FUNDAMENTALS OF NURSING - REFRESHER RN 2024
TOP RANK ACADEMY | NOTES BY: WOLVERINE FARINAS, RN | LECTURER: MR. JESSIE DACLIS
FIRE SAFETY FALL SAFETY
● Fire extinguisher is used for small fires / for incipient ● Intrinsic
(beginning) stage of fire ○ Physiological
(nasa patient makikita)
○ Examples:
TYPES OF FIRE EXTINGUISHERS ■ Dizzy
■ Heart attack
Class A ● Ordinary combustibles ■ Difficulty walking
“abo” (mga nakikita sa bahay na pwede masunog)
● Examples: ● Extrinsic
○ Paper ○ Environmental factors
○ Plastic ○ Examples:
○ Wood ■ Floor is wet
○ Cloth ■ Scattered rugs
■ Dim light
Class B ● Flammable liquids
“boom” ● Examples:
○ Gasoline
Morse Fall Scale
○ Oil ● Assesses the patient’s risk factor for fall
○ Grease ● If the score is above 50, the patient is at high risk for fall
○ Paint
Class C ● Electrical fires
“current” (lahat ng mga desaksak)
● Examples:
○ Printer
○ Computer
○ IV Pump
○ Mech vent
Class D ● Metal fires
“december” ● Examples:
○ Sodium
○ Aluminum
○ Magnesium
○ Potassium
Preventive measures
Management 1.) Fall alert
Utilize the mnemonic “RACE PASS” ● Patient should be close at the nurses station
● Remove 2.) Dim light
● Activate the alarm 3.) Bed at lowest position
● Confine the fire (close the door) 4.) Side rails up
● 2-3 side rails should be the limit to be raised
● Extinguish
● 4 side rails up could mean false imprisonment
● Pull the pin 5.) Call bell
● Aim at the base of the fire ● Respond to call bell asap
● Squeeze the handle and sweep 6.) Night light
● Sweet side to side 7.) Supervision
● Visit the patient every hour
RN 2024 FUNDAMENTALS OF NURSING - REFRESHER 1
, FUNDAMENTALS OF NURSING - REFRESHER RN 2024
TOP RANK ACADEMY | NOTES BY: WOLVERINE FARINAS, RN | LECTURER: MR. JESSIE DACLIS
PHYSICAL ASSESSMENT Normal bowel sounds:
Standard: I → Pa → Pe → A ● 5-20 bowel sounds/min
1.) Inspection *Assess each area for 5 minutes
● Color
● Size Abnormal bowel sounds:
● <5 bowel sounds/min (hypoactive)
2.) Palpation
○ Slow peristalsis
● Masses
○ Constipation
● Tenderness
● >20 bowel sounds /min (hyperactive)
● Organ enlargement
○ Rapid
3.) Percussion (tap)
○ Diarrhea
● Dull sound
○ Soft tissue
● Resonant
○ Lungs (air)
Key points in assessing
● Hyperresonant ● Patient should be relaxed
○ Air trapping (copd) ● Respiratory assessment
● Tympany ○ Position upright or sitting (to assess if the lungs are
○ Tiyan (parang drum) really expanding)
○ Fluids (stomach - ascites) ● Abdominal assessment
4.) Auscultation ○ Dorsal recumbent
● Bell (smaller circle)
○ For low pitch sounds (pulse) SCREENING ASSESSMENTS
● Diaphragm (larger circle)
○ For high pitch sounds (lung sounds)
BREAST SELF EXAMINATION: I → Pa
● Earpiece ● Detects breast cancer
○ Wipe with alcohol when cleaning ● Age:
○ 20 y/o (Breast - Bente)
ABDOMINAL: I → A → Pe → Pa ● Frequency:
○ Monthly
1.) Inspection ● Best time to conduct:
● Size; color; contour ○ 5-7 days after menstruation
2.) Auscultation ○ Not during because the breast is tender
● Bowel sounds ○ Example: June 6-9 ang duration ng mens nya,
Pattern: Mag start ka magbilang sa June 6, plus 5
● RLQ, RUQ, LUQ, LLR days June 10 sya mag check. Hindi
importante kahit duguin sya basta hindi na
tender ang breasts nya
● Menopause:
○ Perform same day each month
○ Example: June 21 nag check, July 21 next
1.) Inspection: (using a mirror)
● Size:
○ Normal - Slightly Asymmetrical
○ Abnormal - Profound Asymmetry
● Color:
Best position: ○ Abnormal - “peau d'orange”
● Left sims position (left natatapos ang large intestine) Orange peel skin
● Also a best position for procedures: ● Contour:
○ Enema ○ Abnormal - Dimpling of skin
○ Colonoscopy 2.) Palpation
○ Rectal temperature / suppository ● Best time to conduct:
○ Rectal suppository ○ Shower
■ Because the hands are
*Auscultation should be done first before percussion & palpation because soapy
it might affect the bowel sounds ○ Supine in bed
RN 2024 FUNDAMENTALS OF NURSING - REFRESHER 2
TOP RANK ACADEMY | NOTES BY: WOLVERINE FARINAS, RN | LECTURER: MR. JESSIE DACLIS
FIRE SAFETY FALL SAFETY
● Fire extinguisher is used for small fires / for incipient ● Intrinsic
(beginning) stage of fire ○ Physiological
(nasa patient makikita)
○ Examples:
TYPES OF FIRE EXTINGUISHERS ■ Dizzy
■ Heart attack
Class A ● Ordinary combustibles ■ Difficulty walking
“abo” (mga nakikita sa bahay na pwede masunog)
● Examples: ● Extrinsic
○ Paper ○ Environmental factors
○ Plastic ○ Examples:
○ Wood ■ Floor is wet
○ Cloth ■ Scattered rugs
■ Dim light
Class B ● Flammable liquids
“boom” ● Examples:
○ Gasoline
Morse Fall Scale
○ Oil ● Assesses the patient’s risk factor for fall
○ Grease ● If the score is above 50, the patient is at high risk for fall
○ Paint
Class C ● Electrical fires
“current” (lahat ng mga desaksak)
● Examples:
○ Printer
○ Computer
○ IV Pump
○ Mech vent
Class D ● Metal fires
“december” ● Examples:
○ Sodium
○ Aluminum
○ Magnesium
○ Potassium
Preventive measures
Management 1.) Fall alert
Utilize the mnemonic “RACE PASS” ● Patient should be close at the nurses station
● Remove 2.) Dim light
● Activate the alarm 3.) Bed at lowest position
● Confine the fire (close the door) 4.) Side rails up
● 2-3 side rails should be the limit to be raised
● Extinguish
● 4 side rails up could mean false imprisonment
● Pull the pin 5.) Call bell
● Aim at the base of the fire ● Respond to call bell asap
● Squeeze the handle and sweep 6.) Night light
● Sweet side to side 7.) Supervision
● Visit the patient every hour
RN 2024 FUNDAMENTALS OF NURSING - REFRESHER 1
, FUNDAMENTALS OF NURSING - REFRESHER RN 2024
TOP RANK ACADEMY | NOTES BY: WOLVERINE FARINAS, RN | LECTURER: MR. JESSIE DACLIS
PHYSICAL ASSESSMENT Normal bowel sounds:
Standard: I → Pa → Pe → A ● 5-20 bowel sounds/min
1.) Inspection *Assess each area for 5 minutes
● Color
● Size Abnormal bowel sounds:
● <5 bowel sounds/min (hypoactive)
2.) Palpation
○ Slow peristalsis
● Masses
○ Constipation
● Tenderness
● >20 bowel sounds /min (hyperactive)
● Organ enlargement
○ Rapid
3.) Percussion (tap)
○ Diarrhea
● Dull sound
○ Soft tissue
● Resonant
○ Lungs (air)
Key points in assessing
● Hyperresonant ● Patient should be relaxed
○ Air trapping (copd) ● Respiratory assessment
● Tympany ○ Position upright or sitting (to assess if the lungs are
○ Tiyan (parang drum) really expanding)
○ Fluids (stomach - ascites) ● Abdominal assessment
4.) Auscultation ○ Dorsal recumbent
● Bell (smaller circle)
○ For low pitch sounds (pulse) SCREENING ASSESSMENTS
● Diaphragm (larger circle)
○ For high pitch sounds (lung sounds)
BREAST SELF EXAMINATION: I → Pa
● Earpiece ● Detects breast cancer
○ Wipe with alcohol when cleaning ● Age:
○ 20 y/o (Breast - Bente)
ABDOMINAL: I → A → Pe → Pa ● Frequency:
○ Monthly
1.) Inspection ● Best time to conduct:
● Size; color; contour ○ 5-7 days after menstruation
2.) Auscultation ○ Not during because the breast is tender
● Bowel sounds ○ Example: June 6-9 ang duration ng mens nya,
Pattern: Mag start ka magbilang sa June 6, plus 5
● RLQ, RUQ, LUQ, LLR days June 10 sya mag check. Hindi
importante kahit duguin sya basta hindi na
tender ang breasts nya
● Menopause:
○ Perform same day each month
○ Example: June 21 nag check, July 21 next
1.) Inspection: (using a mirror)
● Size:
○ Normal - Slightly Asymmetrical
○ Abnormal - Profound Asymmetry
● Color:
Best position: ○ Abnormal - “peau d'orange”
● Left sims position (left natatapos ang large intestine) Orange peel skin
● Also a best position for procedures: ● Contour:
○ Enema ○ Abnormal - Dimpling of skin
○ Colonoscopy 2.) Palpation
○ Rectal temperature / suppository ● Best time to conduct:
○ Rectal suppository ○ Shower
■ Because the hands are
*Auscultation should be done first before percussion & palpation because soapy
it might affect the bowel sounds ○ Supine in bed
RN 2024 FUNDAMENTALS OF NURSING - REFRESHER 2
