lOMoARcPSD|22650627

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lOMoARcPSD|22650627

tAble of contents
1 The professional nurse
2 Nursing theory
3 Evidence-based practice
4 Nursing process
5 Nursing ethics
6 Health care delivery
7 Health promotion
8 Population health
9 Cultural competencey
10 Caring and communication
11 Patient safety

12 Infection prevention
13 Vital signs
14 Head-to-toe assessment
15 Medication administration
16 Medication dosage calculation
17 Pain management
18 Activity, mobility, and exercise
19 Oxygenation and airway maintenance
20 Nutrition
21 Electrolyte imbalances
22 Skin and wound care
23 Hygiene
24 Urinary elimination
25 Bowel elimination
26 Crisis and disaster
27 Legal considerations
28 Documentation
 lOMoARcPSD|22650627

The professional EE
FIFE nurse
-
Levels of Nursing Proficiency
1 Novice:
*Student nurse or RN in a new setting with
no previous experience.
o
2 Advanced
- Beginner:
* RN with some experience in a clinical
setting.
O
3 Competent:
-

*RN with 2-3 years experience in the same

clinical setting. -
Career Development
n
4 Proficient:
.
* Advanced Practice Registered Nurse
* RN with over 2-3 years experience in the * Clinical Nurse Specialist
same clinical setting. *Nurse Practitioner
O
5 Expert:
- * Certified Registered Nurse
*Lengthy experience in a clinical setting. Anesthetist
*Nurse Educator
-
Nursing Process Steps *Nurse Administrator
*Nurse Researcher
A Assessment

D Diagnosis Influences on Nursing

O Outcomes Identification *Rising cost of healthcare
*Affordable Care Act
P Planning *Medically underserved populations
*Demographic changes
I Implementation

E Evaluation Trends in Nursing

⑦
Responsibilities of a Nurse 1 Evidence-Based Practice:
-

* Improves patient safety by basing

nursing practice on the current
* Accountability * Communicator
available evidence.
* Autonomy * Educator
2 Quality and Safety Education for
* Advocate * Manager
Nurses:
* Caregiver * Core Competencies:
* Patient-centered care

→Nursing Code of Ethics

* Ideas of right and wrong that define the
* Teamwork and collaboration
* Evidence-based practice
* Quality improvement
* Safety
principles nurses use to provide care on a daily

I
* Informatics
basis.
 lOMoARcPSD|22650627

2
AFFAIRE
NURSING THEORY
FEET

is
Nightingales Environmental Theory -
Peplaus Interpersonal Theory
* Nurses should be able to manipulate the
environment in a way that will best promote the * The nurse-patient relationship is broken
patient’s overall health and quality of recovery. into several stages:

I Environmental factors that can be controlled:

-

* Light
O
1 Pre-Orientation:
-

*Nurse gathers data related to the

patient before patient interaction.
* Hygiene * Ex- receiving report at the start of
* Nutrition a shift.
* Noise
* Ventilation
o
2 Orientation:
-

* Nurse and patient meet for the

first time, issues/problems the patient
is experiencing is determined, and
goals are formed.

3 Working Phase:
Orems Self-Care Deficit Theory * The nurse carries out nursing
interventions and therapeutic
activities.
1 Patient participation in self-care
activities improves patient outcomes.
4 Resolution:
2 The nurse should assist the patient * Termination of the nurse-patient
when necessary to meet the patient’s relationship.
physical, psychological, developmental,
and sociological needs.

o
3 When assisting a patient with their
self-care needs, the nurse should
encourage the patient to assist to the
I best of their ability.

p
Leiningers Culture Care Theory
Research

/ l .
* Nurses need to incorporate the patient’s
culture, values, and beliefs into the
.

patient’s plan of care in order to provide

'

Practice ← Theory effective, culturally congruent care.

v
:¥⇐⇐ii ÷÷
lOMoARcPSD|22650627

Evidence-Based practice
-
What is Evidence-Based Practice? -
PICOT Questions:
* Evidence-based practice is a step-by-step
process that promotes the best
P: Patient population of interest
*Age, gender, disease, etc.
healthcare practices to achieve the best
patient outcomes.
I: Intervention of interest
* Evidence-based practice integrates: *Treatment, test, etc.

1 Relevant, critically appraised evidence. C: Comparison of Interest

*Typical standard of care
2 The nurses own clinical experience compared to your plan of care.
and expertise.
3 The patients own preferences O: Outcome
and values. *Desired result of the nursing
intervention.
7 Steps of Evidence-Based Practice:
T: Time
1 Cultivate a spirit of inquiry. *Amount of time required
* Question current clinical practices and
methods.
2 Ask a clinical question in “PICOT” format.

o
3 Collect the best evidence.
* Review hospital policy, existing guidelines,
-
Hierarchy of Evidence
quality improvement data, and journal

€
articles.

f
o
4 Critically appraise the evidence.
Reviews of
* Evaluate and determine the RCTs
credibility, value, and usefulness of
the data. Controlled trial with
randomization (RCT)
O
5 Integrate the evidence with your -

Controlled trail, no
le

own clinical expertise and your patient’s

iab

randomization
preferences.
Rel

*Apply the research and data to Case studies

st

your plan of care.

Mo

:
6 Evaluate the outcome of your practice Reviews of qualitative studies
decision.
*Determine if the intervention worked
and if it was effective.
Qualitative studies
.
7 Share the outcomes with others. Opinion of experts

#
 4

FEEEffi EEF
Nursing Process
EE
-
What is the Nursing Process? o
4. Planning
* The nursing process is a 6-step * Nurse must establish priorities when creating
process for nurses to follow to achieve the plan of care.
the best possible patient outcomes. * Maslows Hierarchy of Needs
* The process provides a framework * There are 3 types of planning:
to create a care plan for the patient. 1. On admission after assessment
2. Ongoing planning during care
3. Discharge planning
-
Steps of the Nursing Process:
Maslows Hierarchy of Needs:
o
1. Assessment

nt
ta
* Collect data related to patient health and

r
po
situation.

Im
Self-esteem
* Information is gathered from patient

µ medical history, observation, patient

interviews, physical examinations and
diagnostic reports.
Mo
st Love and belonging

* Collect subjective and objective data. Safety and security ii.

*Subjective: symptoms, feelings, and .
descriptions from patient. Physiological
*Objective: Observation and physical
assessment.
* Interpret and document data. 5. Implementation
2. Diagnosis * Implement the identified nursing
interventions.
* Analyze assessment and determine what * Promote, maintain, and restore patient
nursing diagnoses are relevant to the patient health.
and situation. * Perform nursing actions and document
* Nursing diagnoses are clinical

÷
care.
judgements about the patients current/
potential health problems or needs.

3. Outcomes Identification 6. Evaluation :

* Identify and set measurable and
achievable goals and outcomes for the
patient.
* Goals should be both short and long-term.
* Goals promote individualized care and
patient participation.
* Evaluate the patients responses to the
implemented nursing interventions.
* Determine if the patient has met the
goals and expected outcomes.
* Determine the effectiveness of the
care plan.
 lOMoARcPSD|22650627

5
Nursing ethics
Ethical Principles: Basic Principles of Ethics:
* Standards of right and wrong in relation
to social values and norms. 1 Advocacy:
*Support of the patient's rights.
Values:
2 Accountability:
* Personal beliefs that influence behavior. *Taking responsibility for your own
actions.
Morals: 3 Responsibility:
*Respecting and carrying out
* Personal beliefs about what is and is professional responsibilities.
not acceptable for yourself to do.
4 Confidentiality:
*Protection of patient Privacy.

Ethical Dilemma:

* Occurs when there is a conflict between

2 moral principles, not enough scientific
data, and the decision will heavily impact
the patient.

Ethical Principles for Patient Care Solving an Ethical Dilemma:

1 Autonomy: 1 Question if it is an ethical dilemma.
* An individuals right to make their own
decisions. 2 Gather all important information
2 Justice: related to the dilemma.
* Fair and equal healthcare and
distribution of resources. 3 Reflect on your own values.

3 Beneficence: 4 State the dilemma and related issues.

* Acting in the best interest of others.
5 Analyze all possible options.
4 Non-maleficence:
* The commitment to do no harm. 6 Select a plan that most closely aligns
with the ethical principle in question.
5 Fidelity:
* Remaining faithful to promises
7 Apply the plan and evaluate the
6 Veracity: outcome.
* Commitment to tell the
truth.
 lOMoARcPSD|22650627

6
REA IT RARE
Health Care PFEIFER
Delivery
.

.
T 0
EE
Participants Levels of Healthcare
.

O
* Consumers
* Providers o
1 Preventive: -

* Unlicensed providers * Education and prevention.

n
2 Primary Care:
-
Healthcare Settings
.

* Health Promotion.
* Provider offices, clinics, schools.
* Hospitals * Community health dept.
* Provider's offices * Occupational health o
3 Secondary Care:
-

* Urgent care * Surgical centers * Diagnosis and treatment

* Homes * Assisted-living * Inpatient, emergency care centers.
* Schools * Adult day care
* Hospices O
4 Tertiary Care:
-

* Specialized care.
* ICU, specialty units and centers.
Healthcare Plans
5 Restorative Care:
1 Medicare: * Helps patients reach functional
*Federally funded program for adults 65 potential.
or people with permanent disabilities. * Home care, rehabilitation, extended
care.
2 Medicaid:
*Federally and state funded program for 6 Continuing Care:
patients with low income. * Prolonged care.
* Hospice, assisted living, pallitive care.
3 Private Insurance:
*Traditional Fee-for-service plan.
ta
-
4 State children's Health Insurance program:
*For uninsured children up to age 19.

-
5 Affordable Care Act:
*Also known as Obamacare, increases
access to healthcare and decreases -
Issues Facing Healthcare Delivery
healthcare costs.

}
1 Nursing shortage
2 Provider competency
3 Quality and safety
*Patient Satisfaction
*Outcomes directly related to nursing
care.
4 Nursing Informatics and technological
.
advancements
5 Globalization of healthcare
 lOMoARcPSD|22650627

HEALTH
EEE PROMOTION
EEE River err . .

-
Internal Variables Affecting Health: -
Levels of Prevention:

⇐tE
* Educational level
* Developmental stage
* Age
* Perception of functioning Tertiary
* Spirituality Prevention
* Emotional Factors
* Genetics
Secondary Prevention
-
External Variables Affecting Health:
* Culture
* Family practices Primary Prevention
* Socioeconomic status
* Psychosocial factors
* Environment
1 Primary Prevention:
* Lifestyle
* Focused on health promotion, disease
Risk Factors: prevention, and wellness education.
* Immunizations, yearly wellness visits,

:
1 Genetics: fitness activities, health education.
* Determines predispositions to hereditary
disorders. 2 Secondary Prevention:
* Heart disease, cancer, etc. * Focused on diagnosis and intervention
to delay disease progression.
2 Gender: * Disease screenings, early treatments,
*Some diseases are more common in a exercise programs.
certain gender.
-
3 Tertiary Prevention:
-
3 Physiological: * Focused on rehabilitation, prevention of
*There are certain states in which people long-term consequences, and promoting
are more at risk. independence.
*Ex- pregnancy. * Rehabilitation centers, support groups.

-
4 Environment:
*Frequent exposure to toxic chemicals or
pollutants at home or work.
-
Nursing InterventionS:

J
o
5 Lifestyle:
-

* Assess patient risk factors

*Stress, substance abuse, sun exposure, * Encourage patient behavior-change if
poor diet, lack of exercise. necessary.
* Promote healthy behaviors.
O
6 Age:
-

*Certain health conditions become more

common with aging.
ed
 lOMoARcPSD|22650627

8
Prime referee
Population Health
Social Determinants of Health Vulnerable Populations:

* Social determinants of health are factors 1 People living in poverty:

-
that contribute to an individual's current * Hazardous environments, high-risk
state of health. jobs, less nutritious diets.

O
1 Biology and Genetics:
-
O
2 Older adults:
-

*Sex and age * Chronic diseases and a greater need

for health services.
O
2 Personal Behavior:
O
-

* Alcohol, drug use, sex practices, smoking. 3 Homeless individuals:

-

'
* No proper shelter, poor nutritional
status, lack of access to healthcare.

4 Immigrants:
* Language barriers, lack on benefits,
lack of resources.
3 Social Environment:
* Discrimination, income, gender. 5 People with mental illness:
* Higher risk for homelessness and abuse.
4 Physical Environment:
* Living conditions. 6 People in abusive relationships:
* Urban or rural area. * Possible fear of seeking healthcare.

o
Roles of a Community Nurse:
. * Caregiver * Epidemiologist
* Educator * Patient Advocate
-
5 Health Services: * Counselor * Change Agent
* Access to healthcare. * Collaborator * Case Manager
* Access to health insurance.
-
Community Health Assessment:
-
Health Disparities: * Identifies key heath needs of a population
or community through data collection.
* A higher burden of disease, disability, or
mortality experienced by disadvantaged O
1 Structure:
-

populations that is preventable. * Geography, services, housing,

* Related to unequal distribution of transportation.
resources. o
2 Population:
-

* Can be related to sex, race, ethnicity, * Age, sex, growth, density, ethnicity,
education. income, sexual orientation, religion of members of the community.
or geography. O
3 Social System:
-

* Government, education system, and

health system.
 lOMoARcPSD|22650627

Cultural
: aw ti 's & :m Competency
r rises ima ;D 's 's :# HEY
'
.
'

-
What is Culture?
J
Culture and Perception of Illness
and Disease:
* Customs, norms, and values passed
through generations of a particular * Illness: How patients and their families react to
-

nation, people, or group. a diagnosis or disease.

*Disease: The actual physiological and biological

-
Transcultural Nursing:
-

disease process in the body.

D
* Nursing with a primary focus of

get
understanding similarities and
differences of cultures in order to
grog

⑧
provide culturally competent care.

-
Culturally Congruent Care:
* Nursing care that aligns with the patient's .

cultural beliefs, values, and worldview.

- .

J
Cultural Competency:
5 Components of Culturally
* The ability of a healthcare provider to Congruent Care:
provide care that meets the cultural beliefs
and practices of their patients.
1 Cultural Awareness:
*Examine your own biases, beliefs,
background, and assumptions.

2 Cultural knowledge:
*Knowledge of the beliefs, values, and
Cultural Assessment:
practices of many cultures.

* Completed with the goal of gathering 3 Cultural Skills:

information that is relevant to the patients *Ability to collect relevant cultural data that
culture to form a culturally congruent plan will influence the care of your patient.
of care.
Ask about:
-
-
4 Cultural Encounters:
*Engagements with culturally diverse patients

Doo
* Cultural affiliation that provide opportunities to learn about
* Cultural restrictions other cultures.
* Health beliefs and practices
* Religious affiliation 5 Cultural Desire: -

* Nutrition *Motivation to learn about other cultures

* Primary language and become more culturally aware.
* Values
 lOMoARcPSD|22650627

10
Caring
EEE and communication
EEE EEE MEEE TEA

se -
Aspects of Caring in Nursing: Therapeutic Communication:
1 Be Present: * Encourages patient to express thoughts
* Creates a sense of openness and and feelings.
understanding. * Creates trust and respect between nurse
*Forms a connection between nurse and and patient.
patient.

J
* Includes eye contact, body language, tone Therapeutic Communication
of voice.
Techniques:
o
2 Listening:
-

o
1 Active Listening:
*Interpret and understand what the patient -

* Paying complete attention to the patient.

is saying in an accepting and non-judgmental
o
2 Body Language:
way. -

* Sit facing patient

* Maintain comfortable eye contact and
O
3 Touch:
open position.
-

*Conveys a sense of comfort and security

3 Touch:
to the patient.
* Be comforting and nonthreatening
*Be aware patient's cultural practices
* Ask permission before initiating touch.
related to touch.
4 Silence:
* Allows patient to sort out their thoughts.
4 Relief of symptoms:
5 Validation:
*Improves the patients level of comfort
* Acknowledge patient's feelings / thoughts.
and conveys respect and dignity.
6 Paraphrase:
*Restate what patient said to show active
5 Family Care:
listening.
*Know the family as well as you know the
patient.

-
5 Levels of Communication: Hi
* Intrapersonal:
=
* “Self-talk", your own thinking.
* Interpersonal:
-
Non-therapeutic Communication
*Face-to-face, between nurse and another * Discourages the patient from expressing
person. their feelings.
* Small-Group: * Damages the nurse-patient relationship.
=
*Between a small number of people.
* Public:
* Speaking to an audience.
* Electronic:
JNon-therapeutic
Communication Techniques:
* Personal questions opinions

-8
* Communication using technology.
* Asking for explanations
* Approval or dissaproval
* Arguing
* False reassurance
* Changing the subject
 lOMoARcPSD|22650627

11
FAT T.EE?TTTF
Patient safety

÷i±
-
Basic Physiological Safety: O
Falls:
* Oxygen * Must be met before any * Older adults, people with vision or
* Nutrition other needs! balance problems, and people on certain
* Temperature medications are at higher risk.
* Fall prevention = major nursing priority.

-
Safety Risks By Age: -
Fall Prevention:
o
1 Infant- Preschool:
-
* Complete a fall-risk assessment
* Injuries, accidental poisoning, choking. * Place call bell in reach of patient
2 School-Age * Provide adequate lighting for patient
*Head injuries, bicycle accidents, car * Orient patients to their setting
accidents. * Keep bed in low position with locked brakes
3 Adolescent: * Keep floor clear of obstructions
*Alcohol and drug use, sexually transmitted
infections, car accidents. Seizure Precautions:
4 Adult:
*Alcohol use, smoking, stress, car * Maintain airway patency
accidents. * Remove items that could cause injury
5 Older Adult: * Do not restrain patient
*Falls * Lower patient to floor or bed

Seclusion and Restraint:

* Use only when less restrictive measures are
not effective.

O * Must obtain order from provider ASAP.

* Assess skin integrity frequently and
provide range-of-motion exercises.
* Regularly determine need for restraints.
-
Personal Risk Factors:
* Patient age o
Fire Safety:
* Impaired Mobility

O M}
* Sensory or communication deficits R: Rescue patients
* Lifestyle A: Activate alarm
* Lack of safety awareness C: Contain fire
E: Extinguish fire
-
Risks in Healthcare Facilities:

IT
D
* Falls P: Pull pin
* Accidents that result from an action of the A: Aim at base
patient. S: Squeeze handle
* Procedure- related accidents
* Equipment-related accidents
S: Sweep area
 lOMoARcPSD|22650627

12

TREEET
Infection FEE TIRE
fi prevention

i ÷÷÷:
-
Types of Pathogens: o
Virulence: -
Standard Precautions:
* Bacteria * Fungi * A pathogens * Precautions that apply to all patients.
* Viruses * Parasites ability to invade *Hand hygiene
* Prions and damage a *Gloves when in contact with bodily
host. fluids
-
Types of Immunity: *Masks and eye protection when there is
O
1 Innate: immunity we are born with.
-
potential spraying of bodily fluids.
* Skin and mucous membranes.
c-
2 Adaptive: acquired when people are exposed
to diseases or vaccinations.
-
Transmission Precautions:
O
3 Passive: immunity that is produced by an
-

O
1 Airborne Precautions: protects against
external source and is only temporary.
-

droplet infections smaller than 5 mcg.

*Ex- through breastfeeding *Ex- measles, varicella, tuberculosis.
Chain of Infection: *Private room
*Masks (N95 or HEPA respirator for
1 Causative agent: the pathogen. tuberculosis)
2 Reservoir: areas and objects *Negative pressure room.
where the pathogen can grow *Full face protection if chance of
and multiply. splashing or spraying.
3 Portal of exit: the means by which the
pathogen can leave the reservior. 2 Droplet Precautions: protects against
4 Mode of transmission: how the pathogen can droplets larger than 5 mcg.
spread from one place to another. * Ex- strep, pneumonia, rubella, pertussis,
-
5 Portal of entry: where the pathogen is able mumps.
to invade the host. * Private room or placed with another
-
6 Susceptible host: people with compromised patient with the same condition.
defense mechanisms. * Masks

J
Stages of Infection: E. o
3 Contact Precautions: protects caregivers
-

when within 3 feet of the patient.

-
1 Incubation: time between pathogen invading the * Ex- shigella, wound infections, herpes,
host and the first symptom. scabies.

=
2 Prodromal Stage: time between onset of first *private room or placed with another
symptoms to more distinct symptoms. patient with the same condition.
3 Illness stage: acute, illness-specific symptoms. * Gloves and gown.
-
4 Convalescence: Acute symptoms dissapear, * Infectious dressing material put into
recovery begins. non-porous bag.

=
Personal Protective Equipment: 4 Protective Precautions: protects patients
Donning PPE: Removing PPE: who are immunocompromised.
* Private room with positive airflow and
-

1. Hand hygiene 1. Gloves

2. Gown 2. Goggles HEPA filtration.
3. Mask 3. Gown * Mask for patient when out of their
4. Goggles 4. Mask room.
5. Gloves 5. Hand hygiene
 lOMoARcPSD|22650627

13

Vital Signs

÷÷i÷÷
Temperature: Pulse:
*Rate = beats / min
Oral: (mouth) * Normal = 60-100 beats (min (adult)
*Normal= 96.80-100.4°F or 36-38°C. * Pulse rate is usually higher in children.
*Place thermometer under the tongue. * Rhythm: intervals between pulses.
*Only use with patients age 4 and older. * Strength: strength of each contraction/
Tympanic: (ear) beat.
*Normal = 0.5-1.0°F or 0.3-0.6°C higher 0 = absent
than oral. 1+ = diminished
*Pull ear back and place probe in outer ear 2+ = brisk, as expected
canal. 3+ = increased, strong
* For patients older than 3 months. 4+ = bounding
Rectal:
'
* Tachycardia: Pulse over 100 beats / min.
* Normal = 0.9°F or 0.5°C higher than oral. * Bradycardia: Pulse under 60 beats / min.
* Patient in SIMS position, place probe 1-1.5 * Radial pulse most common for
inches in. measurement.
*Do not use on patients with diarrhea or if * Measure 30 seconds and multiply by 2.
they are on bleeding precautions.
*Use on patients older than 3 Months. * Most common pulse points:
Axillary: (armpit) * Carotid * Popliteal
* Normal = 0.9°F or 0.5°C lower than oral. * Brachial * Dorsalis pedis
* Place in center of armpit and hold arm * Ulnar * Posterior tibial pedis
down. * Femoral
* Can be used with all ages. Blood Pressure:
Temporal: (forehead)
*Normal = 1.0°F or 0.5°C higher than oral. * Width of cuff should be 40% of arm.
*Slide probe across forehead to temporal * Cuff should be placed 1 inch above the
artery. elbow crook in line with brachial artery.
*Can be used with all ages. * Inflate cuff 30mm Hg above estimated
palpated systolic pressure.
Respirations: * Release pressure slowly until first clear
* Rate = full inspirations and expirations in one sound (systolic) and release after
minute. sounds disappear (diastolic).
*Normal = 12-20 breaths / minute (adults), Systolic
30-40/min (newborns), 20-30/min (children). *Recorded as:
Diastolic
* Depth = how much the chest wall expands
* Classifications:
with each breath. Systolic Diastolic
* Rhythm = time intervals between breaths.
Normal < 120 < 80
Pulse Oximetry: Prehypertension 120-139 80-89
* Measures oxygen saturation Stage 1 hypertension 140-159 90-99
* Clips onto finger or earlobe
* Normal = 95-100% Stage 2 hypertension > 160 > 100
 lOMoARcPSD|22650627

14
Head-To-Toe Assessment

Ets
General Survey: O
Mouth: O
Throat:
* Physical appearance * Behavior * Lips should be pink, moist and * Uvula should be pink,
* Body structure * Mood and speech smooth. midline, and should move.
* Nutritional status * Hygiene and dress * Gums and mucous membranes * Tonsils should be the same
* Mobility should be pink with no lesions color as the surrounding
* Teeth should be clean, white, area.
y
Vital Signs: and smooth.
* Temperature * Blood pressure
* Pulse
* Respirations
* Oxygen Saturation 0
Lungs and Heart:
* Chest should be round, convex, and
y
Head and Face: symmetrical.
* Palpate chest surface for lumps and
* Head: lesions.
* Should be symmetrical and proportionate * Percuss thorax and compare each side.
to body. * Auscultate lung sounds on both the anterior and
* Assess for depressions, masses, and posterior sides in ladder formation.
deformities.
* Face: * Auscultate heart sounds:
*Features should be symmetrical and * Aortic: 2nd right intercostal space.
proportionate. * Pulmonic: 2nd left intercostal space.
* Assess for touch sensation and motor *Erbs Point: 3rd left intercostal space.
function by asking patient to run through a *Tricuspid: 4th left intercostal space.
series of expressions. *Mitral: 5th intercostal space at
Neck: midclavicular line.

* Lymph Nodes: Abdomen:

* Palpate from lower head and down the
neck for enlarged nodes. * Inspect shape and symmetry.
* Thyroid: * Auscultate bowel sounds in all 4 quadrants.
* Palpate while instructing patient to swallow. * Percuss all 4 quadrants.
* Assess for any enlargement or masses. * Palpate all 4 quadrants and assess for rebound
* Trachea: tenderness.

J
*Should be midline with no masses.

Eyes:
O
Skin:
* Inspect skin's color, moisture, turgor, texture, and
i.IS
* Assess coordination by asking patient to presence of lesions.
move their eyes in the six cardinal * Assess color, firmness, curvature, and capillary
directions. refill or nails.
* PERRLA: pupils clear, equal, round, reactive to * Assess cleanliness and distribution of hair.
light, and accommodating.

* Note any abnormal discharge or tenderness.
O
Ears:
* Check for lesions,
deformities, and discharge.
* Tympanic membrane
should be intact and
landmarks visible.
-
f
Peripheral Arteries:
O
Nose: * Assess strength and equality of pulses.
* Should be midline and * Assess the presence of edema.
* Edema assessment:
symmetrical.
* Mucous membranes 1+ : 2mm depression, immediate rebound
2+ : 3-4mm depression, rebound < 15 seconds
should be intact and
pink. 3+ : 5-6mm depression, rebound 10-30 seconds
4+ : 8mm depression, rebound in > 20 seconds
 lOMoARcPSD|22650627

15

Medication Administration
I
administration
Pharmacokinetics
A
o
4. Inhalation Route:
-

Absorption: medication reaches the * Administered through nasal or oral

bloodstream from the site of administration. passages. €0
Distribution: medication is distributed to
.
.
5. intraocular Route:
*Administered to the eye area for
-

tissues and organs.

Metabolism: medication reaches the a localized effect.
-

intended site and begins to break down.

Excretion: metabolized medication leaves
-
.
-
Types of Medication Orders:
the body through the kidneys, bowels, lungs O
1. Routine Orders:
-

and glands.
.

.
*Given on a regular schedule until the
provider cancels or replaces the order.
J
Medication Actions o
2. PRN Orders:
-

*Given at the request of a patient

i
Therapeutic effects: expected response
-

Adverse effects: unintended responses or when the RN observes the need.

÷
3. One-Time Orders:
f

*Side effects
*Toxic effects: excess amounts in blood *To be given once at a specific time.
*Idiosyncratic reactions: unexpected 4. STAT Orders:
response *To be given once and immediately.
*Allergic reactions 5. Now Orders:
Medication Interactions *To be given once up to 90 minutes
after the order is given.
Routes of Administration 6 Rights of Medication Administration
1. Oral, Buccal, and Sublingual: 1. Right medication 4. Right route
*Most convenient and easiest. 2. Right dose 5. Right time
*Avoid if patient has difficulty 3. Right patient 6. Right documentation
swallowing, GI issues, or vomiting.
2. Parenteral Routes:
*Intradermal: injection into the dermis
-
Components of Medication Orders

= *26-27 gauge, 10-15 degree angle

*Subcutaneous: injection below the dermis
*
*
Patient’s full name * Route
Date + time of order * Time/frequency
*25-27 gauge, 45-90 degree angle * Medication name * Provider’s signature
*Intramuscular: injection into a muscle
.
* Dosage
* 18-27 gauge, 90 degree angle
*Intravenous: injection into a vein
-

*16-24 gauge, 15-30 degree angle

J i
Preventing Medication Errors
O
3. Topical Administration:
-
* Read labels 3 times and compare with
*Applied to the skin or mucous membranes MAR.
for a localized effect * Use at least 2 patient identifiers.
*Apply evenly with gloves and applicators * Double check all calculations.
* Follow the 6 rights of medication.
l
administration.
*Document all medications as soon as they
l are given.
 lOMoARcPSD|22650627

16

dosage
IT THENIET I
IT Calculation

s
Conversions: s
Liquid Dosages:
* Order: 30mg Prozac PO daily

②* -x
* 1 Kg = 2.2 lbs * 1 L = 1,000 mL * Available: Prozac 20mg per 5mL
* 1 mg = 1,000 mcg * 1 tsp = 5 mL * Solve: How many ML should be administered?
* 1 g = 1,000 mg * 1 tbsp = 15 mL
* 1 oz = 30 mL * 1 tbsp = 3 tsp 5 mL 30 mg
7.5 mL
20 mg X a
Rounding: Injectable Dosages:
* Less than 1.0 = round to nearest * Order: Benadryl 80mg IM four times/day.
hundredth * Available: Benadryl 50mg per mL.
* Greater than 1.0 = round to nearest * Solve: how many ML will be administered?
tenth. 1 mL 80 mg

-x-=£
1.6 mL
y
Dimensional Analysis:
* Order: 600mg acetaminophen q 6 hrs PRN
50 mg X

Weight-Based Dosages:
ng
* Available: 300mg tablets * Order: Amoxicillin 40mg per 1 kg divided into
2 doses

÷
1 Determine the unit that you are calculating. * Available: Amoxicillin suspension 400mg 15mL.
* Tablets * Solve: how many ML given per dose for a
2 Determine the quality available. 22lb child?
* 1 tablet
1 Convert lb to kg: 22 lb / 2.2 = 10 kg
3 Determine the dose available.
* 300 mg 2 Calculate dose in mg: 40 mg 1o kg 400 mg
4 Determine the desired dose. 1 kg
* 600 mg X
3 Divide dose by frequency:
5 Do you need to convert units? 400mg / 2 = 200 mg per dose
* No
6 Set up the problem and solve. 4 Convert mg to mL:
Quanity Desired dose 5 mL 200mg 2.5 mL per dose
× 400 mg X
Available dose X
1 Tablet 600 mg =
O
2 tablets
J
IV Flow Rate with Electronic Pump:
x
* Order: 1000 mL of D5W in 8 hours
-
-

300 mg X
Volume = X ml/hr 1000 mL = 125 mL/hr
o
-
Solid Dosages: Time 8 hours

* Order: Motrin 800mg PO 3 times a day Manual IV Infusions:

* Available: 400mg tablets * Order: 1200mL to be infused over 6 hours.
* Solve: how many tablets per dose? * Solve: how many gtt/min if the drop factor
is 15 gtts 1mL?
1 Tablet 800 mg
x =D
2 Tablets Volume Drop 1200 mL 15 gtts
=L
-
-

400 mg X -

X - x -

50 gtts/min
Time (min) factor 360 min 1 mL
 lOMoARcPSD|22650627

17

PAIN
Pfi MANAGEMENT
IT lit FEET IF .

-
Physiology of Pain: -
Factors That Influence Pain:
O
1 Age
* Transduction:
-

* Infants can't verbalize pain.

* Conversion of painful stimuli to electrical O
2 Cognitive function
impulse. * Patients with cognitive impairment may
* Transmission:
-

have difficulty verbalizing pain.

* Electric impulse travels along nerve fiber.
y
3 Fatigue
* Perception:
s
4 Genetic sensitivity
-

* Awareness of pain in the brain. 5 Anxiety or fear

* Modulation:
-

o
6 Culture:
* Muscle reflexes that move the body away * Influences people's meaning of pain.
from painful stimuli.

* Pain threshold: point at which someone feels J

Patients at Risk for Pain
Under-Treatment:
=
pain.
* Pain tolerance: amount of pain someone can * Older adults
stand. * Patients with substance abuse disorders.
* Children
Types of Pain: * Infants

1 Chronic:
Non-pharmacological Pain
* Ongoing, lasting over 6 months. Management:
2 Acute: * Relaxation
* Temporary, has a direct cause, often * Guided imagery
alters vital signs. * Distraction
3 Nociceptive: * Music
* Caused by tissue damage, localized. * Cutaneous stimulation: heat. ice, etc.
4 Neuropathic: * Acupuncture, acupressure.
* Caused by damaged pain nerves.

-
Pain Assessment: T e
Pharmacological Pain Management:
1 Non-opioid analgesics:
* Heart rate, respiratory rate, blood pressure, * Ex- acetaminophen
and muscle tension may be increased. * Monitor liver function
* Expected behaviors include restlessness, * Take with food
O
2 Opioids:
guarding, crying, grimacing, decreased -

attention span. * Ex- morphine

* Used to manage acute, severe pain
*Ask: * Consistent timing of administration is
* Location and feeling of pain? important
* Rate pain on scale of l-10? * Monitor:
* When did it start? * Respiratory depression
* Is it constant or intermittent? * Sedation
* What makes it better? * Urinary retention
* What makes it worse? * Orthostatic hypotension
* Vomiting
* Constipation
⇐±i÷⇐÷
lOMoARcPSD|22650627

18

Activity
RELIENT and
E. iii. Mobility
EREMITE
-
J
Exercise and Activity: Pathological Influences on
Activity:
* Important for maintaining health.
* Treatment for chronic illnesses. -
1 Disorders involving bones, joints, and
* Enhances functioning of all body systems. muscles:
-

* Osteoporosis: reduction of bone mass.

-
Assessment of Activity: * Osteomalacia: inadequate bone
* Assess body alignment and posture. calcification.
* Ask if patient has any muscle or joint pain. * Arthritis: inflammation in joints.
* Ask if patient has shortness of breath or * Joint degeneration
chest pain during activity. 2 Damage to the central nervous system:
* Ask how often the patient exercises. * Paralysis
3 Musculoskeletal trauma:
Effects of Exercise: * Broken bones
* Increased cardiac output and stronger Maintaining Mobility: :
contractions
* Improved venous return * Stretching exercises
* Improved alveolar ventilation * Active Range of motion exercises
* Improved basic metabolic rate * Low-intensity walking.
* Improved muscle tone
* Improved tolerance to physical activity Assistive Devices for Walking:
* Reduced bone loss
1 Walker:
* Improved stress tolerance
* Provides stability
* Patient steps. Moves Walker forward,
-
Transfer and Positioning: then steps again.
* Use mechanical lifts or teams when patient
is unable to assist. .
2 Cane:
* RN should widen stance for more stability. * Cane goes on the stronger side of the
* RN should lower their center of gravity. body.
* RN should Face the direction of movement. * Patient moves cane forward, steps
forward with weaker leg, then stronger leg.
T
Activity and Chronic Illness:
o
3 Crutches:
o
-

1 Hypertension: * Usually for temporary use.

A
-

* Exercise reduces blood pressure. * Position the grips so bodyweight isn't on

o
2 Coronary Heart Disease:
-

* Reduced mortality and morbidity GE armpits

* Crutches can be used with a 2-point or

o
* Improved ventricular function
* Increased functional ability
3 COPD:
-
Qb swing-through gait.
* When ascending stairs: step up with
unaffected leg, then crutches and
* Helps to lessen progressive deconditioning affected leg follows.
that causes dyspnea. * When descending stairs: crutches are
O
4 Diabetes
-
: placed on the stair below, affected leg
* Improved glucose control and lower blood follows, then unaffected leg.
sugar levels.
 lOMoARcPSD|22650627

19
Oxygenation
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Physiological Impacts on Oxygen Therapy:
Oxygenation: 1 Low-Flow Oxygen Delivery:
-
* Nasal cannula:
1 Decreased oxygen carrying capacity: -

* Delivers 1-6 L / Min, 24-44 %

* Ex: anemia, carbon monoxide poisoning.
* Assess Patency of nose
o
2 Hypovolemia:
-

* Assess for skin breakdown

* Reduced blood volume (dehydration, shock).
O * Simple Face Mask:
3 Decreased inspired oxygen: -

* Delivers 5-8 L / Min, 40-60%

* Ex: airway obstruction.
O * Assess for proper seal and fit
4 Increased metabolic rate:
-

* Assess For skin breakdown

* Ex: pregnancy, wound healing, exercise.
* Partial Rebreather Mask:
=
Changes in Respiratory Function:
* Delivers 6-10 L / Min, 40-70%
* Reservoir bag should not completely
deflate.
-
1 Hyperventilation:
* Non-rebreather mask:
* Rapid respirations causing exhalation of -

* Delivers 10-15 L / Min, 60-100%

excessive amounts of carbon dioxide.
* Frequently assess valve function
2 Hyperventilation:
* Inadequate oxygen intake.
2 High-Flow Oxygen Delivery:
3 Hypoxia:
* Venturi mask :
* Inadequate tissue oxygenation
* Delivers 4- 12 L / Min, 24-50%
* Life-threatening
* Assess flow rate and ensure tubing
Pneumothorax: Air in the pleural space. is free of kinks.
* Aerosol Mask:
Hemothorax: Blood and fluid in the pleural * Face tent, tracheostomy collar

-
space. * Delivers at at least 10 L / min
* High humidification
Lifestyle Factors:
-
Incentive Spirometry:

o
* Nutrition * Substance abuse
* Exercise * Stress * Promotes deep breathing
* Smoking * Prevents postoperative respiratory
complications.
o
Pulse Oximetry:
-
Pursed-Lip Breathing:
* Measures oxygen saturation in blood.
* Measure when patient is experiencing: * Deep inspiration and extended exhalation
* Wheezing * Prevents alveolar collapse
* Coughing
* Cyanosis
* Changes in respiratory rate
IT T
Diaphragmatic Breathing:
* Normal finding = 95-100 % * Improves breathing efficiency
* Values may be lower in older adults and * Focuses on breathing more with the
patients with COPD. diaphragm and less with the accessory
muscles.
 lOMoARcPSD|22650627

20
NUTRITION
www.pogzt.BE
iBaFBFEAm
NUTRITION
imma .

-
Units of Nutrition: -
Nutrition Assessment:
-
1 Carbohydrates: * Dietary History:
* body's main source of energy.
-

* What patient eats in a day

* Ex: whole grain bread, potatoes, brown rice, * Fluid intake
etc. * Allergies
O
2 Proteins:
-

* Appetite
* Growth, maintenance, and repair of tissue. * Religious and cultural restrictions
* Ex: beef, whole milk, poultry, etc. * Activity levels
←
3 Fats:
* Most calorie dense * Clinical Measurements:
-

* Provides vitamins and energy. * Height and weight

4 Water: * Skin fold measurements
* Critical for cell function. * Lab values (cholesterol, electrolytes, etc.)
5 Vitamins: * BMI:
* Necessary for metabolism. Underweight < 18.5
6 Minerals:
*Essential for biochemical reactions in body. Normal 18.5 - .9
Overweight -29.9
Factors Affecting Nutrition: Obese 30-34.9
* Financial Status: Extremely Obese > 35
* Low income patients may not have access
to nutrient-dense foods. Therapeutic Diets:
* Appetite:
* Clear liquid: clear fruit juice, gelatin, broth.
#

* Can increase or decrease with illness, #

medication, and pain. * Full liquid: clear liquid plus liquid dairy.
#

* Age: * Puree: liquids plus pureed meats, fruit, and

T

eggs.
-

* Affects nutritional requirements.

* Religion and culture: * Mechanical: liquid and diced /ground foods.
z
* High fiber: whole grains, fruits.
-

* Some cultural practices influence food

choices. * Low sodium: no added salt, under 2g
sodium.
* Low cholesterol: less than 300 Mg / day.
TL
Eating Disorders: *=Diabetic: Balanced intake of carbs,
proteins, and fats.
O
1 Anorexia:
-

* Dysphagia: thickened liquid, pureed food.

* Consistent restriction of caloric intake. -

* Intense fear of gaining weight.

O
2 Bulimia:
-
J
Recording Input and Output:
* Recurrent cycle of binge eating and * Important for patients with fluid and
purging. electrolyte imbalances.
O
3 Binge-Eating Disorder:
-
* Weigh patients:
* Repeated episodes of binge eating. * Same time of day
* Lack of control. * After voiding
* Wearing the same type of clothing.
 lOMoARcPSD|22650627

21
FIFI
Electrolyte FEIFFER
THEImbalances
Hyponatremia: Na < 135 Hypernatremia: Na > 145
Causes: * Fluid loss * Heart failure Causes: * Diabetes insipidus * Fluid losses
* Hyperglycemia * Diuretics * Heat stroke
* Inadequate sodium intake * Dehydration
* Increased ECF volume * Sodium retention
Symptoms: * Headache * Hypothermia Symptoms: * Hyperthermia
* Confusion * Tachycardia * Tachycardia
* Dizziness * Nausea * Thirst
* Lethargy * Edema * Restlessness

Hypokalemia: K < 3.5 Hyperkalemia: K > 5.0

Causes: * Vomiting Causes: * Sepsis * uncontrolled
* Bulimia
* Diarrhea * Corticosteroids * Trauma diabetes
* Gastric suctioning * Kidney failure * Dehydration
* Osmotic diuretics * Metabolic acidosis

Symptoms: * Hyperthermia * Weakness Symptoms: * Irregular pulse * Abdominal

* Weak pulse * Muscle cramps * Irritability cramps
* Hypotension * Flattening T-Waves * Parenthesis * V-fib
* Respiratory distress * Decreased reflexes

Hypocalcemia: Ca < 9.0 Hypercalcemia: Ca > 10.5

Causes: * Diarrhea * Hypothyroidism Causes: * Bone cancer
* Pancreatitis * Alcoholism * Hypothyroidism
* Malabsorption * Prolonged Immobilization
* Vitamin D Deficiency * Glucocorticoid use
Symptoms: * Numbness Symptoms: * Bone pain
* Prolonged QT * Heart dysthymia
* Tingling interval * Constipation * Anorexia
* Muscle spasms * Weakness
* weak Pulse * Deceased reflexes

Hypomagnesemia: Mg < 1.3 Hypermagnesemia: Mg > 2.1

Causes: * Diarrhea * Alcoholism Causes:
* Gastric suction * Kidney failure
* Thiazide diuretics * Low adrenal function
* Malnutrition * Laxatives containing Mg
Symptoms: * Tatany * Dysrhythmias Symptoms:
* Seizures * Tachycardia * Muscle paralysis * Coma
* Hypotension * Cardiac arrest
* Hypoactive bowel
* Hypertension * Decreased respiratory rate
 lOMoARcPSD|22650627

22

Skin EE EFF
EA and Wound Care

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-
Stages of Wound Healing: -
Pressure Wound Staging:

FIE
o
1 Inflammatory Phase:
-
* Stage 1:
* Lasts 3-6 days after injury
-

* Skin intact, but non-blanchable

* Vasoconstriction and WBCs in the area. * Appears reddened
* Localized redness, warmth, swelling. * Stage 2:
o
2 Proliferative Phase:
-

FIE
-

* Involves epidermis and

* 3-21 days after the inflammatory phase. dermis
* Replacement of lost tissue. * Wound is visible and appears
o
3 Maturation phase:
-

similar to blister/shallow crater

* After day 21, can last up to 1 year. * Stage 3:
* Strengthening of collagen, regaining a more

FIE
-

* Involves subcutaneous tissue

normal appearance. and may extend down to fascia.
* No tunneling, or exposed
Healing Processes: muscle, tendon, or bone.
* Stage 4:
1 Primary Intention: * Extends into muscle, tendon, or
* Little to no tissue loss. bone.
* Clean edges (ex-surgical incision). * May have tissue necrosis and
* Heals quickly, minimal scarring. tunneling.
2 Secondary Intention: * Unstageable:
* Loss of tissue with separated edges. * Stage can't be determined due
* Pressure wounds, burns. to eschar obscuring the view.
* Longer healing time, more scarring.
-
3 Tertiary Intention:
* Very separated and deep. -
Types of Drainage:
* High infection risk.
* Significant drainage. * Serous: clear, watery plasma
-

* Sanguineous: bright red, active bleeding

-
Assessment of Wounds: * =
Serosanguineous: serum and blood, watery
and blood-streaked.
* Assess color:
#
* Purulent: Infected, thick yellow, green, or
#

* Red: healthy regeneration=cover wound brown drainage.

* Yellow: healthy drainage=clean wound * Purosanguineous: pus and blood.

o÷÷÷p
* Black: eschar=debride wound
* Assess size of wound:
-

Wound Drains:
* Length, width, depth
* Presence of tunnels 1 Jackson-Pratt drain:
* Presence of redness / swelling * tube connected to bulb that creates
negative pressure.
T
Possible Complications:
#
O
2 Hemovac Drain:
-

*Similar to Jackson-Pratt but can hold

* Dehiscence: separation of a sutured wound. more mL of drainage.
*=Evisceration: dehiscence that involves the O
3 Penrose Drain:
-

protrusion of internal organs. *Open tube, empties onto absorptive pad.

 lOMoARcPSD|22650627

Hygiene
KEEFE EE
23

-
Factors Influencing Hygiene: o
Oral Hygiene:
* Before performing oral hygiene, assess
* Social and cultural practices
for responsiveness, risk of aspiration,
* Personal hygiene preferences
and ability to swallow.
Socioeconomic status

FEE
* "
* Brush all surfaces of the teeth and at
* Motivation
gum line.
* Body image
* If the patient has dentures, remove
* Age
* Functional ability AI and brush gently with dentures
cleaner, rinse with room temperature
water, and store in a denture cup.
-
Safety Considerations:
* Know proper technique for using hygiene o
Nail Care:
tools such as razors, toothbrush, etc. * Assess size, shape, and condition of
* Be aware of any special considerations nails.
the patient has. * Look for clubbing, and brittleness.
* Ex: Fall risk, aspiration risk * Do not cut the nails of patients with
* Work at a comfortable height diabetes and peripheral vascular
* Older adults have more fragile skin disease.
and mucous membranes. * Instead, file nails using a nail file.
* Dentures need to fit properly
Hair Care:
Bathing:
* Brush or comb the patients hair daily
Types of baths: * Ask patients about their preferences
* Full bed bath for hair care practices.
* For completely dependent patients. * Shampoo troughs and shampoo caps
* Partial bed bath can be used to shampoo the hair of
* Cleans only certain areas of the body. bedridden patients.
* Face, armpits, perineal area.
* Tub Bath
* Shower O
Shaving:
Considerations: * Use an electric razor with patients
* Allow patient to test the temperature of the who are prone to bleeding or are on
water before beginning the bath. anticoagulants.
* Make sure the patient is as covered as * Hold skin taut and slide razor in the
possible during the bath with a blanket or direction of hair growth.
towel. * Use shorter strokes around the chin/lips.
* Use fresh water when cleaning the
perineal area.
O
Foot Care:
O
Perineal Care:
* Don’t moisturize between the toes.
* Ensure proper fit of socks and shoes.
* Clean from front to back
* Contact provider if infections are
* Remove all fecal matter
present.
* Dry completely when finished
 lOMoARcPSD|22650627

24

Urinary FINE
EMI FIERI
Elimination
o
Factors Affecting Urinary
Elimination:
-
Types of Incontinence:
* Stress:
* Age:
F

* Caused by increased abdominal

* Children typically have control of their pressure.
bladder by age 5. * Ex: sneezing, laughing, lifting.
* Women who have had children can have * Overflow:
a weaker pelvic floor from childbirth.
#

* Caused by an over-distention of the

* Older adults have a loss of muscle tone bladder.
in their bladder. * Urge:
* Pregnancy:
-

* Caused by being unable to reach

* The fetus compresses the bladder, a bathroom fast enough because
causing a higher urination frequency. the urge comes on too quickly.
* Diet:
F

* Reflex:
* Sodium = decreased urination
L

* Caused by the bladder contracting

* Immobility without warning.
*=Pain * Usually caused by nerve damage
Decreased urge to urinate * Functional:
* Surgery
-

* Caused by being unable to respond

J=
* Medications to the need to urinate.
Collecting A Specimen: U * Ex: impaired mobility
* Total:
1 Routine urinalysis: * Complete, involuntary loss of urine.
* Non-sterile procedure, use clean specimen
cup
* Collect during voiding or from catheter Catheterization:
2 Clean-catch specimen:
* Types of catheters:
* Sterile specimen cup
* Collect from midstream
1 Indwelling catheters:
3 Sterile specimen for culture and sensitivity:
* Foley catheter
* Collected from straight or indwelling catheter
2 External catheters:
* If it is an indwelling catheter, clamp the
* Condom catheter
tubing below the port and let fresh urine
3 Short-term catheters
collect in the tube.
* Straight catheter
o
4 Timed urine specimen:
-

* Collected at intervals over a specified time

Catheter care:
period (Ex: 24 hours) -

* Catheter insertion is a sterile

* Begins after the first void
procedure.
* Specimens are refrigerated
* Ensure urine is flowing before
Urinary Diversions: inserting the balloon.
* Remove catheter as soon as possible
* Ureterostomy: one or both ureters are to reduce the chance of infection.
connected to the abdominal wall. * Clean the site daily with mild soap or
* Nephrostomy: a tube from the renal pelvis is perineal cleanser.
connected to the abdominal wall by a stoma. * Assess skin integrity regularly.
 lOMoARcPSD|22650627

25

Bowel
IT Elimination
In FEI LI IT Y
'
'

SL
Diarrhea:
-
Factors Affecting Bowel
Elimination: * Frequent loose or liquid stool.
* Causes:
-

* Age: * Viral and bacterial infections of the GI

* Children do not have bowel control until tract.
the age of 2 or 3. * Antibiotic therapy
* Older adults have decreased peristalsis * Inflammatory bowel disease
and gastric emptying. * Irritable bowel syndrome

E¥
* Diet * Complications:
-

* Fluid intake * Dehydration

* Psychological factors * Skin breakdown of perineal are
* Physical activity * Fluid and electrolyte imbalances
* Immobilization suppresses peristalsis. * Interventions:
-

* Positioning: * Determine cause

* Immobile patients cannot maintain * Apply moisture barrier after perineal care
normal “squat” position.
* Pain
* Surgery
* Medications
-
Characteristics of Stool:
* Normal:
* Yellow, brown
* Soft and formed
Constipation:
* Abnormal:
* Difficult or infrequent elimination of * White/clay, black, red, bloody
hard, dry stool. * Foreign bodies, oily, hard, or liquid
* Causes:
* Improper diet Ostomies:
* Reduced fluid intake 1 Colostomy:
* Immobilization * Ends in the colon
* Medications * More formed stool
* Advanced age 2 Ileostomy:
* Complications: * Ends in the ileum
* Fecal impaction * Frequent liquid stool
* Hemorrhoids, rectal fissures Ostomy Care:
* Bradycardia, hypotension, syncope * Empty pouch when 1/2 to 1/3 full
*Interventions:
-

* Assess for skin breakdown every time

*Increase fiber and water consumption. the pouch is changed.
* Give stool softeners or suppositories.

o
Impaction: -
Specimen Collection:
* Hardened stool becomes stuck in the rectum
o1 Fecal occult blood testing:
-

and can not be expelled. * Measures amounts of blood in the stool.

* Main indication is the patient being unable to * Small amounts of stool are placed onto
pass stool for several days. a test card with an applicator.
* Can be removed with cleansing enemas, r
2 Stool culture for parasites/ova:
-

suppositories, or digital removal. * Sample is placed into a clean specimen

container.
 lOMoARcPSD|22650627

26
EERIE
Crisis RE? FREE
and ERIE
disaster ,

O
Disaster: O
Fire:
* A mass casualty or event that * “RACE”
interrupts or overwhelms the normal
functioning of a hospital. g-
R: rescue all patients in the area.
A: sound the fire alarm to notify
others and EMS.
-
g
Internal Emergency: C: contain the fire by closing the door
to the room the fire is in.
* Emergencies that occur inside of E: extinguish fire if it is small enough
the medical facility. to put out with a fire extinguisher.
* Ex: loss of power, loss of water,
fire. o
Severe Storms:
* Close windows and shades
-
External Emergency: * Move beds away from windows
* Relocate mobile patients into the hallways
* Emergencies that occur outside of the
medical facility. * Don’t use elevators if possible
* May bring an influx of patients
* Ex: Hurricane, disease epidemic, building -
Biological Pathogens:
collapse.
* When identified, decontaminate the area
O
Triage: * Isolate affected patients
* Only transport patients for necessary
* Disaster triage is different from the treatments.
triage system that is used during normal
circumstances. Chemical Incidents:
* Categories:
1 Class 1 (Emergent): * Avoid contact with the chemical.
* Injuries are life-threatening, but there * Administer care to affected patients
is a high chance of survival. as needed.
2 Class 2 (Urgent): * Determine the name and concentration
* Major injuries that are not life- of chemical.
threatening. * Clean all areas that chemical has come
* Can wait 45-60 minutes into contact with, including patients
3 Class 3 (Non-Urgent): clothing and bedding.
* Minor injuries tryst do not need
immediate attention. Hazardous Material:
4 Class 4 (Expectant):
* Patients who are not expected to live. * Avoid contact with the material
* Comfort measures can be * Contain the hazardous material
provided. * Notify the hazardous material team

E
* Decontaminate affected patients using
water and soap and place contaminated
material in sealed bags.

_Qo#-
 lOMoARcPSD|22650627

27
Legal ERMEY
KE PEER RRR
Considerations
tf s
Legal Regulation of Nursing: Safeguards for Competent
Nursing Practice:
* Nurse Practice Acts:
* Defines the legal scope of nursing practice * Understand boundaries of nursing
* Standards: practice.
* Healthcare Agency Policy and Procedure * Respect and advocate for patient rights.
* Credentialing:
- * Document carefully and completely.
* Accreditation 00
-

P
* Follow agency policies and procedures
* Licensure: NCLEX ,

O
* Certification

Crime:
00 ⑤ O
HIPPA:
* Ensures the confidentiality of patient health
information.
* A wrong against a person, property, or the * Patient files and papers should not be left
public. in public areas
*Misdemeanor: punishable by fines of * Passwords to electronic medical records
less than 1 year of imprisonment. should not be shared.
* Felony: Punishment of over 1 year of
imprisonment.
Informed Consent:
Torts: * When a patient signs written consent for a
* A wrong committed against a person or treatment or procedure.
property that is tried in civil court. * The patient should know:
*Unintentional Tort: * Why they need the treatment
* Negligence * The potential risks
* Malpractice * Other potential options
* Quasi-intentional Tort: * The role of the nurse is to serve as a

¥ witness for informed consent.

-

* Defamation of character
* Breach of confidentiality
* Intentional Tort:
-
J
Advance Directives:
* Assault * Living will:
* Battery
-

* A legal document that specifies the

* False imprisonment patients wishes for medical treatment if
.

they become incapacitated.

-
Professional Negligence: * Power of Attorney:
-

* When a professional fails to act in a * A legal document that appoints a health

way that someone else with the same care proxy to make medical decisions for
training and experience would. the patient if they are unable.
* Failure to:
-

* Follow the standards of care of -

Mandatory Reporting:
the medical facility.
* Nurses must report:
* Use equipment safely
* Suspicion of elder or child abuse
* Document care properly
* Diagnosis of communicable disease
* Notify the provider of a change
in patient status
 lOMoARcPSD|22650627

28

Documentation
-
e.
Purpose of Medical Records: Documentation Formats:
* Communication 1 Narrative:
* Care planning * Written in “story” format in chronological
* Legal documentation order.
* Diagnostic orders * Addresses patient status, care, events,
* Quality improvement treatments, interventions, and patient

µ;
* Research / Education responses.
* Reimbursement 2 SOAP Note:
* S: subjective (Patient stated “I feel
+
Guidelines for Documentation: worried because...)
* O: objective (Patients BP reading high)
,

* Information should be: * A: assessment (Anxiety related to...)

T
* Factual: * P: plan (Encourage patient to...)
* Objective information about what a O
3 PIE Note: -

nurse sees, hears, feels, etc. * P: problem (Anxiety related to...)

* Nurse should not write any opinions * I: intervention (Encouraged patient to...)
* Avoid using generalized statements. * E: evaluation (Patient responded by...)
* Accurate: -
4 Focus Charting:
* D: data (Patient stated they were
-

* Only use acceptable abbreviations and

use correct spelling.
* Complete
*Information should be thorough and
contain all essential information.
* Current
* Documentation should not be delayed.
* Label all entries with date, signature,
and credentials.
* Organized:
* Information should be presented in a
logical order.
Confidentiality:
* All patient health information should be
kept confidential and is protected under
HIPPA.
* Do not share information with other
patients or health team members who
are not treating the patient.
* Patients have the right to access their
own information.
* Don’t leave patient information in areas
where it may be accessed by
unauthorized people.
worried because...)
* A: action (Encouraged patient to...)
* R: response (Patient responded by...)
Methods of Documentation:
* Narrative documentation
* Problem-Oriented Medical Record:
* Main focus is patient problems
* Organized by problem or diagnosis
* Charting by exception:
* Progress notes are written when
assessment findings are not normal
findings.
* Case management
* Inter-professional approach
* Utilizes critical pathways
-
Incident Reports:
* Incident reports need to be filed when there
is an event that is not congruent with the
standard procedures of the facility.
*Ex: patient falls, medication errors
* Report is confidential and filed with the risk
management agency
* Incident reports DO NOT go in the medical
record of the patient.