Concept I

09/05/2023 First day of class

weeks 1 Week 2 Week 3

Ch. 1 Nursing Today Ch. 9 Cultural Awareness Ch. 26 Informatics and Documentation
Ch. 2 Health Care Delivery System Ch. 16 History Taking Ch. 27 Safety and Quality Care
Ch. 6 ATI Review Book Ch. 22: Ethical Issues Ch. 28 Infection Control
Ch. 24 Communication Ch.23: Legal Ch. 29: Vital Signs
Ch. 40: Hygiene -

*Additionally, please look at ATI Review Book on topics. ATI Review Book: Ch. 1-6, 11-13, 27, 32, 35

H.W. Due: Lab: h.w

ATI orientation module nurses touch
Test taking strategies Therapeutic communication
Culture:
* Health
* Wellness
* Healing
(2 Pages, reference )

A.T.I. Note: therapeutic communication

Non - therapeutic communication
*Healing
Close-ended question
*Health promotion
*Illness prevention

Open-ended question is used in therapeutic communication

 Chapters I
Health care delivery system

Medicaid: is for client who have low incomes

Medicare: for clients 65 years or older or those who have permanent disabilities

Levels of Health Care

Preventive: (educating the pt ) example. Programs to promote immunization, stress management, occupational health and seat belt
Primary: (health promotion) office or clinic visit, community health centers and school appt. Or work-centered screening (vision, hearing ,obesity
Secondary: (diagnosis and treatment of acute illness ) inpatient and emergency, urgent care, diagnostic centers
Tertiary: acute care intensive care, oncology care , and burn center
Restorative care: intermediate follow-up for restoring and promoting self- care: home health care, rehab centers, and skill nursing facilities
Continuing: long term or chronic: end of life, palliative care , hospice, adult day care, assistive living, and in-home-hospice.

Chapter 2
Nursing personnel
Register nurse R.N Practical nurse (p.n.) Assistive personnel
Roles and responsibilities * Works under the supervision of the
* Assessment *Work under the supervision of an R.N.
R.N. And (p.n. )
* Nursing diagnosis *Assist with plan of care
*Grooming, bathing, transferring,
* goals toileting, positioning
* intervention * measuring and recording vital signs
* conduct ongoing P.t. Eva.
* share appropriate info amount other
team members

Prof. Notes
Delegation:
R.N L.p.N. A.P. / c.n.a
Admission Reinforce Stable
Assessment/ comprehensive Teaching V..S
Blood transfusion Admin meds (not I. V in some states. B.g
Education Focus assessment Bathing
N.G. Tube Scheduling Bed making
Foley Suction Foleyeare
Wound care Check ng tube potency Feeding
Enteral feeding Wound care I&O
Unstable pts. Enteral feeding
Suction Tracheostomy care
Nursing today Chapter I
Insert f.olley
ATI Chapter 6
 Five rights
Right person Holistic. Stages of Nursing
Right task. Caring as a whole. Novice: New nurse
Right circumstance *Psycoly Advance beginner: graduated with info
Right direction communication * Mentally but no develop critical thinking
Right evaluation I supervision, feedback. * spiritual Competent. 2 to 3 years
Proficient.
Expert.
Professional responsibility Florence nightingale
Autonomy And accountability Promoted sanitation in battlefield hospital Nurse practice acts.
*Overseen by state of board of Nursing
Trends in Nursing Check P.t. Every 2 hours. * regulate, scope of N.P.
* evidence base practice: If pt is risk Fall band (yellow). * protect public health.
Q.S.E.N. P.t centered care

Levels of Health care Hospice V.S. Palliative

* preventive: reduced and control for disease. * 6 months or less * Comfort
* primary: family planning, Prenatal done * not cure * Pain management
*Secondary: pt diagnostic and treatment. * severe dementia Alzheimer's. * A Oxygen therapy
*Tertiary. Acute care high specialized care * cancer p.t. ( metastatic) *
*Restorative: follow-up care. *End stage liver failure ( hepatic)
Continuing Health care: long-term * end stage renal disease
Respite (care must, know) 15 mil/min glumerodus
* congested heart failure.
Eyection fracture less than 20%

Palliative care can be given together with hospice

 Chapter 3
Ethical responsibilities
Basic Principles of Ethics
Advocacy: support and defense p.t health, wellness, safety, wishes, and personal rights including privacy
Responsibility: respects obligation and follow through on promises
Accountability: ability to answer for one's own action
Confidentiality: protection of privacy

Ethical principles for client care

* Autonomy: the right to make one's personal decision
* beneficence: action that promotes good for others without any self interest.
* fidelity: fulfillment of promises
* justice: fairness in care delivery
* nonmaleficiency: a commitment to do no harm direct causing effect.
* veracity: a commitment to tell the truth.

Understand ethical dilemmas

Ethical dilemmas: are problems that involves more than one's choice

Moral distress: the nurse in in a difficult situation where the action taken are different from what the nurse feels is ethically correct.

Prof: notes

Ethical dilemma
•When two opposing courses of action can both
be justified by ethical principles

Moral distress
•Instead of competing options for action, the
nurse feels the need to take a specific action
while believing that action to be wrong.
 H.I.P.P.A.
Only share client info with the team member directly
Ethics key terms
involve with care!
* need to know basis only! Autonomy: "always in control" Examples
* N.O. O.V.E.R. Sharing info with no-essential Ex: respecting a client right to refuse treatment
personnel (secretaries ) Advocacy: "advocate"
Protect r health, right, and safety
Example: a charge nurse from another unit
Ex. Reporting critical changes in the client's condition
ask about info about a p.t stating is her
Beneficence: “ benefit”
neighbor
Doing & promoting good
Ex. Calling the family of a pt. To tell them we are caring for them
Never discuss infor in hallway or elevator
Fidelity: "faithful"
* No take info pt.at home
Husband request lab results To stay loyal and follow through
Taking home p.t report sheet. must be shredded at the end Ex p.t. Reports 8-10 pain. The nurse states she will return with
of shift. pain meds & follows through with the act.
Justice: to treat fairly & equally
Provide came equally regarding, race gender, religion & culture

Tort law Normaleficence: no-mal-intent. To avoid causing harm.

Ex: double checking drug dosage with another nurse
Unintentional tort: accident that cause harm unintended Veracity "very honest"
Ex: med error with no adverse effect but still reporting it.
* Negligence: The failure to provide adequate care
Ex. A nurse that did not wash her hands To inserting
a Foley catheter Intentional torts :: willful act that violates a pt. Rights

Malpractice: illegal, improper or negligent action A & B:

The r.n failed to check the dosage on a med. Vial Assault: to threat of harm any threat made toward a client.
which harms the p.t. Ex. I will restrain you to the bed if you keep getting up.
Abandonment: desertion of a pt. By anyone who Threatening to place a N.G. Tube in a pt. Who refuses to eat.
has assumed the responsibility of Of care Battery: beating the p.t.: The act of harm
Ex:always give report. Do not leave without given the Physical act that cause harm or unconsenting content that causes harm.
report. Ex. Performing a procedure without consent
Given a med that the p.t refuse
False imprisonment: using physical restrains, seclusion or chemical
restraint to keep someone against their will.
Ex: using restraint on a competent p.t to prevent their leaving health care
facility
Invasion privacy Violating confidentiality rights
Defamation of character:
Making rude, insulting remark that harm the pt. Reputation
Libel: written: memory trick: "library"
Slander: spoken
 Chapter 4: Legal responsibilities
Types of torts
Unintentional:
Negligence : A nurse fails to implement safety measures for a client at risk for falls.
PRACTICE (PROFESSIONAL NEGLIGENCE): A nurse administers a large dose medication due to a calculation error. The client has a
cardiac arrest and dies.
Quasi-intentional torts
BreaCH OF CONFIDENTIALITY: A nurse releases a client's al diagnosis to a member of the press.
DEFAMATION OF CHARACTER: A nurse tells a coworker that elieve the client has been unfaithful to their partner.
Malpractice also called professional negligence

Intentional tort.
Assault: Battery FALSE IMPRISONMENT
The conduct of one person makes Intentional and wrongful physical A person is confined or restrained against
another person contact with a person that their will.
Fearful and apprehensive involves an injury or offensive A nurse uses restraints on a competent
contact. client to prevent their leaving the health care
facility.

Informed consent
Competent adult must sign and must be capable of understanding the information
If p.t is unable to understand due to a barrier language or hearing impairment a trained medical interpreter must intervene (no family)

* Individuals who can grant consent for another person:

Parent of a minor
* legal guardian
* court specified representative
Emancipated minor: married or are independent can consent for themself.

Responsibilities for informed consent

Provider Nurse
Witnesses informed consent.
• The purpose of the procedure. • Ensure that the provider gave the client the necessary
• A complete description of the procedure. information.
• A description of the professionals who will perform and participate • Ensure that the client understood the information and is
in the procedure. competent to give informed consent.
• A description of the potential harm, pain, or discomfort that might • Have the client sign the informed consent document.
occur. • Notify the provider if the client has more questions or appears
• Options for other treatments. not to understand any of the information. The provider is then
• The option to refuse treatment and the consequences of doing so. responsible for giving clarification.
• Document questions the client has, notification of the provider,
reinforcement of teaching, and use of an interpreter.
 Informed consent
Rules Informed Consent
Who can give informed consent? Language: non-english speakers can not consent without a medical
•State Laws determine who can give consent interpreter to translate
• Consent must be given by a competent adult:
• Parent or guardian of a minor
Informed Consent: Roles & Goals
•Legal guardian/court-specified representative
Provider (surgeon) NOT the nurse!
• Healthcare surrogate (Power of Attorney/Proxy)
• #1 responsibility -> obtain informed consent
• Spouse or closest available relative (state laws)
•Explains the procedure: (benefits, risks & alternatives to the procedure)
• Emancipated minors can give their own consent
Answer all the client questions! NOT the nurse!
N.O.T. Competent to provide consent Explains the right to refuse surgery
* unconscious • Client indicates understanding of the info & gives voluntary consent
* mental health: bipolar, schizophrenia
* dementia If an issue arises in surgery needing additional surgery:
* Delirium Call the client's medical power of attorney, legal guardian or next of kin to

Minor less than 18 yrs. Require parent provide consent for additional procedures

consent unless pregnant married, substance

abuse, or minors who are parents Nurse
1. Witness the consent (NOT responsible for obtaining informed consent)
2. Document in the medical record: date & time the signature was obtained
3. Verify the client is competent & voluntarily signing
Advance directive /living will
4. Advocate: Assess client & confirm they received & understands the info
1. Legal documents that outline desired medical care 5. Client Questions?
if the client becomes unable to verbalize their wishes. • Ordinary questions: diet, exercise, breathing etc. after surgery
Example: Client Glasgow Coma Scale (GCS) • Contact the HCP if the client does not have a correct understanding about the
score less than 7 or client with a brain bleed procedure itself!
(intracerebral hemorrhage) with aphasia 6. AVOID
2. Documentation placement: • NO educating about the procedure if there is a misunderstanding
a. Client's medical records NO explaining the right to refuse surgery
b. Copies should be given to family, friends & everyone 7. Client changes their mind?
listed as health care proxies! Notify the provider 1st!
3. NOT needed to be notarized - can be completed DO NOT try to talk the client into a surgery
in the healthcare setting if there are 2 witnesses
• NOT the nurses or HCPs DIRECTLY Involved
In the care of the client Living will:
• NOT Individuals named as health care proxies
a signed document that outlines wishes and desired • Chemical code: medications only (no
medical care if the client becomes incapacitated or CPR, electric shocks or respirations)
unable to communicate • DNR: Do Not Resuscitate

More examples • Level of interventions

• Life-sustaining measures (ex. Ventilator, tube
(No CPR, No bag-valve-mask or
resuscitative actions)
feeding) • AND (Allow Natural Death)
• Code status • DNI (Do Not Intubate)
• Full Code: Full resuscitative measures
 Prof: notes

Must learn 4"d" Negligence Reasonable ) prudent

Duty Vs
Dereliction" breach how duty" Malpractice Professional negligence
Direct "cause effect"
Damages.

Confidentiality do not give information without p.t consent Informed consent Study page 17
Implied consent: what p.t. Wants or not not need a
Quasi-intentional torts sign form
* breach of confidentiality: the nurse releases a client medical in-diagnosis Pt has the right to refuse
* defamation of Character: break someone reputation
Can be slander or libel. Which means spoken and libel written Advance directives
Is to communicate a client wishes regarding end-of life care
AMA P.t wants to leave the hospital refusing treatment
Types of advance directives
Agains Medical advice
Living Will. Page 18
Durable power of attorney for health care
Provider's order

Sentinel event: A vent should never occur example: leave gauges inside p.t.
Futile care

Chief Concern / complaint

Open-ended questions The reason why they are seeking care
Closed-ended questions Do not confuse the patient doesn't have a diagnoses
Do NOT use lead-questions Example: fatigue, chest pain, abdominal pain

History of present illness

P: provoquin Chronology of events How often?
•Health state before present problem What are the meds
Q: quality of pain
•First symptoms * question r/t present illness
•Exposure to infection or toxic What do you think is causing
R:Region
agents
•Typical attack
S: severity
•Illness impact on lifestyle
 Therapeutic communication Chapter 32

Levels of basic communication EFFECTIVE SKILLS AND TECHNIQUES

Intrapersonal: "self talk" Silence: This allows time for meaningful reflection.
Interpersonal: between 2 people. Presenting reality: This helps the client distinguish what is real
Public: large group of people. from what is not and to dispel delusions, hallucinations, and faulty
Small groups: within a group often working forwards same beliefs.
goals. Active listening: This helps the nurse hear, observe, and
understand what the client communicates and provide feedback.
Asking questions: This is a way to seek additional information.

Nonverbal communication Open-ended questions: This facilitates spontaneous responses

and interactive discussion. It encourages the client to explore feelings
Appearance, posture, gait.
and thoughts and avoids yes or no answers.
Facial expressions s eye contact, gestures
Sounds
Clarifying techniques: This helps the nurse determine whether the
Territorially personal space.
message the client received was accurate:
• Restating: Uses the client's exact words
IMPORTANT • Reflecting: Directs the focus back to the client for them to
examine their feelings
BARRIERS TO EFFECTIVE COMMUNICATION • Paraphrasing: Restates the client's feelings and thoughts for
• Asking irrelevant personal questions them to confirm what they have communicated
• Offering personal opinions
• Stereotyping Circular transactional model.

• Giving advice
• Giving false reassurance
• Minimizing feelings
• Changing the topic
• Asking "why" questions or asking for explanations
• Challenging
• Offering value judgments
• Asking questions excessively (probing)
• Responding approvingly or disapprovingly (refusing)
• Being defensive
• Testing
• Judging
•Offering sympathy
• Arguing
• Making automatic responses
• Reacting with passive or aggressive responses
 Prof: notes

Phases of the helping relationship

•Preinteraction phase
Check more example
•Orientation phase
•Working phase
•Termination phase: feedback.

Professional Nursing relationship

* Elements of profession communication
* courtesy
* use of names
*Thruthwothness
* autonomy and responsibility
*Assertiveness

Important concepts
Race and Ethnicity
•Culture
➢Integrated system of shared values
•Acculturation
➢Process of accommodating to another culture
•Enculturation
Forms of communication
➢Process of assuming the traits and behaviors of a given
Silence
culture
Clarifying
•Custom
Focusing
➢Habitual activity of a group or subgroup
Paraphrasing
•Ethnocentrism
Validating
➢Belief in the superiority of one’s own culture with disdain
Confronting
for others
Provide information important(Keep simple )
•Stereotype
➢Simplified, inflexible conception of the members of a group Eg tell me if I understand
Empathetic reflection.
Teach-Back and Plain Language Enhancing Patient Responses

•Plain language •Open-ended question

•Teach-back ➢Allows patient discretion about the extent of an answer

➢Confirms patient understands teaching •Direct question

•Working with interpreters ➢Seeks specific information

•Leading question
➢May limit the information provided to what the patient thinks
you want to know
 Chapter 35 Cultural and spiritual Nursing care
Jehovah's Witnesses Islam ( Muslim)
HEALTH AND ILLNESS: Clients might • Clients might decline porcine-derived medications.
not accept blood transfusions, even in DIETARY RITUALS
life-threatening situations. • Clients often avoid alcohol and pork.
DIETARY RITUALS: Clients might avoid • Clients can fast during Ramadan.
foods having or prepared with blood. Pray towards meka
Hijab covering
Mormonism *Value privacy and same sex provider
DIETARY RITUALS: Many clients avoid
alcohol, tobacco, and caffeine.
• Clients might prefer to wear temple Judaism (Jews)
undergarments. DIETARY RITUALS: Some clients practice a kosher
Mormon polygamy many wife diet

African - american Orthodox jewish individuals do not eat meat WITH

No show pain macularity dairy, pork products, or shellfish. A hamburger is OK,
Japanese but not a Jews no elevators
* guiding to what you are doing women wear. Sheltel to cover head
Eg. I am going to elevate the bed
Latin=
Mostly Catholic
Chinese
* yin( cold ) yang - (hot) Prof: notes
* avoid eye contact
Muslins: Orthodox Jews: Kosher Diet
Value privacy •Muslims: no pork, fast during Ramadan
Hijab •Jehovah witnesses: no blood transfusions
No pork. •Mormons: no caffeine, no alcohol
Ramadan
Fasting
African American
Samen sex provider
Not show pain until they have a lot o pain
Chinese
Some tend to engage in more formal conversation and relationships. Judaism: Amish no cellphone no electricity
They may believe that hot and cold food items treat disease. Kosher diet
Yin-yang Cows gout.
Yin -cold Animal free from disease
Yang= hot
 Risk factors
Modifiable: diabeteS, type 2, hypertension, high cholesterol, smoking Social History: C A G E
Look for a questionnaire
Vs
Non-modifiable: gender, Ethnicity, race, genetics

Recklece homicide

Infection control chap. 11

Microorganism
Bacteria viruses Fungi Protozoa
coiff Influenza Tinea Pedis Atleet Malaria
M.r.s.a Covid foot Toxoplasma
Ecoli. R.s.v Candida Gondii
Cholera Herpes zoster Albicans
V.r.e vancomycin Measles
resistance enterococcus Mumps
T.b Rubella
Anthrax Ebola Chain of infection
H. Pylori HIV
Pertussis Morovirus
Rotaurus (Microbes)
Rhinovirus
House
Susceptible host

Where does it
leave
Muscus
membrane
Direct (sneeze )
Touch (indirect)

Stop mode of transmission wash

hands at less 45ml of soup.

If pt. Have hepatis b or HIV when at the beginning is standard precaution

 Localize US systemic Course of infection by stage box 28.2
•localized infection - a single •systemic infection - affects the entire body
organ or part (e.g., a wound •Symptoms like fever/chills, muscle
infection)
weakness, altered mental status and
•localized symptoms such as
gastrointestinal symptoms
pain, tenderness, warmth,
•can become fatal if undetected and
and redness at the wound
site.
untreated.

Acute vs chronic H.A.I P.P.E.

Less than 6 month Sterilization Gown Gloves
More than 6 months or longer CAutoclave Mask. Googles
Vs Googles Gown
Desinfection Gloves Mask.

Standard precaution Droplet Airborne Contact Protective/ reverse isolation

Hand washing 6 feet away drop it fluids Air = M.T.V. Coiff, M.R.S.A. Aids leukemia transplant
P.P.E. Pertussis, influenza, r.s.v Measles Herpes, zoster, neutrophils
Needle stick. Injury Mumps rubella strep. Tuberculosis Gloves +H.e.p.pa. Filter
Prevention What to wear Varicella Gown * No plants, flowers, raw fruits,
Environmental cleaning Surgical Mask/gloves Pt wear surgical mask and vegetable,
Waste disposal nurse N95
Negative H.E.P.A. Filter.

Vital signs Chapter 27.

Temp: 36°C - 38°C Routes: Pulse pressure B.P. - mhg

96.8°F - 100.4°F oral, tympanic, temporal, rectal 30-50 mhg H.T.M. > 140 > 90
100.4 - fever Oral/ tympanic 37.5°C Systolic - diastolic Normal less than
Avg. 37.°C = 98.6°F Rectal 37.5°C 120 / 80
Elderly ( 35°C -36°C ) Less than 100 / 60 monitor
Hyperthermia > 40 °C
hypothermia <35°C Orthotastic hypotension → drop of
Systolic = contracts 20mm systolic or 10 diastolic
Diastolic = relax

Heat stroke vs othortions

In pt. With enficema or c.o.p.d normal oxygen is 85 or greater

Check For 30sec and multiply by 2 if regular

If irregular for s full min
PULSE SITES

Must know
Respiration 12 to 20
Labor Pulse oximetry

Unlabor Normal 95% - 100%

Tachynea > 20 Earlobe or disposable sensor pads in cute is swollen

Bradypnea < 12/min C.o.p.d 85% is normal

Apnea there is no breathing no rest.

Kussmaul respiration î In p.t with diabetes Heart rate
ketoacidis respiration is rapid and Very fast 60/ 100 Pulse deficit.
breathers but abnormally deep Tachycardia >100 Check apical and other nurse check radial
Chyne- stokes: rapid to shallow and then Bradycardia <60/min
apnea Z+ is normal

Prof: notes
P.t safety and quality
Objective: (see) test measures vital signs
car seat safety
Subjective: P.t. Report not feeling well"

Safety Elderly @ highest risk

Falls
* 3 side rails, call bell, bed@ lowest
Q2hr, light, bed alarm, sitter fall
Non-stick socks
* walker or cane close to them

Oxygen
No smoking
Water soluble
No wool no electric equipment near etc. No close to
electric razor, vertical position, no close to kitchen, Lead poisoning
always check the skin just cotton cloth can use NO *House built, in 1950 (paint.) With toys Suffocation
Many cognitive deficit, mental * drowning
WOOL.
impairments *Teach back to sleep

* Carbon monoxide Lead toxicity

(Tasteless, odorless, clear gas ) Main risk are children ages 3 to 5.
Gas stove always turn off , furnaces to heat house,
chimney smoke, gas generator, bbq, use carbon
Fire safety
Smoke detector
RACE
monoxide detector Fire extinguishes r: rescue P.t.
Sign and symptom: headaches, vomiting, weakness,
a: alarm
nausea and unconsciousness
C: contain/ confine: close the door
Fire safety from ATI. Page 61. E. Extinguish
 If no follow protocol
False impressment
Restrains
Is last resort
* need Dr. Order
* Check every 15min
* 2hr remove to use bathroom
*Dr. Need to update restrains order.
Every 24 hr.
* 30 mi. Check constantly

Shift report: bed-side in front of the p.t.

Never use "I" always 3r person
Face-to-face

Telephone orders
• It is important to:
Chapter: 5 • Have all the data ready prior to contacting any member of
the interprofessional team.
Objective 8 smells vomiting • Use exact, relevant, and accurate information.
Subjective: sign: pain, what pt. Tells US • Document the name of the person who made the call and to
P provoke whom the information was given, the time, content of the
Q quality message; and the instructions or information received during
R. Region the report.
S: sequence severity Telephone or verbal prescriptions
T: timing Transcribe everything Dr. Say meaning repeat back
Document E.H.R.
Example: patient pacing back and forward for agitation
Type or order
For anxiety: P. t. Bitting nails
Physician name
For falling: P.t. Found on the Floor.
Always sign

Incident report.
Falls
Med error
Omission of prescription
And needlesticks

Never put incident report on my documentation

Never judge a p.t.

 Labs skills
Do not check Coratic artery
Systolic/diastolic
4 rails up. ( false impreisoment. ) because block blood to the brain

Call light. Where Pt can reach. S: situation

Arteries have pulse
B: background
Vein don't
P. P. S. T. A: Assessment
Person Place Situation, Time R: Recommendation At the level ofthe heart when taking blood pressure
R: reedback
Systolic heart contract.
Diastolic! Heart relaxes last sound
And 30 ugh when I don't feel pulse

Vital signs skills

Respiration: count breath for 30 Sec. And multiply by 2. A rate faster than 20/min is called
Them count for a full min. To see accurate results tachypnea. Neurological injuries and medications that depress the
to count pulse and check respiration at the same time respiratory system, such as opiates, can slow the respiratory rate. A
rate slower than 12/min is called
Elevate the head of the client's bed 45° to 60°.
bradypnea.

This is a comfortable position for most clients and it allows Cheyne-Stokes respirations are breathing cycles that increase in
full ventilatory movement. Discomfort can increase a rate and depth and then decrease
client's respiratory rate. and are followed by a period of apnea.

Pulse

Apical pulse is in the fifth intercostal Radial pulse

space
Point of maximal impulse (p.m.i.)
 Preparing for Exam 2 Nursing diagnosis

Primary (patient) Interview: General Health status height, weight,

A.D.P.I.E.
Vs allergies, V.S., labs, head to toes assessment,
A.A.P.I.E.
Secondary (family, proxy, comprehensive Dx test.
physician, Ct scam xray

1 Assessment:
Subjective: pt report symptoms
Analyze/diagnose
Actual Nursing D.X. : problem 2
V.S. Related to what is causing the problem etiology as evidence by
Objective: signs (see test results) use: N.AN.D.A.
Seem, tested or measure Risk. D.x: Risk for falls aeb unsteady gait
E.g. Rash, hypoxia, cyanosis, petchia Health promotion
Readiness aeb enhance...

Planning
S specific 3
Implementation
Independent: What you can do for the patient without the doctor’s
4
M. measurable order.
A. attainable Ex: Move the patient, raise the head of the bed, teach the patient, put
R. realistic socks on the patient, prioritizing which patient to see first.
T. time Dependent: What you can do for the patient only with a doctor’s order.
Goals short-long term: Ex: Giving the patient pain medication.
Ex: pt will have oxygen Sat. Greater than Collaborative/Interdependent: Working with other sta
95% within 1. hr. (Short term.) IV/Meds, counseling, ER.
environment, documenting, infection control.
Evaluation
Improvement? Decline? Is the patient unchanged?If it is, we go back and reassess,make other goals, etc. Plan of
care? Are we done yet?
- Ex: “The patient did reach an oxygen saturation above 95% in 30 minutes.” 5
ABC:
- A: Airway (High-Pitched wheezing sound (allergic reaction, airway closing (stridor),hoarse voice,
paradoxical breathing (breath in - chest goes down, breath out - chest goes up) (priority always )
- B: Breathing (Respiratory rate, does the patient use accessory muscles to breathe, labored breathing)
assess chest
- C: Circulation (Capillary refill <2 Secs. (every single finger), >2 Secs (Circulation Issues; plaque building
up, severe dehydration, blood is not flowing to extremities.)
 Clinical Judgment Model: NGN

1. Recognize Cues: Looking for signs (Objective), 4. Generate Solutions: Goals, and potential
you can see, attest, measure, smell, and touch. What interventions, what are the expected outcomes, what
is relevant, immediate, and urgent/concerning? are the interventions I can use, and what should I
avoid?
2. Analyze Cues: What conditions are consistent
with the cues, which signs and symptoms support/ 5. Take action: Nursing interventions that you will do
contraindicate a specific condition, and why is that to your patients, implement goals and interventions on
cue a concern or significant. the patient.

3. Prioritize hypotheses: Which one is urgent, what 6. Evaluate Outcome: What is observed, what is
is likely to happen, and what is the risk, look at the expected, were the interventions effective, do I need to
time, least likely to occur, and most likely to occur. change it.

Patient comes to the ED reporting chest pain on R side of the throat shortness of
breath (dyspnea),
Fever of 39c (102f)+ wet cough
Scenario
• Temp 39 c, RR 32 r/min, pulse : 125bpm, O2 Sat: 89%. on RA. Bp: 120/80
Pain 3 on a scale of 0-10 describes as sharp/ stabting locate @side of the
Thorax type: intermittent, worsen when in haling coughing P.t. Reports Started this
morning

Short term:Within your shift, within a

Rec. Cues: relevant: Analyze cues
week for a rehab, within a visit, hospital
* chest pain Support or
visit 24-48 hrs.
*Fever contraindicated
* Sob Pneumonia
Long term- Greater than 1 week (In a long
* wet coughs
term facility), throughout hospital time, by
*02 89 RA
discharge, greater
P. 12 bpm.
than 48 hours.
R.R. 32.min

Goal for pain: The p.t will be pain free within the next Horus.
The pt temp will decrease by 38 by the next hour
 The goals have to be:
specific
measurable (something to test, ex: vital signs, observable signs)
Attainable/ ACHIEVABLE: (is this something that’s able to do within your shift/resources?)
Realistic (Ex: You cannot cure someone who is terminally ill.)
Time (Must always have a time frame)

Examples:
- Short Term Goal: “The patient will maintain an oxygen saturation level above 95%, within the next 30
minutes”
- Short Term Goal: “The patient will be free of pain within the next hour.”
- Short Term Goal: “The patient’s temperature will decreased below 38 degrees celsius within the next hour”
- Short Term Goal: “The patient will use incentive spirometer within the next 8 hours”
- Long Term Goal: “The patient is going to verbalize understanding of antibiotic use by discharge”
- Long Term Goal: “The patient’s body temperature will remain below 38 degrees celsius for the remaining hospital
stay”
If change of shift report collect and organize data

Chapter 8 Critical Thinking:

● What is critical thinking?

- The active orderly and well-thought-out reasoning process

- Basic critical thinking: limited results Complex critical thinking: nursing begins to

from nursing experience and only trust the express autonomy by analyzing and examining

experts. to determine the best alternative (More experience).

Thinking solely based on the rules: Limited Increase in nursing knowledge, experience, intuition,

knowledge No intuition and more flexible attitude.

● Commitment: The nurse makes choices

without help from others and entirely takes
responsibility. You’re responsible for
consequences that could occur.
Eg. Hold pt. Meds. P.t is receiving fluids and
has edema but you stopped the meds
 Cognitive learning is knowledge: Client edu.
(determining the effectiveness of learning the Affective learning:: involves feeling. Need to know if p.t
new information). wants to learn
For example, cognitive learning takes place Receptive to listen and you need to know how much info
when clients learn the manifestations of p.t. Have.
hypoglycemia and then can verbalize when to
notify the provider. Re-educate a pt. If didn't understood

Best way to know if pt. Learn. Is psychomotor learning: hand on: denmostration

Look for example!!!

Vision and hearing impairment: adequate Lightning

Hearing aids assess: No scream, normal tone speak in front p.t.
No high frequency sound, Visual cues a

Medication Administration: Enteral V.S. Parental

Pharmacokinetics: Movement of a drug within the
Enter to the G.I tract.
body
- Absorption - Distribution - Metabolism - Excrete Types of routes of administration:
Factors that influence absorption: SR, XL Tab/Caps Enteric Coated SL (Sublingual) IM
1. Route of administration Subcut, IV Transdermal Instilitation Inhalation
2. The ability of a medication to dissolve I.M. Is faster. Directly to the muscle. More blood in
3. Blood flow to the side of the administration the muscle
I.V. Faster than all other
4. Body surface area
Inhalation is the second
5. Lipid solubility
faster
Distribution: Excretion:
1. Circulation - Medications exit the body through the:
2. Membrane Permeability 1. Kidney : elderly and kids Tranderma) 15.min.
3. Protein Binding 2. Liver Wear gloves
Metabolism: 3. Bowel Remove hair.
Polypharmacy a lot of Remove old patch
1. Medications are metabolized into 4. Lungs
interaction with Dry skin.
a less potent or inactive form 5. Exocrine glands
medication ( elderly) Rotate side
Liver is main one for
Med. reconciliation
metabolism Slide 18 for Goals and outcomes
Effectiveness /safe Side effect expected outcomes
Example: give penicillin. To a pt. Who to know effective is that kills the Adverse effect. : No expect-need to report.
bacteria is it safe to give penicillin? Is the pt allergic. . Toxicity:
Therapeutic index range between
Selectivity: atendol: beta 1. On the heart. therapeutic effect
Non-selective propranolol: beta 2. Broncoconstriction Half life! How long it take a med to be in
the body by half.
Idiosyncratic or paradoxical: Over-reaction or Peak: highest
underreaction Trought: when we can give the med to the
Synergistic: when 2 med are given together P.t.
increase effect.

Medication reconciliation: When to do med check

Must know p.c.a. pump * retrieve
What p.t takes at home OTC
The p.t is the only one to do reconciliation *Administer
* close M.A.R.

10. Rights: must know High alert med. subc

- Right Patient (Name, DOB, MRN) Insulin
- Right reason (indication) (why are we giving this :P) Heparin
- Right medication (Hydralazine vs Hydrochlorothiazide) Levanox
- Right Dose Need nurse to monitor, the
- Right route (PO IM IV) vesicant dose. Witness
- Right time
- Right documentation
- Right to know
- Right to refuse
- Right Response
 Maslow

Education self,
fulfillment
Growth, independent
respect, comfort
. Family support friendship.

(physical) Violence, theft protection, finance

stability (physiological) Emotional

Oxygen fluid, nutrition, body tempt.

Specially in elderly elimination

Parental admin

Insulin
Short acting. = humulin 30min peak 2. Hrs. Last 8 Subcutaneous
hrs. 45 degrees to 90º
Obese 90°
Intermediate:n.p.h. Effect: 2 hrs. Peak 8 hrs. 6 hrs. Skinny 45°
Check peak because is when hypoglycemia occurs Areas For Subcut Injections:
1. Back of the arm
2. Lower abdominal region
3. The front part of the upper thigh
 Z.track For I.M. Injection

Inject up to 3ml.

Ventrogluteal site Adults only

➢Gluteus medius Always use z track
➢V method external or upper left
➢G method muster quadrant

Only child:
•Vastus lateralis
➢Used for adults and children
➢Use middle third of muscle for injection
➢Often used for infants, toddlers, and children
receiving biologicals

In the middle portion give up to 3. mL.

Deltoid
➢Not well developed in many adults
➢Proximity to nerves and artery create potential for injury
➢Volume: less than 2 mL
➢Site is three finger widths below the acromion process

Find acromion process

Go 3 finger down where pinky fingers is inject
Less than 2 ml
 Intradermal injections
5 to 15° angle 0.1 ml of solution
➢Used for skin testing (tuberculosis [TB], allergies)

Is going to create a little bled. Use a tuberculin or small hypodermic syringe for skin
Induration, check. Pt .in 48 to 72 hrs. testing

Positive results: > 15ml

Immune suppress: 5ml
False positive results: if pt. Took B.C. G vaccine.
Also for allergies

Infiltration VS Phlebitis
- Phlebitis: Inflammation of the Vein (EX: Leaving an IV in for a long time)
- Infiltration: IV fluid leaks into the tissue. In this case, you use a warm or cold compress to reduce
discomfort.

Pain
ATI Mastery Book - Chapter 41
Pain is ultimately subjective, at the level that the patient says it is at. After the pain level is indicated, you must assess
the patient, the pain, location, and severity. The first part of the assessment is PQRSTU

Scales to assist with assessment:

- Pain tolerance: The level at which
- Numeric scale: On a scale of 0-10, how bad is your
you tolerate pain.
pain?
- Pain threshold: When you start
- Comparative Face scale
feeling the pain.
- Wong-Baker Face scale (3-18Yrs)
- FLACC (Infants);
These scales assist us to determine whether or not the
patient has pain.
Verbal Signs: Non- verbal:
Crying Grimacing
Moaning Wrinkle Forehead
Sighing Bite their lower lip
Screaming Restless
Agitation
Throbbing
Guarding
 Nociceptive V.S. Neuropathic

Nociceptive pain: Any pain outside of the nerve. Ex: Tissue Damage, will stimulate nociceptors,
which are pain receptors, and as a result, the patient develops pain. It is typically more localized,
often described as throbbing and achy.

Cutaneous pain: Skin-Cut (ex: first- Visceral: Organ pain. Somatic: Pain in the joint,
degree pain) Examples:
tendons, muscles, or bones.
1. Gallbladder
Referred: Pain felt in another region from Examples:
2. Intestines
the actual point of origin. 1. Rotator cuff tear. Type of
3. Liver
Examples: somatic pain
1. Cholecystitis pain in the gallbladder that. 2. Bone fracture
Radiets- Pain felt in the shoulder 3. Cancer-Bone Pain
2. Pancreatitis - Back pain
( inflammation of the pancreas)
3. MI - Jaw or Left arm.
4. Appendicitis - dull umbilical pain.
( inflammation of the appendicitis)

Neuropathic
: Within the nerve, pain is often described as shooting or throbbing pain.
- Phantom Pain: Pain from an extremity that is not really there. Example:
1. A diabetic patient got gangrene and had to amputate the left foot, but they still feel it

● Patient-controlled analgesia: The patient presses the button whenever they feel pain ‘PCA pump’.
Usually morphine or fentanyl.
Acute VS Chronice: Acute: Less than 6 months Chronic: More than 6 months

- Signs & Symptoms: Acute

1. Guarding Signs & Symptoms: Chronic
2. Grimacing 1. Vital signs are typically stable because the body
3. Restless has adapted
4. Moaning 2. Sighing
5. Sweating (diaphoresis) 3. Rubbing
6. Pale 4. Less active
7. Vital signs go up (Ex: High pulse, High blood pressure, 5. Less appetite
etc.)
Study page 238
 Non-pharmacological pain Management.

Distraction: deep breathing exercise

Music therapy
Imagery
Back rubs
Changing position
Relaxation: meditation

Herbal Remedies:
- Cranberry: Aides with UTIs, it prevents bacteria from sticking to the walls of the bladder.
- Aloe: Aides with sunburn, is good for skin, and sometimes helps with constipation.
- Black cohosh: Used for post-menopausal women to prevent hot flashes and night sweats.
- Chamomile: Good for digestion, good for inflammation and it is good for relaxing.
- Echinacea: Improves immunity, and reduces inflammation. It can lower blood sugar.
- Flaxseed: Good for constipation.
- Feverfew: Reduces fevers, headaches, and arthritis, and it prevents platelets from clogging. Interacts with
other anticoagulants (Aspirin & Warfarin)
- Garlic: Decreases LDL, and cholesterol, and increases HDL, lowers blood pressure. No anticoagulants.
- Ginkgo Biloba: Memory, helps patients walk free of pain. No anticoagulants
- Ginger: Antiemetic, helps with nausea, vomiting, chemotherapy, etc. No anticoagulants.
- St John’s Worts: used to treat depression increase serotonin if pt. Is taking S.S.R.I. Increase serotonin
syndrome. Cause photosensitivity
 Mid term prep.
Wound care
Skin assessment

Decubitos :pressure injury

The skin helps us be protected from pathogens. The issue starts when there is a break in the skin.
—----------------------------------------------------——————————————————————

1. Assessment: The first thing you do when - maceration (Areas that are moistened or pruned,
you’re assessing is observed and inspected. increasing the risk of skin breakdown.)
We’re inspecting for - Chloasma or Melasma (Occurs to women who are
- color pregnant typically because of increase in
- swelling, estrogen; it’s hyperpigmentation)
- erythema - Hirsutism (Excessive hair growth in females, increase in
- Ecchymosis (bleeding) morete androgens. And testosterone ) only females
- inflammation - Striae (Stretch marks)
- bumps - Convex Nail (Normal: 160 degrees, Early clubbing: 180
- nodules degrees, Late Clubbing: 180+ degrees) Schamroth
- pressure injuries (Only occur over bony Window Test Put nail together look like a diamond
prominences.) C.O.P.D
- moles

Risk Factors:
-Sun-exposure 1. Melanoma: Comes from melanocytes, (ones that produce melanin

- UV light and give us color). Cancerous tissues develop in melanocytes and

- Caucasians cause melanoma. Melanoma is the most aggressive.

- Light eyes
- Albinos 2. Carcinoma: Come from different cells but the sun plays a big

- Anyone who has a lot of moles or birthmarks. role. Excessive sun and inadequate protection.
- Family history of skin cancer
- Elderly
- Anyone who is excessively out in the sun
 A. Asymmetry: Is it something you can cut in half and have equal halves? Is it round, or oval?
I
B. Border: Regular or irregular

C. Color: Two or more color. Should be one color only

D. Diameter: What size is it? If it’s bigger than 6mm, or a pencil eraser, keep an eye on it.

E. Evolve Has it changed? New growth, new color, new shape, bleeding, etc.

Palpate:
- Palpate for warmth with the dorsal portion of your hand and assess both extremities so you can tell the difference
- Palpate for nodules, or lesions.
- Palpate for edema
- Edema can be pitting (you press down, and it forms an indentation) or non-pitting edema
- 0-No edema
1+-2mm Tiny indentation
2+ 4mm in-depth
3+-6mm in depth
4+ - 8mm in depth l

- Skin Turgor: When you’re checking for skin turgor, the skin should bounce back in 2 seconds like
a capillary refill. Pinch the skin up slightly and release. If the patient has severe diarrhea, vomiting, or dehydration, it
is called poor skin turgor.

- Clubbing: Shamrothwinda test, you grab the patient’s nail, ask them with their index finger to put them together
and you should be able to see a diamond shape. If you don’t see it there might be clubbing
Primary intention Whenever we talk about - Secondary intention, the patient goes to the
wounds or any sort of incision/laceration, we need dermatologist and they do a biopsy or a pressure
to understand how they heal. They heal by primary, injury. Not all pressure injuries heal but sometimes they do.
secondary, or tertiary intention. For instance, if we
have a surgical wound (c-section), what does the - There are no stitches, no glue, and no staples, the edges
doctor do? are far away from each other. They heal from the inside to
- He can put stitches, medical glue, or staples. the outside. This is secondary intention healing.
- The edges, when they’re closed, are approximated.
This is an example of primary. Heals - Tertiary intention; let’s say the patient has an
from the outside to the inside. Minimal to no abdominal wound, and the doctor attempted to structure it
scarring typically, but depends on genetics or in the palace. The wound began to heal from out to in but
ethnicity. This helps wound healing because it heals then it got infected, so they were removed. They gave the
from outside to inside patient antibiotics and then sutured them. It is a mix of
both, it started with primary, then secondary, then primary
again.
Pressure injury: Decubitus Ulcer Risk:
Preventative: Pre: 15-35 mg/ dl.
- Immobility
- Asses Albumin= 3.5 to 5. G/dl.
- Urinary & stool incontinence (Leads to
- Turn every 2 hours
macerations)
- Look at the diet (decrease in appetite, what does
- Diabetes
it look like on a day to day?)
- Poor nutrition (Diet low in Vitamin A, Vitamin C,
- Clean/Intact skin
Zinc, Copper, & Proteins)
- Med. Reconciliation
- Low fluid intake (Less than 2-3L)
- 30° semi fowlers/side-lying position
- Elderly
- Pillows
- NSAIDs (Decreases Inflammation) delay wound
• request high blood-flow mattres
healing
• High diet of protein
- Glucocorticoids (Decreases Inflammation) delay
• Check albumin and pre: albumin
wound healing

P.t edu = n0 massage because increase wound pressure to prevent.

Essential it. To promote healing
* zinc
* protein
* vitamin. A.
* vitamin C.
* copper.
 Stage 1: (Occipital, elbow, back of the shoulder, Stage 2:
hips, anywhere bony) - Partial thickness skin loss → Dermis (Crater, rupture/
- Nonblanchable redness/erythema blister)
- Skin is intact In the epidermis - Treatment: Hydrocolloid Dressing (Duoderm); made of
- Occurs in a bony prominence gelatin or pectin, allows the site to retain the moisture it
- There is too much friction/shear. needs. (Needed for collagen synthesis) Change 3-5 days.
- Interventions: Asses, document, and notify HCP, Unless it is soiled with stool or yuckies.
of possible wound care consultation depending on
protocol. In stage 3 and up you will see tunneling and undermining.
- Treatment: Turn the patient every 2 hours, put a Tunneling is in the shape of a tunnel, undermining the
barrier cream, aloe vesta, sensi care, space under the border. You might also see necrotic dead
What you need to treat tissue, an example is; Slaugh which is yellow, thick, and
transparent dressing, high flow mattress. moist necrotic dead tissue. Eschar is also necrotic dead
tissue that is tan, brown, or black in color. Anywhere from
stages 3, 4, and unstageable can have Slaugh, eschar,
Stage 3: tunneling, and undermining.
- Full-thickness skin loss → You will
be able to see the 3rd layer (subcutaneous Stage 4:
layer)d - Full-thickness skin loss → Bare muscle, bone, or
- Treatment : Debridement (Getting rid of connective tissue.
the dead tissue), Mepilex (Foam patch), - Treatment: Debridement, and wound vac. Unstageable:
analgesics, hyperbaric oxygen therapy. - Full-thickness skin loss

Unstageable:
- Full-thickness skin loss
Cannot see the base of the wound, slough, or eschar. - Treatment: Debridement

Deep tissue injury: There is damage underneath,

we just don’t know how much. Most commonly
found in heels.
Stage 3 and 4 give medication and come back
- Maroon, purple, red.
- Treatment: Foam offload ( bunny boots
Oxygen promote wound healing
 C: Color (color of the drainage) How to measure
L x w x depth
O: Odor (can signify infection)
C: Consistency (consistency of the drainage present)
A: Amount (how much) (1g = 1ml of drainage)

Debridement: If there is any Slough or eschar present.

mechanical: Wet-to-dry dressing changes only press it
in dead tissue
Sharp: Used with medical instruments to debride the wound. There are a lot of risks involved in
this type of debridement
- Autolytic: Gels, substances, that promote the body with our own enzymes to liquefy and break
down the dead tissue. Hydragel, Aquacel, Medical Honey, and Alginates, are typically used with
Mepinlex. Collagenase, breaks down the collagen in the dead tissue itself.

- Biological: Sterile maggots are grown and used to eat up dead tissue.

Serous drainage: clear watery fluid : made by plasma portion of the blood

Sanguineos drainage: bright: indicates Fresh bleeding

darker: older drainage
can be weight the drainage discarded in the red biazardous

SEROSANGUINEOS: light pink thin watery

puralent drainage: thick green, yellow or brownish in color.

present in stage 3,4, and unstageble

purosanguineos: when. Wound becomes infective: blood and puss combine

 Surgical incision
Open system: Close system :
Pen-rose drainage: prevent hematoma like a vacuum to suck out the drainage
or bleeding inside bc they need to get rid Jackson Pratt: looks like Tony bold: holds 50 to 100 ml of
of fluid : blood flight place inside surgical drainage has a tubing and is coneected in pt insicion: graduated
incision is going to be draining out the cylinder to measure and inspect for color odor and consistency
blood with a safety pin and amount make sure the bold squeeze
the pin is to prevent form going inside the
pt: hemobag: do the same as the pratt but hold 500mland if it is
: monitor and weight what color. Odor more than 500 ml let dr. know because there is hemorrhage in the
consistency COCA pt.

Surgical insicion :
Dehiscent and eviscention
Dehiscence: wear a binding to avoid organs to come out Or splinting whenever they tel pt to breath or cough
place a pillow to create extra support to reduce amount of pressure to avoid open up.
if pt have binder: nursing intervention: pain, pallor, numbness (cutting circulation) paralysis (lack of movement)

Dehiscence: actual opening of the incision: stiches came out Dehiscence: nursing intervention: put pressure
Eviceration: when organ pretrude or are coming out.

What if organs come out?:

nursing intervention: sterile guze and place it on the side gently not push anything back,
Normal saline and sterile,
and the called surgeon inmedetely.
lying down supine no elevete the bed maybe only 15
knees has to be bend
not give anything to eat. Because t will be ASAP TO operator room.

chapter 55: ATI READ!

30 degreed side line position is the best
 Hw just the lab bc mid term is Thursday Respiratory chapter potter book chap. 30

Respiratory system
COPD: CHRONIC OPSTROCTIVE PULMONARY DISEASE
Two main types of copd are Emphysema and chronic bronchitis

Chronic bronchitis: smoking pollution, genetic

Emphysema: alveoli damage by second hand smoke or
Meaning inflammation of the brachios.
smoking
bronchio are inflame and mucus is develop.
Air sack has little chambers what is the process of it: inhale
main difference the are going to have a hacking
air travels to the bronchi’s branches and lean into the alveolar. cough.
depending on the place if the little sacks called alveolar PT. Will have barrel chest RIBS ARE GOING
became damage air become traps in the little sacks TO EXPAND.
more carbon traps on the chamber of the lungs
pt have signs of hypoxia, clubbing bc no enough
oxygenation,

Booth will have dyspnea on execptions shortness of breath.

Shallow respiration.
fatigue
heart rate increase
O2 IS GOING TO BE LOW average is 85%
pt will have wet hacking cough. (Chronic
bronchitis) only
respiratory acidosis.
pursed lip breathing

Nursing education: mucus chronic bronchitis drink 2

Normal is 1 to 2 which is normal
to 3 litter of water.
anterior posterior diameter
Diet: high protein
if pt want to exercise, in the afternoon NOT morning: is Barrel chest anterios posterios diamanter will
morning more secreatiing be 1 to 1.
if pt have emphysema educate passel lip breathing
 Another condition: ATELECTASIS: a pt comes from surgery pt have breath deeply
Pneumonia: Alvela fluid buildup and cough
Form sticky long tissue form means Edu: put pillow. It hurts when they breathe. If they don’t do the
consolidation exercise or coughing
S&S: fever, low oxygen, increase heart rate, sticky lung tissue “consolidation”. Is going to form and lung
chest thoracic pain that feels sharp. collapse.
pt have to used: incentive spirometer.
Empyema: Puss in the lung. Writhing the lining
of the lungs

cancer: also called consolidation : sticky lung

tissue but malignant

Hemothorax: blood in the chest or the lung.

Plural effusion: is fluid in the plural space.

pneomothorax: air in the thoracic region.

spontaneous:
pt is going chest pain, very shortness of Breathe in (inhale) slowly through your mouth as deeply
breath, rapid and hallow breathing, hear rate as you can. You will see the piston slowly rise inside the
increase and HYPOXIA MEANING LOW spirometer. The deeper you breathe in, the higher the
OXYGEN LEVEL piston will rise
lungs collapsed

Spontaneous: a little blebs form in the lung and just rupture danger.
That is called spontaneous.

What happens: the trachea is going to shift to the side that is not affected so organs are going to start
moving is called trachea deviation.
Treatment is needle decompression

pNeomothorax can lead to: crepitus i

When air is build up in the subcutaneous tissue crackle
when palpating the tissue you will hear and feel it when
you touch.
air underneath the subcutaneous tissue.
( pneumothorax)
 Asthma:
What happen is simmilar to chronic brochiting but is no the same:
what happens to pt: inflammation in the bronchias. Airway constricted dry cough
because of it you are going to hear a wheezing sound
Extremely short of breath when an attack.

Hypoxia and hypoxemia

Hypoxemia: Lack of oxygen in the blood
Hypoxia: lack of oxygen in the tissues.
Early signs Late sign
B: BRADYCARDIA
Hypoxia: the early rat is late to bed E: EXTREME RESTLESSNES
R: RESTLESSNESS D: DYSPNEA
A: AGITATED/ AXIETY also cyonocys : bluish discoloration in the mucus
T: TAHYPNEA, TACHYCARDIA membranes. Around the lips, the tongue, sclera of the
eyes, the palms, sole of the feet.
Respiratory Assessment
pegion Excavation

Inspection: looks at chest

Inspection,
Rise of chest
Palpation
labor or unlabor
percussion
abdominal breathing
Auscultation
accessory muscle to breath
resp. Rate.
inpect for symmetry
if pt have 1 TO 1 diameter suspect of COPD
pigeon chest
excavation:

Palpation: TACTILE fremittus: are good running but bad at flight and they
drown.
Pressing down: upper lower, sides, on the back
Any areas with consolidation will increase more on the other
Look for crepitus, masses, thoracic expansion: to see
side. Will increase tactile fremitus.
tactile fremitus: vocal vibration: player or ulnar portion
if pt have emptyhysema: lower lob bad at flying sound less
of your hand pt have to said 99 VOCAL
decrease
VIBRATION HAS TO. BE EVEN
Pneumothorax: decrease or absent tactile fremitus
asthma: decreased. Tactile fremitus
 Auscultation:
Percussion:
pitch, intensity
Resonance: is normal sounds
The diagram of the stethoscope
hyper-resonance: hyper inflated lungs
normal lung sounds :
( pneumothorax) high echo sound when percussing
bronchial highest in pitch over the trachea
Dumbness: fluid on the lungs
brochovesicular: hear it in the middle of the chest
and in d=the back between the scapula moderate in pitch
and intensity
over periphery: lower portion on the back vascular
sound low in intensity and low pitch

Little quiz:
Increase tactile fremitus and dumbness on percussion: consolidation
decrease or absent tactile fremitus and dumbess on percussion: fluid in the lung
decrease or absent and hyper-resonance: air in the lung.

Abnormal sounds:
Crackles: anything that lead to fluid in the lungs RONCHI: anything that cause a lot of mucus, (influenza)
fine: high pitched, and short in duration Sticke secreation:
coarse: Lowe pitched sonoros wheezes

Whizzing: narrow obstructive airway Friction rub: dry, crackly, low

High pitch musical sound pitch
inspiration and expiration Very painful for the pt.

Diminish: barely hear it. Stridor: choking that you hear without stethoscope when
allegoric reaction.
Pt edu. Abdominal cpr

Test is pt have consolidation

Bronchophomy: say 90
pectoriloquy: say 1 2 3 whispering
eghophony: ask pt to say EEEEEE IF change there is a form of consolidation
 Respiratory: Oxygenation
- The fraction of inspired oxygen is 21%
- Hypoxemia: Lack of oxygen in the blood
Adventitious sounds: Sounds that are heard other than the normal breathing sounds Hypoxia:
“The Early Rat Is Late To Bed’
EARLY:
- The lips
R: Restlessness
- The tongue
A: Anxiety
- Fingernails
T: Tachycardia/Tachypnea (Hypertension as well)
- In the conjunctiva/sclera
LATE:
- Palms of the hands
B: Bradycardia
- Soles of the feet
E: Extreme Restlessness D: Dyspnea (Severe)
After assessing, you start with the oxygen devices. You
In the late stage of hypoxia, cyanosis can occur.
start with the lowest and then you go up, the lowest
concentration will be from the nasal cannula. It’s
important to ensure that the head of the bed is elevated.

Oxygen Toxicity:
Considering we put a patient who has hypoxia on a device, we went from one extreme to another. When you put the
patient on an oxygen device, you have to consider the possible risk of getting oxygen toxicity. What if the patient is on
oxygen for too long? What is the prescription on?
S/S of Oxygen Toxicity:
- Confusion
- Restlessness
- SOB (Dyspnea)
- Fatigue
- Substernal chest pain
- Emphysema/COPD/Chronic Bronchitis: They should receive 24-28% oxygen and the rest should be room air.
This is because they have a hypoxic drive, they’re used to more co2. The maximum amount that your doctor should be
ordering is 1-3L of oxygen, the maximum would be 4L. Anytime a patient requires more than 4L, a humidifier must be
placed in the room to reduce abrasion or nasal bleeding.
 FIO2: Fraction of inspired oxygen. Oxygen Devices:

When you read a flow meter, you read it from the middle of the ball. IE; if the ball is at 3, it is 3L.
The will give you 24-44% of pure oxygen. The flow rate is 1-6L.
Keep in mind and observe for deep tissue injuries around the nose, cheek, and behind the ear.
The simple face mask is an aerosol mask, it’s good if the patient is a mouth breather. It’s inconvenient to remove for
food or to talk. You can place the flow rate from 6-12L because if not they would be breathing their own CO2
Partial rebreather mask gives you 60-75% of pure oxygen, the flow meter must be 6-11L per minute. It has a bag and
flaps attached to it. They breathe back 1/3rd of that air.

The risk is co2 could build up with that mask. You want to make sure the bag is more than 2/3rd full.
; 80-95% of pure oxygen, closed flaps. Flow rate is 10-15L/Min fixes O2; 24-50% pure oxygen, the flow rate is
4-12L/Min. Best for COPD patients.
nasal cannula
Mask w bag/ Non rebreather
Venturi Mask

Oxygen Safety:
● All cotton clothing and linen.
● Water-based lubricants
● 4L or more, place a humidifier
● Place oxygen upright
● How far away do you keep oxygen away from
tobacco, kitchen, electrical wiring, etc? 6-10Ft
● Keep it away from alcohol.
● Monitor for signs of oxygen toxicity
● Monitor for skin breakdown or DTIs
 Cardiovascular Assessment
Things to review: Heart Anatomy, pulses, auscultation points, auscultatory areas (slide 62).

Anatomy:
1. Deoxygenated blood goes into the vena cava, Systole: Heart contracts Diastole:
2. which enters into the right atrium. Heart relaxes
3. Then it enters the tricuspid valve,
4. Then the right ventricle.
5. After, it enters the pulmonic valve (the only place
where the veins have oxygenated blood, and arteries
have deoxygenated blood.) Order of assessment for the Cardiovascular System:
6. Then it goes through the lung, gets oxygen, 1. Inspecting
7. and comes back to the pulmonary veins. 2. Palpating
8. It enters the left atrium, 3. Percussion (Optional, not needed.)
9. and flows into the bicuspid/mitral valve. 4. Auscultate
10. Thenitgoesintotheaorticvalve
11. andintotheaorta.
12. Finallyitgoesthroughtherestofthebody.
Systole: Heart contracts Diastole: Heart relaxes

Inspection:

- Ask if they have chest pain, SOB (lying down/sitting up), 1. Inspect for any lift/heaves. It is forceful
cyanosis cardiac contractions that lead to the rigorous
- Family history of cardiac problems movement of the sternum.
- Nutrition 2. Inspect for visible pulsations, (5th intercostal
- Smoking space, midclavicular line.)
- Alcohol 3. Inspect for color; cyanosis, pallor, etc.
- Exercise (Increases the cardiac output and strength) 4. Inspect for jugular vein distention
- OTC medications. 5. Inspect for edema.
a. When the heart cannot b. Left Side Failure S&S: c. Right Side Failure: If d. Right Side Failure
pump blood, this can lead to Restlessness, confusion, the left side is failing, S&S: Fatigue, distended
left-side heart failure. Ie; Left orthopnea, tachycardia, fluid begins to back up jugular veins, dependent
Side: when the ventricles exertional dyspnea, fatigue, in the vena cava. Then edema, anorexia/gi
don’t expand enough or give cyanosis, pulmonary fluid distress,
enough blood to the rest of congestion, cough, begins to seep into the enlarged liver and spleen,
the body, because of that, crackles, wheeze, blood- body. Right side heart peripheral venous
blood is backing up into the tinged sputum, tachypnea, failure typically occurs pressure.
pulmonary veins. Which in and after left side failure
turn causes fluid to seep paroxysmal nocturnal
into the pulmonary, and dyspnea.
manifest into pulmonary
symptoms.

Palpate:
1. Palpate all pulse sites.
2. Capillary refill on each digit, ensure it is less than 2 seconds.
3. Palpate for hepatic jugular reflux
30-45 Degree angle, have the patient turn their neck to the side.
Palpate the liver (Right upper quadrant) and if it stays there for more than a minute
(vein), it is positive for HF.
4. Apical pulse → PMI (point of maximal impulse)
5. Palpate for thrills (Vibration, similar to a cat’s purr), lifts, heaves, and pulsations.

: Blood backs up into the heart : Narrow valve

Turbulent heart flows (Murmurs can cause thrills)

A. Regurgitation Blood backs up into the heart

B: stenosis: Narrow valve
C. Murmur: Turbulent heart flows (Murmurs can cause thrills)
Auscultation/Palpation Points:
All: Aortic (2nd intercostal space, right sternal border.)
People: Pulmonic (2nd intercostal space, left sternal border.)
Eat: Erb’s point. (3rd intercostal space, leftternal border.)
Too: Tricuspid (4th intercostal space, left sternal border.)
Much: Mitral (Apex) (5th intercostal space & midclavicular line (PMI),
left sternal border.)

Auscultation:
1. Use the auscultation points, using both the diaphragm and the bell.
a. Bruits (vascular murmur): Turbulent blood flow due to plaque buildup in the carotid.

Heart Sounds: Extra Sounds:

- S1 (Lub) - Atrioventricular valves & - S3-SplitinS2(LubDubTa)
tricuspid/bicuspid+mitral.) a. Early diastole - Taut Ventide Walls
- S2 (Dub) - Semilunar valves, pulmonic b. Normal in: athletes, pregnant women, children.
aortic. - S4: Before S1 (Ta Lub Dub)
a. Late diastole - non compliant ventricle, ventricular
hypertrophy, or ischemia. Diastolic HF

Midterm review topics: Thursday OCTOBER 26, 2023

Wound care, low protein diet, low fluid, contusions, vitamin a, c , copper, medications a.) Oxygen
equipment & safety, cardiac assessment, sight, pulses, points of auscultation, skin assessment, hirsutism,
curvature, abcde, herbal supplements, hygiene, safety (fall risk.), culture, chain of infection, ppe, MRSA,
influenza, contact precaution, filter, airborne precaution, patient transportation, ethical principles, four d’s,
beneficence, etc. nursing process, pain management, Maslows, informed consent, nightingale, NGN, vital
signs, documentation, communication techniques. Medication administration, patches.
FOCUS ON NEW MATERIAL & TOPICS YOU FUCKED UP ON! (75 Questions.)
 QUIZ/TEST 4 Abdominal Assessment, Abnormal and Normal/ Conditions Gett
in
Ther g
e
Peristalsis/ BM: actual movement of the intestine: Condition:
Bm: pop! Appendicitis: inflammation of the appendix.
flatus: GAS Right lower quadrant the pain is found
what-is the cause: dietary intake, stool stuck, bacteria.

Diverticulosis: (inflammation) S&S: peri umbilical dull pain (top of the umbilical) that will radiate to

Sigmoid part of the colon, is the last part of the the right lower quadrant. Nausea,

large intestine. (Left lower quadrant) treatment: surgery

a pt comes to the ER constipation. No BM. they feel MC BURNEY POINT: (right lower quadrant) 2/3 of the

Danger decrease in bP AND HR. Nasal vagus weight DOWNWARD towards anterior superior ileac

response. Baring down is dangerous. Can lead

to death! a little pouch form, called diverticulum . Diverticulitis
part of the intestinal wall becomes stool get stuck in the litle pouches. Inflammation and
weak.
infection occurs.
2/ 3 days liquid diet so bowel can rest
Constipation:
Causes: no fluid, low fiber diet, no exercise, immobility GERD
age. Hold poop! ignoring the urge to defecate. Don’t The lower esophageol sphincter: come on top of the
eat probiotic. Children potty trained stomache. Pt eats food, the food become ebonies to the
how to know: change in BM. Brown, consistency, hard process of peristalsis. Food is taken down the sphincter.
prevent: 2-3 l. Of fluid. Whole grain, bread cereal, the acid will move back up.
pasta, prunes, fruit, veggies, cottage. Drinking hot * other cause: hiatal hernia: weak diaphgram
fluids increase peristalsis. NURSE EDU: spicy, acid food, tomato sauce, carbonated
beverage, caffeine, chocolate. Chilly sauce, grape,
Parelatic ilius: blueberries, pineapple.
absent in bowel sound in the small intestine. No eat 3 hrs before bed, pillow head of the bed, take
peristalsis: little very diminish movement. small frequent meal., semi-fowlers position.
pt goes to surgery and dr. touch small and large first: CHANGE OF DIET AND THEM MED IF DIET
intestines. Once pt is in recovery, pt will have little or no DIDN’T WORK.
peristalsis. 👩⚕
Peritonitis:
Inflammation of the peritoneum, (the serous silk-like membrane that surrounds all of the abdominal organs) (EX;
appendix ruptures can lead to a severe infection which in turn causes peritonitis.)
a. Risk factors: Abdominal surgery, ectopic pregnancy, perforation (trauma, ulcer, appendix rupture, diverticulum)
b. Manifestations: High pulse, high blood pressure, dehydration, pain, decreased bowel sounds.
c. Nursing care : IV & Electrolyte,
 Crown VS ULCERATIVE
COLITIS:
Crown D.
Can occur any where. If it happen in the large intestine
increase risk for colon cancer.
s&s: abdminal pain, indigestion.
cause: genetic component, stress,
colorectal cancer screening: colonoscopy: to see actual
lining 45 age every 10 years until 75.

ASCITES: FLUIDS in the

abdomen
ULCERATIVE Colitis: only in the colon which is
Barring down: trying to have
the large intestine. Inflammation in the inner
a BM
liner of the colon
The nurse should restrict fluids for a client who S&S BLOODY diarrhea, abdominal pain
has cirrhosis and ascites due to the client's risk
for increased fluid retention

BARRETS ESOPHAGUS: GERD and reflux is constantly baking up meaning pre-cancer

Colocistates: inflammation of gallbladder. Which is in Nocturia : urinate during the night

the right upper quadrant pain can generate right Void: meaning urination
shoulder pain BPH: Benign prostatic. ( no pee in mens) only void little
No food high in fats and lipid bc no able to digest it by little can lead to UTI. Enlarge prostate
well. How to Performed Assessment

Inspection
Auscultation Inspection: *Contour
Percussion *Look skin *Lay down as flat as possible
Palpation *hair distribution *symetry
*striea *surface motion
*lession *breath in and out
*scars *limited movement: peritonitis
Meaning intra-abdominal *pulsation: orta, *linea negra
Bleeding anurism *distention on the abd.
*discoloration: *demenor: little movement. Which is normal
Cullen: bluish color *ripping affect: early intestinal obstruction
 Shapes:

Flat: normal
Scaphoid: anorexia, mal nutrition.
Rounded: toddler.
protuberant: pregnancy, acidic, obesity

Movement by looking:
Smooth movement: normal
limiting movement: inflammation of the peritoneum. EMERGENCY

AUSCULTATION,- Percussion
All four quadrant: like a clock,
Bowel sound: diagram listen in all four quadrant.
percuss for Dullnes: over the organ.
Leave it there and wait in each quadrant
on the intestine will be tympani
5 to 35 per min is normal. Active B.S
extremen fluid = DULLNESS
BORBORYGMI: increase in peristalsis, stomach
chek span of the liver: liver enlargement 6 to 12cm
growling
changes! don’t go crazy!
if you don’t hear anything. Stay in each quadrant for
kidney: for tenderness indirect or direct percussion; if
5 min. Until you hear something
tenderness meaning. POSSIBLE UTI.
hypoactive B.S less than 5 per min.
causes: constipation, late intestinal obstruction bellow
the obstruction, opiods, immobility.
Palpation
Peritonitis: hypoactive BS. Paralytic ileus, and
light and medium
preganancy
Right lower quadrant but if pt have pain leave for last.
hyperactive: > 35/per min. Hunger, diarrhea.
*location
Absent: no BS
*size
BRUITS: only the bell, if bruit present meaning
*consistency
narrow arteries.
*tenderness
a. Palpate stool.
 Contium of abd

Rebound tenderness: also blumberg sign : positive is possible peritonitis or appendicitis

Push down and slowly and deeply then lift up quickly.

Rough it sign: same just specific to appendicitis. Always left lower quadrant place hand at 90
Quickly release if pt have pain in the right. Meaning it is positive for appendicitis.

Positive Murphy’s sign: the pt stop breathing in and winless

with catch in breath
Examiner below costal margin in the right side at the mid clavicle
line.
if they wince and stop breath it is positive for acute
colocistatis

Test for appendicitis

Blumber signs
Rought it sign
Mcburneys point: where the pt feels the most pain

Ilipsoas or Iliossoas muscle pain

Appendice is inflame come contact with the muscle have pain.

How to perform ?
Pt lift right leg straight up and flexing and push up over the lower part or the right tight and if it produce pain it is
positive for appendicitis.
•Obturator muscle test
•Performed when you suspect a ruptured appendix or a pelvic abscess
•For the obturator test, lift the person’s right leg, flexing at the hip, and 90 degrees at the knee. Hold his or her ankle and rotate
the leg internally and externally. There should be no pain.
if produce pain in the right quadrant it is possible appendicitis

Read chapter 47 potter book

Colostomy Stoma pink/red

Ileostomy vs colostomy
Ileostomy consistency is liquid
Stoma: actual petrution of the
more than colostomy. Yellow and
stomach.
greenish. Frequent drainage
pt. Edu: drink a lot of electrolytes
up to 6 time drain the bag

Colostomy is brown thicker

bc is in the large intestine
Pt edu: 2 o 3 day normal
Asses self esteem:
bleeding around the side.
check for cutting circulation How to clean: soap and water
stay away from raw
veggies, beens bc bag can
blow
Chapter 45 potter book add more
Nutrition

Probiotics: constipation helps fiber: whole grain bread, cereal, Potassium: bananas,
women with natural flora and pasta, but also a carbs. Carrots spinach, potatoes,
immunity and gout in the intestine: high in vitamin A as well, veggies oranges, raisins,
butter milk sour bread fruit in general cabbage and apricots.
Yogurt and cottage cheese. cucumber, flax seed.

HCT
Iron: sea food, beef, red beens Labs for hgb: MALE: 41 TO 60%
Raising, spinach, apricots, and dry 12- 16 g/dl (women) WOMEN: 36 TO 48
fruits. 14-18 (male)
TIBC less than 240 mcg/ dl
Absortion help with vitamin C 240 TO 450
 S&s FOR iron deficiency What recomend: iron if that is not enough and it is really low
Fatigue and pale, korlorychia Dr. will order iron pills. What usually helps to vitamin C
(spun, shape nails) IRON MED ALWAYS WITH ORANGE JUICE.
stool get darker is bc of the medication it is normal.

Protein: main one beef, fish, Carbs

vegetarian a soy bean, peanut butter. At least 100 gram per day. if a pt have diabetes avoid carbs bc
Eggs, butter is fat and FAT TURNS into sugar, fruits are cut only 1 fruit per
copd pt and wound healing day , lentils, potatoes, pasta, honey, nuts, seeds, bread, rice,
pees, corn syrup.

Fats: Clients who have type 1 diabetes mellitus

Omega 3: fish, help with coleopteron should limit carbohydrate intake.
mono: less than 10% per day avocado olive oil, good healthy fat, Nonnutritive sugar substitutes allow the
walnut increase levels of cholesterol client to sweeten the taste of foods
saturated: red meets + cheese. without increasing carbohydrate intake.
trans fat: fry food, is bad! wherever fry come to your mind
stay away from it. Lactose free: recommend free:
*soy milk, hazelnut milk, rice mil, oat milk,
Vitamines
*if pt have crown disease: want to reccomend
Fats vs soluble vitamins: lactose milk.
A, D, E, k Water soluble
Vitamin D: SUN / supplement, cod, salmon, Vitamin C: acidic food, kiwi, lemon, grape fruit and
tuna, needed for calcium absorption, produces tomatoes. If the pt has a deficiency: start to feel like getting
a hormone called calcitrium: if pt doesn’t a coght.
produce Vitamin D not enough calcium. High Needed for wound healing, bruising can occur. Inflammation
risk for bone density problem and of the guns. Black teeth, scurvy, gingivitis. If pt is low.
osteoporosis. Children that have high low V.D
SEVERE bowlegs
HELPS WITH THE ABSOPTION OF Vitamin A: decrease risk of cancer and helps promotes healthy
CALCIUM , MAGNESIUM AND growth
PHOSPHOROS. E.g leafy green, carrots, and sweet potatoes,
vision changes, impaired nigh vision bc is needed for the production
of the rhodopsin
 Vitamin E: INMUNITY, also helps with to Vitamin K: interact with anticoagulant (warfarin)
decrease masses, if the pt has breath Stay away form. Food high in K
lump decrease
Search for food types!!!! Supplement is
Water soluble of VB12: injection, shots, soy been, seaweed.
the best option because is the highest.
If pt is deficient: swollen thong, microcytic anemia,

Diets

Npo: nothing by mouth

Full liquid:
Clear diet:
ice cream, milk, yogurt, puree diet, custard.
any liquid that is clear, little to low color.
mechanical soft diet:
Pt that have diverticultisi: plain gelatin, water, apple juice, sprite.
mashed potatoes, ground beef.
regular diet: low in carbs.

Nutrients. Power point

Macro nutrients: carbs, fat, protein

Micro: electrolyte, small amount,
water at all times
Continue of Vitamin
Assess for BMI
QUESTION TO ASK: BELLOW 18.5 UNDERWEIGHT
Have you loss weight?
HEALTHY 24.9
what of you eat daily basis?
overwheight: 25-29.9
any chronic illness, can be due to a malnutrition?
obese: 30 and above
look at lab value
difficulty swallowing? check!!! assess pt
albumiun level Diet pt might be doing? Ask
hemachrotic Excessive exercise?
measure ask
ask
 Anorexia
Nurse Main goal: establish rapport with the pt
pschy disease
Weight pt daily
Maybe genetic component is not known
low bone density: because not enoght vitamin osteopenia
mainly affect adolescent
two types
S&S
restricting ( food intake is voluntarily limited Lanugo hair: soft and sheer like baby not enough adipose tissue
purging (pt engage in putting after eating) Amenorrhea: no menstrual
intolerance to cold: always cold
hair is soft
worry about food:
low calorie intake
become a expert in this topic is important!!!!!

Bulimia
More weight than anorexia also psych Severe the amount of food.
People who have bulimia eat an excessive amount
Two types
of food in a short period of time and the throw it
Purging:
out
Non-purging: extreme period of fasting and extreme exercise.

Malnutrition

Marasmus: very dangerous to reseed the pt. Don’t give a lot of food.
Everything is severely low!!
albumin is decrease, pt will be deficient and dehydration

Kwashiorkor: low protein level.

if pt is deficient in protein rounded belly is because of the protein and fluid just sips out in the tissue other sing is
edema. Abdominal bulging, failure to eat.

Pregnancy
Pica: is when you want something that you can’t eat like paper, napkins

Stay away from alcohol.

Older adult
See what they want to eat monitor nutrition intake.
 Enteral Tube Feeding Chapter 54: ATI BOOK
Throut the GI Tract :
Enteral tube feeding two main one Use for feeding, decompression
nasogastic tube and percutaneous tube Lets say that the pt is overdose and need a lavage
NG AND PEG

Less than 6 weeks NG TUBE

Indication: More that 6 weeks the PEG TUBE
Decompression: removal of gas on stomach ONLY SURGEN FOR PEG TUBE
feeding: alternative to oral route
lavage: washing out the stomach
compression: using an internal ballon to apply pressure

PEG TUBE is in the stomach only surgeon again!!!!

NG TUBE NEEDS DR. ORDER! Look for steps on the book page 334
Is not sterile procedure! 90 degrees position
High fowlers position PH should be less than 4
difficulty swallowing NOT NG TUBE
tip of the nose tip of Ask the dr. to get chest X-ray make sure
the earlobe and then to is not on the lung.
syphoid of the sternum

Pt head needs to be elevated at less 30 degree or 90 What to do first

Pt always need water unless is not contraindicated!! Verify the placement, check X-ray and PH is less
Is usually ordered!
than 4
After 24hr, formula needs to be discarded
* residual volume with the syrenge more than
every 4 hr check residual volume
250ml meaning is not tolerating
continues or intermitente depending on the dr. order
* place residual back on the pt
*flush with 30 ml of water
* give med via gravity and slower, the lower the
when you place pt formula check for date and name of
faster
the pt
*monitor the pt how are they tolerating the feeding.
my initial don’t forget time!
Complication with NG TUBE
*diarrhea
*cramping (room temperature the formula)
*constipation
* dehydration (how much water are you giving to the pt 30 ml every time)
*regurgitation (what to do? stop feeding, turn pt to the side, suction the air way to the pt, give oxygen, check lung
sounds,
 Nausea and vomiting: just slow the rate make sure pt is at 30 degree angle

Total parenteral nutrition vs PPN

TPN PPN
Pt is unable to digest or absorb enteral nutrition *Suplement, still eating by mount is only that they
peripheral or central straight into the heart!!
* need supplement throught an IV
contain glucose, dextrose, protein, vitamin, mineral, lipids.
not central line only IV
s&s hyperglycemia *LOWER in nutrition
The 3 P
Polydipsia: increase thrust If they stop the feeding check for hypoglycemia!!!!
plyuria: increase urination
polyphagia: increase hunger.
 Must know lab values for urinary elimination
urianalysis
Exam 5 Make sure to look at this labs

uryanalisis Red is a must know!!!!!

* specific gravity: concentration of urine: 1.005 to 1.030
let say the pt is dehydrated: more waste than fluids, the lower the # the less the specific gravity
* Protein: 0-8 mg/dl: not normal you fund it unless kidney are not functioning. Urine is foamy
* glucose: < 0.5g/day increase in diabetic pt.
*GFR: < THAN 60 is kidney disease
* nitrates urine contains chemical but bacteria convert in nitrite: is a sign of UTI
*ketones: none: unless they have diabetes ketoacidoss PH IS 4.6 TO 8
* WBC: unless pt have an infection: 0-3 males
* WBC: 0-5 WOMEN
* RBC: hematuria
*CREATINE is chemical waste produc is to supply energy to the muscle: in blood/ urine
in blood males:
0.6 -1.2 mg/dl
women: 0.5- 1.1 md/dl if it high meaning kidney is not functioning well.
BUN: how well is being filtered in the blood. 10-20 mg/dl
should not be in the blood
type of test

Creatine in the blood test is 24 hr urine collection to see how urine removed the waste
Nurse to do: big urine container place in ice at all times.
Tell pt first thing in the morning the first void you DO NOT COLLECT IT. AFTER THE first time collect. Collect the
last one until you get to the 24 hrs. *** kept in ice***

PH DIPSTICK TEST : for UTI > URINE CULTURE: TO SEE Mid stream:
no the first drop of urine
than 8 is possible UTI WHAT specific bacteria is
In the middle of the stream wipe front front
causing the problem.
to back. First is very concentrated so wait.

IV pyelogram: Ask if they are allergic to shellfish, Bladder scan: you have a pt and
moving picture of the kidney uretaer and measuring I&O pt hasn’t voided in 6 hrs.
seaweed.
bladder. Perform an assessment and didn’t work.
Women no pregnant when was the
Inject iodine is an xray suspect of Do a bladder scan first time not need dr.
last menstrual period.
kidney stones. Intravenous bc they order. 250 ml of urine retention.
inject iodine
 Minimum 500 ml in the bladder pt at least 400 ml/24hr.
Normal 30ml/hr
Greater : polyuria: than 2.5 L of urine a lot of urination
Min. 400 to 720/ 24 hrs
Held by the bladder : 500 to 1000
Urinary Elimination

Less than 400ml/24 hr called oliguria Children: up to 5 years they suffer from temporary incontinence.
Void 1 to 2 l per day > polyuria
Bladder signal name is urge or urgency brain signal to relax the sphincter
Another word for urination is call micturition
urine is sterile shouldn’t t have any bacteria

Urinary retention cause to meds( anticholinergic) or some trauma, men (prostate) UTI

Key words:
Anuria: failure to produce or excrete 50 to 100 ml/24 hrs = dialysis
oliguiria: reduce volume 100 < 400 ml/24hr
polyuria: > excessive production or excretion
nocturia: urination at night
dysuria: painful urination ( Infection, kidney stones) toilet paper, unscented soap.
hematuria: blood in the urine ( infection, kidney stones
urinary incontinence: the inability to control urination:
2 types:
stress incontinence, coughing, pregnant =pressure in the bladder, when person is laughing unable to hold
the urine
urge incontinence: pt can’t hold it bladder squeeze and lost of urine
mixed incontinence: stress + urge incontinence.
functional incontinence: unable to reach toilet in time.
urinary retention: inability to control urination
over-flow incontinence: weakened muscle in the bladder, due to spinal damage, nerve disorder, the why is
called incontinence is bc overcome the control also have urinary retention, bladder is unable to control
bladder become distended and palpable.
neurological incontinence: problem with nervous system, no warning
Temporary incontince in Children less than 5 years old.

Urinary retention

Bladder not able to empty due to BPH (Benign prostatic hyperplasia), anticholinergic med, and bladder stones.
 For stress incontince test

Kegel exercise: also pelvic floor muscle prior to child birth

Void or really empty close their eyes and hold the sphincter.
UTI
Most common acquire hospital infection
S&S
# 1 way to prevent, make sure pt doesn’t have any foley Confusion in the elderly
Higher risk than males: WOMEN bc uretra is shorter than men
dehydration: urgency: frequent urination
immobility cloudy urine
diabetic bc of glucose. flenk pain
improper hygiene wiping from back to front
hematuria
not voiding after sexual Intercourse
fever
Prevent
* 2 to 3 l of fluid
*void if they need
*use shower instead of bath
* wipe of front to back
* foley Cath never leave for
long period of time.

Renal calculi = kidney stone

Over production of calcium lead to calcium over production kidney stone

Food high in protein: purine red meet can lead to renal stone why there is an increase of purine it create urine acid and
form kidney stone.
another word for kidney stone is renal calculi
dehydration: urine become more concentrated can also lead to renal calculi

Catheter different types invasive and non invasive = external

External catheter are good in the

# 1 thing is toilet schedule, Cathe is not the first thing to do
defens, reduce risk
Incontinece is bc they can reach the bath in time Watch how the pt is sitting are
chances of delevoping deep tissue
injury
 Primo fit is for male external catheter is Prima fit for women is external labia minora
similar to Condon, tube and fully bag is not suction the urine less risk for infection
inside the pt everything is collected in the why would you pick than one instead is bc is less
bag less risk of infection invasive

Toilet scheduling always # 1 Purewick looks like a little banana is going to

# 2 external catheter suction the urine
Also external
Not external invasive
Indwelling: highest risk for UTI CONECTED
Straight catheter: sterile procedure, do not stay in the pt
TO THE FOLEY BAG, 3 lumen and 1 for
will use this one if 250 ml of urine also to detect Anuria
irrigation, but only dr. order. Don’t go crazy with
Coude catheter: is a catheter can be straight and irrigation. STAY 3 TO 7 DAY
indwelling
Main thing it has a curve tip. Is for pt that have blockega, Steps for straight before, ask pt to bear down to open
even you get small size, inner tip curve upward up the uretra meatus. Is for both males and females
Question in the specialty

Always ask your pt if they are allergic to iodine, fish or clorohexine

Or shellfish, mango, sea fish before insert foley reason Always need dr. order!!
that have urinary retention Please dr. for urinary analysis to place
pt that are IN ICU and remove need dr. order and ask the
PT how are going to surgery proxy before inserting.
always lets them now that you will damage the urethra and hematuria
prior insert asses abd area.

Bowel elimination
Colostomy and Ileostomy musk
know again
Factors influence:
Know difference vs diarrhea and constipation
dehydration: S&S
Obtain stool specimen collection

tumblade and placement on specimen cup

Label
Biohazard bag
not sterile on stool UNLESS dr. order.
 Best time is after meal for pt to POOP!!1 :D

valsava maneuver: decrease blood pressure and HR. HOLD YOUR Breath
Do not place finger on the anus!! DON’T
Up t 3 days if taking colace.
DO AS DR. ORDER enema!!
Laxatives:
Nurse change the pouch, the AP can empty the bag!!! know to promote stool and what is given to
Stoma nice and pink prevent anti diarrheal
how to clean soap and water
empty the bag 1/3 full
assess skin irritation, no purple. 1 hr after meal increase peristalsis, read guidelines!!

musculoeskeletal

Inspection: look at posture, how are they standing, looking at alignment, skin, swelling, redness, mases,

Look contour of the should pt have to be straight, even shoulder blades, scapula, no ribs are the same, not proturion.

Scoliosis Lordosis Kyphosis

Excessive curvature of C curvature: more than 50 degree
In middle school test. the lumbar and curve on curvature of the spina
How to perform test: the spine Scutch back
1. standing and look Pregnant women most elderly: bc of muscle weakness
2. bend forward touching the common. Osteoporosis increase the risk for
toes and kyphosis, poor posture.
3. . hem palpate the spinal muscle weekness in the upper back
Shoulder: uneven,
Ileac crest un even
prominent bridge cage
 Palpation:
Check for temperature with back of the hand, warm
Any sites that feel tender use PQRSTU
range of motion
passive and active
passive ROM: the nurse make the excessive, you help the pt move the arm to the point of maximal resistance.
active: they do it themselves, the nurse doesn’t have to help her.
also palapte for crepitus: air bubble is benign air trap within the joint

Muscle testing: scale form 0 to 5 and the nurse

assess and score the pt
Star with upper extremity: push against my hand,
don’t let me push down
edema:
carpel tunnel:
Temporal mandibular joint.

INSPECT HANDS: make sure have digits,: finger deviation, and the shape.
 Osteoarthritis & Rheumatoid Arthritis

Osteoarthritis Rheumatoid Arthritis

Unilateral Bilateral

Non- inflammatory bc breakdown the cartilage Inflammation of the joint

Stiffness Heat
bony prominence Warm
pain with motion on Bony protuberance, Pain
swelling Swelling

↓ ROM ↓ R.O.M.
bony swelling proximal closer midline of the body
fatigue
#1 reason is obesity bc of more weight
anorexia ( low bone density)
elderly î
weight loss
smoking î
low grade fever
happy: heberden node: bony swelling of the
distal interphalangeal joint swelling of lymph nodes.

birthday: Bouchard node: bony swelling of the ↑ the risk of C.V.D & Heart attack
proximal nterphalangeal
Morning stiffness improves in the
heberden node afternoon
Bouchard node
joing affected are smaller: hands,
wrist, hips and knees.

Ulnar Deviation
 Muscle test
Carpel Tunel syndrome : → for osteoarthritis or R.A.

compression of the What would cause the

medium nerve. Leads medium nerve to be
of pain and tinglen compress? typing, drawing,
found at the level of hair styles, pianist, sewing
Carpal ligament Median nerve the wrist Anything that uses the wrist
movement.
Tendons
Tinel test
Direct percussion of the
location of the median
nerve at the wrist if
produces burning and
tingling it is positive

Rotator cuff tear: consturction Phalen test

worker, meet cutter, baseball
player Ask the pt to hold both
Rotator cuff lesions may cause hands to back while
limited ROM, pain, and muscle flexing the wrist 90° for
spasm during abduction, whereas 60 Sec. If produces
forward flexion stays fairly burning and numbness it
normal. is positive
 More muscle testing
Temporamandibular Joint. (TMJ)
Place the tip of your first two fingers
in front of each ear ask the pt. To
open and close the mouth audible and
click is normal as the mouth open (but)
an audible click, crepitus and ↓ R.O.M.
& inflammation is sign of arthritis

Lower extremities "hip test"

Thomas Test
Bend each knee up to the chest Normal condition
while keeping the other leg
straight
Limited Motion
Pain with motion
If revels a flexion deformity in
the opposite leg it is positive for
Thomas test.
+ for lumbar lordosis
Restricted condition

Romberg Test
Ask the pt. To stand up with feet together
and arm at the side once in a stable position
ask to close eyes and to hold the position,
wait about 20sec. Normal pt maintain
posture. + loss of balance
Positive: occurs with cerebellar ataxia
(multiple sclerosis or alcohol intoxication)
 Trendelenberg test

Used to test any weakness in the

hip or hip joint dysfunction
how to perform
* pt stand and balance first on one
foot and then the other one
observe form behind, notes
asymmetry or change in the level
of the iliac crest drops
Test for scoliosis

Knee
Bulge sign Ballottement of the patella
The bulge sign occurs with very small
amounts of effusion, 4 to 8 mL, from Large amount of fluid are
fluid flowing across the joint present between or inside
Presence of the bulge sign identifies pt the patella
at ↑ risk for knee pain and progressive
osteoarthritis of the knee.

Swelling in the suprapatellar

 Special test for meniscal tears

McMurray test = meniscal tears On pt who had trauma, local pain, pain
m& m that goes away.
Hold the
Heel and flex the knee and hip.
If you hear or feel a "click" it is +

Anterior and posterior drawer test:

instability of cruciate ligaments

•Patient lies supine and flexes the knee

45 to 90 degrees, placing the foot flat on
the table.
•Draw the tibia forward and backward,
forcing the tibia to slide forward of the
femur.
•Anterior or posterior movement of the
knee greater than 5 mm in either
direction is an unexpected finding.

•Lachman test: anterior cruciate

ligament integrity
PULL off if you feel mushy is
positive it should feel firm
 •Varus and valgus stress test:
Varsus Valgus instability of lateral and medial
collateral ligaments
Externally rotate the tibia at the level
of the ankle and feel at the knee if
there is any clicking and if the pt feels
that and pain meaning positive

Assistive Devices for walking (important)

Walkers are extremely light and are about the wait high and made of metal tubing

Standing bc there is nor wheels: hold with upper arm right fit place hands to side and has to be at the level
wrist crips that’s how you know is the proper and when the pt place have to be 15 degree elbow fixation
Look straight ahead and tripod postion an imaginary upside down triangle
if you pt begin to fall and bring the pt down to the floor!!
walker is place 6 to 8 Inches .
# 1 step
# 2 walker
# step
the nurse have to be on the weak side of the pt

Canes
How to know proper fit:
Equal to distance to the greater trochanter all the way to the floor + elbow flex 15 to 30 degree curvature
where do you place: in the strong side if the body
cane always forward place 6 to 10 inches infront
not lean
 Most pressure have to be on the strong side Crushes: should never be share only for pt

# 1 cane Alwasy start 12 inches to the front them 12 inches to side

# 2 weaker leg at the Level of the cane prper fit: 3 to 4 finger away form the axial (paralysis

# 3 stronger pass the cane risk)

pt have to be strong
elbow flex at 30 degree angle

4 points: exact same thing move on at time

2 points: meaning 2 things touching the floor at the

3 point gate: have crush and weak leg is not goin
same time.
to touch the floor.
Right leg is the weak, move the right at the same time
Move crush and them the bad leg and the right and
pass the crushes
Stairs: how to go up ( good ) and down ( bad )

Swing 2: swing to the level of the crush To go up bring the good leg and goo up the step follow
Swing through: pass the crushes by the bad leg
Down bad: to go down the crushes and the bad leg is
To sit on a chair: place both crushes on the strong side first followed by the good leg.
And them to go up place the crushes in the

Need a gait belt the first time

*First you sit them in bed
*Ask them if they feel light headed
Document everything you do in the pt:
*dangle their feet
Anti embolism to prevent dvt
make sure they don’t get dizzy
every 8 hrs compression sock and asses circulation
*lower the bd in the lowest position
every 30 min.
not transfer the pt always make sure the bed is at lowest
check lower extremites
position
asisstive nurse can help but better the nurse to asses
* sit them in the wheel chair make sure break and place at
30 to 45 degree angle
never use you back to transfer the pt alias knee. Boot to put air to promote circulation the AP can help to
prevent DVT. IS BLOOD CLOTH IN the bed
 Important word
Ischemia: reduce blood flow
Hemiparesis: weekness on one side of the body ( pt had stroke or cva)
hemiplagia : paralysis on one side of the body
paraplagia : lower body paralysis
quadriplegia: inability to move all four extremities. (dvt, uti, turning tpt
every 2 hr, passive ROM.

Inmobility
If the pt is inmmobily know prevention: what are they are at risk for ?

GI disturbance: bc you know peristalsis decrease . Indigestion

Decrease in calcium.: lead to muscle atrophy, hight risk the pt develops osteoporosis, low bone density
( ostopenia) ROM is important for this pt calcium is excreted by the kidney.
Constipation: will occur not drink bought water fluid fiber, probiotic
atelectasis: lung collapse ( consolidation) how to prevent is best way to use incentive spirometer.
hypostatic pneumonia: lift them at 60 to 90degree angle also incentive spirometer
anticoagulation: lovanox low molecular dr. may order
reduce blood clots. To prevent use stoking
UTI: PREVENTion must know again!!! GO BACK TO YOUR UP NOTES.
Foot drop: can damage the perineal nerve.
orthostatic hypotension: that’s why you need to dangle feet.
last one pressure injury ( go back again to your notes)
 Topics for Final Exam
Chapter 42. 57& 58 A.T.I.
Fluid & electrolyte
Are essential to maintain osmostacis any or in Electrolytes such as "k" have bad
effects E.g pt. With hypokalemia or hyperkalemia they may develop dysrithmias

Disbluants = wherever you use to dissolve

Balance is needed.!! Osmosis = The movement of water to semi
Solutions permeable membrane
Inside the cell = intracellular
Anything outside the cell is extra cellular HO2 Na
Water follows Na like men follow women

3 types of I.V SOLUTIONS

Isotonic: Hypertonic Hypotonic

ISO = equal High amount of sodium 3%, & 5% *Good for diabetic ketoacidocis (DKA)
Equal concentration from the Treatment for: Becareful :c bc is going to take all the
outside and inside of the cell hyponatremia fluid from the CV system.
cerebral edema = reduce pressure of *Lower volume than the pt body
Example: lactated ringer or L.R.
the brain *is a normal solution
0.9 % NS
cystic fibrosis *lower Na——>0. 45%, 0.33% &
What pt can take it?
severe bronchitis: they fluid to flush D5W
= amount of hydration who needs it?
mucus is dextrose solution is 5 % water:
*Pt. With burn:
Low sodium level only in ICU when dextrose is metabolized it
* pt who is dehydrate
CAUSE is becomes HYPOTONIC.
*vomiting & diarrhea
the water will travel inside of the cell
you want to have the cell Water shift outside
bc there is Na high concentration
hydrated. the cell
EXAMPLE: you have a pt with
There is Na" inside and outside INCREASE ICP (INTERCRANEAL
of the cell PRESSURE) 0.33% NS what can
You need the pt to have equal Breaking of the cell happen MORE SWELLING
amount in concentration nurse needs to
DKA = cell is Lower volume than
dehydrated pt body fluid ↓ in
Na"
Isotonic = 0.9 % N.S. Hypotonic= lower # Hypertonic =bigger #
0.45%,0.33 % & DSW 3% & 5%

Acid Base Balance

Respiratory system= regulate Carbon dioxide Exhale = Carbon dioxide
Excreted by kidneys
pH = measures how acidic or base is the blood
Ranges: 7.35 to 7.45
PAC02: how well is the lung
: less than .35 acidosis & more than.45 alkalosis
functioning to exhale
PA02: 80 to 100
PAC02 35 to 45
amount of oxygen found in artery
If pt have less than 35
Partial pressure of oxygen how well lung are
* panic attacks = leaving more
functioning to pull oxygen into bloodstream
*Anxiety
Low hypoxemia= low oxygen level
*Pregnancy
Anything that causes hyperventilation
Respiratory alkalosis
* pulmonary embolism
Is when pt blows up C02= hyperventilation
Panic attack= a bag to keep the CO2

Respiratory acidosis = pt. Retains C02

What types of condition < than 35= alkalosis Paco el viejito de Hialeah
COPD Less than 35 = alkalosis
> than 45= acidosis More than 45 = acidosis
Bronchoconstriction : asthma
Decrease expiation of chest=
Chest trauma
Opioid
Hold breath under water long period
of time
Airway obstruction
Anesthesia
 Bicarbonate
HC03 21 to 28
Metabolic issue: Metabolic alkalosis: suctioning a pt to
Metabolic acidosis: get rid of acid, vomiting
Furosemide
Overdose of aspirin Loop diuretic
Any condition that comes from the Greater than 28
ass
Diarrhea , ileostomy drink to much
Consumption of bicarbonate
Less than 21 Practice PH: 7.35 to 7.45
PH: 7.23 PAC02: 35 to 45
PAC02 37 HC03: 21 to 28
HC03 18 PA02: 80 to 100
PA02 90
Metabolic Acidosis

Respiratory alkalosis PH: 7.30

PAC02: 65
PH: 7.050 HC03:22
PAC02: 32 PA02: 70
HC03 24 Respiratory acidosis with
PA02 80 hypoxemia

PH: 7.20 PH: 7.30

PAC02 49 PAC02 36
HC03 25 HC03 16
PA02 80 PA02 80
Respiratory acidosis Metabolic acidosis
 IV THERAPY: TYPES OF IV SOLUTIONS
Fluid in our body is found in 2 places: if

Intracellular & Extracellular

icf
Intracellular (ICF) Extracellular (eCF) if

is Fluid INSIDE the cell is Fluid OUTSIDE the cell icf

(Millions of these cells in our body) iv if

icf
Interstitial (IF) Intravascular (IV)
is fluid that
is plasma in
surrounds the cell icf
the blood vessels
AKA fluid in the tissues if

HYPERTONIC "Enter the vessel from the cells"

5% dextrose in 0.9% saline (D5NS) USES
• Cerebral Edema
5% dextrose in 0.45% saline • Low levels of sodium (hyponatremia)
• Metabolic alkalosis
5% dextrose in LR • Maintenance fluid
• Hypovolemia

More concentrated & ↑ osmoladity

ISOTONIC "Stays where I put it"

0.9% saline (NS) USES
Used with • EXPANDS intravascular fluids volume &
Lactated Ringers BLOOD replaces the fluid loss associated with...
PRODUCTS • Burns
Ringer’s lactate (LR) • Hemorrhage
• Surgery
5% dextrose (D5W) • Dehydration
Same osmolality as body fluids ➥ Vomiting & diarrhea
(ISO means Equal) • Also used for fluid maintenance
(Equal water & particle ratio)

HYPOTONIC "Go Out of the vessel" & into the cell" In DKA, there is
so much glucose
0.45% NS in the cells
they need water!
Fluids goes Out
of the vessel &
into the cell making
2.5% Dextrose Uses
• Intracellular dehydration such as DKA
the cell SWELL!
0.33% NS • Never give to clients with burns
"Water flows where or liver disease
More diluted & ↓ osmolality sodium (particles) goes" • Helps kidneys excrete excess fluids
(less salt, more water)
© 2021 NurseInTheMaking LLC 31
 Continue of fluid & Electrolyte
Summary chapter 58 ATI
Electrolyte Imbalances

Focus on Na in the blood and is less than 136

Sodium: Na 136- 145mg/l What is the risk: vomiting, diarrhea, excessive water intake why: bc is
> hyponatremia less than 136mg/l going to dilute the na. And don’t eat a diet normal in na everything
> hypernatremia more than 145 mg/ l you eat low in na. RISK FOR HYPONATREMIA
it apply to all hypos:
Tx: drink less fluid DON’t STOP S&S: confusion main sign, cause and vomiting, unsteady gate
Assess pt specially in elderly, lethargy, headache & fatigue.
high sodium foods
olive, cheese, condiments, Hypernatremia: greater than 145mg/l
severe Na: THEM hypertonic solution. Due to: no enough water = dehydration, kidney failure
PO is first choice!!! S&S: increase in body temperature, thirsty, weak
gradually overtime bc increase seizures. pulse, irregular, mucus membrane dry, muscle
twitching, flush skin: red skin. Urine ouput:
BOTH IF THEM tx: MONITIOR i&o GIVe Iv fluidD lactated ringers.
LETHAL ARRITTHMIAS die low in Na.
K AND NA
Potassium K 3.5 - 5 Mg/l
Hypokalemia
vomiting diaphoresis, low diet in K,
oranges, apricots, bananas, TX: iv K and slowly bc heart can Hyperkalemia > than 5
mg/l
S&S: weak and irregular pulse, stop!! That’s a way to kill your pt.
Pt edu in eating high in K Due to: kidney function, k sparing
arrhythmia heart is uncontrollable.
pO : K PILLS don’t crush diuretic, weak irregular pulse,
Weaknes, fatigue, hypotension, bp is
dysrithmia , huypotension, numbness
going to increase,
and tingling= paresthesia.
respiratory distress, cardiac arrest,
TX: lactulose, restric K in the diet
first sigh in elderly: sitting muscle
IV regular insulin with dextrose: a little
cramps like hay hay hay!!!!
transportation device, is going to to
shift the K into the cell.
 Calcium Ca
Hypocalcemia < 9 Hypercalcemia > 10.5 mg/dl
Vitamin D deficiency Risk: hypertyordysm ttoo much calcium intake, vitamin D
tyroid surgery: if the accidentally removed the parathyroid overload, thiazide diuretic
pt will develop hypocalcemia s&s dysrithmias, confusion, weakness,
S&S: pt 48 hrs after surgery, numbness and tingling in Tx: increase fluid to flush extra electrolytes
the finger, mouth and sole of the feet.
test to see if pt is low:
chuvostic: tap pt on the chic and if pt twitch
trousleous signs: the bp cuff leave for 5 min and finger
passing, wrist flexion. and ofc dysrythimiaa
tx: oral and vitamin calcium and supplement
and food that are high in ca. cheese, leafy greens.

Magnesium 1.3- 2.1

Hypomagnesemia: Hypermagnesemia
Risk: thiazides and loop diuretic. Risk: TPN, IV mag, po too much
diarreah and vomiting s&s: muscle paralysis, shallow respiration, dysrithmias
S&S: constipation, dysrithmias= paralitic ilius tx: monitor, magnesium free IV
tx: high mangnesium fluids, antidote, calcium glucanote.

Blood
Protein molecules that may or may no be found

Blood B
Blood “A”
Antigent molecules
Cell antigen the immune system doesn’t attack it.

Blood type “0”

Blood type AB
No protein or molecule on the surface of the cell
CARRY BOTH
Asian cultures mostly
O- negative is universal.

Rhesus factor: Hemolytic reaction: make sure pt blood type

Rh+ Rh-
AB+: universal receiver
A typing screen: screen blood type and see what type the pt has
Nurse do cross-matching : what they do is RBC aglutinate to avoid
hemoglitic reaction the don’t “CLOT”

Autologous blood: pt with history of cancer to current infection are not candidates for auto transfusion

Jevoba witness: always ask

18 to 20 gauge IV for transfusion

Need dr. order
Type screen and cross math do both!!

Consent is required: by the pt or the proxy Must know

Vital sign have to be taken, before, during and after no more than 1 hr before
ask the dr for med: Benadryl, tylenol is to avoid allergic reaction
infusion can lead to fever and STOP THE TRANSFUSION
If pt have cardiovascular disease fluid over load give diuretic to get rid extra fluids. 1 hr Despues.

Given within 30 min bc you can’t send it bag to storage 2 RN’s TO VERIFY ID BANd special (2 blood
risk for bacteria band) , ORDER REPORT AND the blood unit.
* you have to give he blood within 4 hrs. Risk for Special requirements:
bacteria can penetrate Pt name
* assess lung sounds anything that can signify a medical record order
transfusion reaction bc can happen 15 min later of the Expiration date of the blood before given.
transfusion.

Give blood with 0.9% NS only

Most reaction accord within 15 min with only 10 to 15 ml of blood

Reaction:

Hemolytic reaction: break Febrile reaction

down of the small cells
Whenever the pt is 2 degree increases
back pain, fever, flank pain and
Allergic reaction: shortness of breath
brown or red urine
XX ERROR in blood type XX
MUST KNOW STEPS
Start the infusion little by little: eg 10ml/hr, asses pt every 15 min.
Within the 4 hrs.
new tubing for 0.9% NS
 Loss & Grief
Chapter 36 & 37
Loss: The absent of someone or Grief: the pt response
something. Person, pet or thing & places to the absent.
the person has form an attachment.

Actual loss Perceive loss Ambiguous loss

Is unnoticeable, happens more Similar is not the same.
Someone family in the pshycologycals. happens after a disaster any
member just example. Best friend betrayed sort of the pt is in coma
passed away. you. In the mind the person is physical there. Suffer
not there. another example: psychological. Vegetal stage, if
divorce. someone is kidnaped.
this type of pt never
recovers.
Situational loss
Car accident, maybe pt had
amputation
not able to work in the
same place. Anything that
cause a change in life
style .

Maturational loss vs maturational grief

Maturational loss Grief signs and symptoms

When you move out and parent Perceive this person as
start missing you. not longer in your life.
loss is actual. Life development
toddler: seperation anxiety
Anticipatory grieving
Lets say pt is in hospice and is
really bad and you star grieving
also cancer pt.
chronic: Exaggerated: delay:
pt never finish griving, Is like extreme pt family die they
major depression response: result to drug don’t cry. But their
greater than 6 months is Mal-adaptive. dog dies and cry a lot

Mass grieving:
palpitation, blood
pressure, insomnia.
Normal vs maladaptive
Normal Maladaptive
*Heart Mal is bad
*palpitations *Chest pain: at says is normal but is
*agitated not normal. Chest tithnes
*anger *high blood pressure
*headache *pt that leave the room the same in 5
*inability to focus year parent loss their son 5 year ago
*weight loss and room is the same
*insomnia *smoking
*alcohol
*drug abuse

Stages of grief
Made by Elizabeth Five stages
Denial Denial: example: thinks dr. is playing or joking
Anger Anger: to the dr.
bargaining Bargaining: if god does this I will not drinks
depression
acceptance Depression: they don’t want to go out extreme depressed.
Hopeless. You have to screen pt for suicide risk. You have to
Acceptance: advace ask: have you ever tought of hurting yourself
directive. whats the plan?
not leave pt alone in the room
report to the dr. Inmidiatley
 Beaker acting: 1 to 1 observation and the nurse responsible if the pt kills himself.
Security will removed everything for the room.

Remember hospice vs palliative care

Always explore pt feeling

Post Morten care; go to ATI

MUST KNOW STEPS
CONFIRM time of death
STRESS
Eustress vs distress
Good and bad
How do you perceive stress? A challenge! Which is good.
Extremely bad stress affect the body: gastritis. When d
Stress appraisal is how you view stress!
New borns good stress
Marriage
starting a new Job
Acute vs chronic
Acute less than 6 months Chronic
Bad distress to for example f Pt that have chronic pain
someone is robe RA arthritis
knife, trauma, car accident, gun chrons disease
shot family dynamics: chronic
finances: chronic acute at certain
levels but mostly is chronic
 Stress can have negative effects in the body and decrease the lymphocyte of
the body and leads to infection bc lower the immune system
Sympathetic NS Parasympathetic
Kicks when you are stress
great load of it than can damage your Slow HR
organs Bronchial constriction
Fight & flight Increase peristalsis
pupil dilatation, increase blood glucose, increase secretion
increase bp, dilate airways (body gets
prepared the pt breath more to run
away) RR increase, urine retation,
increase HR
cold hands
increase heart disease.

Things that can be done to reduce stress

Sing deep breathing exercise

Draw meditation
jurnal pray
exercise avoid anything that make then
jeterdy
no coffee
debriefing: for nurse
 Ptsd vs acute stress disorder

ACUTE STRESS DISORDER Ptsd: post traumatic stress disorder

HIGH LEVELS OF STRESS Nightmare
over a periods of 1 months Flashback
Flash back major pt military and also nurses (second
insomnia victim syndrome)
nightmares symptoms begin after 1 month and last
Everything go back to forever
normal after a months or Different categories
so begin to settle down
Intuisive thoughts: war triggers that toughs
came back, no control just come back to them
They might see a fan and reminder a
helicopter, smell, they may see a certain
object, taste.
severe car accident
avoiding sysmtos
cognitive syndrome: guilt,
arousal: super alert, jumpy, agitated, jetardy

Compassion fatigue vs burn out

Feel compassion for other people and pshycolgycal general exhaustion lack
you take the energy at home of interest and motivation in your
You don’t feel empaty for the pt work place or school

pshysiological stress
Is in the body
Coping mechanisms for stress
Displacement Reaction formation
Stress and you take it to other people A lot of stress and you react on the
is wrong!! don’t do it!! opposite way. Also bad way.
 Regression sublimession
High period of stress
and start voiding in bed Is when reach Chanel all you stress into
something positive
This is good!! Best way to cope with stress
if you like to write and you start writing
something productive and good for you.
Type of crisis
Develompmental crisis Situational
Part of the normal life cycle is you kid job change, motor vehicle
goes to another college crashes, severe illness
Adventitious
Natural disasters
anything like huracane
earthquake
the Surfside accident.