lOMoARcPSD|7425677

Fundamentals: Safety, Precautions, Nursing Requirements

• Levels of health care

- Preventative health care focuses on educating and equipping clients to
reduce and control risk factors of disease. Examples include programs that
promote immunization, stress management, and seat belt use.
- Primary health emphasizes health promotion, and includes prenatal and well-
baby care, nutrition counseling, and disease control. This level of care is based
on a sustained partnership between the client and the provider. Examples include
office or clinic visits and scheduled school or work-centered screenings (Vision,
hearing, obesity).
- Secondary health care includes the diagnosis and treatment of emergency,
acute illness, or injury. Examples include care that is given in hospital settings
(inpatient and emergency departments), diagnostic centers, or emergent care
centers.
- Tertiary health care involves the provision or specialized highly technical
care. Examples include oncology centers and burn centers.
- Restorative health care involves intermediate follow up care for restoring
health. Examples include home health care, rehabilitation centers, and in-home
respite care.

 Nursing ethical principles

o Autonomy
- Ability of the client to make personal decisions, even when those decisions
may not be in the clients own best interest.
o Beneficence
- Agreement that the care given is in the best interest of the client; taking
positive actions to help others.
o Fidelity
- Agreement to keep ones promise to the client about care that was offered.
o Justice
- Fair treatment in matters related to physical and psychosocial care and use
of resources.
o Nonmaleficience
- Avoidance of harm or pain as much as possible when giving treatments.
o Veracity
- It is the basis of the trust relationship established between a patient and a
health care provider.
• Ethical decision making in nursing
o Ethical dilemmas are problems about which more than one choice can be made and the
choice made is influenced by the values and beliefs of the decision makers. These are
common in health care, and nurses must be prepared to apply ethical theory and
decision making to ethical problems.
o A problem is an ethical dilemma if:
- It cannot be solved by a review of scientific data.
- It involves a conflict between two moral imperatives.
- The answer will have a profound effect on the situation/client.

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  The nurses basic code of ethics and principles remains constant. These basic principles include:
o Advocacy
- Support of the cause of the client regarding health, safety, and personal rights
o Responsibility
- Willingness to respect obligations and follow through on promises
o Accountability
- Ability to answer for one’s own actions
o Confidentiality
- Protection of privacy without diminishing access to quality care.
 Intentional torts
o Assault
- The conduct of one person makes another person fearful and
apprehensive (Threatening to place a nasogastric tube in a client who is
refusing to eat).
o Battery
- Intentional and wrongful physical contact with a person that involves an injury
or offensive contact (restraining a client and administering an injection against
his/her wishes).
o False imprisonment
- A person is confined or restrained against his will (Using restraints on
a competent client to prevent his leaving the care facility).
 Unintentional torts (didn’t intend to harm patient but you did)
o Negligence
- A nurse fails to implement safety measures for a client who has been
identified as at risk for falls.
o Malpractice (Professional negligence)
- A nurse administers a large dose of medication due to a calculation error.
The client has a cardiac arrest and dies.
 Informed Consent
o Responsibility of the provider
 Communicate purpose of procedure, and complete description of procedure
in the patients primary language (use medical interpreter if needed, NOT
family member).
 Explain Risks vs. benefits
 Describe other options to treat the condition.
o Responsibility of the RN:
 Make sure provider gave the patient the above information.
 Ensure patient is competent to give informed consent (i.e. patient is an adult
or emancipated minor, not impaired)
 Have patient sign consent document
 If pt has further questions call provider and have them come back and
explain things further BEFORE they sign the form
• Patient Education
o Assessment: identify patient needs, learning style (auditory, visual, kinesthetic),
abilities, available recources.
o Planning: develop mutually agreeable goals/outcomes.
o Implemmentation: DO NOT use medical jargon. Make sure materials are at a sixth
grade level (or below).
o Evaluation: ask patient to explain the teaching in their own words, or have the patient
do a return demonstration for psychomotor learning.

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 o DO NOT perform patient teaching when client is: in pain or has anxiety, or is in any
way mentally impaired.
 Advance Directives
o Living will: communicates patients wishes regarding medical treatment if
patient becomes incapacitated.
o Durable power of attorney (health care proxy): patient designates health care proxy
to make medical decisions for them if they become incapacitated.
o Provider’s orders: prescription for DNR (do not resuscitate) or AND (allow
natural death)
o Mandatory Reporting for RNs:
 Suspicion of abuse (child, elderly, domestic violence)
 Communicable diseases to local/state health department (mandated by state).
 Nursing Documentation
o Objective data: what you see, hear, smell. Do not include opinions or interpretations
of data.
o Recording subjective data: document as direct quotes, or clearly identify information as
a statement by patient.
o Legal guidelines for documentation:
 Don’t leave blank spaces in documentation.
 Never use correction tape or fluid or scratch out or black out words
 Include name and title on documentation
 Incident reports
o When accident occurs (falls or med error)
 Used for quality improvement for facility (for hospital)
o Not part of the patients records and should not be referenced in the patients record
 Need to document the incident and patient’s reaction and incidence report is
for the hospital not for the patient’s medical record
 Telephone Orders and Information Security
o Telephone orders: have second RN listen in on call, repeat prescription back, make
sure provider signs prescription within 24 hour.
o After provider says the order you FIRST want to read back the order to the provider,
To ensure it is accurate.
 Information security
o HIPAA: ensures the confidentiality of health information only those responsible
for patient’s care may access the patient’s medical record.
 Don’t use patient names on public display boards
 Communication about a patient should happen in a private place or at
nursing station.
 Password protect and do not share passwords
 Log off or lock computer when you walk away
 Do not share information with unauthorized people
o Code system can be used
 If pt doesn’t want to tell anyone they are at the hospital
 Delegation (VERY IMPORTANT)
 DO NOT DELGATE WHAT YOU CAN EAT; (Evaluate, Asses, Teach)
o What RN has to do
 Patient education
 Nursing judgement
 Assessment
 Blood transfusions

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  Unstable patients
o What a PN can do (LPN)
 Med admin
 Enteral feedings
 Urinary catheter insertion
 Suctioning
 Trach care
 Wound care
 Reinforce patient teaching you (RN) have already done
 Can care for STABLE patients
o What a NAP/UAP/CAN
 Bathing
 Dressing
 Ambulating
 Toileting
 Feeding without swallowing precautions
 Positioning
 Vitals
 Specimens
 I+Os
 Basic CPR
o 5 Rights to Delegation
 Right task
 Repetitive noninvasive and not a lot of supervision
 Right circumstances
 Do not assign a patient who is unstable
 Right patient
 Competent and within their scope of practice
 Right direction and communication
 Specific details and timeline for completion and expectation for
reporting findings back to you
 Right supervision and evaluation
 May need to intervene
 Provide feedback
 Nursing process:
o Assessment and data collection:
 What do you see, hear, feel?
 Collect objective and subjective data
 Verify that the data you collected is clear and accurate
 Do assessment BEFORE action.
o Analysis and data collection:
 What are priority problems?
 Interpret the information collected
 Identify an appropriate Nursing Diagnosis
 Document your diagnosis and communicate it to the healthcare team
 Determine the health team’s ability to help
 Cluster collected data
 Any patterns and trends
 Compare data you gathered from baseline

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 o Planning:
 How will you fix them?
 Prioritize the outcomes of care.
 Develop and modify plan of care.
o Implementation:
 What interventions?
 Organize and manage the clients care including safety, communication,
culture, and delegation of tasks.
 Carry out clients plan of care
 Counsel and educate the client
o Evaluation:
 How well did the invertentions work?
 Compare actual outcomes with the planned/ expected outcomes
 Evaluate patients compliance
 Document clients response to plan
 Modify plan and reassess as needed
 Patient admission
o Document patients:
 Advanced directions ASAP
 Vital signs
 Allergies
 Height and weight
 Head to toe assessment
 Health history
 Spiritual or cultural considerations
o Assess their ability to swallow safely:
 Give a little water and assess what the patient does
 Any concern is NPO until swallow evaluation by speech language pathologist
o Assess safety:
 Implement fall precautions if appropriate.
o Patient belongings and inventory:
 Valuables should be sent home with family if possible or lock valuables
in facility safe.
o Medication reconciliation:
 Very important
 Compare home meds with providers prescription
o Discharge planning:
 Starts AT ADMISSION!!!
 Patient transfer (one unit to another)
o Use SBAR:
 Hand off tool to use when giving report to next nurse
 (Situation, Background, Assessment, Recommendation)
 Discharging a Patient
o Included in patient discharge instructions:
 Patients diet and activity restrictions
 Detailed instructions for procedures to be done at Home (such as wound
dressing changes).
 List of medications, when to take them, precautions regarding medications.
 Signs and symptoms of complications, when to seek medical attention.
 Follow up information and appointment
 Names and numbers of community resources or providers
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 • List the pertinent information that should be included in a transfer report:
o These should include demographic information, medical diagnosis, providers, an
overview of health status (physical, psychosocial), plan of care, recent progress, any
alterations that might become urgent or emergent situation, directives for any assessments
or client care essential within the next few hours, most recent vital signs, medications and
last doses, allergies, diet, activity, specific equipment or adaptive devices (oxygen,
suction, wheelchair), advance directives and resuscitation status, discharge plan
(teaching), and family involvement in care and health care proxy.
• Therapeutic Communication:
o What NOT to do:
 DO not ask ‘why’ questions; NEVER PICK WHY!!!
 Do not ask yes/no questions, except in the case of possible self harm.
 Do not focus on the nurse
 Do not explore
 Do not say “Don’t Worry”
o What to do:
 Respond to feeling tone
 Provide information
 Focus on the client
 Use silence (offer to stay with a patient)
 Use presence (stay and comfort a patient by just being there to hold their hand).
 ALWAYS GO WITH ANSWER THAT ALLOWS A PAITENT TO
EXPRESS THEIR FEELINGS.
 SELCET “TELL ME MORE or HOW does that make you feel” ANSWERS.
• What patient do you see first?
o Consider:
 Unstable vs. stable; ALWAYS see patient who is unstable FIRST!
 Unexpected vs. expected; Ask are the symptoms expected or unexpected?
See unexpected FIRST!
 ABCs: Always remember (Airway, Breathing, Circulation) if patient
doesn’t have a patent airway seem them FIRST!!!!
 Acute vs. Chronic; example asthma attack or broken bone is acute (severe
sudden onset), COPD or osteoporosis is chronic (long developing
syndrome)
 Actual vs. potential; Actual (problem related to cause as evidenced/
manifested by the signs and symptoms), Potential (potential problem related to
the cause; there are no signs and symptoms, because the problem has not
occurred yet.
 Hand hygiene:
o When to use soap and water:
 Hands are visibly soiled
 Before eating meals
 After using the restroom
 Contact with bodily fluids
 Wash for > 15-20 seconds. Dry w/ clean paper towel before turning off faucet.
o Alcohol-based products
 3-5 mL of product
 Rub hands continuously until dry
 Ways to Prevent Spread Infection
o Cover mouth or nose when sneezing or coughing
o Use tissues and proper disposal of tissues
o Stand at least 3 ft away of ppl who are coughing or provide a mask
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 o Short nails and no artificial nails or gel nail polish
o Remove jewelry from hands and wrists
o Don’t shake linen
o Clean least soiled areas first and move towards more soiled
o Don’t put soiled items on the floor
 Sterile Fields
o Setting up sterile field:
 Position package with TOP FLAP facing AWAY from you.
 Open top flap AWAY from you.
 Open right-side flap with right hand, open left side flap with left hand.
 Open last flap towards you.
o Sterile solutions:
 Place bottle cap FACE UP on non-sterile surface.
 Hold bottle so the label is AGAINST your palm
 Pour a small amount (1-2mL) away.
 When pouring solution, do not touch bottle to site.
o Sterile field:
 Do not cough, sneeze, or talk over field.
 1” edge of field is NOT sterile; discard any item that comes in contact with
this area.
 Any object held below the waist or above the chest is contaminated.
 Add objects to sterile field at LEAST 6” above the field.
 NEVER turn your back on a sterile field or reach across a sterile field.
 Any sterile item that comes in contact with moisture is considered non-sterile.
• Preventing Falls
o Fall prevention:
 Advise patients with orthostatic hypotension to sit at the side of the bed
before standing up. Tell patient to get up slowly.
 Provide regular toileting to patients requiring assistance.
 Provide skid proof socks.
 Place patients at risk for falls near nurses’ station.
 Round on your patients hourly
 Make sure frequently used items are within reach:
- Call button
- Water
- Phone
 Position bed to lowest position, lock brakes, set bed alarm.
 DO NOT put up all 4 side rails for patients who will try to get out of bed
on their own.
 Frequent used items are within reach
 Seizures
o Implement seizure precautions
o Padding siderails
o Suction and oxygen equipment available at bedside
o LOWER patient to floor or bed, turn patient to the SIDE.
o Clear area for safety
o Loosen restrictive clothing
o DO NOT restrain patient, or put anything in the mouth (airway, tongue blade).
o Note onset and duration of seizure
• After Seizures
o Take vital signs, perform neurological checks.
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 o Reorient patient
o Identify possible trigger
o Implement seizure precautions (Pad bed rails).
 Restraints
o Physical (vest, belt, mitten) or chemical (sedative or antipsychotic medication).
o Before we apply it
 Try alternatives FIRST
 Reorientation
 Supervision
 Diversions
o If they fail, then we can apply
o In emergency RN can apply but prescription is needed ASAP within 1 hour
o Orders can be written for up to 4 hours for adults
o Provider must rewrite restraint orders every 24 hours and no PRN orders
o Apply padded portion to client’s wrist
o Perform neurovascular checks at least every 2 hours
o Assess pts skin integrity
o ROM exercises regularly
o Use least restrictive restraint that can help (mittens are better than wrist restraints)
o Apply so 2 fingers can fit between restraint and patient
o Use a quick release knot (slip knot don’t use square knot)
o Movable portion of the bedframe NOT on siderails and NOT on an unmovable part of
the bedframe
o Always apply belt restraints over clothing or gowns
 Fire safety
o RACE
 R (Rescue): move pateitnts to safer location. Horizontal evacuation first,
then lateral evacuation if needed.
 A (Alarm): Activate alarm system.
 C (Contain): Close doors/windows, turn off oxygen sources.
 E (Extinguish): Use fire extinguisher.
 Horizontal then lateral evacuation
o PASS
 P: Pull the pin
 A: Aim at the base of the fire
 S: Squeeze the handle.
 S: Sweep from side to side.

• Injury prevention: Infants and toddlers

o Avoid foods that can cause chocking: popcorn, raisins, peanuts, grapes, raw
carrots, hotdogs, celery, peanut butter, candy, tough meat.
o Place infants on back to sleep. Do not place anything in the crib with the baby.
Make sure crib slats are < 2 3/8 inches apart.
o Keep plastic bags, houseplants, cleaning agents out of reach. Lock up medications.
o Use rear facing car seat until 2 years old. Use car seats with 5-point harness, place
in back seat.
o Turn pot handles away from front of stove.
o Close bathroom doors; keep toilet lids down.

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  Injury prevention: School age children
o Use car booster seat while child is under 40lbs or under 4’0”. Keep child in
backseat until 12 years old.
o Use protective gear (ex: helmets, pads) for bicycling, sports.
o Reduce water heating setting to less than 120 degrees F.
o Keep guns locked up, bullets stored in separate location.
o Enclose pools with locked fence, supervise children in pools/water.
• Injury prevention: Adolescents
o Educate teens on risks associated with smoking, drugs, alcohol, unprotected sex.
o Warn against distracted or impaired driving. Reinforce need to wear seat belts.
o Monitor teens for mental health issues (depression, anxiety).
• Injury prevention: Older Adults
o Remove trip hazards from home: scatter rugs, loose carpet.
o Place electrical cords against walls (Behind furniture)
o Install grab bars in bathroom/ shower, use nonskid mat in shower.
o Ensure adequate lighting in home. Use colored tape on step edges.
 Oxygen safety
o Oxygen equipment increases risk of combustion.
o Place “no smoking” sign at front door of home.
o Make sure electrical equipment is grounded, and in good shape. No extension cords.
o Cotton bedding and clothes NO SYNTHETIC OR WOOL FABRICS
o Keep flammable items away from oxygen equipment (includes nail polish).
• Bed positions
o Sims: Patient lies on their left side, with their left hip and lower extremity straight,
and right hip and knee bent; used for enemas and rectal examinations.
o Trendelenburg: Whole bed is tilted with HOB lower than foot of bed; promotes
venous return.
o Reverse Trendelenburg: Whole bed is tilted with foot of bed lower than
HOB; promotes gastric emptying (prevents reflux).
o Modified Trendelenburg: Patient lies flat with legs elevated above his/her heart;
good for hypovolemia.
o Semi-fowlers: 15-45 degrees (usually 30 degrees); prevents aspiration and helps
with ventilation.
o Fowlers: 45- 60 degrees; good for procedures (ex: suctioning), provides
better ventilation.
o High fowlers: 60-90 degrees; good for severe dyspnea and during meals (to
prevent aspiration).
o Supine: patient is flat on back
o Prone: patient is on stomach; helps to prevent hip flexion contractures after
lower extremity amputation.
o Orthopneic: patient sits on side of bed with arms on overbed table; good for
COPD (Promotes lung expansion)
• Patient movement and positioning
o Moving patient from bed to gurney (or vice versa):
 Lower head of bed
 Have patient tuck chin to chest
 Tell patient to cross arms over his/her chest
 Position destination bed/gurney slightly lower.
o Preventing foot drop:
 Place foot board perpendicular to mattress and against soles of patient’s feet.

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 • Ergonomics
o Spread feet apart to lower center of gravity, which increases stability.
o Distribute your weight between the major muscle groups in your arms and legs
when lifting.
o When lifting an object, hold it as close to your body as possible.
o Avoid twisting or bending at the waist.
o Get help when repositioning a patient.
o Use smooth movements when moving patients.
• Range of Motion:
o ROM: the full movement potential of a joint, usually its range of flexion and extension.
 Active: patients move their limbs by themselves without assistance
 Passive (PROM): therapist or equipment moves the joint through the range of
motion with no effort from the patient.
• Injury prevention: Food poisoning
o Perform frequent hand hygiene.
o Immunocompromised individuals (at higher risk for food poisoning) should
only consume pasteurized dairy products.
o Refrigerate perishable products within 2 hours (or within 1 hour when temperature is
90 degrees or more)
o Prevent cross-contamination during food preparation (handle raw and fresh
food separately)
o Cook foods to recommended temperatures.
• Injury Prevention: Carbon monoxide
o Carbon monoxide is odorless, tasteless. Carbon monoxide binds to hemoglobin,
reducing O2 supplied to the body.
o Use carbon monoxide detectors.
o Maintain proper ventilation when using fuel-burning items (ex: wood stoves,
gas fireplaces).
o Know symptoms of carbon monoxide poisoning: Nausea/ vomiting, headache, loss
of consciousness.
• First Aid
o Bleeding: Apply direct pressure to wound, do not remove impaled object
(stabilize instead).
o Fractures: apply splint. Assess neurovascular status below injury.
o Sprains: use RICE (rest, ice, compression, elevation)
o Frostbite: Warm affected area in 98.6-108 degrees F water. Administer tetanus vaccine.
o Burn: remove agent causing burn, elevate extremities, administer fluids and
tetanus vaccine.
• Inflammation
o Inflammation: body’s local response to injury/infection
o First stage: erythema (redness), warmth, edema, pain at the site of the injury.
o Second stage: WBCs kill the micro-organisms. Exudate containing WBCs and dead
tissue cells accumulate at the site. Exudate may be: Serous (clear), Sanguineous
(Bloody), serosanguineous (Combination or clear and bloody), or purulent (containing
leukocytes and bacteria).
o Third stage: damaged tissue is replaced by scar tissue.
• Infection
o Systemic infection: symptoms include fever, chills, malaise, fatigue,
increased respiratory rate, increased pulse
o Local infection: symptoms include edema, pain, erythema, warmth in a particular
area of the body.

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o Lab tests that indicate infection:
 WBCs > 10,000
 Left shift (Immature WBCs)
 Erythrocyte sedimentation rate (ESR) >20
 C- Reactive Protein (CRP) >3
 Positive culture result (get culture before starting antibiotics!!)
o Chain of infections: Causative agent (ex: toxin, bacteria)  reservoir (ex: human, soil)
 portal of exit (ex: contact, droplet)  portal of entry  susceptible host.
o Risk factors: compromised immunity, chronic/acute disease, poor personal and
hand hygiene, crowded living environment, IV drug use, unprotected sex, poor
sanitation.
o Virulence: the ability of a pathogen to produce disease.

• ABCDE Principle in Nursing

o A (Airway): Ensure patent airway. Stabilize cervical spine if neck/head trauma
is suspected.
o B (Breathing): assess for respirations.
o C (Circulation): check heart rate, blood pressure, capillary refill.
o D (Disability): assess patients’ level of consciousness.
o E (Exposure): assess patients’ body for trauma, exposure to heat/cold.
• Herpes Zoster (Shingles)
o Herpes Zoster is caused by reactivation of the varicella zoster virus (virus that
causes chickenpox).
o Risk factors: compromised immune system, stress, fatigue, poor nutrition
o Symptoms:
 Painful unilateral rash that runs horizontally along a dermatome.
 Rash that is vesicular, pustular, or crusting
 Low- grade fever
 Paresthesia
o Nursing care:
 Isolate patient until vesicles have crusted over.
 Avoid patient exposure to individuals who have not had chickenpox (or
who have not been vaccinated against chickenpox)
 Administer antiviral medications (ex: acyclovir) and analgesics.
o Complications:
 Postherpetic neuralgia, which is pain that continues at least 1 month after rash
is gone.
o Prevention:
 Shingles (Zoster) vaccine recommended for adults over 60.
• General Survey
o Physical Appearance: age, race, gender, level of consciousness (LOC), signs
of substance abuse, signs of distress.
o Body Structure: height, weight, nutritional status, posture, obvious
abnormalities (amputations).
o Mobility: gait, ROM (Range of Motion), movement
o Behavior: mood, speech, grooming
o Vital Signs: temperature, pulse, respiratory rate, blood pressure, O2 saturation.
• Physical Assessment
o Inspection: Use sight to assess for size, shape, color, symmetry.
o Palpation: use touch to assess for temperature, texture, tenderness, size. Assess most
tender areas last. Dorsal surface of hand is best for assessing temperature. Palmar
surface of hand is best for assessing vibration.

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 o Percussion: tap body parts to assess for size, tenderness, and density of tissue.
o Auscultation: listen for sounds; assess amplitude, intensity, frequency,
quality. Examples: bowel, lunch, heart sounds.
o Normal order: inspect, palpate, percuss, auscultate
o Order for abdomen: inspect, auscultate, percuss, palpate (to avoid altering
bowel sounds).
• Abdominal assessment
o Bowel sounds:
 Expected: high pitched clicking and gurgling.
 Unexpected: loud growling sounds, no bowel sounds after listening for
5 minutes.
o Percussion: tympany sound is expected, dullness over the liver (RUQ  Right Upper
Quadrant).
o Expected size of liver: 6-12 cm.
***Palpate tender areas LAST.
• Lung Assessment
o Percussion:
 Expected: resonance
 Unexpected: dullness (tumor, pneumonia), hyperresonance
(pneumothorax, emphysema).
o Auscultation:
 Expected: bronchial (over trachea), bronchovesicular (over large
airways), vesicular (over peripheral areas of lungs).
 Unexpected: crackles (bubbly sounds), wheezes (whistling, musical
sounds), rhonchi (coarse rumbling sounds), pleural friction rub (GRATING,
rubbing sounds).
• Eye assessment
o EOM (Extraocular muscle): six muscles that attach outside the eyeball and that
move the eye in its socket. The EOM are: the inferior and superior oblique muscles,
and the lateral, medial, inferior, and superior rectus muscles.
 Corneal light reflex: shine light on eyes, check for symmetry on corneas.
 Cover/uncover test: tests for strabismus  (the eyes don’t look in exactly the
same direction at the same time).
 Check six cardinal gaze positions by having patient follow your finger as
you make a large “H” pattern in front of them.
o PERRLA:
 (P) pupils clear, (E) equal to 3-7 mm diameter, (R) round, (RL) reactive to light,
(A) accommodation to far/near objects.
 Pupils clear, equal, round, reactive to light and accommodation.
o Artery/vein ratio: 2:3
• Ear Assessment
o Alignment: top of auricles should be at the same height as inner canthus of eyes.
o Otoscope: pull auricle up and back for adults, down and back for children under 3
(use same method to administer ear drops as well). Insert 1-1.5 cm into ear canal. DO
NOT touch ear canal.
o Tympanic membrane: should appear pearly gray, intact.
o Light reflux: visible at 5 o’clock (right ear) or 7 o’ clock (left ear), in a cone shape.
o Cerumen: expected finding in ears
• Hearing Assessment
o Whisper test: whisper from 1-2 ft away while occluding one ear (don’t let patient
see your mouth move).

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 o Rinne test: hold vibrating tuning fork on mastoid bone, then in front of the ear
canal. Tests for conductive or sensorineural hearing loss. Expected: air conduction >
bone conduction.
o Weber: hold vibrating fork on top of patient’s head, to compare hearing on right vs.
left side.
• Vision Assessment
o Snellen chart: Have patient stand 20’ from chart. Determines if a patient has
myopia (impaired far vision).
 20/40: means patient needs to be 20 ft away from a letter that a person
with normal visual acuity can read at 40ft away.
o Rosenbaum eye chart: hold 14” away from patient. Determines if a patient has
presbyopia (impaired near vision).
o Ishihara: tests for color vision.
• Blood Pressure
o Pulse pressure: Systolic BP minus Diastolic BP
o BP cuff: cuff width should be 40% of arm circumference. Bladder should surround
80% of arm circumference.
o Cuff too large: get falsely low reading
o Cuff too small: get falsely high reading
o Key points when taking BP:
 DO NOT take BP in arm with IV infusion running.
 DO NOT take BP on side where patient had a mastectomy, AV shunt, or fistula.
 To estimate SBP using auscultatory method: palpate radial pulse and inflate
cuff until pulse disappears, inflate the cuff another 30 mmHg, release
pressure and not when pulse is palpable again.
 If patient is sitting make sure their feet are flat on the ground, make sure
their legs are uncrossed, before taking BP.
• Blood Pressure Classifications
o Normal: SBP < 120 and DBP < 80
o Prehypertension: SBP 120-139 or DBP 80-89
o Stage 1 hypertension: SBP 140-159 or DBP 90-99
o Stage 2 hypertension: SBP > 160 or DBP > 100
o Hypotension: SBP < 90
 Hypertension = BP readings elevated on 3 separate visits over several weeks.
• Orthostatic hypotension
o Orthostatic hypotension: take patients BP in supine position. Sit patient up and wait 2-
3 minutes. Take patients BP sitting. Stand patient up and wait 2-3 minutes. Take
patients BP standing.
o Positive for orthostatic hypotension:
 SBP decrease of more than 20 mmHg when changing position AND/OR
 DBP decrease of more than 10mmHg, with a 10-20% increase in heart rate.
o Nursing care: assist with ambulation, have patient sit at edge for 1-2 minutes
before standing up. Change positions slowly.
• Respirations
o Respiratory rate: normal = between 12-20 breaths/ min (35-40 for infants, 20-30
for school age children)
o Assess: rate, depth (deep, shallow), rhythm (regular, irregular)
o When chemoreceptors in body detect rising CO2 levels in blood, respiratory
control center in brain increases respiratory rate.

13
 o How to take: place patient in Semi fowlers position, place hand on patients’
abdomen. For regular rate of 12-20, count for 30 seconds and multiply by 2. For
irregular rate, count for full minute.
o Ventilation: exchange of O2 and CO2 in the lungs
o Diffusion: exchange of O2 and CO2 between the alveoli and RBCs (in the bloodstream).
o Perfusion: exchange of O2 and CO2 between the RBCs and the body tissues.
o Increases RR: anxiety, smoking, illnesses, anemia, high altitude
o Decreases RR: opioid/ sedative medications, age
o SpO2: normal= 95-100% (Low 90s expected for COPD patients).
• Pulses
o Rate: normal range for adults is 60-100 beats/ minute (120-160 for infants)
o Rhythm: regular/ irregular
o Equality: right vs left side pulses
o Strength:
 0 (absent)
 1+ (Diminished)
 2+ (Normal)
 3+ (Strong)
 4+ (Bounding)
• Radial and Apical pulse
o Radial pulse: take on thumb side of the wrist. For regular pulse, count for 30
seconds and multiply by 2. For irregular pulse, count for full minute.
o Apical pulse: take at fifth intercostal space at left midclavicular line. For regular pulse,
count for 30 seconds and multiply by 2. For irregular pulse (or if patient is taking
cardiac medications), count for full minute.
o Pulse deficit: difference between apical pulse rate and radial pulse rate.

• Tachycardia and bradycardia

o Tachycardia (heart rate > 100 beats/min): fever, exercise, medications,
pain, hyperthyroidism, stress, hypovolemia
o Bradycardia (heart rate < 60 beats/min): medications, athletes 9excellent
fitness), hypothyroidism, hypothermia.
• Temperature
o Oral: 36-38 degrees C (average 37 degrees C)
o Rectal: 0.5 degrees higher (36.5-38.5 degrees C)
o Axillary: 0.5 degrees lower (35.5-37.5 degrees C)
o Temporal: 0.5 degrees higher (36.5-38.5 degrees C)
o Factors that impact body temperature:
 Newborns have lower temps (36.5-37.5 degrees C)
 Older adults have lower temps (average 36 degrees C)
 Things that increase temps: Hormonal changes (menstruation,
ovulation, menopause), exercise, dehydration, illness
 Food, fluids, smoking can impact oral temperature
 95-100 F is (35-38 degrees C).
 To convert Centigrade to F. F= C = 40, multiply 9/5 and subtract 40
 To convert Fahrenheit to C. C= F + 40, multiply 5/9 and subtract 40.
• Taking temperatures
o Rectal: place patient in Sims position. Use lubrication. Insert 1-1.5” for adults. No
rectal temp for babies under 3 months old or for patients with high risk of bleeding
(rectum is very vascular).

14
 o Tympanic: for adults, pull ear up and back. For children under 3 years old, pull
ear down and back. Excess earwax can impact tympanic temperature.
o Temporal: slide probe across forehead to hairline, touch soft depression behind ear.
o Nursing interventions for:
 Hyperthermia (over 39 degrees C or 102 F): obtain blood cultures (and/or
other specimens). Administer antibiotics, antipyretics, fluids as ordered.
Prevent shivering. Provide blankets if patient is having chills.
 Hypothermia (under 35 degrees C or 95 F): provide warm blanket, warmed
IV fluids, increase room temperature, keep head covered.
• Transmission Based Precautions
o Airborne:
 Measles, Chickenpox (varicella), Pulmonary TB, Disseminated Varicella Zoster
 Nursing care: private room, negative pressure room, N95 mask or
higher, surgical mask on client if they need to leave the room, gloves,
gown, hand washing, disposable supplies
o Droplet:
 Think of SPIDERMAN!
 S - sepsis
 S - scarlet fever
 S - streptococcal pharyngitis P - parvovirus B19
 P - pneumonia
 P - pertussis
 I - influenza
 D - Diphtheria (pharyngeal)
 E - epiglottitis
 R - rubella
 M - mumps
 M - meningitis
 M - mycoplasma or meningeal pneumonia/ An – Adenovirus
 Nursing care: Private room or shared room if patient has same bacteria
strain, surgical mask if within 3 ft of patient, mask on client if they leave the
room, disposable supplies.
o Skin Infections:
 SKIN INFECTIONS VCHIPS
 V - varicella zoster
 C - Cutaneous diphtheria
 H - herpes simplex
 I - impetigo
 P - pediculosis S – scabies
 Nursing Care: CONTACT PRECAUTIONS; private room, gloves, gown.
Thorough hand washing before leaving room, disposable supplies.
o Contact:
 Think MRS.WEE!!
 M - multidrug resistant organism
 R - respiratory infection
 S - skin infections *
 W - wound infection
 E - enteric infection - clostridium difficile (C. diff)
 E - eye infection – conjunctivitis
 Nursing Care: private room or shared room if other patient has same
bacteria strain, Gloves, and gown.

15
 • Donning PPE
1. Gown
2. Mask
3. Goggles
4. Gloves
*In that order*
• Removing PPE
1. Gloves
2. Goggles
3. Gown
4. Mask
*REMOVE most soiled to least soiled*
• Basic Human Needs
• Maslow’s Hierarchy of Needs:
o Physiologic:
 Air, food, water, shelter, sleep, and temperature regulation.
o Safety & Security:
 Physical and emotional safety
o Love & Belonging:
 Affection, feeling loved, relationships
o Self-esteem:
 Self-respect and independence
o Self-actualization:
 The realization of one’s best qualities and drive to reach their full potential

• Pressure Injuries
o Pressure Injury: Pressure against a vessel near the skin prevents adequate blood
flow and causes skin breakdown (especially near pony areas)
o Stage 1: Non-Blanchable but intact/unbroken skin
o Stage 2: partial-thickness injury, extends up to epidermis or dermis.
o Stage 3: full thickness injury extends past dermis FAT visible.
o Stage 4: full thickness injury extends past subcutaneous/ BONE visible.
o Unstageable: unable too see thickness layers due to excess exudate.
o Wound healing is promoted by a diet that is rich in protein and vitamin C.

• Nutrition
o Fiber: fruits, beans, veggies, wheat and bran
o Potassium: sweet potato, tomato, spinach, yogurt, raisins, bananas
o Sodium: pizza, canned soup (almost any canned food), bread, cold cuts, cheese
o Vitamin C: oranges, strawberry, Brussel sprouts
o Vitamin B12: eggs, milk, cheese, meat, fish, shellfish
o Magnesium: rhubarb, spinach, avocados, nuts, tofu, sesame.

• Nasopharyngeal and nasotracheal suctioning:

o Place patient in Fowlers or High Fowlers position.
o Lubricate distal 6-8cm of catheter with water soluble lubricant.
o Insert catheter during inhalation. Insert distance from tip or nose to base of earlobe.
o Apply suction intermittently while withdrawing the catheter and rotating it for
10- 15 seconds.
o Perform up to 2 passes, waiting for 1 minute between passes.

16
 • Endotracheal Suctioning:
o Place patient in Fowlers or High Fowlers position.
o Catheter diameter should be < = half of diameter of the endotracheal tube.
o Hyper-oxygenate the patient with 100% O2 prior to and between suctioning.
o Use suction pressure of 120-150 mmHg.
o Advance catheter until you reach resistance, pull back 1cm (above carina) prior
to suctioning.
o Apply suction intermittently while withdrawing the catheter and rotating it for
10- 15 seconds.
o Do not reuse suction catheter.
• Tracheostomy Care:
o Give oral care every 2 hours, tracheostomy care every 8 hours.
o Suction tracheostomy PRN (not routinely)
o Apply oxygen loosely if patients SpO2 decreases during procedure.
o Use surgical asepsis to remove and clean inner cannula.
o Use split gauze dressing under tracheostomy plate (DO NOT CUT GAUZE!).
o Replace tracheostomy ties as needed. Secure new ties before removing soiled ones.
o Home care: cleanse with normal saline using medical asepsis, cover tracheostomy
when outside.
• Nasogastric (NG) tubes:
o Place patient in High Fowlers position
o Agree on signal that patient can use if he/she is feeling distress during procedure.
o Lay towel across patient’s chest.
o Use water-based lubricant.
o Have patient sip water while inserting.
o Withdrawal slightly if patient gags/chokes.
o Check placement by checking pH of gastric contents, confirm placement with x-ray.
o Verify tube placement with x-ray BEFORE feeding the first time.
o Verify presence of bowel sounds before feeding, check gastric contents pH (should
be between 0-4).
o Discard bags/tubing every 24 hours.
o Measure gastric residual every 4-6 hours; return residuals to stomach. Hold feeding
for residual amount over hospital policy (500mL).
o Flush feeding tubes with 30 mL water every 4 hours.
o Formula should be at room temperature.
• Nurses should have the capabilities of data interpretation:
o Nurses should be able to interpret data: for example, a patient with hypertension has
prescription for low sodium (Na) diet; the nurse should be able to interpret why the low
Na (Sodium) is prescribed. The reason is that Na retains water hence when Na is reduced,
there will be no retention of water
• Nurses should have the ability to make predictions: Below are some examples
o If a nurse administers Demerol, the nurse should expect it to start pain relieve within 30
minutes in case a patient ask when they should expect pain relief. Regular insulin
works within first 30minutes; therefore, if a nurse administers regular insulin she/he
should anticipate the medication will start action within 30 min.
o You need this information to synchronize meal times and the time to administer
the insulin.
o If you remove CSF (Cerebrospinal fluid) during lumbar puncture, it will cause fluid loss
and hence headache (NCLEX Note): Remember the positioning for this procedure is the
fetal position or knee chest position at the edge of the bed. The first 4 hours after
lumbar puncture, the nurse then places the patient in a prone position to allow the
process of

17
 coagulation to take place; thereafter, the nurse places the patient in a supine or
flat position to apply pressure on the punctured site.
o When taking care of a patient with Rheumatoid arthritis, a systemic and
autoimmune disease that if left untreated will affect the heart, (carditis is a
complication); patient, therefore, needs absolute bed rest especially in the acute
stage.
• Planning phase:
o In planning, set you priority first. Short term goals first before long term ones.
o Consult with client/family in developing a plan of care e.g. a patient needs amputation;
let the patient or family be aware. In the course of your duty, you are about to transfer
patient out if her condition changes, inform patient or family. This is to reduce
anxiety.
o Planning phase involves setting goals with client or for the client.
• Types of goals:
o Short term goals: These are immediate actions; for example, a client in a state of
anxiety due to pain; the best solution is to relieve the anxiety by relieving the pain.
Another example, if a patient is bleeding, from a surgical incision site, stop the bleeding
by reinforcement of wound dressing or apply pressure to bleeding site.
o Long-term goals: These take a long time to achieve. Sets up your priorities or
prioritizes your goals. Use Maslow Hierarchy to prioritize. Remember to use your ABC,
safety etc.
.
• Implementation Phase:
o This is carrying out the planning phase or accomplishing the defined goal It
involves implementation of care Reporting significant changes in client’s condition
o Documentation of client care
o Communicating client’s needs to others (health team)
o Utilizing client’s strength to achieve goals of care
o Examples of the implementation process:
 Give orange juice with iron for better absorption.
 Do not give diuretics at night, patient wakes up several times to go to
the bathroom at night
 hence patient will have sleepless nights. It is best to give diuretics in the morning.
• Evaluation phase:
o This determines the extent at which your goals have been achieved
o Compares client’s responses to expect outcome
o Evaluation revise goal of care to accommodate client values, customs, culture, dresses
in cultural outfits.
o Gather data to indicate effectiveness of each intervention
o Determine impact of therapeutic intervention on client
o Determine if goal of care is being achieved
o Identify need for change approach to client care
o Revise approach to care in order to meet client’s specific needs
o Examples of the evaluation process:
 An evaluation of an anemic woman on iron medication after three months,
will indicate her Hemoglobin will go up effectively (12-18gl)
 A patient c/o of headache, after given two Tylenol, within 30 min, she
expresses relief of Pain.
 COPD patient has decrease oxygen and increase CO2, give oxygen to
patient, patient will have effective breathing. There will be decreased
hypoxia and hyperoxygenation (increased oxygenation 95% and above).
 A premature baby is too small for mother to carry. Evaluate mother whether
she would be able to carry her new baby without fear.
18
 • Death and dying issues:
o Kubler Ross (1969) studied grief and death reactions, and outlined five stages
of reactions
o such as: (use mnemonic: D.A B.D.A)
 D= Denial and isolation
 A= Anger
 B= Bargaining
 D= Depression
 A= Acceptance
• Denial and Isolation:
o This is usually defined as refusal to accept fact of loss. “No, not me, not my child.” They
o tend to go from one hospital to the other to disprove the initial diagnosis
• Anger:
o Feeling of emptiness, angry and questioning “why me?” Reality began to penetrate their
consciousness
• Bargaining:
o Changes from “not me” to “yes me, but why now?” I have an unfinished project
or business.
o The patient pleads for more time to live. My son has just entered college, etc. It helps to
o cope, understand that bargaining is very helpful to patient. Help them to set their goals
• Depression:
o Pt will turn self inward. They will simply say yes I am ready to go or ready to give
up those
o she loves and has. E.g. children or money. This is silent grief and mourning. Be available
o to the patient in major depressive mood. Reassure them that you can understand their
o feelings.
• Acceptance:
o Patient is ready and has accepted death or loss. The patient will say I have done all I can.
o Looks at life well spent. They want God to take them or to allow them to go. In
o acceptance, they will detach from family members. They may turn to the wall, for
o example. It’s a normal reaction.
• Euthanasia:
o Implies painless actions to end the life of individual suffering from to incurable or
terminal diseases are also defined as good dying. Means mercy killing. This is killing of
patients by administering a lethal injection or carbon monoxide, even when performed
with compassionate intent at the request of the pained. Euthanasia is deemed immoral and
illegal hence nurses should not participate in euthanasia. It is against nursing ethics.
• Meaning of death to pediatric clients:
o Birth to 1yr death has no meaning to child.
o 1-4 yrs: regards death as temporary separation
o 5yrs and above: regards death as permanent or irreversible.

19
 NURSING PROCEDURES

• Hand washing is the most single important procedure for the prevention of nosocomial infection
• To help prevent the spread of infection, nurses must wash their hands for 30 seconds
before and after each direct contact with a client or each use of client care items
• When removing a packing from a sterile wound use a sterile glove
• When opening a sterile package, the first fold should go away from you and the last fold
towards you.
• When cleaning a surgical wound, clean from the inside to the outside of the wound.
• Use a mask when working within 3 feet of client on droplet precaution
• Standard Precautions apply in the following situations: contact with blood, contact with
body fluids, excretions and secretions (except for sweat), contact with non-intact skin, contact
with mucous membranes.
• When passing an NG tube, advance tube at the naso-pharynx, at pharynx, ask patient to flex head.
• The most efficient way to check for proper placement of an NG tube is by X-Ray or testing
for acid in the gastric content aspirated.
• Observe the client for signs of orthostatic hypotension if the client had been on bed rest for a
long period of time
• Complaints of vertigo, lightheadedness, fainting, pallor, nausea, or a sudden drop in blood
pressure (25mm Hg systolic or 19mm Hg diastolic) when moving the client from a horizontal to
a vertical position are indicative of orthostatic hypotension.
• The most accurate area on the body to assess dependent edema in a bedridden client is the
sacral area. Sacral or dependent edema is secondary to right-sided heart failure.
• A woman should not douche for several days before a Papanicolaou test.
• The priority nursing action after a pap smear is wiping the cells immediately across a clean glass
slide and fixed with a spray e.g. Aqua Net hair spray. The slide is labeled with the patient’s
name, age, and parity and with the date of her last menstrual period
• Before a sigmoidoscopy, the client usually receives a clear liquid diet 24 hours before the
test and a warm tap water enema or fleet enema until returns are clear.
• For colonoscopy, the client is usually sedated and positioned on the left side with the knee bent.
• Explaining an impending surgical procedure and risk involved is a physician’s responsibility
• When a patient returns from surgery, encourage early ambulation, and provide oxygen support
during ambulation.
• Peritoneal dialysis involves the use of the peritoneal membrane as semi-permeable
membrane across which excess wastes and fluids move from blood in peritoneal vessels into a
dialysate solution that has been instilled into the peritoneal cavity.
• The peritoneal dialysis process has three steps:
 Filling
 dwell time
 draining.
• Monitor for signs of infection by observing for cloudy color of dialysate effluent.
• When instilling an ophthalmic ointment medication, start at the inner canthus and extend
the medication outward towards the outer canthus.
• To avoid damaging or staining a patient’s teeth, give acid or iron preparations through a straw
• When attempting to dislodge a foreign body obstructing the airway of a pregnant woman,
stand behind her and place your arms under her armpits and around her chest
• The Snellen chart is used to test for visual acuity
• The terminology 20/20 means the numerator, 20, is the distance in feet at which the letter
is readable by a person who has normal eyesight. Each line has a distance value attached to
it.

20
 • Skin color changes in dark-skinned persons can best be seen in areas of less
pigmentation, such as lips, mucous membrane, ear lobes, palms, and soles.
• Jaundice in dark–skinned person is detected by observing the sclera of the eyes.
• Cyanosis in a dark-skinned person is best observed in skin—check oral mucosa, conjunctivae
and nail beds
• For pallor check areas of with least pigmentation, such as conjunctivae, mucous
membrane. Brown skin appears yellow-brown, black skin is ashen-gray.
• The primary purpose of pap smear is to screen for cervical cancer
• To maintain drainage of a surgical wound, compress Jackson-Pratt bulb or Hemovac container
every 4 hours.
• Administering pain medication and waiting for its effect before any activity will increase
client compliance.

Guide to common clinical signs

• Babinski Reflex- Dorsiflexion of the big toe after stimulation of the lateral sole; associated
with corticospinal tract lesions.
• Brundzinski sign- Flexion of the hip e knee induced by flexion of the neck; associated
with meningeal irritation.
• Chadwick’s sign- Cyanosis of vaginal and cervical mucosa, associated with pregnancy
• Chvostek’s sign- facial muscle spasm induced by tapping on the facial nerve branches.
If positive check calcium levels, could indicate hypocalcemia.
• Cheyne-Stokes respiration- Rhythmic cycles of deep and shallow respiration often with
apneic periods; associated with central nervous system.
• Cullen’s sign: bluish discoloration around the umbilicus; seen in acute pancreatitis
• Harlequin sign- In the newborn infant, reddening of the lower half of the laterally
recumbent body and blanching of the upper half, due to a temporary vasomotor disturbance.
• Hegar’s sign- Softening of the fundus of the uterus, associated with the first semester pregnancy
• Homan’s sign- Pain behind the knee, induced by the dorsiflexion of the foot, associated
with peripheral vascular disease, especially venous thrombosis in the calf.
• Kernig’s sign- Inability to extend leg leg when sitting or lying with the thigh flexed on
the abdomen; associated with meningeal irritation.
• Kussmaul’s respiration- Paroxysmal air hunger, associated with acidosis, especially
diabetic ketoacidosis. It is characterized by a deep sighing respiratory pattern.
• McBurney sign- Tenderness at the McBurney’s point (located two-thirds of the distance from
the umbilicus to the anterior-superior iliac spine); with appendicitis
• Rovsing’s sign- Pain in the right lower quadrant when the left lower quadrant. This is a positive
sign of appendicitis.

• TUBERCULOSIS
o Tuberculosis bacteria is transmitted by aerosolization; bacillus multiplies in bronchi
and alveoli resulting in pneumonitis, may lie dormant for many years and be reactivated
in periods of stress
o Signs and symptoms include:
 Progressive fatigue, anorexia, nausea, weight loss
 Irregular menses
 Low grade afternoon fevers over a period of time
 Night sweats
 Cough with mucopurulent sputum, occasionally streaked with blood

21
 o Diagnostic procedures:
 Skin test – Mantoux Test (PPD), Tine Test
 Sputum smear for acid-fast bacilli ( the most reliable)
 Chest x-ray- routinely performed on all persons with positive PPD to detect
old and new lesions
o TB Skin testing:
 Given intradermally in the forearm
 10-mm induration (hard area under the skin) indicates significant
positive reaction. An
 induration of 5-mm is positive for clients with AIDS
 Does not mean that active disease is present but indicates exposure to TB
or presence of inactive dormant disease.
 Read in 48-72 hours
• HEPATITIS
o Acute inflammatory disease of the liver resulting in cell damage from liver
cell degeneration and necrosis
o Sign and symptoms:
 Jaundice (icterus), yellow sclera
 Clay colored stools, tea colored urine
 Anorexia, RUQ pain
o Patient Teaching:
 Bed rest for severe symptoms
 Avoid alcohol and potential hepatotoxic prescription/OTC
medications (particularly aspirin,
 Tylenol and sedatives)
 Do not donate blood
 NCLEX Note: You must learn the means of transmission of different types of
hepatitis; (Hepatitis A, B, C, D, E) Study Tip: Hepatitis A and E are by
enteric transmission; the rest are blood borne transmission.
• LYME DISEASE
o A multi-system infection transmitted to humans by tick bite; most common in
summer months.
o Signs and symptoms (stage 1):
 Rash (erythematous papule that develops into lesions with a cleared
center) develops at site
 of tick bite within 2 to 30 days; concentric rings develop, suggesting a bulls-
eye; lesion
 enlarges quickly
 Development of flu like symptoms (malaise, fever, headache,
myalagia, arthragia,
 conjunctivitis) within one to several months, last 7-10 days and may reoccur
o Signs and symptoms (stage 2):
 Cardiac conduction defects
 Neurological disorders: Bell’s palsy: paralysis that is not permanent
o Signs and symptoms (stage 3):
 Arthalgias, enlarged and inflamed joints occur within one to several months
after the initial infection
 May persist for several years
o Patient Teaching:
 Cover exposed areas when in wooded areas
 Check exposed areas for presence of ticks

22
 • AIDS
o AIDS (acquired immunodeficiency syndrome) – a syndrome distinguished by serious
deficits in cellular immune function associated with positive human immunodeficiency
virus (HIV): evidenced clinically by development of opportunistic infections (e.g.
Pneumocystis carinii pneumonia, candida albicans, cytomegalovirus), enteric
pathogens, and malignancies ( most commonly Kaposi’s sarcoma)
o Special nursing considerations:
 Monitor for HIV positive-presence of HIV in the blood
 AIDS-syndrome with CD4TC count below 200
 Opportunistic infections: P. carinii pneumonia, C. albicans stomatitis
or esophagitis
 Positive HIV antibody on enzyme-linked immunosorbent essay (ELISA)
and confirmed Western blot assay or indirect immunofluorescence assay
(IFA)
 CBC reveals leucopenia with serious lymphopenia, anemia, thrombocytopenia
• CHLAMYDIA
o Caused by Chlamydia trachomatis; produces infections in both men and
women (fallopian tubes, cervix, and urethra) and can develop in PID.
o Spread through sexual contacts with an incubation period of 5-10 days or longer
o Special nursing considerations:
 Observe for a discharge-vaginal or urethra
 Assess for burning.
 Assess for bleeding or pain with coitus.
 Monitor Chlamdiazyme enzyme immunoassay test and Microtak-
direct fluorescent antibody test.
 Treat with doxycycline and Erythromycin
 Penicillin does not treat Chlamydia
• SYPHILLIS
o A chronic infectious disease caused by Treponema pallidum. Transmission is by
physical contact with syphilitic lesions which are usually found on the skin or the
mucous membrane of the mouth and the genitals.
o The first sign of the disease is an open chancre in the genitalia
o The progression of the disease is marked in stages: primary stage, secondary stage
and tertiary stage.
 The primary stage is the most infectious stage marked by an appearance of
a chancres, ulcerative lesions; usually painless
 The secondary stage is the highly infectious stage marked by lesions which
may occur anywhere in the skin
 The tertiary stage is when the spirochetes enter internal organs and
cause permanent damage.
o Special nursing considerations:
 Assess for symptoms related to nervous system invasion such as
Meningitis, Locomotor ataxia (foot slapping and broad-based gait),
progressive mental deterioration leading to insanity.
 Assess for cardiovascular damage to the aorta and the aortic valve.
o Diagnostic Test:
 Conduct serum test for syphilis (STS)
 Monitor treatment with procaine Penicillin G.

23
 • GONORRHEA
o An infection caused by Neisseria gonorrhea, which causes inflammation of the mucous
o membrane of the genitourinary tract.
o Transmission is almost completely by sexual intercourse
 Signs and symptoms in the male is marked by painful urination, pelvic pain
and fever and epididymitis
 Signs and symptom in the female (usually asymptomatic) is marked by
vaginal discharge, urinary frequency and pain.
o Pelvic inflammatory disease (PID) in the female can lead to sterility.
o Infection may be transmitted to the baby’s eyes during delivery causing blindness.
o Administer prophylactic medication of broad spectrum antibiotic or 1% silver nitrate
(not commonly used) to newborn
o Important to treat sexual partners, as patient may become re-infected.
• HERPES SIMPLEX VIRUS (HSV)
o Herpes Infection is caused by the herpes simplex virus (HSV). It affects external
genitalia, vagina cervix and the penis. It develops into painful, sometimes draining
vesicles. Virus may be lethal to fetus if inoculated during vaginal delivery. (Fifty
percent of HSV infected infants, die.).
o Delivery, therefore, usually is by C-Section should the outbreak occur during around
time of delivery.
o Special Nursing Interventions:
 Maintain precautions during vaginal examinations of patient.
 Maintain isolation precautions during hospitalization if disease is active.
• VENEREAL WARTS
o A sexual transmitted infection caused by the human papillomavirus (HPV) The
virus affects cervix, urethra, penis, scrotum and anus.
o Warts appear 1 or 2 months after exposure transmitted through intimate sexual contact.
o Special nursing interventions:
 Teach client that there is no cure for HPV. Key is prevention just like in
any other STD infections
 Suggest Pap test every year due to cancer risk.

24
 NUTRITION
• One gram of protein contains 4 calories
• Processed and canned foods are generally very high in sodium
• Fresh fruits and vegetables are usually low in sodium
• Clear liquids are those you can see through; orange juice is not included. Examples of
clear liquids are gelatin, broth, apple juice, cranberry juice, and tea
• Low Residue Diet is ordered to reduce fiber for patients with Crohn’s disease, colon or rectal
surgery, esophagitis, diarrhea. Examples are clear liquids, fats, eggs, peeled white potatoes.
Milk products should be avoided in a low-residue diet.
• High Fiber Diet is ordered to provide bulk in the stool and bring water into the colon for
patients with constipation or diverticulitis. Examples are raw fruits and vegetables, whole grains
• Sodium Restricted Diet is ordered for patients with kidney, cardiovascular disease or
hypertension to control the retention of sodium and water and thus lower blood pressure. Foods
not allowed are canned prepared foods, table salts and most prepared seasonings not labeled
low sodium. Canned soups are high in sodium and should be avoided by people on low sodium
diet. Most canned soups contain about 1000mg of sodium per serving.
• Vitamin K deficiency may affect blood coagulation.
• Gluten-free Diet is ordered for patients with malabsorption syndromes such as Celiac
• disease.
• Meals with green leafy vegetables are high in vitamin K which is antagonistic
to coumadinmExamples of green leafy vegetables are Kale, spinach.
• Think beyond banana when searching for examples of potassium rich foods; baked potato is
rich in potassium, so is avocado, cantaloupe, tomatoes, orange juice.
• A cholesterol level of 200mg/dl is associated with increased risk for coronary artery disease.
Meals high in cholesterol would involve those with cheese and eggs, Organ meats, sardines in
oil, beans, lentils (high protein diet) should be avoided by a client with gout
• The most significant impact on reducing the risk of kidney stone formation is increased intake
of fluids.
• The 12 amino acids the liver is able to synthesize is called nonessential amino acid
• The 8 amino acids the liver cannot synthesize are called essential amino acids. Essential
amino acids required in the diet.
• Vitamin B12 is found only in animal food.
• After gastrectomy, the patient will have to receive vitamin B12 injections periodically. The
intrinsic factor which is necessary for the absorption of B12 is produced in the stomach. Strict
vegetarians should include a reliable source of vitamin B12 in the diet such as fortified
breakfast cereal. Treatment of pernicious anemia requires B12 injections for a lifetime
• Vitamin D may be a nutrient of concern for elderly patients in long term facilities, Vitamin D
status may be impaired for older clients because synthesis is decreased in older adults. Signs
and symptoms of vitamin D deficiency is Osteomalacia (adults): weakening and softening of
the bones
• A good source of calcium for clients who do not like milk is green, leafy vegetables. A low
calcium diet is prescribed for patients at risk for renal calculi (such as immobilized
patients)
• The order of fuel use to meet the body’s energy demands during brief periods of starvation
is; carbohydrate, fat, protein.
• Clients receiving MAOIs who also consume foods high in tyramine may experience a
hypertensive crisis that could be fatal. MAOI = NOT TYRAMINE FOODS!!!!!
• Foods high in tyramine include avocados; figs; overripe bananas; fermented and aged meats;
sausages such as bologna. Pepperoni, and salami; cheese; and foods containing yeast,
including beer and wine and monosodium glutamate.

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• The reason older adults are often dehydrated may be that they often have diminished sense
of thirst.
• For a patient who is bedridden or is inactive in bed, provide small meals with high fiber to
prevent constipation.
• Risk for prostate cancer may be reduced by increasing consumption of fruits, vegetables,
and whole grains.
• Iron needs increase during pregnancy because of maternal red blood volume and iron storage
in the fetus
• Common food sources of iron include spinach, beef, liver, prunes, pork, broccoli,
legumes, whole bread and cereal
• If maternal dietary intake of calcium is inadequate, the mother would lose her stores of calcium
• Cow’s milk is not suitable for infants (under one year) because it is high in protein which
may lead to dehydration
• A sign of readiness for introduction to solid foods is when the baby shows an interest in what
the family is eating
• Babies born prior to 34 weeks are often lacking a coordinated suck-swallow reflex as a result
they often require tube feeding
• Chemotherapy can contribute to the development of malnutrition as a result of
chemotherapeutic agents effects on the GI tract, effect on basal metabolism, and association with
nausea and decreased food intake. To assist the client suffering from taste/smell alterations as a
result of cancer or cancer therapy, recommend the use of eggs or cottage cheese in place of
meats.
• Surgical treatment of pancreatic cancer may result in Type 1 diabetes mellitus
• A useful suggestion for encouraging food intake for clients with pulmonary disorders is to
encourage rest before meals.
• Clients on hemodialysis are routinely supplemented with calcium, vitamin B6, and folic acid
• Clinical manifestations of nephrotic syndrome include hypoalbuminemia and hyperlipidemia
• Clients with chronic renal failure need supplementation of water-soluble vitamins.
• For adults, a desirable total cholesterol level is less than 200 mg/dl
• If a client with congestive heart failure tires easily, it might be best to offer smaller
meals throughout the day
• The objectives of medical nutrition therapy for the client with congestive heart failure are
to minimize cardiac workload and reduce edema
• DAILY weights are the best indicator of fluid balance (same time, same clothing (usually
mornings is best)
• A client with chronic renal failure is placed on low protein, low potassium diet
• In a client with type 2 diabetes mellitus, the more body fat the client has, the more resistant
the body cells are to insulin
• The Islamic religion excludes pork from the diet. Also, Orthodox Judaism excludes pork from
the diet.
• Observant Jews will wish to eat only kosher foods. Kosher foods have been prepared under strict
guidelines for how animals are slaughtered, separating milk and meat, and avoiding certain
foods such as pork and some seafood. Can have a burger but cannot have a burger with cheese.
Meat and dairy cannot be eaten together!!

• DIETS:
o HIGH FIBER DIET: The diet is a normal diet with increased fiber content. Examples
are raw fruits and vegetables, whole grain bread and cereals. It increases the volume
and weight of the stool. Recommended for clients with constipation, hemorrhoids and
long term management of diverticulosis.
o SODIUM RESTRICTED DIET: The aim of this diet is to promote the loss of sodium
from the associated advanced liver and renal disease, clients with congestive heart
failure,
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 as a treatment for essential hypertension, and with clients receiving adrenocorticoids.
Avoid foods which are processed or canned with preservatives.
o BLAND DIET: This diet excludes food that may be chemically and mechanically
stimulating or irritating to the gastrointestinal tract... Small frequent meals may be
indicated. Prescribed for clients with ulcers and post-operatively after some
surgeries. Bland diet should be free of fried foods, meat extracts, pepper, and chili
powder.
o LOW FAT DIET: The fat-controlled diet limits foods containing cholesterol and
saturated fatty acids and increases foods high in polyunsaturated fatty acids.
(Cholesterol intake should be limited to 300mg daily) Foods recommended are skim
milk, egg white, lean meats, and fat free soups.
o BROW FREE (GLUTEN FREE) DIET: Recommended for patients with Celiac
disease; patients with gluten intolerance and poor digestion of fat. BROW stands
for barley, rye, oats and wheat
o BRAT DIET: is used in treating Gastroenteritis because it is low-fat, low residue
and nondairy. BRAT stands for banana, rice, apple, tea.
o LOW PURINE DIET: Foods low in purine (Protein) is recommended for patients with
recurrent gout. Foods such as organ meats, shellfish, and oily fish (e.g. sardines) are
high in purines and should be avoided
o LOW RESIDUE DIET: Food high in carbohydrates.
o HIGH RESIDUE DIET: Are foods that contain skins, seeds, and leaves. Salads, fresh
vegetables or grains would be considered high residue diet. extracellular compartments
of the body. It is used primarily for clients with ascites/edema

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