FUNDAMENTALS

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 FUNDAMENTALS

HEALTH CARE BASICS

PRIMARY HEALTH CARE SECONDARY HEALTH CARE TERTIARY HEALTH CARE

Primary = Prevention Secondary = Screenings Tertiary = Technical

Preventing disease through Mammograms and blood ICUs, oncology centers, and
yearly physicals, prenatal visits, glucose testing are used to burn centers provide
and nutrition guidance. screen for and treat acute technical and specialized
illness or injury. care for current issues.

Nursing Process: A ADPIE

ASSESSMENT: Obtaining information from patients using subjective and objective data.
Subjective Data: What SUBJECT says to you. Information provided by the patient or family to the nurse.
Ex: Patient pain report 6/10.
Objective Data: What information the nurse OBSERVES. Ex: Vital Signs, EKG

Types of Assessments

Initial or Baseline: Focused: Emergency: Continuous:

At the time of admission, Assessment of ABCs (airway, At a later date, compare
the patient is evaluated the state of a breathing, the patient's status
for the first time. specific problem circulation) to the baseline.

DIAGNOSIS: Identify the problem to create a Nursing Diagnosis. Types:

Risk: patient at risk for____ Actual: the patient has____

PLANNING: Setting SMART goals to solve the problem.

S: Specific M: Measurable A: Attainable R: Realistic T: Timely

IMPLEMENT: Beginning a Nursing Intervention

EVALUATE: Determine the consequence of objectives, actions. Was it successful? What should be altered?
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 FUNDAMENTALS

INTERPROFESSIONAL TEAM

Provider (MD, PA, DO, NP): disease or injury is assessed, diagnosed, and treated

Registered Nurse or Practical Nurse: nursing procedure (assess, diagnose, plan, implement, evaluate)

Assistive Personnel (AP): certified nursing assistants who operate under the supervision of RN/LPN.

Occupational Therapist: supports clients in regaining abilities for everyday life tasks (ADL).

Physical Therapist: helps clients reclaim musculoskeletal function and mobility.

Respiratory Therapist: assesses respiratory condition and begins treatments such as chest physiotherapy.

Social Worker: coordinates inpatient and community resources to address the client's physical, emotional needs.

Speech-Language Pathologist: treats speech, swallowing, and language problems or injuries.

Pharmacist: medication is provided, monitored, and evaluated.

Laboratory Technician: performs tests on bodily fluids (urine, saliva, blood).

Nursing Ethics Legal

Beneficence: “Do Good” increase patient Negligence: Nurse fails to deliver standard and safe treatment
safety and health to patients, putting clients in danger.

Autonomy: right to make one’s own Malpractice: failure of a professional to operate reasonably
decisions and prudently, resulting in HARM.

Nonmaleficence: “Do No Harm” Assault: threats spoken

protect the patient from harm Battery: injury-causing physical contact

Veracity: Inform the truth False Imprisonment: client restrained or confined against his

Justice: All patients should receive or her will and without justification

equitable care and resources. Informed Consent: The customer must provide written

Fidelity: keep your promises authorization for the healthcare staff to execute a

Advocacy: assist and defend the client's procedure.Nurse is the Witness

healthcare decisions and rights HIPAA: Health Insurance Portability and Accountability
Act to protect a client’s private health information

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FUNDAMENTALS
DELEGATION

Delegation is the transfer of a task to a STABLE patient with EXPECTED OUTCOMES to

another member of the healthcare team while remaining accountable for the outcome.

EX: A Registered Nurse asking a CNA to ambulate a patient to the dining hall.

TASK RN LPN AP

Administer IV Chemo or Blood

Rights of Delegation
Set Up Care Plans

Primary Assessment or Education “Terrific Care Promotes

Reassessment or Reeducation
Client Safety”
Trach Care & Suction Task
Circumstance
Inserting a Urinary Catheter
Person
Administering Oral Medications Communication
Ambulating Supervision
Vital Signs

Measuring Intake & Output

Bathing, Grooming, Feeding

Asepsis: best way to prevent infection is with proper Hand Hygiene

Medical Asepsis: reducing # Surgical Asepsis: eliminating

of microorganisms ALL microorganisms

Sterile Field: When a nurse performs a high-risk infection procedure, (ex: Trach
Care) they must create a sterile field in which the equipment can remain sterile.

Here are the guidelines:

• Outer 2.5 cm (1 in) of drape border is NOT STERILE

• Never reach across or turn your back on a sterile fieldtt

• Materials below waist or above chest are CONTAMINATED

• Only sterile items can be in the Sterile Field

• Keep sterile field dry and discard wet, punctured or torn packaging
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 FUNDAMENTALS
SAFETY PRECAUTIONS
STANDARD: AIRBORNE: get CONTACT: please do not DROPLET: drop it
stands for all ready to go on the come into contact with like it is hot for your
AIR at MTV. anything in a SEWER. PIMP
Use: gown, gloves,
goggles, mask as M: Measles S: Skin Infections P: Pertussis
NEEDED T: Tuberculosis E: Enteric (C Diff) I: Influenza
V: Varicella W: Wound Infection M: Mumps
E: Eye Infections P: Pneumonia
Use: N95 mask, R: Rotavirus
negative pressure Use: surgical mask,
Use: Strict Hand
airflow, private door closed,
Hygiene, Gown,
room and closed door private room
Gloves, Disposable
Equipment

Putting on PPE “Donning”

Biggest Equipment to Smallest Taking off PPE “Doffing”
1) Gown 3) Goggles 1) Gloves 3) Gown
2) Mask 4) Gloves 2) Goggles 4) Mask

Assistive Devices

Crutches: Walker:
Note: For length, allow 2-3 finger width between crutch and Four-legged metal frame Maintaining a 30° flexion of the
axillary, elbows extended 30°, and bottom of crutches elbows, move forward 12 inches, then move the afflicted limb
more than shoulders width apart. forward first. Make sure the patient is wearing nonslip shoes
and a gait belt.
UP Stairs: Walking up to the GOOD place so
advance GOOD leg first, then use affected leg.
Cane:
DOWN Stairs: Walking down to the BAD place so A bar was employed for support. Types: straight (single prongs),
advance bad “broken” extremity first. tripod (3 prongs), quad (4 prongs). Hold cane on strong side.

2 Point Gait 3 Point Gait 4 Point Gait Swing Through

RIGHT crutch with BOTH crutches Resembles “Normal Both crutches
LEFT foot first then LEFT forward with weak Walking” Left Crutch forward then both
crutch with RIGHT foot. leg then advance then Right Foot then legs swing forward
strong leg. Right Crutch then Left Foot
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 FUNDAMENTALS

PATIENT POSITIONING

Supine: “On my Spine”: Flat on Back Prone: “Away from that Tailbone”: Flat on Stomach
Uses: neck or spinal cord injuries, Uses: advanced acute respiratory distress
abdominal or facial surgery syndrome, spinal cord operations

SIMS: On your stomach, with your leg

Lateral: Patient on Side
flexed and your arm flexed at the elbow.
Uses: one sided injuries
Uses: evaluating the rectal, vaginal areas

Fowlers: Sitting Up
Lithotomy: Flat on your back, knees
Low Fowlers: 15-30°
bent, and feet on stirrups
Semi Fowlers: 30-45°
Uses: examine the genitalia, reproductive
High Fowlers: 60-90
tract, and rectum of the female.
Uses: tube feeding or maintain ICP in neuro patients

Trendelenburg: Lay flat on your back with

Reverse Trendelenburg: Flat on
head lowered below the level of your feet.
back, with your head elevated above your feet.
Uses: air embolism, central line
Uses: GERD, pulmonary aspiration prevention
placement, hypotension

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 FUNDAMENTALS
VITALS
Vital Signs Include: Temperature, Pulse, Respirations, Blood, O2 Saturation, Pain

Pulse
Blood Pressure
Temporal
Normal Pulse Carotid
SYSTOLIC DIASTOLIC
110-160: Fetal HR
(heart contracts) (heart relaxes)
100-160: Newborn Brachial
80-120: Child NORMAL < 120 < 80
Radial
60-100: Adult (18+) Femoral Elevated 120 - 129 < 80

HTN Stage 1 130 - 139 80 - 89

Popliteal
Pulse Strength
HTN Stage 2 > 140 > 90
0 = Absent Posterior Tibial
1+ = Diminished, Weak Pedal Hypertensive Crisis > 180 > 120

2+ = Normal, Easy to Palpate

BP = Hypertension BP = Hypotension
3+ = Increased, Strong
4+ = Full Volume, Bounding Orthostatic Hypotension: BP when patient

HR = Tachycardia HR = Bradycardia

Temperature
Pain Level Normal Temperature Modes
O-L-D-C-A-A-R-T-S Oral: Mouth
98.6°F (37°C): Normal
O: Onset (acute or chronic) Axillary: Armpit
>100.4°F (38°C): Fever
L: Location Rectal: Buttocks
D: Duration Tympanic: Ear
C: Characteristics (sharp, dull) Temporal: Forehead
A: Aggravating Factors (what makes it worse)
A: Alleviating Factors (what makes it better)
R: Radiates
T: Treatment (what was used to treat it) Respirations
S: Severity (0-10 pain scale)
Normal Terms
0 1-3 4-6 7-9 10
Respirations RR: Tachypnea
40 - 60: Newborn RR: Bradypnea
20 - 30: Children Dyspnea: Difficulty Breathing
12 - 20: Adult

Oxygen Saturation
Normal Oxygen Saturation: 95-100%
Note: a patient with COPD can run lower
o2 saturation levels.
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 FUNDAMENTALS
WOUND CARE
Stage 1 Stage 2 Stage 3 Stage 4

Redness Partial Thickness Full Thickness Full Thickness Tissue

Mild Pain, Red w/ Loss of Dermis Tissue Loss Loss with Exposed
and Warm Skin
Moderate Pain, Pink, Moderate-Severe Pain, Bone, Muscle, Tendon
Fluid Blisters Pink-White, May have
No Pain, Black w/ Eschar,
undermining or tunneling.
Undermining, Infection Risk,
Tunneling.

Wound Healing Phases Wound Healing Intentions

• Hemostasis Phase: Injury begins during the 1. Primary Intention: The edges are approached
Hemostasis Phase. Blood vessels constrict and (ex: a surgical incision), there is little to no tissue
platelets clump to limit bleeding. loss, there is less possibility of infection, and the
• Inflammation Phase: There is heat, swelling, wound heals quickly.
redness, and anguish at the location. WBCs visit 2. Secondary Intention: Unpredictable wound
the region. aging, tissue loss, greater risk of infection and
• Proliferative Phase: Fibroblasts split and secrete scarring, longer healing time
collage. New blood vessels form within the incision, 3. Tertiary Intention: deep and widely spaced,
and a scar forms. lengthy healing time, significant risk of infection,
• Remodeling Phase: Scar tissue changes, need wound debridement to heal
restoring skin integrity.

Serosanguineous Purosanguineous
Serous Drainage: Sanguineous Purulent
Drainage: pink (mix Drainage: pus &
watery Drainage: Bloody Drainage: infected
of blood & water) blood

Wound Cleaning Wound Terms

Irrigation: Acute Wound: <6 wks, Chronic Wound: >6 wks
Passive irrigation entails gently washing contaminated Macerated: “Moisture” Overhydrated
areas with gauze and solution, whereas mechanical Desiccated: “Desert” Dry Skin
irrigation entails pouring cleansing solution over the Dehiscence: partial/total seperation of wound
wound via gravity. Eviscerated: separation of wound with viscera
Dressing: protruding
Woven Gauze: dry gauze pad secured to wound Periwound: skin surrounding wound
Wet-To-Dry: saline soaked gauze placed on wound Erythema: redness of skin, Edema: swelling of skin
Hydrocolloid: dressing swells in presence of exudate Indurated: firm or hard skin around wound
Hydrogel: becomes gel after contact with exudate
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 FUNDAMENTALS
MEDICATION ADMINISTRATION

Rights of Medication Administration Plunger Orders

“Patients Do Drugs Round The Day” PRN: “As Needed”
Patient Single One Time Dose: give only once,
Drug not on a reoccurring basis.
6 Rights Barrel
Dose Routine or Standing: nurse can give
Route Hub med on a regular schedule without
T ime Needle order expiring.
Documentation STAT order: give medication immediately
Lumen

Routes

Oral: by mouth “PO” Parenteral: by injection

• Most prevalent and least expensive IM = Intramuscular “Into the Muscle” 90°
• Before administration, clients should sit up 90 degrees. Needle Length: 5/8 - 1.5”
• Check to see if your prescription should be taken with food. Needle Gauge: 18 - 25
• Crushing Extended Release should never be done Sites: Deltoid, Ventrogluteal, Vastus Lateralis
Sublingual: under tongue
Buccal: between cheek and gum SQ = Subcutaneous “Into SQ Fat” 45°
Topical: by skin or mucous membranes Needle Length: 3/8 - 5/8
• Less negative consequences Needle Gauge: 25 - 27
• Always use gloves when applying. Sites: Abdomen or Back of Arm
• Wash your skin with soap and water and pat it dry. Uses: Heparin or Insulin Injection
Transdermal: skin patch absorbs into skin
GAUGE
ID = Intradermal “Into Dermis” 10-15° =
Ophthalmic: by eyes
LUMEN
Needle Length: 3/8 - 1/2
• Maintain the sterility of medications. (opening) of
Needle Gauge: 25 - 27
• Dispense into conjunctival sac corner needle
Sites: Inner Surface of Forearm
• Wait at least 5 minutes between infusing each medication.
Uses: Tuberculin (Mantoux) Skin Test
Otic: by ears
IV = Intravenous “Into Vein” 25°
• Allow the client to sit upright or lie on their side.
• Patient remain on side 2-3 min post admin
< 3 yrs: Pinna DOWN & BACK GREEN PINK BLUE YELLOW PURPLE
>3 yrs: Pinna UP & OUTWARD 18 G 20 G 22 G 24 G 26 G
Nasal: by inhalation through nasal passage
• For Nasal Spray: Prime the tip, insert it into the nares, point
it away from the center of the nose, and push down.
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 FUNDAMENTALS
IV THERAPY & IV FLUIDS

Starting an IV Securing an IV Discontinuing an IV

• Use Cephalic, Basilic or Cubital • Apply transparent dressing • Close roller clamp to avoid spilling
Vein in Hand or Forearm over vein IV fluid
• Apply Tourniquet 4-6 inches • Leave connection catheter • Pull dressing and tape toward
above site hub and IV uncovered injection site
• If excess body hair, do not • Place tape over hub and • Assess IV site for signs of infection
shave, only clip off hair NOT insertion site after removing IV
• Use ~20-22 gauge adult, 22-24
gauge pediatric
IV TUBING REPLACEMENT: Note: if catheter broke off in vein, it
• Insert tubing to spike bag and
Continuous: Q72 - 96 hrs can cause an embolus. Monitor.
prime tubing
Intermittent: Q24 hrs
• If no continuous infusion, initiate
TPN: Q24 hrs
a saline lock
Blood Tubing: Every 1 Unit of
Blood or Q4 hrs

Phlebitis Infiltration Extravasation

Look: Pain, Redness Look: Edema, Pallor, Look: Burning,
Along Vein, Warm Skin Pain, Cool Skin Redness, Pain, Edema
Treatment: discontinue IV, apply Treatment: discontinue Treatment:
warm compress, scale of 0-4 for IV, elevate extremity, apply warm Discontinue IV, apply cold
severity, monitor Q1hr or cold compress, monitor Q1 hr compress, give antidote drug

IV FLUID THERAPY

HYPOTONIC HYPERTONIC ISOTONIC

Fluid goes INTO cell to expand Fluid goes OUT of cell to Replenished cells without
cells to total body fluid volume. fluid levels. changing shape to replace fluid
EX: 1/2 NS EX: 3% NS losses.
USES: We need to DIG USES: I need to get the fluid EX: 0.9% NS
fluids into the cells. out of my soaked SOCK. USES: BAD Situations

D: DKA S: Severe Hyponatremia B: Burns or Blood Loss

I: Increased Total Fluid O: Overload of Fluid A: Anaphylaxis/Sepsis
G: Gastric Fluid Loss C: Cerebral Edema
K: Ketosis
D: Dehydration
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FUNDAMENTALS
CENTRAL VENOUS ACCESS DEVICE

A central venous access device is a type of IV therapy where a tube is inserted into a large VEIN that
ends in the superior vena cava. Can last several weeks to years. Uses:

• Parenteral Nutrition • Parenteral Nutrition • Burn or Trauma Resuscitation

• Chemotherapy Administration • Blood Administration • Antibiotics Administration

Types of Central Lines

PICC Line: Central catheter placed from the outside.
• Access to the Basilic Vein
• Clots or infections are extremely likely
• The gadget is not sutured and can be removed by the nurse
Port-A-Cath: a surgically implanted device with a catheter linked
to a subcutaneous pocket
• Common with Chemo Patients
Tunneled: put into vein through skin, generally in the chest
Central Line Care
• Usual in a Domestic Setting • Maintain Line Patency
• Long-Term Application Use Push/Pause method to risk of clots
• Reduced Infection Risk 10 mL of sterile 0.9 NS flush
• Catheter with cuff attached to anchor it to the skin
Hemodialysis: central catheter (temporary) • Dressing Care
• Larger Lumen = Faster Flow Check that the dressing is clean, dry, intact
• Short Term Application Dressing Changes Every 7 Days

• Infection Control
Change Injection Cap on Lumens Q7 days
Use an Antimicrobial Patch (CHG)
Lumen Types
Keep an eye out for Infection Signs
A lumen is an aperture at the distal end of a Sterile Gloves During Dressing Care
catheter that can be used to infuse or
aspirate fluids.
Number of Lumens =
Diameter of Each Lumen
Single Lumen: Sheath with a big bore for
quick or massive infusions.
Multiple Lumen: used to give many
incompatible medications
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FUNDAMENTALS
URINARY CATHETER

A Urinary Catheter is a type of catheter that is inserted through the urethra and into the bladder to
withdraw urine. Uses:

• Empty Bladder Pre/Post Surgery • Prostate Enlargement • Spinal Cord Injury

• Relieve Urinary Retention • Measure Urine Output • Obtain Sterile Specimen

Types of Urinary Catheters Catheter Sizes

Catheters are classified on a
Indwelling “Foley” Catheter
French scale based on lumen size.
-Standard catheter that can be used for
up to two weeks on average.
8-10 Fr: Children
-To keep the catheter from dislodging, a balloon
14-16 Fr: Females
is inflated with sterile water.
- Infection Risk 16-18 Fr: Males

Intermittent Catheter For latex-allergic clients, silicon

-Used for a single urine specimen and or Teflon should be utilized.
then discarded

Coude Tip
-Curved tip for dealing with blockages or
challenging anatomical features. Catheter Care
-Frequently used for Prostate Enlargement
COLLECTION BAG SHOULD BE BELOW
Three-Way Catheter WAIST LEVEL TO PREVENT BACK-FLOW
-Three tubes:
1) Inflate Balloon to Prevent Dislodging • At the insertion site, use soap and water
2) Irrigation of the Bladder • Q3x/day Catheter Cleanse
3) Bladder Drainage • Monitor for Signs of Infection (dysuria,
fever, hematuria)
Suprapubic Catheters
• Examine the Tubing for Kinks or Sediment
-Directly inserted into the bladder through
the abdominal wall.

Condom Catheter
-Nothing is introduced into the bladder; instead,
a sheath that fits around the penis
and collects urine is used.

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 FUNDAMENTALS
BOWEL ELIMINATION
A regular bowel movement can vary, but one every 1-3 days is the usual.

Life Span Considerations Types of Bowel Movements

Infants
The Bristol Stool Chart
• Stools from breast milk are watery and yellow brown
• Pasty and dark stools from formula feeding Type 1:
Severe Constipation “Maltesers”
Children
• Bowel control between the ages of 2-3 years Type 2:
• Gastric acid secretion has increased Mild Constipation “Grapes”
• Large intestine growth has been accelerated
Type 3:
Older Adults Normal “Toffee Crisp”
• Peristalsis has been reduced
• Gastrointestinal Reflexes are Reduced Type 4:
Normal “Smooth Sausage”

Type 5:
Lacking Fiber “Chicken Nuggets”

Promotion for Bowel Elimination Type 6:

Mild Diarrhea “Porridge”
Fluid Intake to 2-3 L/Day
Fiber Intake of 25-38 g/day Type 7:
Physical Activity Severe Diarrhea “Gravy”

Terms
Diagnostics
Laxatives: soften stools
Fetal Occult Blood (Guaiac) Test: stool sample for bleeding detection
Incontinence: inability to control defecation
Colonoscopy: Endoscopic examination of the colon and small bowel
Flatulence: gas
Sigmoidoscopy: Endoscopic examination of the sigmoid colon
Hemorrhoids: swollen & dilated blood
and rectum.
vessels in rectal wall
Diarrhea: loose stool
Constipation: difficulty with bowel movements

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 FUNDAMENTALS
OSTOMY CARE

An ostomy is a surgical opening (stoma) in the abdominal wall that allows for the passage of stool
and urine. It could be required because of:

• Irritable Bowel Disease • Diverticulitis • Ruptured Diverticulum

• Bladder Cancer • Colon Cancer • Traumatic Injury to Bowel/Rectum

Transverse
Types of Ostomies Colostomy

Colostomy: diversion of the “Colon” of the large

intestine It could be caused by IBD, Colorectal Disease,
or Diverticulitis. There are three varieties:
Descending: stool semi-formed
Descending
Transverse: stool unformed
Colostomy
Ascending: liquid stool
Ascending Sigmoid
Ileostomy: "Ileum" diversion of the small intestine Ileum Colostomy Colostomy
May be due to Colon Cancer, Polyps, Trauma. Amount
of Output. Ileostomy Colostomy

Ostomy Care Stoma & Pouch

• To limit the possibility of leaks and odors, To eliminate waste, a stoma is an opening in the
empty the Ostomy Appliance when it is abdominal wall attached to the redirected area of the
1/3 - 1/2 filled. digestive system (colon=colostomy, ileum=ileostomy).
• For redness or irritation, apply powder
• For additional assistance, contact a WOC Red-Pink: Normal Stoma
(wound, ostomy, continence) nurse. Purple-Blue: Ischemia
• The stoma may be large at first, but it will settle Pale Pink: Anemia
in size 6-8 weeks after surgery.
A pouch is a device that connects to the stoma to
• Keep Skin C/D/I: clean, dry, intact
collect bowel contents (gas, feces).
• Monitor for Signs of Dermatitis or Yeast infection
• Offer emotional support and encouragement
for a new body image

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 FUNDAMENTALS
ENTERAL FEEDING

Enteral feeding is used to provide nutrition to patients who are unable to eat foods orally but have a
working gastrointestinal tract. The following conditions warrant the use of an NG tube:

• Inflammatory Bowel Disease • Obstructed Bowel • Mild Pancreatitis

• Head and Neck Cancer • Stroke • Parkinson’s Disease

Enteral Access Tubes

Short Term: feeding through nasogastric route
Open Vs. Closed System
(via nose) for less than 4 weeks.
Long Term: For more than 4 weeks, feeding through Open System: formula from cans either bottles are
a surgical incision in the small intestine (jejunostomy) bloused into feeding tube, fed via pump either
or stomach (gastrostomy). gravity drip. Discard formula Q4 hrs.

Closed “Ready to Hang”: sterile, pre-filled

formula containers that are spiked by the feeding

Enteral Formulas & Feeding Schedules tube and fed via pump.

• Standard “Polymeric”: 1-2 kcal/ml

- Milk Based or Blenderized Foods
- Complete Nutrient Formula
- Requires patient to absorb entire nutrients Verify Tube Placement

• Modular Formulas: 3.8-4 kcal/ml Normal pH: 0-4 Xray: Gold Standard

- Need to Supplement with other foods since not Check color and consistency of aspirate

nutritionally complete
- Preparation of a Single Macronutrient (protein,
glucose, polymers, lipids)
• Elemental Formulas: 1-3 kcal/ml
Complications
- Used for partially dysfunctional GI tracts
- Contains predigested nutrients GI Discomfort : 3 or more bouts of diarrhea in a 24-hour

• Specialty Formulas: 1-2 kcal/ml period Nausea or Vomiting. Slow Infusion.

- Used in patients with hepatic failure, respiratory

disease, or HIV Aspiration of Formula: Withhold feeding, turn the client

- Meets specific needs related to individual illness on his or her side, suction the airway, and provide oxygen.

Bolus: formula feeding in <15 minutes

Intermittent: feeding in 30-45 minutes 3-4x daily.
Continuous: feeding 24 hrs/day, flush Q4-6 hrs
and recheck BG Q6 hrs 45
 FUNDAMENTALS
URINARY ELIMINATION
<30 ml/hr of urine output is concerning

Meds That Change Urine

Life Span Considerations

Infants Phenazopyridine: Amitriptyline:

• Adults have a higher glomerular filtration rate Orange-Red Green-Blue
• Increasing the frequency of elimination(8-10 diapers/24 hrs)
• Urine more cloudy Levodopa:
• Because of the decreased capacity, the bladder has
Riboflavin:
Dark Bright Yellow
become more fibrous.

Children
• Toilet training begins at the age of 3
• Kidneys of school-age children double in size
Urinary Incontinence
• Enuresis (bedwetting) is frequent till the age of 5

Older Adults
TYPE DEFINITION CAUSES
• Reduced renal function as a result of decreasing blood
supply to the kidneys Incontinence that is Diuretics, UTI, and
Transient
• Decreased bladder contractility = urine retention reversible Hyperglycemia

• Urine more dilute due to increased frequency

The bladder does not Multiple Sclerosis,
• Decreased bladder muscle tone empty entirely, and little Spinal Cord Injury,
Overflow
volumes of urine are and Enlarged Prostate
• At night, the kidneys excrete more pee (nocturia)
regularly expelled

Sneezing, coughing, and

laughing cause urine loss Menopause,
Stress
due to weak pelvic floor Post childbirth
Key Terms muscles.

Inability to use the restroom Overactive Bladder,

Polydipsia: extreme thirst Urge
due to an overactive UTI
Oliguria: <400 mL produced in 24 hours detrusor muscle

Anuria: <100 mL produced in 24 hours Due to detrusor muscle Stroke, Multiple

Reflex hyperreflexia, there is no Sclerosis, and Spinal
Nocturia: incontinence at night
sensation to urinate. Cord Injuries
Dysuria: urinating difficulties
Urine loss due to Cerebral Palsy,
Urine Specific Gravity: 1.005-1.030 ( = dehydrated) Functional
impaired mobility Arthritis

42
 FUNDAMENTALS
OXYGENATION
Normal Oxygen Saturation: 95-100%

Basic Information Lung Sounds

Lungs: breathe in oxygen and exhale carbon dioxide
Normal “Vesicular” Wheezing
Bradypnea: leisurely breathing Tachypnea: quik breathing
air passing in & out. Blowing a
Dyspnea: hassle breathing Apnea: being without breathing
Musical Horn
Orthopnea: shortness of breathing from changing positions Coarse Crackles
Found in: Allergies
from lying down to standing/sitting up. Shoveling large rocks
Kussmaul: profound breathing found in DKA Found in: Pneumonia, Rhonchi
Cheyenne Stokes: ending of life breathing with periods of apnea. CF, Bronchitis Snorkeling or Snoring
Hypoxia: decreased oxygen supply to tissues & cells. Found in: COPD
Early Sx: Late Sx: Pleural Friction Rub
• Anxiety, Restlessness • Cyanosis Walking on a Stridor
• High HR/RR/BP • Stupor, Confusion Creaky Wooden Floor Seal Barking

• Pale Skin • Low HR/RR/BP Found in: Inflammation of Found in: Croup
Pleura

Fine Crackles
Pop Rocks or
Life Span Considerations Slurping Last of Drink
Infants: 25 million alveoli at birth vs. 300 million at adulthood Found in: Pneumonia,
Children: shorter & narrower airway, aspiration risk CF, Bronchitis
Elderly: weakened diaphragm muscle required for adequate
airflow, air sacs lose shape, coughing reflex sensitivity

Oxygen Delivery Devices

NASAL CANNULA SIMPLE FACE MASK PARTIAL REBREATHER

Nasal Cannula = Can You Put Simple Face Mask = Simple Issues Partial Rebreather = Partially Breathe
this in Nose? like dizziness or minor bleed. well on their own.

FiO2: 24-44% FiO2: 35-50% FiO2: 60-75%

Flow Rate: 1-6 L/Min Flow Rate: 6-12 L/Min Flow Rate: 6-11 L/Min

NONREBREATHER VENTURI AEROSOL MASK/TENT

Nonrebreather = Not Breathing Venturi = “Vent-Turni” you can Facial Tent = Facial Trauma
well on own so this delivers the turn this device to deliver precise or Burns
highest concentration of O2 oxygen concentration.
FiO2: 24-100%
FiO2: 80-95%
Flow Rate: 10-15 L/Min
FiO2: 24-50%
Flow Rate: 4-12 L/Min
Flow Rate: >10 L/Min

46
FUNDAMENTALS
NEUROCOGNITION

Cranial Nerves Alert & Oriented

1. OLFACTORY: odor (smell) A & O x 1 = Oriented to PERSON

Sample Question: “Can you state your
2. OPTIC: vision (sight)
name and date of birth?”
3. OCULOMOTOR: Muscle movement in the eyes
A & O x 2 = Oriented to PLACE
4. TROCHLEAR: superior oblique eye muscle movement Sample Question: “What city are we in?”

5. TRIGEMINAL: skin sensation and jaw movement A & O x 3 = Oriented to TIME

Sample Question: “What year is it?”
6. ABDUCENS: eye abduction
A & O x 4 = Oriented to EVENT
7. FACIAL: facial movement
Sample Question: “What brought you into
8. VESTIBULOCOCHLEAR: hearing
the hospital today?”
9. GLOSSOPHARYNGEAL: taste and swallowing

10. VAGUS: parasympathetic stimulation

11. SPINAL ACCESSORY: shoulder abduction

Mental Status
12. HYPOGLOSSAL: tongue abduction

Full Consciousness
A&Ox4
or Alert

Inability to think quickly,

Nerves & Reflexes Confusion poor memory, and short
attention span

Deep Tendon Reflex Scale:

Able to open eyes and
0 = Nonreactive Lethargic respond, but tired and falls
1+ = Hyperactive asleep rapidly

2+ = Normal Response to vocal cues is

3+ = Brisker than Average Obtunded slow, and there is
some shaking.
4+ = Hyperactive with Clonus
Unresponsive save to
Stupor
painful stimuli
Spinal Nerves:
Pink: Cervical Glasgow Coma Scale: Unresponsive as
Comatose
Eye, Verbal, Motor well as to stimuli
Blue: Thoracic
Purple: Lumbar Severe: <8
Moderate: 9-12
Green: Sacral
Mild: 13-15
Normal: 15

47
FUNDAMENTALS
PAIN MANAGMENT

A patient's response to and perception of pain can vary. Everyone interprets pain differently, and the
patient's self-report of pain is the most reliable predictor.

Acute vs. Chronic Pain Scales

Acute Pain: <6 months and causes sympathetic “fight FACES: most common for adults and children 3+

or flight” symptoms such as increased HR/BP, anxiety, CRIES: 0-6 months

diaphoresis. COMFORT: Intubated pts (objective findings)

Chronic Pain: >6 months and has no effect on vital indicators. NUMERICAL PAIN SCALE: 0-10 pain scale.

Chronic pain can also be idiopathic (no known cause). PAINAID: ALZHEIMERS
FLACC: 2 mo - 7 yrs for nonverbal face, legs, activity,
cry, consolability.

Nociceptive vs. Neuropathic 0 1-3 4-6 7-9 10

Nociceptive Pain: normal pain processing from a

stimulus. There are 3 variations:
No Pain Mild Moderate Severe Very Worst Pain
• Somatic: Subcutaneous tissue or skin Sx: Localized Severe Possible
and Sharp. Ex: Cut Finger
• Visceral: the lining of organs and internal organs. Sx:
Dull, Deep, Aching. Ex: MI
• Referred: detected in a location other than the origin Pain Management
Ex: Shoulder Pain from MI
Opioids for Severe Pain
Neuropathic Pain: abnormal pain processing caused by +/- Adjuvants or Non-Opioids
dysfunctional or damaged pain nerves There are 3 variations:
Pain Increases
• Diabetic Neuropathy: Diabetes causes severe, shooting,
Opioids for Mild to Moderate Pain
scorching, and "pins and needles" sensations in the limbs.
+/- Adjuvants or Non-Opioids
• Phantom Pain: limb amputation pain
Pain Increases
Non-Opioids: NSAIDs or Tylenol
+/- Adjuvants: Gabapentin, Amitriptyline

Terms to Know Nonpharmacological

Pain Threshold: min amount of pain before felt Heat/Cold Distraction

Pain Tolerance: max amount of pain a person can bear Massage Acupuncture
Modulation: nerves of the spinal cord cause muscles to Imagery
contract away from area of painful stimuli.
Transduction: conversion of pain to an electrical impulse
through peripheral nerve fibers (nociceptors).
Transmission: electrical impulse travels along nerve fibers
48
 FUNDAMENTALS
THERAPEUTIC COMMUNICATION

Therapeutic communication is a communication approach that uses verbal and nonverbal

gestures to address a patient's physical and emotional needs.

Communication Between
Types of Communication
Interdisciplinary Team
Assertive: expressing sentiments or wants Incivility: harsh words or actions (sarcasm, eye roll)
clearly without infringing on the rights of others Bullying: repeated threats or intimidation
“I respect your feelings and here are mine...” Lateral Violence: peers' abusive comments or deeds
Aggressive: expressing feelings and thoughts (gossip, threats, defamation)
in a loud manner that violates the rights of
others “I am never wrong!” Inappropriate Behavior of Staff
Passive: evading or neglecting to express
1. Is there 2. Is anyone in physical 3. Is the behavior
individual feeling or wants. “I don’t care
actions illegal? or psychological harm? simply inappropriate?
about this.”
Passive Aggressive: On the appearance,
Yes Report Yes Confront and Yes Talk to
passive, yet after discourse, covert hostility,
to Supervisor take over to keep them regarding
either alone or with others. “That is fine, but
No Go to #2 others safe. your concerns at a
don’t be surprised if others get mad.”
No Go to #3 convenient time.

Do’s Dont’s
Nonverbal Cues ”Don’t Worry”
(eye contact, nodding) Disregardes their concerns

What? Why?
What makes you feel that way? Why did you do that?

Closed-Ended
Open-Ended Questions
Questions “Yes or No”
How are you feeling today?
(Except in Self-Harm)

Clarifying Techniques
Restating: use the client's precise words
Paraphrasing: Restate the client's opinions to
confirm what they said.
Exploring: allows the nurse to collect additional
information
49
FUNDAMENTALS
ARTERIAL BLOOD GASES (ABG)

ABGs are used to assess the acidity, pH, oxygen, and carbon dioxide levels in the blood.

Main Value Levels Acidosis Vs. Alkalosis

Arterial Blood pH: 7.35-7.45
Alkalosis: HCO3 Acidosis: PACO2
PACO2 (Acidic): 35-45
If high HCO3 = If high PACO2 =
HCO3 (Alkaline): 21-28
Body Speeds Up Body Shuts Down

Other Values: PaO2 (80-100) or

Signs: HR/RR, tremors, Signs: HR/BP/RR,
SaO2 (oxygen saturation (95-100)
irritable Fatigue, Coma
Causes: Vomiting, Suction Causes: Diarrhea

Uncompensated, Partially or Fully Compensated

Uncompensated: PH is ABNORMAL, PACO2 OR HCO3 ABNORMAL
Fully Compensated: PH is NORMAL, PACO2 AND HCO3 ABNORMAL
Partially Compensated: All three main value levels ABNORMAL (PH, PACO2, HCO3)

How to Answer Any ABG Question Made Simple:

Ex: ABG lab values for a customer are as follows: PH 7.31, HCO3: 27, PACO2: 65.
What is the client's imbalance?

Step 1: Write lab values out across paper:

PH: 7.31 HCO3: 27 PACO2: 65

Step 2: Write arrows to indicate if acidic of basic.

PH: 7.31 (acidic) HCO3: 27 (normal) PACO2: 65 (acidic)

Step 3: Match abnormal arrows. If all three abnormal, match PH arrow to HCO3/PACO2 arrow.
PH: 7.31 (acidic) HCO3: 27 (normal) PACO2: 65 (acidic)

Step 4: If PACO2 = RESPIRATORY, if HCO3= METABOLIC.

The answer to this question is Respiratory Acidosis.
50
NOTES