Table of Contents

1- Lab Values
2- Cranial Nerves
3- Nursing in Health Care
- Maslows's Hierarchy of Needs
- Nursing Theories
- Levels of Health Care
- Phases (Planning, Implementation, Evaluation)
4- ABCDE Principle in Nursing
5- Nursing Process
6- NANDA Nursing Diagnosis List (4 Pages)
7- Patient Admission
8- Delegation
9- Nursing Ethics
10- Safety
11- Mobility
12- Infection
- Chain of infections
- Transmission Precautions (Airborne, Droplet, Contact)
- PPE
13- Assessment and Vital Signs
14- Medical Administration
15- Death, Loss and Grief
16- Fluids, Electrolytes
17- Acid-Base Balance
18- Nutrition
19- Therapeutic Diets
20- Urinary Elimination
21- Skin Integrity NursingStoreRNbyANA
 Lab Values
Electrolytes: Arterial Blood Gases (ABGs)
Sodium (Na): 135-145 mEq/L pH: 7.35-7.45
Chloride (Cl): 98-106 mEq/L PaCO2: 35-45 mmHg
Calcium (Ca): 8.5-10.5 mg/dL PaO2: 80-100 mmHg
Potassium (K): 3.5-5.0 mEq/L HCO3: 22-26 mmHg
Phosphorus (PO4): 2.5-4.5 mg/dL SaO2: 95-100%; <95% Indicates Hypoxemia
Magnesium (Mg): 1.5-2.5 mEg/L

CBC WBC Differential Count:

RBC: males 4.7-6.1 million/uL; females 4.2-5.4 million/uL Neutrophils: 55-75%
Hgb: males 14-18 g/dL; females 12-16 g/dL Lymphocytes (T & B Cells): 20-40%
Hct: males 42-52%; females 37-47% (hct 36-54 nclex) Monocytes: 2-8%
WBC: 5,000-10,000 mm3 Eosinophils: 1-4%
Erythrocyte sedimentation rate (ESR): <20 mm/hour Basophils: 0.5-1%
Serum lactate (lactic acid): 0.5-1.0 mmol/L

Blood Lipid Levels

Total serum cholesterol: desirable <200 mg/dL
LDL (low-density lipids): desirable <130 mg/dL; Dad Cholesterol
HDL (high-density lipids): males >45 mg/dL; females >55 mg/dL; Good Cholesterol
Triglycerides: desirable <150 mg/dL; males 40-160; females 35-135; over 65 years: 55-220 mg/dL

Anticoagulant Therapy Coagulation Times Liver Function Tests

Therapeutic INR: 2-3 sec (without Warfarin: <1) Albumin: 3.4-5.0 g/dL
PT: 11-12.5 sec Ammonia: 15-45 mcg/dL
Platelets: 150,000 - 400,000/mm3 Total bilirubin: 0.1-1.0 mg/dL
Indirect/unconjugated bilirubin: 0.2-0.8 mg/dL
Liver Enzymes Urinalysis Total protein: 6-8 g/dL;
ALT: 7-56 u/L Specific gravity: 1.005-1.030 Prealbumin: 19-38 mg/dL
AST: 10-40 u/L Protein: 0-8 mg/dL
ALP: 40-120 u/L Glucose: <0.5 g/day Renal Function
pH: 4.6-8 Creatinine: 0.6 - 1.2 mg/dL
BUN: 10-20 mg/dL
Blood Glucose Levels
Glucose (fasting): 70-110 mg/dL Thyroid
Glycosylated hemoglobin (HbA1c): 4-6% T3: 70-205 ng/dL
T4: 4-12 mcg/dL
I&O Thyroid Stimulating Hormone (TSH): 0.3-0.5 microunits/mL
Fluid intake: 2,000-3,000 mL/day
Daily urine output: 1,200-1,500 mL/day BMI Ranges Therapeutic Medication Monitoring
Hourly urine output: ≥30 mL/hour; <30 mL Underweight: <18.5 Digoxin level: 0.8-2.0 ng/mL
for >2 consecutive hours = CONCERN!! Healthy: 18.5-24.9 Lithium level: 0.4-1.4 mEq/L
Polyuria (consistently high urine volume): Overweight: 25-29.9 Phenobarbital: 10-40 mcg/mL
>2,000-2,500 mL/day Obese: ≥30 Theophylline: 10-20 mcg/mL
Dilantin: 10-20 mcg/mL
Carbamazepine level: 4-10 mcg/mL
Valproic Acid level: 50-100 mcg/mL
 Cranial Nerves
I: Olfactory II: Optic III: Oculomotor
Sensory Sensory
Smell Visual Acuity Pupillary Constriction (PERRLA)
Pt should be able to ID aromas. Ask Pt to read Snellen’s Chart Assess ocular movements and
-Assess Patency occluding one about 20 ft away. Close one eye pupil reaction.
nostril at the time. at the time. PERRLA: Pupils Equal, Round,
-Close eyes, occlude one nostril If Pt with Glasses, leave them React to Light, and
and smell. on. Remove only reading Accommodation. MIX
glasses

IV: Trochlear V: Trigeminal VI: Abducens

Motor MIX
Vertical Eye Movement S: Face Sensation Horizontal Eye Movement
Ask Pt to move eyeballs up and Light touch, wipe forehead, cheeks Ask Pt to move eyeballs
down (following object) and chin with cotton (eyes closed) laterally (following object)
M: Mastication Muscles
Palpate Temporal and masseter
muscles as Pt clenches the teeth Motor

VII: Facial VIII: Acoustic IX: Glossopharyngeal

MIX Sensory
S: Taste anterior 2/3 Hearing + Equilibrium S: Taste posterior 1/3
Ask Pt to ID various tastes Hear loud and soft-spoken M: Pharynx
placed on the tip and side of words. Gag Reflex
the mouth Whispered Voice Test. Depress tongue, Pt says
M: Facial Expression Tuning Fork: Hearing by air and “Ahhhh” uvula and soft palate
Ask Pt to do facial expressions, bone conduction. WEBER - should rise to midline
smile, frown, raise eyebrows RINNE MIX

X: Vagus XI: Spinal Accessory XII: Hypoglossal

MIX Motor
S: Sensation pharynx, viscera, Movement Trapezius and Movement of Tongue
carotid body Sternomastoid Muscles Inspect the tongue. Tongue in
M: Pharynx and Larynx Ask Pt to rotate the head midline as Pt protrudes the
Ask Pt to swallow, Assess against resistance applied to tongue. Ask Pt to say: “light,
Speech for hoarseness. side of chin. tight, dynamite”
Ask Pt to shrug the shoulders
against resistance. Motor
 Nursing in Health Care
Origin of Nursing
Florence Nightingale: Founder of Modern + Infection Control. First epidemiologist.
Clara Barton: Founded the American Red Cross.
Maria E. Mahoney: 1st black graduate who advocated for fair treatment or black patients.
Dorothea Dix: Advocated for fair treatment of Mentally Ill.
Mary Breckinridge: Started one of the 1st midwifery schools in the US.

*Holistic Care: Healthcare that emphasizes the whole mind, body and spirit.

Levels of Health Care

- Preventative health care focuses on educating and equipping clients to reduce and control risk factors of
disease. Examples: Blood Pressure and Cancer Screening, 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: ICU, 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.

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Planning phase:
- In planning, set you priority first. Short term goals first before long term ones.
- 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.
- Planning phase involves setting goals with client or for the client.
Types of goals:
- 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.
- 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:
- This is carrying out the planning phase or accomplishing the defined goal It involves implementation of care
Reporting significant changes in client’s condition
- Documentation of client care
- Communicating client’s needs to others (health team)
- Utilizing client’s strength to achieve goals of care
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:
- This determines the extent at which your goals have been achieved
- Compares client’s responses to expect outcome
- Evaluation revise goal of care to accommodate client values, customs, culture, dresses in cultural outfits.
- Gather data to indicate effectiveness of each intervention
- Determine impact of therapeutic intervention on client
- Determine if goal of care is being achieved
- Identify need for change approach to client care
- Revise approach to care in order to meet client’s specific needs
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.

Nursing Theories:
Nightingale’s Theory: Founder of Modern Nursing and Pioneer of the Environmental Theory. Defined Nursing
as “the act of utilizing the environment of the patient to assist him in his recovery.”
Peplau’s Interpersonal Theory: Mother of psychiatric Nursing. Theory of Interpersonal Relations. “An
interpersonal process of therapeutic interactions between an individual who is sick or in need of health
services and a nurse especially educated to recognize, respond to the need for help.”
Leininger’s Culture Care Theory: Culture Care Theory of Diversity and Universality. Focuses on the fact that
various cultures have different and unique caring behaviors and different health and illness values, beliefs, and
patterns of behaviors.

MASLOW’S HIERARCHY OF NEEDS

Self-actualization – e.g. morality, creativity,
problem solving.
Self-Esteem – e.g. confidence, self-esteem,
achievement, respect.
Love and Belongingness – e.g. love, friendship,
intimacy, family.
Safety and Security – e.g. security of environment,
employment, resources, health, property.
Physiological – e.g. air, food, water, sex, sleep,
other factors towards homeostasis.
 ABCDE Principle in Nursing

A (Airway): Ensure patent airway. Stabilize cervical spine if neck/head trauma is suspected

B (Breathing): assess for respirations.

C (Circulation): check heart rate, blood pressure, capillary refill.

D (Disability): assess patients’ level of consciousness.

E (Exposure): assess patients’ body for trauma, exposure to heat/cold.

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 Nursing Process

1- Assessment: 2- Diagnosis:
What do you see, hear, feel? What are priority problems?
Collect objective (Measurements and Interpret the information collected.
observations by the nurse) and subjective
Identify an appropriate Nursing Diagnosis
(patient verbal description) data.
Document your diagnosis and communicate it to the
Verify that the data you collected is clear and
healthcare team.
accurate.
Determine the health team’s ability to help
Ask Closed-Ended Questions (one or two words
answer) and Open-Ended Questions (describe in Cluster collected data
more than 2 words)
Any patterns and trends
Compare data you gathered from baseline

3- Planning:
4- Implementation:
How will you fix them?
What interventions?
Prioritize the outcomes of care.
Organize and manage the clients care including safety,
Develop and modify plan of care.
communication, culture, and delegation of tasks.
Carry out clients plan of care
Counsel and educate the client

5- Evaluation:
How well did the interventions work?
Compare actual outcomes with the planned/
expected outcomes
Evaluate patient’s compliance
Document client’s response to plan
Modify plan and reassess as needed
 NANDA Nursing Diagnosis List (4 Pages)
1. Health promotion 3. Elimination and exchange
Class 1. Health awareness Class 1. Urinary function
Decreased diversional activity engagement (Nursing Care Impaired urinary elimination
Plan) Functional urinary incontinence
Readiness for enhanced health literacy Overflow urinary incontinence
Sedentary lifestyle (Nursing care Plan) Reflex urinary incontinence
Class 2. Health management Stress urinary incontinence
Frail elderly syndrome (Nursing care Plan) Urge urinary incontinence
Risk for frail elderly syndrome Risk for urge urinary incontinence
Deficient community health Urinary retention
Risk-prone health behaviour Class 2. Gastrointestinal function
Ineffective health maintenance (Nursing care Plan) Constipation (Nursing care Plan)
Ineffective health management Risk for constipation
Readiness for enhanced health management Perceived constipation
Ineffective family health management Chronic functional constipation
Ineffective protection Risk for chronic functional constipation
Diarrhea
2. Nutrition Dysfunctional gastrointestinal motility
Class 1. Ingestion Risk for dysfunctional gastrointestinal motility
Imbalanced nutrition: less than body requirements Bowel incontinence
(Nursing care Plan) Class 3. Respiratory function
Readiness for enhanced nutrition Impaired gas exchange
Insufficient breast milk production
Ineffective breastfeeding (Nursing care Plan) 4. Activity/rest
Interrupted breastfeeding (Nursing care Plan) Class 1. Sleep/rest
Readiness for enhanced breastfeeding Insomnia
Ineffective adolescent eating dynamics Sleep deprivation
Ineffective child eating dynamics Readiness for enhanced sleep
Ineffective infant feeding dynamics Disturbed sleep pattern
Ineffective infant feeding pattern (Nursing care Plan) Class 2. Activity/exercise
Obesity Risk for disuse syndrome
Overweight Impaired bed mobility
Risk for overweight Impaired physical mobility
Impaired swallowing (Nursing care Plan) Impaired wheelchair mobility
Class 2. Metabolism Impaired sitting
Risk for unstable blood glucose level (Nursing care Plan) Impaired standing
Neonatal hyperbilirubinemia Impaired transfer ability
Risk for neonatal hyperbilirubinemia Impaired walking
Risk for impaired liver function Class 3. Energy balance
Risk for metabolic imbalance syndrome Imbalanced energy field
Class 3. Hydration Fatigue
Risk for electrolyte imbalance Wandering
Risk for imbalanced fluid volume
Deficient fluid volume (Nursing care Plan)
Risk for deficient fluid volume
Excess fluid volume (Nursing care Plan)
4. Activity/rest (Cont.) 6. Self-perception (Cont.)
Class 4. Cardiovascular/pulmonary responses Class 2. Self-esteem
Activity intolerance Chronic low self-esteem
Risk for activity intolerance Risk for chronic low self-esteem
Ineffective breathing pattern Situational low self-esteem
Decreased cardiac output Risk for situational low self-esteem
Risk for decreased cardiac output Class 3. Body image
Impaired spontaneous ventilation Disturbed body image
Risk for unstable blood pressure
Risk for decreased cardiac tissue perfusion 7. Role relationship
Risk for ineffective cerebral tissue perfusion Class 1. Caregiving roles
Ineffective peripheral tissue perfusion Caregiver role strain
Risk for ineffective peripheral tissue perfusion Risk for caregiver role strain
Dysfunctional ventilatory weaning response Impaired parenting
Class 5. Self-care Risk for impaired parenting
Impaired home maintenance Readiness for enhanced parenting
Bathing self-care deficit Class 2. Family relationships
Dressing self-care deficit Risk for impaired attachment
Feeding self-care deficit Dysfunctional family processes
Toileting self-care deficit Interrupted family processes
Readiness for enhanced self-care Readiness for enhanced family processes
Self-neglect Class 3. Role performance
Ineffective relationship
5. Perception/cognition Risk for ineffective relationship
Class 1. Attention Readiness for enhanced relationship
Unilateral neglect Parental role conflict
Class 2. Cognition Ineffective role performance
Acute confusion Impaired social interaction
Risk for acute confusion
Chronic confusion 8. Sexuality
Labile emotional control Class 1. Sexual function
Ineffective impulse control Sexual dysfunction
Deficient knowledge Ineffective sexuality pattern
Readiness for enhanced knowledge Class 2. Reproduction
Impaired memory Ineffective childbearing process
Class 3. Communication Risk for ineffective childbearing process
Readiness for enhanced communication Readiness for enhanced childbearing process
Impaired verbal communication Risk for disturbed maternal-fetal dyad

6. Self-perception 9. Coping/stress tolerance

Class 1. Self-concept Class 1. Post-trauma responses
Hopelessness Risk for complicated immigration transition
Readiness for enhanced hope Post-trauma syndrome
Risk for compromised human dignity Risk for post-trauma syndrome
Disturbed personal identity Rape-trauma syndrome
Risk for disturbed personal identity Relocation stress syndrome
Readiness for enhanced self-concept Risk for relocation stress syndrome
9. Coping/stress tolerance (Cont.) 10. Life principles (Cont.)
Class 2. Coping responses Readiness for enhanced emancipated decision-making
Ineffective activity planning Moral distress
Risk for ineffective activity planning Impaired religiosity
Anxiety (Nursing Care Plan) Risk for impaired religiosity
Defensive coping Readiness for enhanced religiosity
Ineffective coping Spiritual distress
Readiness for enhanced coping Risk for spiritual distress
Ineffective community coping
Readiness for enhanced community coping 11. Safety / Protection
Compromised family coping Class 1. Infection
Disabled family coping Risk for infection
Readiness for enhanced family coping Risk for surgical site infection
Death anxiety Class 2. Physical injury
Ineffective denial Ineffective airway clearance
Fear Risk for aspiration
Grieving Risk for bleeding (Nursing Care plan)
Complicated grieving Impaired dentition
Risk for complicated grieving Risk for dry eye
Impaired mood regulation Risk for dry mouth
Powerlessness Risk for falls
Risk for powerlessness Risk for corneal injury
Readiness for enhanced power Risk for injury
Impaired resilience Risk for urinary tract injury
Risk for impaired resilience Risk for perioperative positioning injury
Readiness for enhanced resilience Risk for thermal injury
Chronic sorrow Impaired oral mucous membrane integrity
Stress overload Risk for impaired oral mucous membrane integrity
Class 3. Neurobehavioral stress Risk for peripheral neurovascular dysfunction
Acute substance withdrawal syndrome Risk for physical trauma
Risk for acute substance withdrawal syndrome Risk for vascular trauma
Autonomic dysreflexia Risk for pressure ulcer
Risk for autonomic dysreflexia Risk for shock
Decreased intracranial adaptive capacity Impaired skin integrity (Nursing Care Plan)
Neonatal abstinence syndrome Risk for impaired skin integrity
Disorganized infant behaviour Risk for sudden infant death
Risk for disorganized infant behaviour Risk for suffocation
Readiness for enhanced organized infant behavior Delayed surgical recovery
Risk for delayed surgical recovery
10. Life principles Impaired tissue integrity
Class 1. Beliefs Risk for impaired tissue integrity
Readiness for enhanced spiritual well-being Risk for venous thromboembolism
Class 2. Value/belief/action congruence
Readiness for enhanced decision-making
Decisional conflict
Impaired emancipated decision-making
Risk for impaired emancipated decision-making
11. Safety / Protection (Cont.)
Class 3. Violence
Risk for female genital mutilation
Risk for other-directed violence
Risk for self-directed violence
Self-mutilation
Risk for self-mutilation
Risk for suicide
Class 4. Environmental hazards
Contamination
Risk for contamination
Risk for occupational injury
Risk for poisoning SAMPLE
Class 5. Defensive processes
Risk for adverse reaction to iodinated contrast media Nursing Diagnosis: Constipation
Risk for allergy reaction
Latex allergy reaction Related to: (why)
Risk for latex allergy reaction
Class 6. Thermoregulation as evidenced by: (proof that the
Hyperthermia
Hypothermia constipation is a problem... can be
Risk for hypothermia something you see (objective) or
Risk for perioperative hypothermia something your patient tells you
Ineffective thermoregulation
Risk for ineffective thermoregulation (subjective).

12. Comfort D(x): Constipation r/t (why) immobility

Class 1. Physical comfort due to recent surgery aeb (proof)
Impaired comfort
distended, tender abdomen and pt.
Readiness for enhanced comfort
Nausea states, "I haven't moved my bowels in 5
Acute pain days!"
Chronic pain
Chronic pain syndrome
Labor pain
Class 2. Environmental comfort
Impaired comfort
Readiness for enhanced comfort
Class 3. Social comfort
Impaired comfort
Readiness for enhanced comfort
Risk for loneliness
Social isolation

13. Growth/development
Class 1. Development
Risk for delayed development

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 Patient Admission

Document patients: Patient transfer (one unit to another)

-Advanced directions ASAP Use SBAR:
-Vital signs -Hand off tool to use when giving report to next nurse
-Allergies -(Situation, Background, Assessment, Recommendation)
-Height and weight

-Head to toe assessment Discharging a Patient

-Health history Included in patient discharge instructions:
-Spiritual or cultural considerations -Patients diet and activity restrictions
Assess their ability to swallow safely: -Detailed instructions for procedures to be done at Home
-Give a little water and assess what the patient does (such as wound dressing changes).

-Any concern is NPO until swallow evaluation by -List of medications, when to take them, precautions
speech language pathologist regarding medications.

Assess safety: -Signs and symptoms of complications, when to seek medical

attention.
-Implement fall precautions if appropriate.
-Follow up information and appointment
Patient belongings and inventory:
-Names and numbers of community resources or providers
-Valuables should be sent home with family if
possible or lock valuables in facility safe.

Medication reconciliation:

Very important

-Compare home meds with providers prescription

Discharge planning:

-Starts AT ADMISSION!!!

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:
What to do:
What NOT to do:
-Respond to feeling tone
-DO not ask ‘why’ questions; NEVER PICK WHY!!!
-Provide information
-Do not ask yes/no questions, except in the case of
possible self harm. -Focus on the client
-Do not focus on the nurse -Use silence (offer to stay with a patient)
-Do not explore -Use presence (stay and comfort a patient by just being
there to hold their hand).
-Do not say “Don’t Worry”
-ALWAYS GO WITH ANSWER THAT ALLOWS A PAITENT TO
EXPRESS THEIR FEELINGS.

-SELCET “TELL ME MORE or HOW does that make you feel”

ANSWERS.

Note
What patient do you see first?
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.

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 Delegation

5 Rights to Delegation

1- Right task DO NOT DELGATE WHAT YOU CAN EAT;

Repetitive noninvasive and not a lot of supervision (Evaluate, Asses, Teach)

2- Right circumstances What RN has to do

Do not assign a patient who is unstable Patient education

3- Right person Nursing judgement

Competent and within their scope of practice Assessment

4- Right direction and communication Blood transfusions

Specific details and timeline for completion and expectation for Unstable patients
reporting

findings back to you

5- Right supervision and evaluation What a PN can do (LPN)

May need to intervene Med admin
Provide feedback Enteral feedings

Urinary catheter insertion

Suctioning
What UAP can do: Trach care
Bathing Wound care
Dressing Reinforce patient teaching you (RN) have
already done
Ambulating
Can care for STABLE patients
Toileting

Feeding without swallowing precautions

Positioning

Vitals

Specimens

I+Os

Basic CPR
 Ethics

Nursing ethical principles

Autonomy: Ability of the client to make personal decisions, even when those decisions may not be in the clients own
best interest.

Beneficence: Agreement that the care given is in the best interest of the client; taking positive actions to help others.

Fidelity: Agreement to keep ones promise to the client about care that was offered.

Justice: Fair treatment in matters related to physical and psychosocial care and use of resources.

Nonmaleficence: Avoidance of harm or pain as much as possible when giving treatments.

Veracity: It is the basis of the trust relationship established between a patient and a health care provider.

Code of Ethics
Advocacy: Support of the cause of the client regarding health, safety, and personal rights

Responsibility: Willingness to respect obligations and follow through on promises

Accountability: Ability to answer for one’s own actions

Confidentiality: Protection of privacy without diminishing access to quality care.

Intentional torts
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).

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).

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)

Negligence: A nurse fails to implement safety measures for a client who has been identified as at risk for falls.

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
Responsibility of the provider

-Communicate purpose of procedure, and complete description of procedure in the patient’s primary language (use
medical interpreter if needed, NOT family member).

-Explain Risks vs. benefits

-Describe other options to treat the condition.

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 patient has further questions, call provider and have them come back and explain things further BEFORE they sign the
form

Patient Education
Assessment: identify patient needs, learning style (auditory, visual, kinesthetic), abilities, available resources.

Planning: develop mutually agreeable goals/outcomes.

Implementation: DO NOT use medical jargon. Make sure materials are at a sixth-grade level (or below).

Evaluation: ask patient to explain the teaching in their own words, or have the patient do a return demonstration for
psychomotor learning.

DO NOT perform patient teaching when client is: in pain or has anxiety, or is in any way mentally impaired.

Advance Directives
Living will: communicates patients wishes regarding medical treatment if patient becomes incapacitated.

Durable power of attorney (health care proxy): patient designates health care proxy to make medical decisions for them
if they become incapacitated.

Provider’s orders: prescription for DNR (do not resuscitate) or AND (allow natural death)

Mandatory Reporting for RNs:

-Suspicion of abuse (child, elderly, domestic violence)

-Communicable diseases to local/state health department (mandated by state).

Nursing Documentation
Objective data: what you see, hear, smell. Do not include opinions or interpretations of data.

Recording subjective data: document as direct quotes, or clearly identify information as a statement by patient.

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
When accident occurs (falls or med error)

-Used for quality improvement for facility (for hospital)

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

Telephone orders: have second RN listen in on call, repeat prescription back, make sure provider signs prescription
within 24 hours.

After provider says the order you FIRST want to read back the order to the provider, to ensure it is accurate.

Information security
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 patient doesn’t want to tell anyone they are at the hospital
 Safety

Injury prevention: Infants and toddlers

Avoid foods that can cause chocking: popcorn, raisins, peanuts, grapes, raw carrots, hotdogs, celery, peanut butter,
candy, tough meat.

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.

Keep plastic bags, houseplants, cleaning agents out of reach. Lock up medications.

Use rear facing car seat until 2 years old. Use car seats with 5-point harness, place in back seat.

Turn pot handles away from front of stove.

Close bathroom doors; keep toilet lids down.

Injury prevention: School age children

Use car booster seat while child is under 40lbs or under 4’0”. Keep child in backseat until 12 years old.

Use protective gear (ex: helmets, pads) for bicycling, sports.

Reduce water heating setting to less than 120 degrees F.

Keep guns locked up, bullets stored in separate location.

Enclose pools with locked fence, supervise children in pools/water.

Injury prevention: Adolescents

Educate teens on risks associated with smoking, drugs, alcohol, unprotected sex.

Warn against distracted or impaired driving. Reinforce need to wear seat belts.

Monitor teens for mental health issues (depression, anxiety).

Injury prevention: Older Adults

Remove trip hazards from home: scatter rugs, loose carpet.

Place electrical cords against walls (Behind furniture)

Install grab bars in bathroom/ shower, use nonskid mat in shower.

Ensure adequate lighting in home. Use colored tape on step edges.

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Oxygen safety
Oxygen equipment increases risk of combustion.

Place “no smoking” sign at front door of home.

Make sure electrical equipment is grounded, and in good shape. No extension cords.

Cotton bedding and clothes NO SYNTHETIC OR WOOL FABRICS

Keep flammable items away from oxygen equipment (includes nail polish).

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.

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.

Seizures
Implement seizure precautions

Padding siderails

Suction and oxygen equipment available at bedside

LOWER patient to floor or bed, turn patient to the SIDE.

Clear area for safety

Loosen restrictive clothing

DO NOT restrain patient, or put anything in the mouth (airway, tongue blade)

Note onset and duration of seizure

After Seizures

Take vital signs, perform neurological checks.

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Reorient patient

Identify possible trigger

Implement seizure precautions (Pad bed rails).

Restraints
Physical (vest, belt, mitten) or chemical (sedative or antipsychotic medication).

Before we apply it, Try alternatives FIRST:

-Reorientation -Supervision -Diversions

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

RACE PASS
R (Rescue): move patients to safer location. Horizontal P: Pull the pin
evacuation first, then lateral evacuation if needed.
A: Aim at the base of the fire
A (Alarm): Activate alarm system.
S: Squeeze the handle.
C (Contain): Close doors/windows, turn off oxygen sources.
S: Sweep from side to side.
E (Extinguish): Use fire extinguisher.

Horizontal then lateral evacuation

 Mobility / Immobility

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)

Bed Positioning - Procedures

Mastectomy
Position: Arm elevated on pillow. Turn only to unaffected side and back
Why? Promotes lymphatic fluid drainage from accumulating (decreases lymph edema).

Head Injury / Surgery

Position: Semi-Fowler’s (HOB usually about 30-45 degrees); Head midline, no head flexion. Do not position
client on side where there is a removed bone flap
Why? Reduces ICP by allowing venous drainage from head. Head flexion will increase ICP. Lying on side where
there is a bone flap will increase ICP.
Immediate Post-Op /Post Procedure (in clients who aren’t yet alert)
Position: Side-lying
Why? Allows secretions to drain from mouth and prevents aspiration.

COPD / Respiratory Distress

Position: High Fowler’s / Elevate HOB 90 degrees / Tripod or orthopneic position
Why? Increases maximum lung expansion, allowing for more ventilation and oxygenation.

Enema Administration
Position: Left-lateral or Sim’s position
Why? Allows solutions to flow by gravity into the natural direction of the colon.

Leg Amputation
Position: Elevate affected limb on pillow x 24 hours only Prone as tolerated, 20-30 mins at a time, at least
twice daily
Why? Reduces edema post-op, however, after 24 hours, DO NOT elevate stump because it can lead to
contractures. Prone position will stretch out hip and leg muscles to prevent hip flexion contraction.

Thyroidectomy
Position: Head midline / Semi-Fowler’s to Fowler’s (30 to 45 degrees) / Support neck while turning/moving
Why? Reduces swelling and edema in the neck area.

Shock
Position: Modified Trendelenburg
Why? This will aid in perfusion of upper body and head without causing pulmonary edema.

Thoracentesis
Position: Seated upright at side of bed, with an overbed table in front of client.
Why? This will exposure required area for procedure.

Liver biopsy
Position: During: On the client’s left side to exposure liver area (which is on the right).
After: On the client’s right side.
Why? Left side during the procedure will expose the area for biopsy site.
Right side after procedure will use gravity to help stop bleeding

Paracentesis
Position: Seated upright in chair or semi-Fowler’s in bed.
Why? To exposure area for puncture site, as this will assist in insertion of needle.

Nasogastric or Gastrostomy Tubes

Position: High Fowler’s for NG insertion.
HOB at least 30 degrees (semi-Fowler’s) for NG/GT feeding, irrigation.
Why? For insertion: It will aid in insertion by closing off the trachea and opening the esophagus.
For NG/GT feed and irrigation: To prevent aspiration of gastric contents.
Laminectomy
Position: Keep client straight. Logroll the client
Why? To avoid twisting of the spine, as this may cause complications.

CVA (Ischemic / Hemorrhagic)

Position: Ischemic – Usually flat
Hemorrhagic – HOB 30 degrees
Why? Ischemia – Head flat to perfuse blood to head.
Hemorrhagic – HOB 30 degrees to avoid ICP.

S/P Cardiac catherization

Position: Bedrest x 6 hours. Affected extremity straight. HOB no more than 30 degrees
Why? This position avoids pressure on the puncture site. Client can turn from side to side, but must avoid
pressure on insertion site.

Maternal Patient with Dizziness

Position: Left lateral
Why? As the uterus enlarges, pressure on the inferior vena cava increases. This pressure compromises venous
return and causes blood pressure to drop, which may lead to syncope and accompanying symptoms when the
client is supine.
Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and
blood pressure.

Patient movement and positioning

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.

Preventing foot drop:

- Place foot board perpendicular to mattress and against soles of patient’s feet.

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:

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.
Type of Assist Devices
Canes: Elbows flexed 150 - 300

*Crutches: Position 6 inches laterally to side and 6 inches in front of pt feet. Crutches PAD should be 1 ½ - 2 Inches or
2-3 fingers under axilla with elbows slightly flexed.

Walkers: Elbows flexed 300

Crutches Ascending Stairs:

1- Unaffected leg
2- Affected Leg and Crutches

Crutches Descending Stairs:

1- Affected Leg and Crutches First
2- Unaffected Leg

Crutches Rise and Sitting from chair:

1- Both crutches are hold with ONE hand
2- Patient transfer weight to crutches and unaffected leg
3- Grasp arm of chair and lower/rise from chair

You will always see questions about: CRUTCHES

 Infection
Systemic infection: symptoms include fever, chills, malaise, fatigue, increased respiratory rate, increased pulse
Local infection: symptoms include edema, pain, erythema, warmth in a particular area of the body.

Lab tests that indicate infection:

- WBCs > 10,000 [Normal 5000-10,000]

- Left shift (Immature WBCs)
- Erythrocyte sedimentation rate (ESR) >20
- C- Reactive Protein (CRP) >3
- Positive culture result (get culture before starting antibiotics!!)

Chain of infections:
Infectious Agent (ex: toxin, bacteria)
Reservoir (ex: human, soil)
Portal of exit (ex: blood, skin, mucous)
Mode of Transmission (ex: contact, droplet)
Portal of entry (ex: enter the body)
Susceptible Host (ex: patient)
Risk factors: compromised immunity, chronic/acute disease, poor personal and hand hygiene, crowded living
environment, IV drug use, unprotected sex, poor sanitation.

Virulence – ability to produce disease

Infection Stages:

Incubation Period: Contact to Initial S/S

Prodromal Stage: Most Infectious. Full S/S
Illness Stage: Specific S/S
Convalescence: Recovery period

Standard Precautions – ALWAYS to ALL Patients

Transmission Based Precautions

- Airborne [Measles, Chickenpox (varicella), Pulmonary TB]
Private Room, Neg Pressure, Sign, PPE, N-95 Mask, glove, gown, eye protect)
- Droplet [sepsis, pneumonia, pertussis, Diphtheria, epiglottitis, rubella, meningitis]
No eye protection, Private room or shared room if patient has same bacteria strain
- Contact [multidrug resistant organism, respiratory infection, skin infections, wounds]
No eye protection, Gloves, and gown.

Hand hygiene:
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.
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
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
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.
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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.

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.

PPE
Donning PPE Removing PPE
1. Gown 1. Gloves
2. Mask 2. Gown
3. Goggles 3. Goggles
4. Gloves 4. Mask
*In that order* *REMOVE most soiled to least soiled*
 Assessment and Vital Signs

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
Inspection: Use sight to assess for size, shape, color, symmetry.
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.
Percussion: tap body parts to assess for size, tenderness, and density of tissue.
Auscultation: listen for sounds; assess amplitude, intensity, frequency, quality. Examples: bowel, lunch, heart sounds.
Normal order: inspect, palpate, percuss, auscultate
Order for abdomen: inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).

Eye assessment
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.
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

Vision Assessment
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.
Rosenbaum eye chart: hold 14” away from patient. Determines if a patient has presbyopia (impaired near vision).
Ishihara: tests for color vision.

Ear Assessment
Alignment: top of auricles should be at the same height as inner canthus of eyes.
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.
Tympanic membrane: should appear pearly gray, intact.
Light reflux: visible at 5 o’clock (right ear) or 7 o’ clock (left ear), in a cone shape.
Cerumen: expected finding in ears
Hearing Assessment
Whisper test: whisper from 1-2 ft away while occluding one ear (don’t let patient see your mouth move).
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.
Weber: hold vibrating fork on top of patient’s head, to compare hearing on right vs. left side.

Abdominal assessment
Bowel sounds:
- Expected: high pitched clicking and gurgling.
- Unexpected: loud growling sounds, no bowel sounds after listening for 5 minutes.
Percussion: tympany sound is expected, dullness over the liver (RUQ --> Right Upper Quadrant).
Expected size of liver: 6-12 cm.
***Palpate tender areas LAST.

Lung Assessment
Percussion:
Expected: Resonance - NORMAL
Unexpected: dullness (tumor, pneumonia), hyperresonance (pneumothorax,emphysema).
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).

Vital Signs
Blood Pressure
Pulse pressure: Systolic BP minus Diastolic BP
BP cuff: cuff width should be 40% of arm circumference. Bladder should surround 80% of arm circumference.
Cuff too large: get falsely low reading
Cuff too small: get falsely high reading
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

Normal: SBP < 120 and DBP < 80
Prehypertension: SBP 120-139 or DBP 80-89
Stage 1 hypertension: SBP 140-159 or DBP 90-99
Stage 2 hypertension: SBP > 160 or DBP > 100
Hypotension: SBP < 90
Hypertension = BP readings elevated on 3 separate visits over several weeks.
Orthostatic hypotension
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.
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.
Nursing care: assist with ambulation, have patient sit at edge for 1-2 minutes before standing up. Change positions
slowly.

Respirations
Respiratory rate: normal = between 12-20 breaths/ min (35-40 for infants, 20-30 for school age children)
Assess: rate, depth (deep, shallow), rhythm (regular, irregular)
When chemoreceptors in body detect rising CO2 levels in blood, respiratory control center in brain increases respiratory
rate.
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.
Ventilation: exchange of O2 and CO2 in the lungs
Diffusion: exchange of O2 and CO2 between the alveoli and RBCs (in the bloodstream).
Perfusion: exchange of O2 and CO2 between the RBCs and the body tissues.
Increases RR: anxiety, smoking, illnesses, anemia, high altitude
Decreases RR: opioid/ sedative medications, age
SpO2: normal= 95-100% (Low 90s expected for COPD patients).

Pulses
Rate: normal range for adults is 60-100 beats/ minute (120-160 for infants)
Rhythm: regular/ irregular
Equality: right vs left side pulses
Strength:
0 (absent)
1+ (Diminished)
2+ (Normal)
3+ (Strong)
4+ (Bounding)

Radial and Apical pulse

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.
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.
Pulse deficit: difference between apical pulse rate and radial pulse rate.

Tachycardia and bradycardia

Tachycardia (heart rate > 100 beats/min): fever, exercise, medications, pain, hyperthyroidism, stress, hypovolemia
Bradycardia (heart rate < 60 beats/min): medications, athletes 9excellent fitness), hypothyroidism, hypothermia.
Temperature
Oral: 36-38 degrees C (average 37 degrees C)
Rectal: 0.5 degrees higher (36.5-38.5 degrees C)
Axillary: 0.5 degrees lower (35.5-37.5 degrees C)
Temporal: 0.5 degrees higher (36.5-38.5 degrees C)
Most Accurate: Tympanic and Rectal

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 Fahrenheit to C 0
F= (0C x 1.8) + 32
- To convert Centigrade to F 0C= (0F – 32) / 1.8
Tip: Since 0C is smaller than 0F, always multiply and add to get 0F
Since 0F is bigger, subtract and divide go the 0C (the smaller one)
Some students prefer the equation on the right, but I prefer the equation with 1.8

Taking temperatures
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).
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.
Temporal: slide probe across forehead to hairline, touch soft depression behind ear.

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 war

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 Medical Administration

Pharmacology - most simply defined as study of drug.

Fundamentals of Pharmacology
1. Pharmacokinetics
- study of drug’s changes as it enters and passes through the body.
a. absorption
b. distribution
c. biotransformation / Metabolism
d. excretion

2. Pharmacodynamics
- mechanism by which drugs produce changes in body tissue.
a. desired effect - intended action of drugs
b. adverse effect - harmful unintended reactions
c. side effects – consequence reactions
d. toxicity – the degree which something is poisonous
e. Idiosyncratic reaction – pt over react or underreact to meds, or has a react diff to normal

Safety and Efficacy

Nursing Principles:
1. Always verify the Six Rights:
a. the right medications
b. the right client
c. the right dosage
d. the right form, route and technique
e. the right time
f. the right documentation

2. Chart drug administration only after it has been given, never before.
3. Never leave the medication on cart or tray unattended.
4. Chart observed therapeutic and adverse effects accurately and fully.
5. Check history for allergies and potential drug interactions before administering a newly ordered drug.
6. Inform the prescribing physician of any observed adverse effects; if cannot be located, inform the nursing supervisor
7. Question drug orders that are unclear, that appear to contain errors, or that have potential to harm.
8. Take the following actions if an error occurs:
a. immediately notify the nursing supervisor, the prescribing physician, and the pharmacist.
b. assess the client’s condition and provide any necessary care.
9. For postpartum women, advice to take drugs after breastfeeding.
Administration of Drugs:

Routes and Nursing considerations:

1. Enteral – oral, sublingual, rectal, gastric tubes
- capsulated pill, sustained release and enteric coated should not be crushed.
2. Parenteral – IV, IM, SQ, ID, IT, IA, epidural.
- vastus lateralis (safest site for IM)
3. Topical – skin, inhalants, mucus membrane.

Eye medications:
- administer eyedrops first then ointment.
- use a separate bottle for each client.
- instruct the client to tilt the head backward, open eyes and look up.
- avoid contact of medication bottle to the eyeball.
- place prescribed dose in the lower conjunctival sac.
- instruct the client to press the inner canthus for 30-60 seconds.
- instruct the client to close the eye gently.

Ear drops
- in infant and children younger than 3 y.o, pull pinna downward and backward.
- in older children and adult, upward and backward.
- direct the solution on the wall of the ear canal, not directly on the ear drum.

Administering Medication Through an Enteral Tube

- Fowlers position (450)
- If continuous enteral feeding tube feeding, hold
- Check Gastric Residual Volume. Draw 10-30 ml of air into a syringe and connect to tube feeding, flush with air,
and pull back slowly. If GRV is more than 500 mL, HOLD feeding for 2h and hold meds and contact Dr
- Flush the tubing, before and after, and in between medications with 30mL of water

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.

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 asks
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
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.

NursingStoreRNbyANA
 Death, Loss and Grief

Death and dying issues:

Kubler Ross (1969) studied grief and death reactions, and outlined five stages of reactions,
such as: (use mnemonic: D.A B.D.A)
D= Denial and isolation
A= Anger
B= Bargaining
D= Depression
A= Acceptance

- Denial and Isolation

This is usually defined as refusal to accept fact of loss. “No, not me, not my child.” They tend to go from one hospital to
the other to disprove the initial diagnosis
- Anger
Feeling of emptiness, angry and questioning “why me?” Reality began to penetrate their consciousness
- Bargaining
Changes from “not me” to “yes me, but why now?” I have an unfinished project or business.
The patient pleads for more time to live. My son has just entered college, etc. It helps to cope, understand that
bargaining is very helpful to patient. Help them to set their goals
- Depression
Pt will turn self-inward. They will simply say yes, I am ready to go or ready to give up those she loves and has. Eg.
children or money. This is silent grief and mourning. Be available to the patient in major depressive mood. Reassure
them that you can understand their feelings.
- Acceptance
Patient is ready and has accepted death or loss. The patient will say I have done all I can.
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
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:

- Birth to 1yr death has no meaning to child.
- 1-4 yrs: regards death as temporary separation
- 5yrs and above: regards death as permanent or irreversible.
 Fluids, Electrolytes and Acid-Base Balance

Fluids (Water)

Overview

• Carries: nutrients to body cells, waste products from

cells
• Provides medium within cells for chemical reactions
(metabolism occur); lubricates tissues, maintenance of
acidbase balance, heat regulation
(Metabolism is basically chemical reaction. Water is needed to
do chemical reactions)
Largest component of body (50 to 80% of total body weight)
Newborn: 70%-80%
Age 12/adult: 50%-60%
Older adult: 45%-50%
• More than half of infant’s body fluid is found outside cells (extracellular fluid)
• Extracellular fluid is lost from the body more rapidly than intracellular fluid (fluid inside cells). (water if found
outside the cell evaporates more rapidly)
• A loss of 10% body fluid is serious, 20% is fatal

Fluid Components

Overview

Extracellular: contains fluid outside of

Interstitial fluid: found between cells (lymph, cerebrospinal fluid, gastrointestinal secretions)
Intravascular fluid: plasma within vessels (serum, protein)
Intracellular and extracellular separated by semipermeable (cell controls how much water enters and
exits) membrane.

Intake and Output

Overview

• As water moves through body, fluid is lost and must be replaced

• Homeostasis: process of keeping body fluids in balance
• Average adult fluid intake: 2200 to 2700 mL/day; oral intake should be 1100 to 1400 mL/day; solid foods
contribute to approximately 800 to 1000 mL/ day. Fluid produced from cellular metabolism provides 300
mL/day.
(you get a lot of fluid from your diet)
• Thirst mechanism: hypothalamus called osmoreceptors which measure concentration of the blood
• Sensible vs insensible fluid loss
 (Measurable output vs unmeasurable output)

(measurable output: would be urine, bowel movement / unmeasurable: would be sweat, tears ) Kidneys regulate

fluid balance (kidneys filter 125 mL/minute or 180L daily); glomerular filtration rate

• Weigh patient the same way with same conditions daily !!!!! (Important)(1 liter of fluid equals 2.2 pounds or 1
Kg)
• Specific gravity 1.003-1.030
• Kidneys must secrete a minimum of 30ml/min to filter blood supply adequately
(its easier to lose fluid over solid mass; Oliguria is urinating less than 30 mL/hour)

Movement of Fluid and electrolytes

Overview

• Body fluids in constant motion; extracellular, intracellular

• Substances (ELECTROLYTES AND NUTRIENTS) cross cell
membranes by way of passive or active transport
• Active transport requires energy (ATP: adenosine triphosphate);
passive transport do not.

(ATP: is like paying a toll when you are using the road)

Passive transport

Overview

• Diffusion: natural tendency of a substance to move from an area of higher concentration (The amount of
particles in water) to a lower concentration. Diffusion like areas of low concentration.
• Facilitated diffusion: process by which material combines with carriers to cross the cell membrane

Overview

• Osmosis: movement of water across a

semipermeable membrane from an area
of lower concentration to high
concentration. (MOVEMENT OF
WATER; “TOO DILUTE”)
• Isotonic: when concentrations of body
fluids and solution is the same; expands
body’s fluid volume without causing a shift from one compartment to another. Fluid make up is the Same
(Osmolality is the same) fluid outside the cell has the same concentration of particles and electrolytes and inside
the cell.
• Hypertonic: solutions that have higher concentrations of electrolytes than body fluids; pulls fluid from cells.
Hyper= Excessive, high concentration in ECF (given when cells get enlarged)
• Hypotonic: fewer electrolytes than body fluids; moves fluid into the cells causing them to enlarge. Hypo= “low”,
lower concentration
Overview

on a vessel wall

Overview

• The process of moving molecules against pressure through a membrane with the use of carriers and energy

Electrolytes

• A substance that develops an electrical charge when it dissolves in water; electrically charged particles are ions:
positive ions are cations. Negative ions are anions. ***Think; cats (cations) are positive, and onions (anions) are
negative***
• Cations and anions maintain homeostasis and are balanced in maintain electrical neutrality
• Milliequivalents (mEq) measures chemical activity of an ion
 Sodium (Extracellular)

Most abundant electrolyte in body; regulates fluid volume, contractility of muscle (especially heart),
maintains nerve conduction, acid base balance; diet is a major source. Normal range: 135 to 145 mEq/L
Sodium is found outside the cell & is responsible for fluid volume, muscle contractions, nerve impulses, and for
ph.
Repolarization

Hyponatremia

Low sodium; potassium shifts out of cell (weakness, anorexia, muscle cramps, Decreased LOC, fatigue,
headache, edema, seizures, dizziness, tachycardia)

Hypernatremia

High sodium; dehydration, lethargy, agitation, hypertension, seizures; potassium imbalances

Potassium (Intracellular)

Regulates water and electrolyte content within cell; promotes transmission of nerve impulses and skeletal
muscle function; regulates hydrogen ions and thus acid-base balance; too little or too much potassium affects
heart; normal: 3.5 to 5.0 mEq/L
Potassium is found in the cell and is Responsible for nerve impulses, fluid balance, muscle contractions, and pH
Depolarization

Hypokalemia

Decrease in body’s potassium level; major cause due to renal excretion and GI losses; effects skeletal and cardiac
function; life-threatening; causes (bilateral muscle weakness, abdominal distension, decreased bowel sounds,
dysrhythmias, Inverted T wave

Hyperkalemia

Caused often by renal disease in which potassium is not excreted adequately by kidney; may be due to excessive
intake of potassium, certain drugs, chemotherapy; causes (quadricep weakness, abdominal cramps, diarrhea,
irritability, dysrhythmias, peaked T wave)

Chloride (Extracellular)

Usually bound to another ion (sodium or potassium); necessary for gastric secretions and acid-base balance;
normal: 96 to 106 mEq/L (Separated by 10)
Chloride is found outside of the cell and Responsible for Gastric Secretions and pH

Hypochloremia

Low chloride; often due to vomiting, diarrhea, gastric suctioning, and infection. Causes; hypertension, muscle
spasms, shallow respirations, tetany.
Hyperchloremia

High chloride: when bicarbonate levels decrease and metabolic acidosis occurs; chloride increases to
compensate. Cause; tachypnea, muscle weakness, lethargy.

Calcium (Bones and Teeth)

Found in bones and teeth and is released when calcium levels fall; necessary for blood clotting; depresses
neuromuscular irritability, promotes normal nerve impulses; regulates muscle contraction and relaxation; holds
cells together by establishing thickness and strength in cell membranes; enzymes activator for chemical
reactions; normal: 4.5 to 5.6 mEq/dL
Can be found in the cell and outside the cell and is responsible for building and repairing bones/teeth, nerve
impulses, muscle contractions, blood clotting. Inverted relationship with phosphorus

Hypocalcemia

Low calcium; neuromuscular irritation and increased excitability, hyperactive reflexes and seizures (tetany),
cramps, numbness/tingling.

Hypercalcemia

High calcium; cause; neuromuscular activity depression, renal calculi (Kidney stones), anorexia, fatigue,
hypoactive reflexes, lethargy, decreased LOC.

The amount of phosphate in the blood affects the level of calcium

in the blood. Calcium and phosphate in the body react in opposite
ways: as blood calcium levels rise, phosphate levels fall. A
hormone called parathyroid hormone (PTH) regulates the levels of
calcium and phosphorus in your blood. When the phosphorus
level is measured, a vitamin D level, and sometimes a PTH level, is
measured at the same time. Vitamin D is needed for your body to
take in phosphate.

Phosphorus (Bones and teeth)

Found in bones and teeth with calcium; inverse relationship with calcium; essential component of phospholipids
(structural components of cell membranes); acid-base balance; promotes effectiveness of many B vitamins;
normal nerve and muscle activity, needed in carbohydrate metabolism; normal: 2.4 to
4.1 mEq/dL
Phosphorus can be found inside the cell and outside the cell and is responsible for building and repairing
bones/teeth, muscle contractions, nerve impulses, pH, vitamin B
Hypophosphatemia

Muscle weakness (especially respiratory muscles) with bone and joint pain, disorientation and confusion,
lethargy, seizures, memory loss, hypertension.

Hyperphosphatemia

Commonly due to renal insufficiency; tetany (twitching), numbness, tingling, muscle spasms, tachycardia,
anorexia, vomiting, hyperactive reflexes.

Magnesium (Intracellular)

Activates many enzymes; regulation of calcium, phosphate, potassium; enhances effectiveness of treatment for
asthma, depression, diabetes, hypertension, cardiac arrhythmias, migraines, fibromyalgia, osteoporosis, restless
leg syndrome; normal: 1.5 to 2.5 mEq/L
Magnesium is found in the cell and it regulates other electrolytes; and imbalance will manifest in nerve and
muscle.

Hypomagnesemia

Neuromuscular irritability, tremors, cramping, numbness, tingling, disorientation, confusion, tetany, seizures,
positive Chvostek’s sign, hyperactive reflexes, dysphagia, hypertension, tachycardia

Hypermagnesemia

Severely restricts nerve and muscle activity and causes respiratory depression, hypotension, cardiac arrest,
hypotension, hyporeflexia, vomiting, altered mental status, confusion, agitation, vomiting

Bicarbonate (Extracellular)

• Alkaline electrolyte; regulates acid-base balance; normal: 22 to 24 mEq/L

NursingStoreRNbyANA
 Acid-Base Balanced
Overview

• Acid-base balance: homeostasis (Balance) of the hydrogen ion concentration in the body fluids; hydrogen is
acidic; inverse relationship exists between hydrogen ion concentration and pH; when hydrogen decreases, pH
increases; normal: 7.35 to 7.45
• When hydrogen decreases pH increases; when hydrogen increases pH decreases.

Blood Buffers

• Includes bicarbonate / carbonic acid buffering; decreases strength of potentially damaging acids and bases
(strongest mechanism)

Respiratory System

• By speeding up or slowing down respirations, the lungs can increase or decreases amount of carbon dioxide.

Kidneys

• Regulates pH by excreting acids and bases as needed; also forms bicarbonate (weakest mechanism)

Types of Acid-Base Imbalance

Overview

• Four types of acid-base imbalances: respiratory acidosis, respiratory alkalosis, metabolic acidosis, and
metabolic alkalosis

Respiratory Acidosis

Any condition that impairs normal ventilation and prevents the respiratory system from eliminating the appropriate
amount of carbon dioxide causes respiratory acidosis; body attempts to eliminate excess carbon dioxide by increasing
respirations; nervous system depressed, heart rate increases, palpitations and dizziness.

Respiratory Alkalosis

• Frequently caused by respiratory problems; kidneys

attempt to compensate by saving hydrogen and
excreting bicarbonate ions; lightheadedness,
numbness and tingling sensation in extremities,
tinnitus, blurred vision, increased heart rate and
irritability; confusion, seizure activity and loss of
consciousness

Metabolic Acidosis

• When pH falls; compensatory mechanisms: kidneys, lungs, etc.

Metabolic Alkalosis

When significant amount of acid is lost from body or bicarbonate level increases; hypoventilation, renal compensation;
depressed central nervous system, headaches, irritability, lethargy, changes in level of consciousness, confusion;
changes in heart rate; slow, shallow respirations, nausea and vomiting, numbness in the extremities may be present.

Steps to ABG Analysis:

1- Look at the pH (7.35 - 7.45)

- If the pH is HIGH, this is ALKALOSIS

- If the pH is LOW, this is ACIDOSIS

2- Look at the PaC02 (35 - 45) - PaC02 – Respiratory

- If PaC02 is HIGH, this is ACIDOSIS

- If PaC02 is LOW, this is ALKALOSIS

3- Look at the HC03 (22 - 26) - HCO3 – Metabolic

- If HC03 is HIGH, this is ALKALOSIS

- If HC03 is LOW, this is ACIDOSIS

Interpret

Step 1: Analyze the pH. It will tell you ACIDOSIS or ALKALOSIS

Step 2: Analyze the PaC02 and the HC03

- Is PaC02 below 35? It is Alkalotic. Above 45 it is Acidic

- Is HC03 below 22? It is Acidic. Above 26 it is Alkalotic

Step 3: Match the PaC02 or the HC03 with the pH

For example, if the pH is acidotic, and the PaC02, then the Acid-Base disturbance is being caused by the respiratory
system. Therefore, we call it Respiratory Acidosis

Step 4: Does the PaC02 or the HC03 go the opposite direction of the pH?

If so, there is compensation by the systems. For example, if the pH is acidotic, and the PaC02 is acidotic, and the HC03 is
alkalotic.

If they don’t go the opposite direction, It is UNCOMPENSATED

Step 5: Is the pH in normal range? Fully Compensated / Partially Compensated / Uncompensated

If there is Compensation, and the pH is in normal range (7.35-7.45), then it is Fully Compensated

If there is Compensation, and the pH is out of range, then it is Partially Compensated

Step 6: Are the pO2 and the O2 saturation normal?

If they are below normal, there is evidence of Hypoxemia
1- Practice Question
A 72 yr. old with pneumonia.

pH - 7.31 (Acidic)

PaC02 – 60 (Acidic)

HC03 - 34 (Alkalotic)

pO2 – 50 (LOW)

#1 – pH is below 35, so It is Acidosis

#2 – Who is doing the same as the pH (Acidic)? PaC02

It is Respiratory
#3 – Does the HCO3 go in opposite direction as the pH? YES – Alkalotic
So, there is Compensation
#4 – Is the pH in normal range? NO
So, it is Partially Compensated
#5 – Is the pO2 in normal range? NO
The patient has Hypoxemia

The full Diagnosis is:

Partially Compensated Respiratory Acidosis with Hypoxemia

2- Practice Question
A 20 years old, acute renal failure

pH - 7.18 (Acidic)

PaC02 – 44 (Normal)

HC03 - 16 (Acidotic)

pO2 – 92 (Normal)

#1 – pH is below 35, so It is Acidosis

#2 – Who is doing the same as the pH (Acidic)? HC03

It is Metabolic
#3 – Does the PaC02 go in opposite direction as the pH? NO
So, there is NO Compensation
#4 – Is the pH in normal range? NO
So, it is Uncompensated
#5 – Is the pO2 in normal range? YES
The patient doesn’t have Hypoxemia

The full Diagnosis is:

Uncompensated Metabolic Acidosis.

NursingStoreRNbyANA
 Practice
1. pH: 7.11 CO2: 51 HCO3: 27

2. pH: 7.39 CO2: 54 HCO3: 38

3. pH: 7.14 CO2: 51 HCO3: 28

4. pH: 7.39 CO2: 53 HCO3: 27

5. pH: 7.45 CO2: 40 HCO3: 22

6. pH: 7.50 CO2: 44 HCO3: 31

7. pH: 7.35 CO2: 20 HCO3: 17

8. pH: 7.12 CO2: 44 HCO3: 14

9. pH: 7.28 CO2: 54 HCO3: 26

10. pH: 7.30 CO2: 35 HCO3: 17

11. pH: 7.19, CO2: 39, HCO3: 18

12. pH: 7.7, CO2: 52, HCO3: 35

13. pH: 7.42, CO2: 54, HCO3: 28

14. pH: 7.84, CO2: 49, HCO3: 30

15. pH: 7.75, CO2: 43, HCO3: 37

16. pH: 7.87, CO2: 26, HCO3: 24

17. pH: 7.37, CO2: 20, HCO3: 15

18. pH: 7.14, CO2: 31, HCO3: 20

19. pH: 7.58, CO2: 50, HCO3: 36

20. pH: 7.43, CO2: 32, HCO3: 12

 Answer

1. pH: 7.11, CO2: 51, HCO3: 27 - Partially Compensated Respiratory Acidosis

2. pH: 7.39, CO2: 54, HCO3: 38 - Fully Compensated Respiratory Acidosis

3. pH: 7.14, CO2: 51, HCO3: 28 - Partially Compensated Respiratory Acidosis

4. pH: 7.39, CO2: 53, HCO3: 27 - Fully Compensated Respiratory Acidosis

5. pH: 7.45, CO2: 40, HCO3: 22 - Normal

6. pH: 7.5, CO2: 44, HCO3: 31 - Uncompensated Metabolic Alkalosis

7. pH: 7.35, CO2: 20, HCO3: 17 - Fully Compensated Metabolic Acidosis

8. pH: 7.12, CO2: 44, HCO3: 14 - Uncompensated Metabolic Acidosis

9. pH: 7.28, CO2: 54, HCO3: 26 - Uncompensated Respiratory Acidosis

10. pH: 7.3, CO2: 35, HCO3: 17 - Uncompensated Metabolic Acidosis

11. pH: 7.19, CO2: 39, HCO3: 18 - Uncompensated Metabolic Acidosis

12. pH: 7.7, CO2: 52, HCO3: 35 - Partially Compensated Metabolic Alkalosis

13. pH: 7.42, CO2: 54, HCO3: 28 - Fully Compensated Metabolic Alkalosis

14. pH: 7.84, CO2: 49, HCO3: 30 - Partially Compensated Metabolic Alkalosis

15. pH: 7.75, CO2: 43, HCO3: 37 - Uncompensated Metabolic Alkalosis

16. pH: 7.87, CO2: 26, HCO3: 24 - Uncompensated Respiratory Alkalosis

17. pH: 7.37, CO2: 20, HCO3: 15 - Fully Compensated Metabolic Acidosis

18. pH: 7.14, CO2: 31, HCO3: 20 - Partially Compensated Metabolic Acidosis

19. pH: 7.58, CO2: 50, HCO3: 36 - Partially Compensated Metabolic Alkalosis

20. pH: 7.43, CO2: 32, HCO3: 12 - Fully Compensated Respiratory Alkalosis

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

NUTRITION Notes
• 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 coumadinm Examples 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.
• 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.
• 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!!
 Urinary Elimination
Medications Affecting Color of Urine
- Anticoagulants: red urine
- Diuretics: pale yellow urine
- Pyridium: orange to orange-red urine
- The antidepressant amitriptyline or B-complex vitamins: green or blue-green urine
- Levodopa: brown or black urine

Urgency
An immediate and strong desire to void that is not easily deferred

Dysuria
Pain or discomfort associated with voiding

Frequency
Voiding more than 8 times during waking hours and/or at decrease intervals such as less than every 2 hours

Hesitancy
Delay in the start of urinary stream when voiding

Polyuria
Voiding excessive amounts of urine

Oliguria
Diminished urinary output in relation to fluid intake

Nocturia
Awaken from sleep because of the urge to void

Dribbling
Leakage of small amounts of urine despite voluntary control of micturition

Hematuria
Presence of blood in the urine
*Gross hematuria (blood is easily seen in urine)
*Microscopic hematuria (blood not visualized but measured on urinalysis)

Retention
Acute retention: suddenly unable to void when bladder is adequately full or over full
Chronic retention: bladder does not empty completely during voting, and urine is retained in the bladder

Common causes urgency

Full bladder, urinary tract infection, inflammation or irritation of the bladder, and overactive bladder

Common causes dysuria

Urinary tract infection, inflammation of the prostate, urethritis, trauma to the lower urinary tract, urinary tract tumors
 Skin Integrity

Serous Exudate
Clean wound. Watery in consistency & contains very little cellular matter. Consist of serum (straw colored fluid that
separates out of blood when clot is formed)

Sanguineous
Deep wounds or wounds highly vascular areas. Bloody drainage. Damage to blood capillaries. Fresh bleeding produces
bright red drainage, whereas older, dried blood is darker, red blown color

Serosanguineous Drainage
New wounds. Combination of bloody & serous drainage

Purulent drainage
Thick, often maldodorous, drainage that is seen in infected wounds. Containing pus, a protein-rich fluid filled w/WBCS,
bacteria, & cellular debris.

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

Primary skin lesions are present at the onset of a disease. In contrast, secondary skin lesions result from changes over
time caused by disease progression, manipulation (scratching, picking, rubbing), or treatment.

NursingStoreRNbyANA
Skin Lesions
 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
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

• 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.

• GONORRHEA
o An infection caused by Neisseria gonorrhea, which causes inflammation of the mucous 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.