gum
3. Clients should not eat or drink while the tablet is in place or until it has
completely dissolved
c.
Transdermal
1. Wash the skin with soap and water, and dry it thoroughly
2. Place the patch on a hairless area and rotate sites
d.
Instillation
1. Rest your dominant hand on the client’s forehead, hold the dropper above the
conjunctival sac
2. If instilling more than one medication in the same eye, wait at least 5
minutes between them
3. Ears
a. Clients lie on their side
b. Pulling the auricle upward and outward for adults or down and back for
children
c. Dropper 1 cm above the ear canal, instill the medication, and then
gently apply pressure with your finger to the tragus
d. 2-3 min after installation of ear drops
e.
Inhalation
1. Metered-dose inhalers (MDI)
a.
Shake inhaler
2. Dry powdered inhalers (DPI)- do not shake
f.
Nasogastric and gastrostomy tubes
1. Verify proper tube placement
2. Do not mix meds with enteral feedings
3. Completely dissolve crushed tablets and capsule contents in 15-30 mL
water
4. Flush the tubing before and after each med with 15-30 mL water
g.
Intradermal
1. 0.01-0.1 mL in a 26-27 gauge
2. Bevel up, small bleb should appear
h.
Subcutaneous
1. 3/8-5/8 in, 25-27 gauge or 28-31-gauge insulin syringe
a. Inject no more than 1.5 mL of solution
2. 45-90 angle; use a 90 degree and
i.
Intramuscular
1. Common sites: ventrogluteal, deltoid and vastus lateralis
(pediatric)
2. 18-27 gauge, 1-1.5 in long
3. Use Z track method
47. SAFE MEDICATION AND ADMINISTRATION AND ERROR
REDUCTION
A. Pregnancy risk categories
a.
A, B, C, D, E, X
B. Types of medication prescriptions
a.
Routine/ standard prescriptions
1. Regular schedule
b.
Single- or one-time prescriptions
1. Administration once at a specific time or as soon as possible
c.
Stat prescriptions
1. One and immediately
d.
Now prescriptions
1. Only admin. Once, but up to 90 min from when the nurse received the
prescription
e.
PRN prescriptions
1. Specifies what dosage, what frequency, and under what conditions a nurse
may administer the medication
f.
Standing prescriptions
1. For specific circumstances or for specific units
C. Components of a medication prescription
a.
b.
c.
d.
The clients full name
Date and time
Name of the medication
strength and dosage
e.
f.
g.
h.
route of admin
time and frequency
number of refills
signature of the prescribing provider
D. Rights of safe medication administration
a.
b.
c.
d.
e.
f.
g.
h.
i.
E.
Right medication
Right dose
Right time
Right route
Right documentation
Right client education
Right to refuse
Right assessment right evaluation
Common medication errors
a.
b.
F.
Right client
Administration of a medication to which the client is allergic
Omission of a dose or extra dose
Error-prone abbreviation list
Do not use
Use
MS, MSO4
Morphine
MgSO4
Magnesium sulfate
Decimal point without a
leading zero (0.5 mg)
Small units (500 mcg) or
a leading zero (0.5 mg)
Trailing zero (1.0
mg,100.0 g)
Without a trailing zero
( 1 mg, 100 g)
U, U, IU
units
q.d, qd, Q.D., QD, q1d,
i/d
daily
q.o.d., QOD
Every other day
SC, SQ, sub q
Subcutaneously
G. Implementation
a.
b.
c.
d.
48.
Prepare medications for one client at a time
Doses are usually one to 2 tablets or one single-dose vial
Only give meds that you have prepared
Do not leave medication at the bedside
DOSAGE CALCULATION
A. Standard conversion factors
49.
INTRAVENOUS THERAPY
A. Intraprocedural
a.
b.
c.
Apply a clean tourniquet or blood pressure cuff (especially for older adults) 10-15
cm (4-6 in) above the insertion site to compress only venous blow flow
Distal veins first on the nondominant hand
Avoid the following
1. Varicose veins
2. Flexion areas
3. Near valves
4. 10-30-degree angle
B. Post procedure
a.
Maintaining the patency of IV access
1. Flush intermittent IV catheters
2. Every 8-12 hours
b.
Discontinue IV therapy
1. Elevate the extremity and apply pressure
2. Apply tape over the gauze
3. Check the catheter for intactness
C. Complications
a.
Infiltration
1. Local swelling at the site, decreased skin temp around the site, damp
dressing, slowed rate of infusion
2. Elevate the extremity and apply a warm or cold compress
b.
Phlebitis
1. Edema, throbbing, burning, or pain at the site, erythema, red line up the arm
2. Discontinue the infusion
3. Elevate the extremity
4. Apply warm compresses
5. Obtain a specimen for culture
c.
Fluid overload
1. Distended neck veins, increased blood pressure, tachycardia, ,
shortness of breath, crackles in the lungs, edema
2. Treatment
a. Stop the infusion, raise the head of the bed, measure vital signs and
oxygen saturation, adjust the rate after correcting fluid overload, admin
diuretics
d.
Cellulitis
1. Pain, warmth, edema, induration, red streaking, fever, chills malaise
2. Treatment
a. Discontinue the infusion and remove the catheter
b. Elevate the extremity
c. Apply warm compresses 3-4 times/days
d. Obtain a specimen for culture
e. Admin the following
i.
e.
Antibiotics, analgesics, antipyretics
Catheter embolus
1. Missing catheter tip on removal, severe pain at the site with
migration
2. Treatment
a. Place a tourniquet high on the extremity
b. Prepare for removal under x ray or via surgery
50. ADVERSE EFFECTS INTERACTIONS, AND
CONTRAINDICATIONS
A. Extrapyramidal symptoms
a.
Tremors, restlessness, acute dystonia (spastic movements)
B. Anticholinergic effects
a.
Dry mouth, urinary retention, constipation
b.
c.
Wear sunglasses, increase dietary fiber and fluids
Can’t see, can’t pee, cant spit, cant poop
C. Medication- food interactions
a.
Tyramine
1. Avocados, cheese, smoked meats
2. MAOIs can lead to hypertensive crisis
b.
Vitamin K
1. Can decrease effects of vitamin K
c.
Dairy
1. Don’t take Tetracycline within 2 hours of consuming any dairy
products
d.
Grapefruit juice
51. INDIVIDUAL CONSIDERATION OF MEDICATION
ADMINISTRATION
A. Pharmacology and older adults (65+ years)
a.
b.
c.
d.
e.
f.
Increased gastric pH
Decreased gastrointestinal motility and gastric emptying time
Decreased blood flow
Decreased kidney function
Decreased protein binding sites, resulting in lower serum albumin levels
Decreased body water, increased body fat, and decreased lean body mass
52.
SPECIMEN COLLECTION FOR GLUCOSE MONITORING
A. Intra procedure
a.
b.
c.
d.
e.
f.
g.
Wrap the site in a warm, moist towel to enhance circulation
Cleanse the site with warm water and soap or an antiseptic swab and allow it
to dry
Put finger in dependent position
Pierce the skin using a sterile lancet and holding it perpendicular to the skin
Wipe away the first drop of blood with a cotton ball
Do not touch the site directly to stimulate bleeding
Hold the test strip next to the blood on the finger tip
1. Do not smear blood onto the strip because this can cause an
inaccurate reading
B. Interpretation of findings
a.
b.
Greater than 200 mg/dL indicates hyperglycemia
Less than 70 mg/dL indicates hypoglycemia
C. Indications
a.
b.
53.
Perform urine glucose testing
Greater than 240 mg/dL to identify the presence of ketones
AIRWAY MANAGEMENT
A. Interpretations of findings
a.
Expected reference range: 95-100%
1. Hypoxemia: less than 90%
b.
COPD norm: 89-100%
B. Oxygen Therapy
Hypoxemia
Hypoxia
C. Low- flow oxygen delivery systems
a.
Nasal Cannula
1. tubing with 2 small prongs for insertion into the nares
2. 1-6 L/min
3. Provide humidification for flow rates of 4 L/min and greater
b.
Simple face mask
1. 5-8 L/min
c.
Partial rebreather mask
1. 6-10 L/min
2.
d.
Keep reservoir bag 1/3 to ½ full on respiration
Nonrebreather mask
1. 10-15 L/min to keep the reservoir bad 2/3 full
2. Hourly assessments of the valve and the flap
D. High-Flow oxygen delivery systems
a.
Venturi mask
b.
1.
4-12 L/min
2.
Most precise oxygen concentration
Aerosol mask
1. Face tent: fits loosely around the face and neck
2. High humidification with oxygen delivery
E.
Complications
a.
Oxygen toxicity
1. Nonproductive cough, substernal pain, nasal stiffness, nausea,
vomiting, fatigue, headache, sore throat, and hypoventilation
b.
Combustion
1. Post “no smoking” or “oxygen in use” signs to alert others to the fire
hazard
2. Have client wear cotton gown
3. Ensure electrical devices are working well
4. Make sure all electric machinery is grounded
5. Do not use volatile, flammable materials (alcohol, acetone, nail polish)
near clients receiving oxygen
F.
Chest physiotherapy
a.
b.
c.
d.
Use set of techniques that loosen respiratory secretions and move them into
central airways where coughing or suctioning can remove them
Percussion- use of cupped hands to clap rhythmically on the chest to break
up secretions
Vibration- use of shaking movements during exhalation to help remove
secretions
Postural drainage- use of various positions to allow secretions to drain by gravity
G. Considerations
a.
Schedule treatments 1 hr before or 2 hr after meals to decrease the
likelihood of vomiting
b.
Admin bronchodilator medication or nebulizer treatment 30 min to 1 hr prior to
postural drainage
H. Suctioning
a.
b.
c.
d.
e.
Put client in high fowler’s positions
For nasopharyngeal and nasotracheal suctioning lubricate the to distal 6-8 cm with
water soluble lubricant
The catheter should not exceed one half of the internal diameter of the
endotracheal tube
Use suction pressure no higher than 120-150 mmHg
Additional guidelines for nasopharyngeal and nasotracheal suctioning
1. Insert the catheter into the naris during inhalation
2. Apply suction intermittently by covering and releasing the suction port
with the thumb for 10-15 while rotating thumb and forefinger
3. Do not perform more than 2 passes with the catheter. Allow at least 1
min
f.
Additional guidelines for endotracheal suctioning
1. Advance the catheter until resistance is met- should reach the level of the
carina
2. Pull the catheter back 1 cm
3. Apply suction intermittently by covering and releasing the suction port with
the thumb for 10-15 seconds and rotate it with the thumb and forefinger
54.
NASOGASTRIC INTUBATION AND ENTERAL FEEDINGS
A. Nasogastric feedings
a.
Intra procedure
1. High fowlers position
2. Check placement by testing pH
3. Confirm placement with an X ray
B. Enteral Feedings
a.
b.
c.
Fowlers position
Auscultate for bowel sounds
Monitor tube placements
1. Contents for pH (between 0-4)
d.
55.
Check placement every 4-6 hour and check tube placement again
PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT
A. Stages of wound healing
a.
Inflammatory stage
1. Lasts 3-6 days
2. Vasoconstriction, clot formation, hemostasis, phagocytosis of
microorganisms
b.
Proliferative stage
1. 3-24 days
2. Replacing lost tissue or granulated tissue
3. Contracting with wound’s edges
4. Resurfacing of new epithelial cells
c.
Maturation or remodeling stage
1. After day 21
2. It can take more than 1 year to complete
B. Healing processes
a.
Primary intention
1. Edges approximated as with a surgical incision
2. Heals rapidly
3. Minimal scarring
b.
Secondary intention
1. Loss of tissue
2. Wound edges widely separated longer healing time
3. Increase for risk of infection
4. Scarring
c.
Tertiary intention
1. Spontaneous opening of a previously closed wound
2. Closure of wound occurs when free of infection
C. Factors affecting wound healing
a.
b.
Increased age delays healing
Impaired immune system function
D. Assessment/data collection
a.
b.
c.
d.
Red- healthy regeneration of tissue
Yellow- presence of purulent drainage and slough
Black- presence of eschar that hinders healing and requires removal
Types of drainage
1. Serous drainage: Watery and clear
2. Sanguineous drainage: serum and red blood cells
3. Serosanguineous drainage- both serum and blood
4. Purulent drainage- result of infection
e.
Perform wound cleansing
1. Cleanse from the least contaminated toward the most
contaminated
2. If irrigating
a. Apply 5-8 psi
3. Use a 30-60 mL syringe
E.
Dehiscence vs evisceration
F.
Pres
a.
Stages
1. Stage 1- non-blanchable erythema- intact skin
2. Stage 2- partial thickness- affects epidermis and dermis
3. Stage 3- full thickness skin loss- cannot see muscle and bone
4. Stage 4- full thickness skin loss- can see muscle and bone
5. Unstageable- depth unknown
b.
Prevention
1. Reposition the client in bed at least every 2 hours and every 1 hour in a
chair
2. Keep the head of the bed at or below 30 degrees
3. Encourage proper nutrition
56.
SKIP- WENT OVER ALREADY
57.
FLUID IMBALANCES
A. Fluid Volume deficiency
a.
Expected findings
1. Tachycardia, hypotension, orthostatic hypotension, decreased central
venous pressure, tachypnea, dry mucus membranes, oliguria, diminished
capillary refill, diaphoresis, flattened neck veins, decreased skin turgor
b.
Lab tests
1. Hct- increased
2. Serum osmolarilty- increase
3. Urine specific gravity- increase
c.
Nursing Care
1. Monitor I&O – less than 30 mL/hr
2. Observe level of gait stability
B. Fluid Volume excess
a.
Expected findings
1. Tachycardia, bounding pulse, hypertension, tachypnea, weight gain,
dyspnea, crackles, edema, distended
b.
Lab tests
1. Hct- decreased
2. Serum osmolarity- decreased
3. Decreased electrolytes, BUN, and creatinine
4. Urine specific gravity decreased
58.
ELECTROLYTE IMBALANCES
Hyponatremia
Hypernatremia
Less than 136 mEq/L risk
Greater than 145 mEq/L risk
factors:
factors:
- GI losses, diuretics, skin
losses, edematous,
hyperglycemia
expected findings:
- water deprivation, excessive
sodium intake, kidney failure,
Cushing’s syndrome
Expected findings
- tachycardia, hypotension,
confusion, fatigue, nausea,
- Tachycardia, muscle twitches,
muscle weaknesses, edema
vomiting
Hypokalemia
Hyperkalemia
Less than 3.5 mEq/L Risk
Greater than 5.0 mEq/L Risk
factors
factors
- GI losses, diuretics, skin
losses, metabolic alkalosis
Expected findings
- Diabetic ketoacidosis,
uncontrolled diabetes mellitus,
kidney failure, salt substitutes
Expected findings:
- Hypotension, muscle
weakness, muscle cramping,
dysrhythmias
-
dysrhythmias
Hypocalcemia
Hypercalcemia
Less than 9 mg/dL
More than 10.5 mg/dL
Risk factors:
Risk factors:
- diarrhea, vitamin D deficiency,
hypoparathyroidism
expected findings:
- hyperparathyroidism, bone
cancer, long term glucocorticoid use
expected findings
- numbness and tingling,
muscle spasms, positive
Chvostek’s sign, positive
trousseau’s sign
- decreased reflexes.
Constipation, lethargy
Hypomagnesemia
Hypermagnesemia
Less than 1.3 mEq/L Risk
More than 2.1 mEq/L Risk
factors:
factors
- GI losses, loop diuretics,
malnutrition, alcohol use disorder
Expected findings
- Kidney disease, laxatives
Expected findings
- Hyperactive DTRs, seizures,
positive Chvostek’s and
trousseau’s sign, seizures
- Dysrhythmias, tachycardia,
hypertension
- Muscle paralysis, shallow
respirations, decreased
respiratory rate, hypotension,
cardiac arrest, lethargy
