lOMoARcPSD|32226831

FUNDAMENTAL BUNDLE
38 pgs.

Created by ÒNurseThoughts on Etsy

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TABLE OF CONTENTS
> Legal Laws 1
> Ethical Principles, Informed Consent, HIPPA, & Client Rights 1, 2
> ABCÕs and MaslowÕs Hierarchy of Needs 2
> Scope of Practice 3
> Nursing Process 4
> Client Safety 5, 6
> IV Therapy Complications 6
> Fluid Compartments, Osmosis, & Solution Types 7
> FVE, FVD 8
> Sodium, Potassium 9, 10
> Calcium, Magnesium 11, 12
> Electrolyte Relationships 13
> Lab Values & Memory Tricks 14, 15
> Vital Signs 16
> Common Med. Abbreviations 17-19
> Types of Positions 20
> 9 Sites of Pulse 21
> Auscultating Lung-sounds & Landmarks 22
> Infection Control 23
> Isolation Precautions 24
> Fire Safety 24
> Blood Types & Transfusion Reactions 25, 26
> Med. Administration 27
> Pharmacokinetics 28
> Non-Parental Administration 28, 29
> Parental Injections 30, 31
> Enteral Feeding 32
> Bowel Elimination 33
> Urine Elimination & Urinary Complications 34, 35
> Pressure Ulcers 35
> CPR (Infant, Child, Adult) 36-38

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LEGAL LAWS
CRIME: intentional wrong doing against another TORT: person injured due to another personÕs unintentional or intentional
person, people, or environment. Considered both failure to act. Injury can be physical, emotional, or financial.
felony & misdemeanor.
Unintentional tort: negligence
> Felony: serious crime ―> insurance fraud, > Negligence: person harmed due to neglected duties, procedures, or
practicing w/o license, theft of narcotics, etc. precautions.
> Misdemeanor: not serious as felony, but still a - FAILURE TO: follow standard protocols; report equipment malfunctions;
crime ―> possession of controlled substances, etc. give standards of safe care; prevent injuries; question physicianÕs
incorrect orders; AND performing procedures you were NOT taught.
LIABILIT Y: deliberate ÒcommissionÓ of a forbidden > Malpractice (Professional Negligence): improper or injurious treatment
act or ÒomissionÓ of an act required by law. from a licensed personÕs actions or lack of actions.
Òact of commissionÓ ―> participating in illegal
abortion, giving person wrong med & is harmed, Intentional tort: assault, battery, false imprisonment, etc.
etc. > Assault: threat or attempt to do bodily harm ―> telling elder his/she
Òact of omissionÓ ―> person not given will take a shower even if he/she refused.
scheduled med & is harmed, failure to report elder > Battery: physically touching someone or his/her possessions w/o
or child abuse, etc. consent ―> beating person, caring out procedures the person refused,
forcing person out of bed, etc.

Quasi-Intentional:
> Libel: written statement or photo that is false of damaging.
> Slander: malicious verbal statements that are false or injurious ―>
gossip & exaggeration.
> Defamation: act that harms a personÕs reputation.

ETHNICAL PRINCIPALS & CLIENT RIGHTS

ET HNICAL PRINCIPLES CLIENT RIGHTS

> Advocacy: supports a personÕs health, wellness, safety, > 1972 A PatientÕs Bill of Rights adopted by AHA.
privacy, and personal rights. > ClientÕs rights must be respected and NURSES are
> Responsibility: respect obligations and follow through on responsible for protecting the rights of the client.
promises. > Client has the right to details of procedures,
> Accountability: willingly taking responsibility for oneÕs own informed consent, advance directives, & confidentiality
actions. of information
> Confidentiality: protection of a personÕs privacy. > Client has the right to REFUSE/DISCONT INUE
> Autonomy: a personÕs right to make own decision. treatment/medication/etc. (whether admission is
> Beneficence: act of kindness and doing good for others. voluntary or involuntary)
> Fidelity: keeps promises and fulfills them. > Client has the right to be active in decision-making
> Justice: fair treatment of giving safe and quality care to of care plan, accept/refuse/modify care plan, receive
each individual. competent care & respect.
> Non-maleficence: commitment to do no harm.
> Veracity: commitment to telling the truth.

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HIPAA & INFORMED CONSENT

HIPAA INFORMED CONSENT
> 1996 Health Insurance Portability and Accountability Act. > Legal documentation of pt.Õs approval to perform tests,
> Protects pt. info to remain private. Pt. has the RIGHT to treatments, surgeries, or give certain meds or blood products.
privacy. > Pt. must be 18 or older, competent, & verbal.
> DO NOT give pt. info to family or friends w/o the pt.Õs > Parent, guardian or advance directive signs consent if pt. is a
consent. minor, unconscious, unable to communicate, or mentally disabled.
> Keep info within staff members who are directly involved > Emancipation minors are LEGALLY capable of signing an
in pt.Õs care (HCP, nurse, can, therapist, dietician, social informed consent.
worker, etc.) In a life or death situation, two physicians can sign emergency
> DO NOT leave papers out in the open. Have them consent if pt.Õs family is NOT immediately located (some facilities
face-down. allow this).
> Secure pt. info on computer screen from others. > Non-consensual physical contact can be required if pt. is
ALWAYS log off before leaving computer. mentally ill, intoxicated, or endangering self or othersÕ safety.
> Wait for pt.Õs visitors to leave before discussing pt.Õs info > Only the Physician MUST detail and explain the purpose of
(unless pt. gives consent to discuss with visitor(s) in the procedure, explain benefits & risks, & give options for alternative
room). treatments
> ALWAYS close the door when discussing private matters. > Nurse MUST witness pt. sign consent and makes sure the
> DO NOT discuss pt. info w/ other health professionals patient understands what was said.
during break, lunch, or outside of workplace. > If does NOT understand, inform the physician & the physician is
responsible to re-explain & answer questions about the procedure.
> ALL T EACHING MUST BE DOCUMENT ED.
Students DO NOT obtain or witness consent forms.

ABCÕs (AIRWAY, BREATHING, CIRCULATION)

Oxygen is one of the most essential of all basic survival
MASLOWÕS
needs. Without oxygen circulating in the bloodstream, a person
SELF-
HIERARCHY
will die in a matter of minutes. Oxygen is provided to the cells OF NEEDS
ACT UALIZAT ION
by maintaining an open airway and adequate circulation.
Òreach for his/her
highest potentialÓ
ABC is essential for survival
Airway: determine whether airway is patent (open) or not. SELF EST EEM
Remove anything that obstructs the airway whether it's food, Self image, Self respect,
Perception of self-adequacy
blood, vomit, or the tongue falling back (common in unconscious
person). LOVE, AFFECT ION, & BELONGING
Breathing: listen to breath sounds, watching for chest Social needs & Spiritual needs
movements, & lay your cheek against personÕs chest.
Circulation: The heart must pump effectively for oxygen to be SECURIT Y & SAFET Y
Freedom from harm (abuse), Healthcare, Shelter
carried to the cells. Also, there must be sufficient blood volume
to carry needed oxygen. BASIC PHYSIOLOGICAL
Find a pulse, observe the pulse, reassess breathing, & assess Oxygen, Water, Food, Elimination, Sleep, Exercise, Sexual Gratification
for signs of internal or external bleeding, control (for the survival of species), and Temperature Regulation
hemorrhage if bleeding does occur.

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SCOPE OF PRACTICE

> hang & administer blood

> initial assessment on admitted patient
> patient care plan

RN >
>
discharge teaching
start IV & administer IV meds
> performs same duties as LPN/LVN & UAP

> reinforce client teaching taught by RN

> report ABNL findings to RN & HCP
> performs more ÒskillÓ procedures
> tracheostomy care & suctioning
LPN/LVN > check NG tube latency
> enteral feedings
> insert urinary catheters
In some states,
> administer meds ――>
CANNOT give IV meds

> ADL (activity of daily living): hygiene, dressing, ambulating,

feeding (NO aspiration risk pts.), bathroom breaks
> position & transfer (bed to chair, chair to bed)
UAP > bed-making
DO NOT > specimen collection
delegate, teach, > I&Os
demonstrate, explain, &
> vital signs (stable patients)
use clinical judgement

FIVE RIGHTS OF DELEGAT IONS

RN delegates the LPN/LVN and UAP Right task
LPN/LVN delegates UAP Right circumstance
Right person
Right direction & communication
Right supervision & evaluation

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NURSING PROCESS

1. ASSESSMENTS 2. DIAGNOSING

> Subjective data (what the patient tells you; chief complaint) > Statement about the actual or potential health problem
and Objective data (what you, as the nurse, observes); of the patient that can be managed through independent
interview (medical history); Head-to-Toe Assessment nursing interventions
Analyze Data: > Medical Diagnosis vs Nursing Diagnosis
> Recognize significant data (which data is relevant or not to > Three Components of a Nursing Diagnosis:
P Ð Problem
the patientÕs care)
E Ð Etiology (cause)
> Validate observations (Òcheck them outÓ)
S Ð Signs and Symptoms (objective and subjective data)
> Recognizing patterns (when does the symptom occur?
> Writing a Diagnostic Statement:
night, after eating, certain position, etc.) and clusters
> Example: Fluid Volume Deficit (P) related to physiologic
(relationship among symptoms). Ex: abdominal pain, bloating, and
effects of dehydration (E) as evidence by dry mucous
NO bowel movement in 3 days
membrane, increased HR and RR, poor skin turgor,
> Identifying strengths (ways patient can cope with problem) orthostatic hypotension, and fatigue (S).
and problems (actual or potential problems)
> Analyzing data to reach conclusions (no problem; may have
problems; risk of problem; or clinical problem)
> Continuously update information

3. PLANNING

> Development of goals to prevent, reduce, or eliminate problems and identify nursing interventions (actions taken)
that will help client in meeting goals.
> Set priorities (survival needs or imminent life-threatening problems is highest priority; MaslowÕs Hierarchy of Needs
and ABCs)
> Establish expected outcomes (client-oriented, specific, reasonable, and measurable)
- Short-term objective (goal met in hours or few days) vs Long-term objective (goal require longer time to
accomplish)
> Select nursing interventions (orders or actions taken to help client reach goal)
> Write nurse care plan (formulated by entire nurse team)

4. INT ERVENT IONS 5. EVALUAT ION

> ÒDo itÓ - putting nurse care plan in action > Analyze clientÕs response (measure clientÕs progress; were
> Continue collecting data (observe carefully, listen to the goals met?)
what client says, watch what they do, check vital > Identify factors contributing to success or failure of care
signs) plan
> ÒShare itÓ - discuss clientÕs progress or setbacks > If care plan was not successful, modify goals and/or
with nurse team interventions and rewrite care plan
> ÒWrite it downÓ - document care given > Discharge (problems are resolved; clientÕs plan is individualized;
healthcare team conference with client and family to discuss
continued or new goals at home; next visit/ follow-up)
> Plan for future nursing care

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CLIENT SAFETY

FALL PRECAUTIONS
Who are more at risk:
> Greater than 65 yrs.
HOW FALL RISK PTS. ARE IDENT IFIED:
> Impaired mobility + yellow wristband
> Cognitive and Sensory impairment + yellow non-skid socks
> Bowel and Bladder dysfunction + Òfalling starÓ sign outside room door
> Adverse effects of medications
> Hx of falls

> Determine individualized care plan based on Fall Risk Assessment

> Orient the patient around assigned room and the use of grab bars and call light
> Place Òfall riskÓ patient close to the nurseÕs station and check on frequently
> Non-skid socks
> Important note! Before transferring the pt., have pt. put on non-skid socks or hard sole footwear.
> Lock wheels on bed, wheelchairs, lifts
> Keep floor free of clutter (extension cords, carpet, coffee table, etc.). Clean up spills.
> Provide good lighting to prevent falls at nighttime (lamp, plug-in, overhead light, bathroom light, etc.)
> Instruct patient on the use call light for assistance before ambulating
> Place call light within patientÕs reach. Answer call lights promptly; especially with patients known for trying to walk independently.
> Set bed at lowest height & Place floor mats on both sides of bed
> Use bed sensors or chair/side table to stop patients from getting up without assistance or supervision.
> Assistive devices if needed (wheelchair, cane, walker)

SEIZURE PRECAUTION
Considerations:
> Assist with ambulation and transferring to prevent injury
RESCUE EQUIPMENT:
+ oxygen
> Saline lock for immediate IV access for high risk patients
+ suction
> Remove items around patient that could cause injury during a seizure
+ side rail padding
> DO NOT restrain patient during a seizure, can cause injury
+ oral airway

During A Seizure:
> Stay with patient and Call for Help
> If on floor, place pillow under head to prevent head trauma
> Turn patient on side to prevent aspiration; loosen clothes
> Maintain open airway and suction secretions to prevent aspiration
> Administer medications
> DO NOT put anything in clientÕs mouth (finger, tongue blade, etc.) can bit down or choke.
> Note duration of seizure, sequence, and type of movement
> After seizure, determine mental status, measure O2 stat and vital signs. Explain what happened and
provide comfort.
> Document seizure and describe event (movements, injuries, duration, aura, postictal state), report to HCP

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CLIENT SAFETY CONTINUED…

RESTRAINTS & SECLUSION
Types: human, mechanical, chemical, & physical device Side Rails:
> Top 2 are used and bed at lowest height.
Considerations: > NOT considered restraint when used to
> LAST measure used if less restrictive interventions does NOT work prevent sedated person from falling out of bed.
(diversion, frequent observations, calm/quiet environment, etc.)
> Prescribed for the SHORT EST DURAT ION as possible Physical device:
> ALWAYS a PhysicianÕs order (written) > 2 finger width of space between restraint
> Prescription should be renewed every 24 hrs (if still needed)
and patient
> Prescription must include reason, type, location, duration, and type of
> Use quick-release knot to tie restraint to bed
behavior that permits use of restraint.
frame
> ALWAYS check the facilityÕs policy on restraints
> Remove every 2 hrs. Have patient perform
> NOT given as PRN
ROM.
> Restraints SHOULD NOT
- intend to harm the patient > Monitor neurovascular status and skin integrity
- be used for convenience, punishment, or for patients who are every 30 mins. (pulse, skin color, movement)
physically or emotionally unstable.
> Assess neurovascular & circulation status and skin integrity (pulse, blood
pressure, pulse ox, color, movement, pain) every 30 mins
> Documentation every 15-30 mins
- reason, type of restraint, date & time, duration, neuro/circulation/skin
assessment checks, evaluation of behavior for need to discontinue or
prolong restraint use, clientÕs behavior, medications given, vital signs, food &
fluid intake, bathroom use
IV THERAPY COMPLICATIONS
PHLEBITIS AIR EMBOLISM CATHETER EMBOLISM
Inflammation of the vein Air enter veins through an IV Catheter tip breaks off in vein during IV
Symptoms: Erythema (redness), Symptoms: Tachycardia, Hypotension, insertion or removal
Warm, Tender, Pain Cyanosis, Dyspnea, Decreased LOC Symptoms: Missing catheter tip on removal,
Tx: Stop infusion, Remove IV, Apply Tx: Notify RN, Clamp tubing, Turn pt. Hypotension, Pain along vein, Weak & rapid pulse
warm compression, Notify HCP & RN, to side & place in Trendelenburg Tx: Notify RN & HCP, Place tourniquet high
Restart insertion & infusion elsewhere position, Notify HCP above the IV site, X-ray, Surgery

INFILTRATION EXTRAVASATION CIRCULATORY OVERLOAD

Needle dislodged from vein & fluid Leakage of vesicant or irritant solutions into Or ÒFluid Overload.Ó Excess volume of
leaks into surrounding tissue surrounding tissue causing tissue damage. fluid infused into vein over short period
Symptoms: Edema, Pale skin color, Similar to ÒINFILT RAT ION.Ó Symptoms: Distended JVD, SOB,
Coolness, Damp, Pain, Slow IV Symptoms: Edema, Pain, Erythema (redness), Crackle lung sounds, HT N, Tachycardia
infusion rate Sloughing of skin (necrosis), Blisters, Skin Tx: Raise HOB, Adjust & slow infusion
Tx: Stop infusion, Remove IV, discoloration rate, Monitor vital signs & O2,
Elevate extremity, Warm or cool Tx: Stop infusion, Aspirate remaining solution Give diuretics
compression (depends on what was through IV line, Antidote (per agency protocol),
infused), Do NOT rub area, Restart Remove IV, Elevate extremity, Warm or cool
insertion & infusion elsewhere compression (depends on what was infused),
Restart insertion & infusion elsewhere

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FLUID COMPARTMENTS
Intracellular Fluid (70%)
Intracellular Fluid (ICF) ―> Fluid inside the cell.
Extracellular Fluid (ECF) ―> Fluid outside the cell. Interstitial
fluid (third spacing) is included in this compartment which is

:
fluid surrounding cells, blood, lymph, bone, connective tissue,
water & transcellular fluid. Third spacing refers to
accumulation of trapped fluid (edema) in a body cavity
(pericardial, pleural) due to disease or trauma.
Intravascular ―> Fluid in the blood vessel.

Major ICF ions Major ECF ions

↑

IntraVascular (6%)
Extracellular Fluid (30%) Potassium Sodium
& Magnesium Calcium
Interstitial Òthird spaceÓ (22%)

OSMOSIS & SOLUTION TYPES

ISOTONIC (NORMAL) HYPOTONIC (DILUTED) HYPERTONIC (CONCENTRATED)

Equal concentration on either Solution has lower concentration of solute Solution has higher concentration of solute
side of the semipermeable compared to a more concentrated solution. compared to a less concentrated solution.
membrane. Fluid enters the cell & causes the cell to Fluid leaves the cell & causes the cell to
swell & sometimes burst b/c of excess fluid. shrink & shrivel from dehydration.

· ·

· ·
·

·
· ·

· · ·
·
·
+ 5% dextrose in Lactated RingerÕs
+ 0.9 % normal saline (NS) + 0.45% normal saline (1/2 NS)
+ 5% dextrose in 0.45% normal saline (D5 1/2
+ 5% dextrose in water (D5 W) + 0.225% normal saline (1/4 NS)
NS)
+ 5% dextrose in 0.225% normal + 0.33% normal saline (1/3 NS)
+ 5% dextrose in 0.9% normal saline (D5 NS)
saline (D5 1/4 NS)
+ 10% dextrose in water (D10 W)
+ Lactated RingerÕs
+ 3% normal saline
+ 5% normal saline

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FVD vs FVE

FLUID VOLUME DEFICIT

Loss of fluid & electrolytes in the ECF & blood SYMPTOMS
So
th
(hypovolemia). > Extreme thirst > Cool, clammy skin & slow
Loss of fluid without losing electrolytes (dehydration). > Tachycardia, thready pulse capillary refill
> Orthostatic hypotension > Fatigue, dizziness, syncope,
CAUSES 1 > Weight loss, N/V
> Dry mucous membranes,
confusion, weakness
> Oliguria (urine is dark &
> Diarrhea, Vomiting
> DI poor skin turgor concentrated)
> Overuse of Diuretics
> Drainage of wounds & burns
> Excessive sweating (diaphoresis) INT ERVENT IONS
> Hemorrhage > Monitor VS especially respiratory, BP, pulse, & O2 stat
> Poor fluid intake, NPO, & dysphagia > Check for SOB & Dyspnea, Give Oxygen as needed
> GI suctioning & Colostomy drainage > Check for orthostatic hypotension
> Determine LOC & check neuro status me
que so
DIAGNOST IC LAB T EST & PROCEDURES > Monitor I&O, weigh daily
> Hct > Give oral & IV fluids (isotonic)
> Osmolarity: >295 mOsm/kg > Initiate fall precautions
> protein, electrolytes, BUN, glucose, & urine specific > Encourage pt to turn & stand slowly
gravity (>1.030) > Give frequent mouth care
> sodium (>145) > Check skin turgor (In older adults, check over forehead or
sternum due to loss of skin elasticity on the hand)

FLUID VOLUME EXCESS

Fluid intake or retention that exceeds the body's SYMPTOMS ~
e
need (overhydration). > Cough, dyspnea, crackle lung sounds > JVD d
wn3
Retention of water & Na+ in high proportions, > Orthopnea > Ascites
especially water (hypervolemia). > Tachycardia, HT N, bounding pulse > Confusion, weakness

CAUSES
E > Pitting edema, weight gain > urine output (urine light
yellow/clear & diluted)
> Kidney & Heart failure
> Long-term use of corticosteroids INT ERVENT IONS
> Excessive sodium intake > Monitor VS especially respiratory, BP, & pulse & Neuro. status
> SIADH > Auscultate lungs
>
>
Overhydration with IV fluids
Burns
O > Check for SOB & Dyspnea, Give Oxygen as needed
> Monitor edema on scale 1+(mild) and 4+(severe)
> Strict I&O and weigh daily (notify HCP of 1-2 lb gain in 24hrs
DIAGNOST IC LAB T EST & PROCEDURES or 3 lb in a week)
> Hct & Hbg > Monitor for abdominal distension (ascites)
Osmolarity: <280 mOsm/kg
> electrolytes, BUN and creatine, & urine specific
> Fluid and sodium restriction
> Administer loop diuretics (furosemide)
A
gravity (<1.005) > High-Fowler's position, turn every 2 hrs., & support extremities
ABG's: Respiratory alkalosis
Sodium: normal range (135-145)

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FUNCT ION MEMORY T RICK

SODIUM > Maintain water balance in body
ÒUnder 135, in water you dive.
> Normalizes function of nerve & muscle
cells (smooth, skeletal) -Over 145, you thrive to go dry.Ó
(135 - 145 mEq/L)
> Maintain acid/base balance for kidney function

For hyponatremia, itÕs either:

HYPONATREMIA
Body lose excess Na+ & water (hypovolemia)
In the body, Na+ is diluted in excess water (hypervolemia)
< 135
SYMPTOMS INT ERVENT IONS
If taking lithium, > HR, Thready pulse > Monitor I&Os, weigh daily
risk of lithium toxicity
> Orthostatic hypotension > Replace Na+ (Na+ rich
> H/A, N/V foods/supplements)
CAUSES > Hyperactive BS & ABD cramps > Closely monitor respiratory
> Na+ intake, Na+ excreting > DT R, Muscle weakness stat & LOC
diuretics (thiazide, loop) > Confusion, Lethargy, Fatigue If Hypovolemia occurs, give hypertonic IV
> Diarrhea, vomit, GI suction > Seizure & Coma therapy (3% NS)
> sweating, burn, & wound drainage Risk of
> Kidney & Heart Failure respiratory If Hypervolemia occurs, restrict fluid intake
> SIADH, Adrenal crisis (Addison's) failure > Seizure precaution
shifts fluid OUT of
> water intake & hypotonic IV fluids cell & INTO the
> Hyperglycemia Na+ RICH FOODS blood to INCREASE
cheese, milk, tomato soup fluid volume
table salt, processed foods

HYPERNATREMIA

> 145
CAUSES SYMPTOMS INT ERVENT IONS
> Na+ intake, water intake > HR, Orthostatic hypotension > O Restrict Na+
> Kidney Failure, Cushing's syndrome > Dry mucous membrane > Monitor I&Os, report
> Dl, Diarrhea > Thirst, Poor skin turgor > urine output
> Fever > urine output (oliguria) > Monitor LOC & behavior
> Heat stroke, Sweating > temp & flushed, dry skin > Give loop diuretic (furosemide) to
> Hypertonic IV fluids, Hypertonic > DT R, Muscle weakness excrete Na+
enteral feeding, & Bicarbonate Disorientation, Irritability, Restlessness > Give oral & IV fluids (Hypotonic)
> Glucocorticosteriods > LOC, Seizure (0.33% or 0.45% NS)
Edema (pitting)

Q Q
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FUNCT ION MEMORY T RICK

POTASSIUM > Maintain water balance in body
ÒBuy 3-5 bananas in a bunch
> Essential for contraction of
(3.5 - 5 mEq/L) cardiac, muscle, & neuron transmission & get them 1/2 ripe.Ó
> Maintain acid/base balance for kidney function

HYPOKALEMIA NEVER give If taking digoxin, K+

K+ IV push! causes digoxin toxicity
< 3.5
affects
CAUSES SYMPTOMS respiratory
movement
> K+ intake > Muscle cramps & weakness
K+ needed for
> Diarrhea, vomit, & GI suction > Weak, irregular pulse muscle & cardiac
> Overuse of K+ excreting > Hypoactive reflexes, Paresthesias contractions
diuretics (loop), laxatives, & corticosteroids > Respiratory distress, Shallow
> sweating, burn & wound drainage respirations 0
ECG Read o

> TPN > Confusion, Lethargy, N/V

+ depressed ST
> Alkalosis, Cushing's syndrome > Constipation, Hypoactive BS, & ABD distention
+ Flat/Inverted T wave
+ Prominent U wave
INT ERVENT IONS
> Replace K+ (K+ rich foods/supplements)
> Monitor ECG & cardiac rhythm K+ RICH FOODS
> Monitor respiratory & Breath sounds potatoes, avocado, tomatoes,
respiratory failure
> Monitor I&Os, ABD distention, & Bowel sounds is major risk bananas, cantaloupe, green
> Closely monitor LOC ―> fall precautions leafy vegetables, pork
> Check deep tendon reflexes & muscle
weakness (handgrips)

HYPERKALEMIA

>5
CAUSES INT ERVENT IONS
> K+ intake, salt substitutes > O Restrict K+ & salt substitutes
> Kidney Failure, dehydration > Monitor ECG & cardiac rhythm
> Acidosis > Give fluids & monitor I&Os
> K+ sparing diuretics, ACE inhibitors > Regularly check K+ level
> Blood transfusion > Monitor muscle movement
> Fever, Sepsis, Trauma, & MI > Give loop diuretic (furosemide), 50% glucose w/regular
insulin hypertonic solution, & sodium polystyrene sulfonate
SYMPTOMS
> Muscle cramps & weakness ..
ECG Read
cardiac arrest
> Ventricular fibrillation is major risk + Tall, peaked T wave
> Weak pulse, Hypotension
+Flat P wave
> Hypoactive reflexes, Paresthesias
>
>
Confusion, Irritability
Diarrhea, Hyperactive BS
QQ + Wide QRS
+ Prolong PR interval

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FUNCT ION MEMORY T RICK

CALCIUM > Essential for blood dotting
ÒCall 911Ó
> Essential in neurotransmitter release
(9 -11 mg/dL) > Strengthens bones & teeth
> Normalizes function of nerve & contraction of muscle cells (smooth, skeletal, & cardiac)

HYPOCALCEMIA

<9
CAUSES SYMPTOMS INT ERVENT IONS
> Ca++ intake & Vitamin D > Tetany Replace Ca++ (Ca++ rich
> Overuse of Ca++ excreting meds > Muscle twitching, Cramps, DT R foods/supplements) & vitamin D
(diuretics, caffeine, anticonvulsants) > Weak, thready pulse Seizure precaution
> Hypoparathyroidism > Dysthymia, Hypotension Give IV calcium gluconate or
> P-3 intake, M++ intake > Laryngospasm calcium chloride (watch
> Crohn's Disease > Positive ChvostekÕs (facial twitching) Ca++ levels)
> End-stage kidney disease > Positive Trousseau's (hand, finger spasm w/ Keep room quiet & avoid extra stimuli
> Chronic diarrhea BP cuff inflation) Monitor ECG
> Rapid blood transfusion > Paresthesias (fingers,toes, lips numbness)
> Confusion, Anxiety, Seizure
> Diarrhea, Hyperactive BS O
ECG Read O

+ Prolong QT & ST
Ca++ RICH FOODS interval
cheese, milk, yogurt,
kale, tofu, sardines

HYPERCALCEMIA

> 11
CAUSES SYMPTOMS INT ERVENT IONS
> Ca++, Vitamin D intake > Dysrhythmia, HR, HT N > O Restrict Ca++ rich foods/supplements
> Glucorticosteroids > risk of blood clots > Give excreting diuretics
> Meds: antacid containing Ca++, > Hypotonicity, DT R > Give phosphorus, bicarbonate, & aspirin/NSAIDS
thiazide diuretics, & lithium > Constipation, Hypoactive BS > Dialysis if meds fail
> Hyperparathyroidism > Confusion, Lethargy, Coma > Strain urine for stones
> Bone resorption or destruction > Renal calculi (flank/ABD pain) > Monitor ECG
(osteoporosis, immobility, fracture) > Bone pain > Check for blood dots
> PagetÕs disease

..
ECG Read

00 + Short QT interval
+ Prolong ST interval

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MEMORY T RICK
FUNCT ION
MAGNESIUM > Maintain & form bones, Regulates BP ÒMagnifying glass
> Easily allow tissue to absorb insulin magnifies by 1.5-2.5xÓ
(1.5 - 2.5 mEq/L) > Triggers Na+/K+ pump to maintain normal ion balance
> Normalizes function of nerve & contraction of muscle cells (smooth, skeletal, & cardiac)

HYPOMAGNESMIA

< 1.5
CAUSES SYMPTOMS INT ERVENT IONS
> Mg++ intake > Tetany > Replace Mg++ (Mg++
> Overuse of laxatives > Muscle twitching, DT R foods/supplements)
> Thiazide/loop diuretics > Paresthesias (fingers,toes, lips numbness) > Give magnesium sulfate IV & closely
> Alcoholism > Positive ChvostekÕs (facial twitching) monitor Mg++ levels
> Diarrhea, GI suction > Positive Trousseau's (hand, finger spasm > Seizure precautions
> Eclampsia, Hyperglycemia w/ BP cuff inflation) > Monitor ECG
> Celiac Disease, Crohn's Disease > Dysthymia, HR, HT N
> Ca++ intake > Confusion, Irritability, & Seizure
> Constipation, Hypoactive BS, & ABD distention O
ECG Read O

+ Depressed ST
Mg++ RICH FOODS + Flat T wave
whole grain, spinach, broccoli, + Wide QRS
oatmeal, raisins, peas, chicken, +Prolong PR & QT interval
cauliflower, canned white tuna

HYPERMAGNESMIA

> 2.5
CAUSES SYMPTOMS INT ERVENT IONS
> Overuse of antacids/laxatives containing > Muscle paralysis, DT R > O Restrict Mg++ rich foods/supplements
Mg++ (T UMS, milk of magnesia) > Bradycardia, Dysrhythmia > Closely monitor LOC, cardiac, & respiratory
> Kidney Failure > Hypotension, Cardiac arrest status
> Tx of preeclampsia with magnesium > respiration, Shallow breathing > Give IV calcium gluconate or
sulfate > Lethargy calcium chloride (for severe cardiac changes)
> Give loop diuretic (furosemide)

Calcium gluconate is O
ECG Read O

①O antidote to
MAGNESIUM TOXICIT Y + Wide QRS
+Prolong PR & QT interval

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ELECTROLYTE RELATIONSHIPS

·
INVERSE SIMILAR

SODIUM = POTASSIUM SODIUM = CHLORIDE

.
Kidneys primarily maintain fluid balance in the body. Both are important ECF ions, one being positively
When K+ level in the body increases, the kidney charged & the other negative. This allows the ions
excretes more Na+. Vice Versa for increased Na+ to combine & form sodium chloride, or better known
and excretion of K+. as ÒNormal Saline.Ó

INVERSE SIMILAR ·

MAGNESIUM = PHOSPHORUS MAGNESIUM = POTASSIUM

Kidneys primarily maintain fluid balance in the Both are important ICF ions. K+ deficiency can be
body. When K+ level in the body increases, the related to Mg++ deficiency. When Mg++ level falls, so
kidney excretes more Na+. Vice Versa for does K+. Also known as secondary potassium depletion.
increased Na+ and excretion of K+. BUT when K+ level falls, Mg++ does NOT.

INVERSE SIMILAR

CALCIUM = PHOSPHORUS CALCIUM = MAGNESIUM

When P-3 increases in the blood, Ca+ lowers Mg++ activates Vitamin D & Vitamin D
because P-3 attaches itself to the decreasing increases the bodyÕs ability to absorb Ca+.
Ca+ available in the blood.

·
·

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LAB VALUES

LIVER
SERUM ELECTROLYTES LIPID
AST: 0-35 u
Sodium: 135-145 mEq/L Cholesterol: <200 mg
3

p-
ALT: 4-36 u
Potassium: 3.5-5.0 mEq/L LDL "bad": <100 mg ALP: 30-120 u
N+
Calcium: 9-11 mg/dL Mg+ +
HDL "good": Bilirubin: 0.3-1 mg
Magnesium: 1.5-2.5 mEq/L Male: >45 mg Albumin: 3.5-5 g
Chloride: 95-105 mEq/L Ca + +
Female: >55 mg Lipase: 0-160 u
Phosphorus: 2.5-4.5 mg/dL Triglycerides: <150 mg Amylase: 30-220 u

COAGULATION CBC ABGÕs 08

-
Platelet: 150,000-400,000 RBC: 888 pH: 7.35-7.45
INR: 0.8-1.1 sec (on warfarin, 2-3 sec) Male: 4.7-6.1 PaCO2: 35-45 o
PT: 11-13 sec Female: 4.2-5.4 HCO3: 22-26
aPT T: 30-40 sec (on heparin, 1.5-2.5x WBC: 5,000-10,000 PaO2: 80-100 mmHg
the control value) Hgb: SaO2: 95-100 mmHg
Male: 14-18
Female: 12-16
THERAPEUTIC MED LEVELS Hct: BLOOD GLUCOSE
Digoxin: 0.8-2.0 ng/mL ⑭ Male: 42-52% Fasting Glucose: 70-110
⑭
toxic: >2.4 Female: 37-47% HbA1c: 4-6%
Lithium: 0.4-1.4 mEq/L
toxic: >2.0
#E
Phenobarbital: 10-40 mcg/mL URINALYSIS
toxic: > 40 Urine Specific Gravity: 1.005-1.030 RENAL
Theophylline: 10-20 mcg/mL Protein: 0-8 mg/dL BUN: 10-20
toxic: >20 Glucose: less than 0.5 g/day Creatinine: 0.5-1.2
Dilantin: 10-20 mcg/mL
pH: 4.6-8
toxic: >20
Magnesium Sulfate: 4-8 mg/dL
Lab values vary in schools,
toxic: >9
& textbooks, & medical facilities, but
theyÕre always close in range.

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LAB VALUES: MEMORY TRICKS

SODIUM Ñ Under 135, in water you dive. CALCIUM Ñ Call 911

135 - 145 Over 145, you thrive to go dry. 9 - 11

MAGNESIUM Ñ Magnifying glass magnifies

POTASSIUM Ñ Usually buy 3-5 bananas in a 1.5 - 2.5 by 1.5-2.5x
3.5 - 5 bunch & are 1/2 ripe.

PHOSPHORUS Ñ Phor: 4
CHLORIDE Ñ Take a dip in Chlorine pool on a 2.5 - 4.5 Us: 2 (us two together)
95 - 105 summer day & temp. is between 95-105 F
donÕt forget
the .5

URINE SPECIFIC GRAVIT Y Ñ On average, a person takes BUN Ñ Hamburger (BUN). Costs big bucks
1.005 - 1.030 in 1-3 L of water/day. 10 - 20 ($10-20) to buy a burger & fries
BUT realistically, itÕs as at a restaurant
remember where to less as 0.5 L, so 0.5-3 L
place the zeros

CREAT ININE Ñ Think ÒhalfÓ. In decimal (0.5) &

0.5 - 1.2 fraction (1/2). But the value is
written in decimal form 0.5-1.2
CHOLEST EROL Ñ 200 lbs or more is
> 200 considered obese. Fatty
plague (cholesterol) in the Hbg Ñ Girls (12-16) mature faster
heart can cause heart attack.
F: 12-16 than boys (14-18)
M: 14-18

*
HDL Ñ Older men (45 yrs) have INCREASED
M: > 45 risk of heart attack, so they have
F: > 55 to take control of their health earlier than Hct Ñ Again, girls (37-47%) mature
women (55 yrs)
F: 37-47 faster than boys (42-52%).
M: 42-52 Here, theyÕre older

FAST ING BLOOD GLUCOSE Ñ Òsugar high heaven

7 - 11 at 7-11Ó WBC Ñ Fight! 1 punch (5 fingers)
5,000-10,000 2 punches (10 fingers)
PT Ñ Pre-Teens (11 - 13 yrs.)
11-13

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VITAL SIGNS

PULSE Listen to apical pulse with stethoscope for a

FULL minute. Detects irregular/dysrhythmic
Normal: 60-100 bpm heartbeats, esp in pts. with a heart condition
> 100 bpm is called tachycardia (fast heart rate).
< 60 bpm is called bradycardia (slow heart rate). PULSE ST RENGT HS
Sites to check pulse: radial; brachial; carotid; apical; popliteal; 0 = ABSENT
1+ = DIMINISHED, WEAK
femoral; pedal; temporal
2+ = NORMAL
3+ = INCREASED, ST RONG
4+ = FULL, BOUNDING

BLOOD PRESSURE RESPIRATIONS

Normal: 80-120/ 60-80 Normal range: 12-20 bpm (adult)
Systolic: measures heartbeat during each heart > 24 bpm is called tachypnea (fast breathing)
contraction/ Diastolic: measures heartbeat when < 10 bpm is called bradypnea (slow breathing)
heart relaxes before it contracts again. NO respiration is called apnea (cessation of
Hypotension: very low blood pressure is a breathing)
possible sign of hemorrhage (excessive bleeding)
or shock. RR below 12 is sign of
Hypertension (HT N): elevated blood pressure is a respiratory distress.
sign of circulatory problems. INT ERVENE & report
- Prehypertension: 120-139/ 80-89 IMMEDIAT ELY!
- Stage 1 HT N: 140-159/ 90-99
- Stage 2 HT N: 160+/ 100+

TEMPERATURE PULSE OX
Oral: 95.9-99.5 F (35.5-37.5 C) Normal: 95%-100%
Rectal: 97.9-100.4 F (36.6-38 C)
Temporal (forehead): 96.4-100.4 F (35.8-38) In COPD pts., pulse ox of
Tympanic (ear): 96.4-100.4 F (35.8-38 C) 88-92% is NORMAL &
Axillary(armpit): 94.5-99.1 F (34.7-37.3 C) EXPECT ED.

ALWAYS add 1 degree to axillary

If pt. recently had hot/cold food
temp b/c the armpit is generally
or drink OR smoked, wait 15
a degree lower than the mouth.
mins before taking oral temp. to
Hold thermometer tightly in place
get an accurate reading
to get accurate reading

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COMMON MED. ABBREVIATIONS

abd ―> abdomen D/C ―> Discontinue

ABG ―> Arterial Blood Gas dig ―> digoxin
ac ―> before meals DM ―> Diabetes Mellitus
ADL ―> Activities of Daily Living DOA ―> Dead on Arrival
ad lib ―> as much as desired DOE ―> Dyspnea on Exertion
A-line ―> Arterial line DOS ―> Dead on Scene
AED ―> Automated External Defibrillator DVT ―> Deep Venous Thrombosis
AF ―> Atrial Fibrillation D5W ―> Dextrose 5% in Water
AKA ―> Above Knee Amputation Dx ―> Diagnosis
AMA ―> Against Medical Advice
AMS ―> Altered Mental Status ECG, EKG ―> Electrocardiogram
AO x 4 ―> alert and oriented to person, EENT ―> eyes, ears, one, throat
place, time, & self ETA ―> Estimated Time of Arrival
AV ―> atrioventricular, arteriovenous ETOH ―> Ethyl Alcohol

b.i.d ―> twice daily FBS ―> Fasting Blood Sugar

BKA ―> Below Knee Amputation FHR ―> Fetal Heart Rate
BM ―> Bowel Movement FHT ―> Fetal Heart Tone
BP ―> Blood Pressure FHx ―> Family history
BPM ―> Beats Per Minute fx ―> fracture
BS ―> Bowel Sounds, Blood Sugar,
Breath Sounds GI ―> Gastrointestinal
bx ―> biopsy GSW ―> gunshot wound
gtt ―> drops
CABG ―> Coronary Artery Bypass Graft
GT T ―> glucose tolerance test
CAD ―> Coronary Artery Disease
GU ―> Genitourinary
CBC ―> Complete Blood Count
gyn ―> gynecology
C/C ―> Chief Complaint
CCU ―> Coronary Care Unit
CHF ―> Chronic Heart Failure H&H ―> Hemoglobin & Hematocrit
CO ―> Cardiac Output H/A ―> headache
COPD ―> Chronic Obstructive Pulmonary Disease Hct ―> hematocrit
CPR ―> Cardiopulmonary Resuscitation HF ―> Heart Failure
CRT ―> Capillary Refill Time Hgb ―> hemoglobin
CSF ―> Cerebral Spinal Fluid hs ―> at bedtime
CVA ―> Cardiovascular Accident HT N ―> hypertension
CVP ―> Central Venous Pressure Hx ―> history
CXR ―> Chest X-Ray

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I&O ―> Input & Output OB ―> Obstetrics

ICP ―> Intracranial Pressure OD ―> overdose, right eye
ID ―> intradermal OP ―> outpatient
IM ―> intramuscular OR ―> operating room
IO ―> intraosseous OS ―> left eye
IV ―> intravenous OU ―> both eyes

JVD ―> Jugular Venous Distention pc ―> after meals

PE ―> pulmonary embolism, physical examination
PERRLA―> pupils equal, round, & reactive to
KCl ―> Potassium Chloride
light, & accommodate
KUB ―> Kidneys, Ureters, & Bladder
PID ―> pelvic inflammatory disease
KVO ―> keep vein open
PO ―> by mouth, postoperative Òpost-opÓ
LE ―> lower extremity, lupus erythematosus PRN ―> pro re nata (as needed)
LLL ―> left lower lobe (lung) PT ―> physical therapy
LUL ―> left upper lobe (lung) PT T ―> partial thromboplastin time
LLQ ―> left lower quadrant (abdomen) PVD ―> peripheral vascular disease
LUQ ―> left upper quadrant (abdomen)
LMP ―> last menstrual period qd ―> every day
LOC ―> level of consciousness qh ―> every hour
qid ―> four times a day
MAE ―> moves all extremities qod ―> every other daywwuhbtuvodm
MAP ―> mean arterial pressure
MCL ―> midclavicular line RA ―> Rheumatoid Arthritis, right atrium
MI ―> Myocardial Infarction RBC ―> red blood cells
MRI ―> magnetic resonance imaging RHD ―> Rheumatoid Heart Disease
MS ―> morphine sulfate, multiple sclerosis RL ―> RingerÕs Lactated
MVA ―> motor vehicle accident RLL ―> right lower lobe (lung)
MVC ―> motor vehicle crash RUL ―> right upper lobe (lung)
MVP ―> mitral valve prolapse RLQ ―> right lower quadrant (abdomen)
RUQ ―> right upper quadrant (abdomen)
N/A ―> not applicable R/O ―> rule out
NG ―> nasogastric ROM ―> range of motion
NICU ―> neonatal intensive care unit Rx ―> prescription
NKA ―> no known allergies
NPO ―> nothing by mouth
NS ―> Normal Saline
N/V ―> nausea & vomiting
NVD ―> neck vein distention

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SC, SQ, Sub Q ―> Subcutaneous

MEASUREMENTS
SICU ―> Surgical Intensive Care Unit
SIDS ―> sudden infant death syndrome cc ―> cubic centimeter
SL ―> sublingual cm ―> centimeter
SOB ―> shortness of breath cm3 ―> cubic centimeter
S/S ―> signs & symptoms fl, fld ―> fluids
stat ―> immediately g, gm ―> gram
SVT ―> supraventricular tachycardia gr ―> grains
Sx ―> symptoms h, hr ―> hour
kg ―> kilogram
tab ―> tablet L ―> Liter
TB ―> tuberculosis lb ―> pounds
TBA ―> to be admitted, to be announced m ―> meter
T IA ―> transient ischemic attack mcg ―> microgram
tid ―> three times a day mEq ―> milliequivalent
T KO ―> to keep open mg ―> milligram
TPR ―> Temperature, Pulse, Respiration min ―> minute
Tx ―> treatment mL ―> milliliter
mm ―>millimeter
UA ―> urinalysis
mm Hg ―> millimeters of mercury
UE ―> upper extremity
Tbsp ―> Tablespoon
URI ―> upper respiratory infection
tsp ―> teaspoon
UT I ―> urinary tract infection
U ―> units
VD ―> venereal disease vol ―> volume
VS ―> vital signs

w/ ―> with
WBC ―> white blood cells
WNL ―> within normal limits
w/o ―> with out
wt ―> weight

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TYPES OF POSITIONS

Supine Prone Trendelenburg

Lithotomy Dorsal Recumbent Reverse

Trendelenburg

Semi-Fowler Fowler High-Fowler

Knee-Chest SimsÕ
(genupectoral)

Lateral, Semi-Prone (L or R) Lumbar Puncture Orthopneic

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9 SITES OF PULSE

temporal

carotid

apical

brachial

radial

femoral

popliteal

posterior tibial dorsalis pedis (pedal)

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AUSCULTATING LUNG SOUNDS & LANDMARKS

NORMAL VESICULAR BRONCHIAL

soft, low pitched during inspiration hollow; high-pitched compared to
and even softer during expiration vesicular sounds; auscultated over
the trachea

BRONCHOVESICULAR
equal, normal sounds; mixture of
bronchial and vesicular; auscultated
over bronchi (between trachea and
alveoli of lungs)

ABNORMAL
WHEEZE RHONCHI CRACKLES (RALES)
high-pitched musical sound; heard low-pitched, coarse, loud, snore-like; FINE: high-pitch crackling, popping
more at expiration than inspiration heard mostly at expiration. noise heard during end of inspiration.
Ex: Asthma Clears with cough Not cleared by cough
Ex: Chronic bronchitis Ex: Heart Faikure, Pneumonia

COARSE: low-pitched, bubbling or

PLEURAL RUB FRICTION gargling sounds at early start of
inspiration and expiration. Louder and
low-pitch, rubbing or grating sound;
lasts longer than fine crackle
heard at both inspiration and expiration.
Ex: Pulmonary Embolism
Loudest over the lower anterolateral
surface. Not cleared by cough
Ex: Pleurisy (inflammation of pleural
surfaces)

anterior posterior

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INFECTION CONTROL

MEDICAL ASEPSIS SURGICAL ASEPSIS

(CLEAN TECHNIQUE) (STERILE TECHNIQUE )

> Handwashing. Handwashing! > Avoid coughing, sneezing, and talking

HANDWASHING! over sterile field
> Use PPE > 1-inch border of field is NOT sterile
> Do not shake linen > ONLY dry, sterile items belong on
> Clean least soiled area to most sterile field
soiled area > Prolonged exposure to airborne
> Place moist items in plastic bag organisms can make sterile items unsterile
> Keep objects and gloved hands above
waist and within vision (DO NOT turn
back to sterile field)

DONNING Ñ GO UP & OUT DOFFING Ñ ALPHABET ICAL ORDER

I gown gloves I
Wash hands BEFORE
2 mask donning & AFT ER goggles 2
doffing
goggles gown
i gloves
B 2 mask
34
HELPFUL 2 4
* T IPS

GLOVES I B GOWN
> DON: most cleanest/sterile; > DOF: grab underneath the
always put on last to remain gown, tug until it rips, and roll
clean/sterile the gown with the outside
> DOF: most dirtiest; always 4 4 I I tucked inside.
taken off first to avoid cross
contamination GOOGLES
> DOF: grasp ONLY the ear
MASK extensions to remove
> DOF: grasp ONLY the tie
and undue to remove

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ISOLATION PRECAUTIONS

STANDARD DROPLET

> HANDWASHING! All day, everyday. > coughing or sneezing respiratory

secretions larger than 5 mcg, close
contact with mucous membranes
CONTACT

> fecal, wound drainage, or other bodily > PEE: mask

fluids (blood, vomit, saliva)
> Meningococcal; pneumonia; rubella;
> PEE: gloves, gown, mask if needed mumps; pertussis; scarlet fever

> C-diff; herpes simplex; hepatitis A;

MRSA; rotavirus; bacterial infection; AIRBORNE
VRE > coughing or sneezing respiratory
secretions smaller than 5 mcg; close
contact with mucous membranes
FIRE SAFETY
> PEE: N95 mask

R.A.C.E
> Tuberculosis; measles; varicella;
R - Rescue herpes zoster (shingles)
A - Alarm
C - Confine/Contain
E - Extinguish CLASS OF EXTINGUISHERS

> Class A (combustibles): paper, wood, plastic,

P.A.S.S
cloth, upholstery, rubbish fires
P.A.S.S
P - Pull the pin > Class B: flammable liquid or gases, grease,
A - Aim at base of fire tar, oil-based paint fires
S - Squeeze the handle
S - Sweep from side to side > Class C: electrical fires

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BLOOD TYPES
fights other
blood groups

Antibody Antigen Donates to Receives from

> If incompatible blood is given to the pt., a
A A B A, AB A, O life-threatening reaction can occur.
Blood Groups

I
B B A B, AB B, O > Rh+ can receive BOT H Rh+ and Rh-
A, B > Rh- can ONLY receive Rh-
AB A, B none AB AB, O
A, B
#O none A, B AB, O O If Rh+ is given to a Rh- person, the
body will develop antibodies & aim to rid
the foreign object (+ blood)
AB ―> universal recipient (takes blood)
O ―> universal donor (gives blood)

two forms of identity, pt. identification-band # same as #

BLOOD TRANSFUSION BASICS on blood product, compatible blood group & Rh type, unit #,
type of component transfused
> informed consent is required
> two nurses (either two RNs or RN & LPN)
> prior to transfusion, be sure you have correct pt. and blood product
> assess the pt. (get baseline vital signs & document)
watch for
> when giving transfusion, stay with pt. for first 15-30 mins ―>
signs of reaction

NEVER!

IF A REACTION OCCURS O
leave the pt.
If for any reason you are the only nurse in the room,
> stop transfusion IMMEDIAT ELY yell for help or to a bypassing nurse to notify the HCP.
> give normal saline in new tube
> notify HCP ―> one nurse notifies the HCP, while the other stays with the pt.
> assess pt. and recheck vital signs ―> compare to previous (baseline) vital signs
> notify blood bank ―> send blood product & tubing back to blood bank for testing.
> get a urine & blood sample ASAP
> stabilize the pt. & treat symptoms

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TYPES OF REACTIONS

ACUT E HEMOLYT IC FEBRILE

Transfusion of incompatible blood type & group. Development of antibodies due to transfusion of
Manifestations: leukocytes (WBC) or platelets.
> Chills, Fever, Low-back pain, Tachycardia, Chest pain, > Manifestations:
Chills, 1 F (0.5 C) increase compared to temp. prior
00

Hypotension, Flushing, Tachypnea, Nausea, Hemoglobinuria, Anxiety,

Impending sense of doom to transfusion, Flushing, Hypotension, Tachycardia
Care: > Care:
> Give 0.9% NS, Diuretics (furosemide), Vasopressor (dopamine) Antipyretic (acetaminophen)

ALLERGIC BACT ERIAL (SEPSIS)

Hypersensitivity to transfused blood. Transfusions of contaminated blood.

> Manifestations: > Manifestations:
- Mild ―> Itching, Urticaria (hives), Flushing Wheezing, Dyspnea, Chest tightening, Cyanosis ÒblueÓ lips,
- Severe (Anaphylactic) ―> Bronchospasm, Laryngeal Hypotension, Shock
edema, Shock > Care:
> Care: Give 0.9% NS, Antibiotics
Give 0.9% NS, Vasopressor (epinephrine), Antihistamine
(diphenhydramine), Steroids, Oxygen, Maintain open airway
& adequate breathing

CIRCULATORY OVERLOAD

Rapid transfusion rate (older adults and pts. with existing

elevated circulatory volume are at high risk).
> Manifestations:
Crackles, Dyspnea, Cough, JVD, Tachycardia, Anxiety, can
progress to Pulmonary Edema
> Care:
Give 0.9% NS, Diuretics (furosemide), Oxygen, Maintain
open airway & adequate breathing, High-FowlerÕs position,
Feet lower than level of heart

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MED. ADMINISTRATION

6 RIGHTS OF DRUG ADMINISTRATION TYPES OF MED. ORDERS

Standing: med. pre-established

RIGHT PAT IENT RIGHT ROUT E
& approved to give in the
absence of HCP or attending.
RIGT MEDICAT ION RIGHT T IME
Single: given one time only.
PRN: given as needed.
RIGHT DOSE RIGHT DOCUMENTAT ION
STAT: med. given soon as
possible.
ABBREVIATIONS TO
AVOID ―> WHAT TO USE INSTEAD COMPONENTS OF MED.
PRESCRIPTION
+ U ―> unit
+ IU ―> intentional unit
> Pt. full name
+ Q.D., QD, q.d., qd ―> daily
> Date & time of Rx
+ Q.O.D., QOD, q.o.d., qod ―> every other day
> Name of med. (generic or brand)
+ MS ―> morphine sulfate
> Strength & dosage
+ MSO4, MgSO4 ―> magnesium sulfate
> Route
+ Trailing zero (Decimal point could be overlooked or
> Time & frequency
not written) Ex: 5.0 mL ―> write 5 mL
> Quantity & number of refills
+ NO leading zero (Decimal point could be overlooked
> Signature of prescribing provider
or not written) Ex: .5 mL ―> write 0.5 mL
+ > sign ―> greater than
+ < sign ―> less than COMMON MED. ERRORS
+ cc ―> mL
+ Write FULL medication name > Wrong med or IV fluid
> Incorrect dose or IV rate
> Wrong client, route, & time
> Administration of an allergy-inducing med.
ALWAYS ask about

& allergies during

medical Hx interview
> Omission of dose
> Administration of extra dose
> Incorrect discontinuation of med or IV fluid
> Inaccurate prescribing
> Giving med that has similar name to other
med(s)

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PHARMACOKINETICS
A.D.M.E

A - ABSORPTION D - DISTRIBUTION
> Meds. administered from its starting location > Transportation of medication by bodily fluids to
to the bloodstream. where they need to go
In order from fastest to slowest absorption What Affects This?
rate: IV, IM, SC, ID, PO (oral) > Circulation (conditions that hinder blood flow &
> Route and amount of med. affects perfusion).
absorption. > Permeability of the cell membrane (certain
meds. must go through tissues & membranes to
M - METABOLISM reach targeted areas).
> Plasma protein binding sites (two meds. fighting
> How the medication is broken down. Enzymes cause for same binding site to reach targeted area).
meds to become less active or inactive. Primarily
occurs in the liver, but also in the kidneys, lungs,
intestines, & blood.
E - EXCRETION
What Affects This? > Eliminating med primarily through the
> Age (older adults are given smaller doses due to kidneys. Also excreted by the liver, lungs,
risk of accumulation). intestines, & exocrine glands.
> Increased Dose on med. > Kidney dysfunction can cause accumulation
> First-pass effect (liver inactivates the first-time of med. in body Ñ TOXIC LEVELS (monitor
med before it reaches the systemic circulation. Should BUN & creatinine levels).
give med non-enteral i.e. IV).
> Similar Pathways (two meds taken, rate of
metabolism decreases for one or both meds.)
> Poor nutrition
NON-PARENTAL

ORAL (ENTERAL) SUBLINGUAL & BUCCAL

Contraindications: Little GI mobility, No gag reflex, Sublingual: under tongue
Vomiting, Dysphagia, Decreased LOC. Buccal: b/w cheeks & gum
> Remain upright (High-FowlerÕs) > Med must completely dissolve.
> DO NOT give with interacting foods & drinks > NO food or drink until med dissolves.
(grapefruit).
> DO NOT crush time-released & enteric-coated meds.
> Mix crushed med with SMALL portion of food if
needed.
> For liquid meds, base of meniscus (lowest fluid line) at
level of ordered dose.

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NON-PARENTAL CONTINUED…

TRANSDERMAL TOPICAL
> Clean & dry skin before and after use. > DO NOT apply with bare hands.
> Place patch on hairless area. > TO apply ointment & cream, use gloves,
> Rotate sites to avoid skin irritation. tongue blade, or cotton swab.

EYE, EAR, & NOSE INHALATION

Eye: MDI:
> Place dropper 1-2 cm above the conjunctival sac (inner > Hold 2-4 cm away from front of mouth or
corner of eye). completely close mouth around mouthpiece.
> Gently close eyes & if blinks during instillation, repeat > Take deep breath & exhale.
the process. > Tilt head up, & at same time, press inhaler &
> Gently press on nasolacrimal duct for 30-60 secs. deeply inhale.
> Wait 5 mins if instilling more than one med. > Deeply inhale for 3-5 secs and hold breath for
> For ointment, apply thin layer from inner edge of 10 secs.
lower lid to the outer. > Once finished, remove mouthpiece & exhale.
Ear: DPI:
> For adult, pull ear up & outwards. For children, pull ear > Follow directions for prepping med.
down & back. > Exhale, close mouth around mouthpiece, & deeply
> Place dropper 1 cm above ear. inhale.
> Once instilled, gently press tragus of ear unless itÕs too > Hold breath for 5-10 secs.
painful. > Once finished, remove mouthpiece & exhale.
> Remain still for 2-3 mins. > Rinse mouth or brush teeth to lower risk of
Nose: fungal infection.
> Use medical aseptic technique.
> Breath through mouth & not blow nose for 5 mins.
SUPPOSITORIES
Rectal:
NS & GASTROSTOMY TUBES
> Left lateral or SimsÕ position.
> To prevent, clogging, flush with 15-30 mL of > Insert beyond internal sphincter.
sterile water before & after giving meds. > Remain still for 5 mins.
> Liquid meds recommend & if donÕt have, Vagina:
crush tablets & capsules (but not extended/ > Lithotomy or dorsal recumbent position.
time-released). NO sublingual meds. > Place 7.5-10 cm on posterior wall of vagina.
> Completely dissolve crushed meds in 15-30 > Remain still for 5 mins.
mL sterile water before administration.
> DO NOT mix meds.

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PARENTAL INJECTIONS

> Parental Route are injections absorbed through the blood

stream, muscle, & tissue.
Parental Routes: intradermal (ID), subcutaneous (SC), intramuscular
(IM), and intravenous (IV).

The gauge (G) is the needleÕs inner diameter (bore), through

which medication is administered.
> Example: A 23-G bore used for IM injection of more thicker
liquids. An 18-G bore used for IV injections of large amounts of
medication.
Determine length based on the type of injection.
> Example: Med given ID, use short length needle b/c it's a
superficial injection. Med given IM, use longer needle b/c it's
beneath skin and underlying tissue.

Larger the #,
Smaller the gauge

ROUT E GAUGE LENGT H SYRINGE ANGLE OF INSERT ION

ID 25-27 G ½ or 5/8 1 mL 10¡-15¡

-

SC 25-27 G 3/8 or 5/8-1 in 1-2 mL 45¡-90¡

-

IM 20-22 G 1-1 ½ in 2-3 mL 90¡

-

IV 14-18 G 0.5-1 ½ in No specific syringe 10¡-30¡

(emergic, blood)
20-22 G
(standard
infusion)
22-24 G
(children, older
adults)

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PARENTAL INJECTIONS CONTINUED…

INTRADERMAL SUBCUTANEOUS
> TB skin test & medication or allergy > Divided into two doses if injecting more than
sensitivities. 1 ½ mL.
> DO NOT MASSAGE > Once injected, remove needle at same angle.
> Bleeding or NO wheal formation indicates > DO NOT MASSAGE
injection was given incorrectly. > DO NOT ASPIRAT E, cause nodules & tissue
damage.
> Sites w/ adequate fat (abdomen, upper hips,
INTRAMUSCULAR lateral upper arms, thighs).
> For average-sized patients, give at 45¡-90¡.
> ASPIRAT E. If you aspirate blood, it is NOT in the
Obese patients, give at 90¡.
muscle, but the vein.
> Z-track method
Sites: Dorsogluteal (back of hip), Ventrogluteal (side
of hip), Deltoid (upper arm), Vastus lateralis (side of INTRAVENOUS
thigh), Rectus femoris (anterior thigh) > ASPIRAT E. If you aspirate blood, GOOD JOB!
> Ventrogluteal: common site for infants and You're in the vein!
children less than 3 yrs. > Monitor the IV site for infiltration, air embolism,
> Rectus femoris: rarely used site b/c itÕs very phlebitis, infection, tissue damage.
close to the sciatic nerve and numerous blood > Potassium (K+) is a VERY uncomfortable and
vessels. If hit, permanent damage or paralysis. Only life-threatening electrolyte to give though IV.
used when other sites are not available. Potassium is rather given by mouth. If given IV, it
must be diluted in solution (0.9% Normal Saline, 5%
Dextrose, etc.) and regularly check on the patient.
Potassium should NEVER be given IV push
A few meds/supplements/other(s) given for each
because it can stop the heart leading to death.
parental route:

&
Most common sites to start an IV are at
> ID: tuberculin (TB skin test)
peripheral veins: hand, forearm, and antecubital
> SC: heparin, insulin
(inner elbow).
> IM: iron, steroids, Influenza vaccine,
> IV: electrolytes, fluid (0.9% Normal Saline), Before inserting
morphine, blood products, TPN (Total Parental needle, be sure to
Nutrition) rid of air bubbles
inside syringe

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ENTERAL FEEDING

Reasons forventeral feeding? Types:

> Poor gag reflux (stroke, decreased LOC) Nasogastric; Nasoduodenal; Nasojejunal:
> Poor nutrient intake > Inserted via nose
> Trauma (burns) ―> increased nutritional > Short-term (less than 4 wks.)
needs Gastrostomy; jejunostomy:
> Cancer affecting head, neck, and upper > Long-term (more than 4 wks.)
GI tract > Inserted surgically
> GI disorders (IBD, enterocutaneous fistula) Percutaneous endoscopic gastrostomy (PEG);
percutaneous endoscopic jejunostomy (PEJ):
> Long-term (more than 4 wks.)
> ASEPT IC T ECHNIQUE (avoid bacteria
> Inserted endoscopically
entering the GI tract)
> Semi or High FowlerÕs position during & 30
mins after feeding Complications:
> Flush feeding tube with 15-30 mL (0.9% NS) > Aspiration!
before and after administering medication > Gastric residual more than 250 mL (withhold
> DO NOT crush a enteric coated or time- feeding and notify HCP)
release tablet and give by GI tube > Diarrhea 3x or more in 24 hrs.
> Flush tube with 30-50 mL (0.9% NS) every > Infection or Bleeding at insertion site
4-6 hrs. if on continuous feeding to prevent > Dislodge of tube
clogging.
Nasogastric: give nose and mouth care (clean
nose, brush teeth, moisturize)
PEG: check skin integrity, for infection or
drainage

To check placement:
> x-ray

*> aspirate gastric content and measure pH.

Gastric pH is
between 1.5-4

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BOWEL ELIMINATION

What affects bowel elimination? Diagnostic Tests:

> Immobility > Fecal occult blood test (guaiac test): test
> Too much/too little of fiber (require 25-30 feces for blood
g/day) > Specimen for stool culture: test to find
> Decreased peristalsis, relaxed anal possible bacteria, parasites, etc.
sphincter in older adults Colonoscopy; Sigmoidoscopy
⑳
w
> Little fluid intake (require 2-3 L/day)
> Physical activity
Incontinence: Determine cause (medication,
> Opioid/narcotic common SE is constipation
infection, impaction).
> Emotional distress or depression
> Give regular perineal care (to prevent skin
> Constipation and hemorrhoids during
breakdown and bad odor).
pregnancy
Flatulence (trapped gas): Check for abdominal
> Medications (stool softeners, overuse of
distention.
laxatives causing diarrhea)
> Ambulate to pass gas.
Hemorrhoids: Use moist wipes to soothe and
cleanse perineal and apply prescribed creams.
CONSTIPATION > Sitz bath or ice pack to relieve pain.
Manifestation/Care: Ostomies (surgical bowel diversions through
> Abdominal distention, cramping permanent or temporary stomas).
> Straining to defecate, hard feces
> Irregular bowel movement
> Increase fiber and fluid intake
DIARRHEA
> Increase physical activity (ambulate, etc.) Manifestation/Care:
> DO NOT strain/bare-down during bowel movement > Frequent loose stool
> Place feet on step stool or basket (ÒsquattingÓ > Watery consistency
position to relieve pressure on colon) > Abdominal cramping
> Deep breathing exercises while defecating > Determine and treat underlying cause (IBD/IBS,
> Give enemas, stool softeners, laxatives as needed antibiotic therapy)
Complications: > Administer medications to slow GI activity
> Fecal impaction > Give perineal care and apply prescribed cream
> Hemorrhoids and rectal fissures after each bowel movement (prevent skin
> Bradycardia, hypotension, syncope (associated with breakdown)
straining or bearing down) > After diarrhea stops, eating yogurt re-establishes
an intestinal balance of ÒgoodÓ bacteria
Complications:
> Dehydration, F&E imbalance
> Skin breakdown around anus

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URINARY ELIMINATION

What affects urine elimination? Average excretion of urine by adult:

> Kidney failure 30 mL/hr (appox. 500-2,400 mL/day)
> Too much/too little fluid intake To determine average urine excretion by all
> Weight of fetus on woman's bladder during ages and sizes:
pregnancy and relaxation of the woman's 0.5 mL/kg/hr
sphincter Lab tests:
> Immobility (incontinent) > BUN: 10-20
> Hypo & Hypernatremia > Creatine: 0.5-1.2
> Emotional stress and anxiety > Urine Specific Gravity: 1.005-1.030
> Medications (diuretics, antihistamines, etc.) > Urine's pH: 4.5-6.5
> Pain (withhold urge to pee to avoid pain, UT I)

URINARY TRACT INFECTION

Diagnostic test:
Manifestation/Care:
> *Urinalysis
> Urgency, Frequency
> Renal function test (BUN, creatine)
> Dysuria
> Radiologic tests (kidney/uterus/bladder x-ray)
> Chills
> Renal angiography; Cystoscopy; Renal biopsy
> Abdominal and flank pain
* Reagent strip test "dip-stick": test urine > Urine appears cloudy
acidity, specific gravity, test for glucose, > Drink 2-3 L fluids/day; avoid caffeinated drinks
protein, nitrates, blood, WBCs, ketones. > Administer prescribed antibiotics
Assess urine's color, clarity, odor, volume. > Encourage frequent voiding
> Female: wear cotton panties; wipe perineal front
to back; use unscented soap; NO scented perfumes
Specimen Collection:
Clean-catch urine sample (common method) altered mental status
Urinary catheter sample: (confusion) can be primary
> Straight: in and out catheter to collect sample sign of UT I in older adults,
for those unable to urinate. esp. older women
> Indwelling: insert needless syringe into sample
port of the indwelling catheter.
both samples
are done
ST ERILE less than 30 mL of urine

& over 2 hrs. is concerning

& should be assessed

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URINARY ELIMINATION CONTINUED…

ABNORMAL URINARY PATTERNS

Urinary frequency: voiding more than usual

Urgency: sensation to void immediately; common to experience involuntary leakage
Dysuria: difficulty urinating due to pain and burning sensation (associated w. infection
Nocturia: frequent voiding at night
Enuresis: "bedwetting"
Polyuria: excessive excretion of urine; >2,500 mL/day is considered polyuria
Oliguria: little excretion of urine; <500 mL/day is considered oliguria
Incontinence: inability to control bladder
Urinary suppression: stopping urination
Anuria: absence of urine (<100 mL/day)
Urinary retention: inability to empty bladder fully

PRESSURE ULCERS
Stage 1: nonblanchable erythema: Stage 4: full-thickness:
intact skin; redness typically over bony dead tissue; damage of muscle, bone, and
prominence; tissue swollen with possible supporting structures; infection, tunneling,
discomfort; on darker skin, ulcer appears blue undermining, eschar (black scab-like), or
or purple. slough (tan, yellow, green scab-like).

Stage 2: partial thickness: Unstageable, full-thickness skin/tissue loss,

extends to epidermis and dermis; red-pink depth unknown:
superficial area; NO slough or bruising; looks cannot determine stage because eschar or
like an abrasion or blister; edema; ulcer can slough conceals the wound.
become infected; pain and little drainage.

Stage 3: full-thickness:
damage, dead subcutaneous tissue; drainage
and infection are common.

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CPR + AED and Heimlich Maneuver

C = cardio (heart) Important note! If person is left without
P = pulmonary (lungs) CPR for 2-3 minutes, cerebral ischemia
R = resuscitation (recover) can lead to worsening brain injury. By 9
minutes, severe and irreversible brain
CPR supports circulation and ventilation for a victim in damage is likely. After 10 minutes, the
cardiopulmonary arrest. It helps provide oxygen to the chances of survival are low. The longer
brain, heart, lungs, and other organs until advanced life the brain is deprived of oxygen, the
support arrives (EMTs, paramedics, trained nurses). worse the damage will be.

General: Infant (0 months-1 yrs), Child, Adult AED Tips: Infant, Child, Adult
Ensure surrounding is safe and clear of danger DO NOT place pads on wet area
Check for responsiveness: (dry area if wet) or on top of
Infant: tickle (if baby cries, baby does not need CPR) medical device (pacemaker, etc.)
Child: shake and yell "Are you okay!" Rather place the pad at least 3
Adult: shake, tap face, and yell "Are you okay!" cm from device.
Manifestations: unconscious, little to no breathing (GASPING Continue CPR as other person
is NOT normal), no pulse felt within 10 seconds, blue lips places AED pads.
Pulse check: Infant=Brachial artery; Child & Adult=Carotid Follow the AED instructions
Call 911/ Call for help EXACTLY as said (easy peesy!)
When shock is delivered, DO
If alone without phone, get phone, call 911, and get AED
NOT touch the person.
(if one is available), then initiate CPR; otherwise, if more
After shock is said to be
persons, send someone to call 911 and get AED while you
delivered, return to doing CPR
immediately initiate CPR
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Infant and Child CPR Adult CPR

Chest compressions: Chest compressions:
Infant: 2 fingers in center of chest; below nipple 2 hands (one above the other);
line
lower half of sternum
Child: 2 hands or 1 hands (depend on size of
child); lower half of sternum Rate: 100 -120/min
Rate: 100 -120/min Depth: 2 in (5 cm)
Depth: 30:2 (30 pumps to chest and 2
Infant: 1 1/2 in (4 cm) mouth-to-mouth breaths)
Child: 2 in (5 cm)
30:2 (30 pumps to chest and 2 mouth-to-mouth
Tilt head, lift chin, seal nose
breaths) shut, deliver mouth-to-mouth
Infant: Tilt head, lift chin, cover NOSE and Continue CPR until person is
MOUTH with your mouth when giving breathing and conscious, help
breaths
arrives, or AED is available.
Child: Tilt head, lift chin, seal nose shut,
deliver mouth-to-mouth
Continue CPR until person is breathing and
conscious, help arrives, or AED is available.

Important note! When delivering mouth-to-mouth:

completely seal mouth to person's mouth
look for chest rises when giving breaths

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Heimlich maneuver: maneuver used when airway is obstructed with foreign object (food, etc.)
Manifestations in Infant, Child, Adult: Partially obstructed airway: person has good gas
cyanotic (blue) exchange to cough forcefully; Encourage person to
stops breathing, cannot talk, little to no cough; DO NOT intervene when person is attempting
cough to expel the object, but stay with person to closely
collapses for no apparent reason monitor. If condition does not improve (high-pitch
Other manifestations: wheezing, cyanotic), immediately call 911/ for help.
hands clutching at neck and gasping
panicking, looks frightened
Infant Heimlich Child & Adult Heimlich
1. Sit or kneel with infant in lap 1. Stand behind person (Kneel to child's
2. hold baby face down (head lower than chest) within height)
your forearm and SUPPORT the baby's neck and jaw. 2. Wrap arms around person's abdomen (1
3. Deliver 5 back slap with palm of hand (use sufficient or 2 arms for child; 2 arms for adult) For
force) obese or pregnant person, wrap arms
4. Cradle baby with 2 hands and flip baby onto back under the chest.
3. Place your dominate hand above the
(head lower than truck)
belly button; with hand balled into fist
5. Deliver 5 chest pumps with 2 fingers (SUPPORT the
and your thumb against the abdomen
baby's back and head)
4. Wrap your non-dominate hand onto the
6. Repeat sequence until object is expelled or baby is
dominate hand.
still unresponsive
5. Give several thrusts until the foreign
7. If unresponsive call 911/ call for help
object is removed.
8. Perform CPR and continuously look inside for
6. Child: DO NOT thrust hard enough to lift
foreign object, but DO NOT do a blind finger sweep.
child off his/her feet.
Could push object further into airway.
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