Fundamentals
- Rest and sleep: interventions to promote sleep
o Establish a routine bedtime
o Limit waking clients during the night
o Help with personal hygiene needs or a back rub prior to sleep to increase comfort
o Instruct client to:
Exercise regularly at least 2 hours before bedtime
Arrange the sleep environment for comfort
Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
Limit fluids 2-4 hr before bedtime
- Pharmacokinetics and routes of administration: selecting intramuscular site
o Ventrogluteal, dorsogluteal, deltoid, and vastuc lateralis (pediatric)
1-3 mL otherwise it needs to be divided into separate syringes.
- NG intubation and enteral feedings: evaluating proper function of NG tube
o Aspirate and x-ray
o pH up to 4.5
- Mobility and immobility: appropriate use of crutches
o Do not alter crutches after fitting
o Follow the prescribed crutch gait
o Support body weight at the hand grips with the elbows flexed at 30*
o Position the crutches on the unaffected side when sitting or rising from a chair
- Urinary elimination: performing closed intermittent irrigation
o 50 cc sterile solution
- Nutrition and oral hydration: findings to report
o Nausea, vomiting, diarrhea, constipation
o Flaccid muscles
o Mental status changes
o Loss of appetite
o Change in bowel pattern
o Spleen, liver enlargement
o Dry, brittle hair
o Loss of subcutaneous fat
o Dry, scaly skin
o Inflammation, bleeding of gums
o Poor dental health
o Dry, dull eyes
o Enlarged thyroid
o Poor posture
- Pressure ulcers, wounds, and wound management: preventing delays in healing
o Encourage intake of 2,000 to 3,000 mL of fluids/day
o Provide education about good resource of protein
o Lack of protein increases the risk for a delay in wound healing and infection
o Provide nutritional support
o Clean wounds from least contaminated towards the most contaminated
o Use gentle friction when cleansing or applying solution to the skin
, o Use a piston syringe or a sterile straight cath for deep wounds with small openings 30-60
mL syringe with a 19 gauge needle.
- Nursing Process – Family Concerns
- Infection Control: Contact Precautions
o Person to person, object to person, fecal oral route
o Protect visitors and caregivers when they are within 3 ft of the client (Respiratory
synctytial virus, shigella, wounds, herpes simplex, impetigo, scabies.
o Private room or a room with other client with the same infection.
o Gloves and gowns
o Infectious dressing material into a single, nonporous bag without touching the outside
bag
- Mobility and Immobility: benefits of applying ice to extremity
o Decreases inflammation
o Prevents swelling
o Reduces bleeding
o Reduces fever
o Diminishes muscle spasms
o Decrease pain
o Assess every 5-10 minutes
- Vital Signs – Calculating pulse pressure
o Systolic – Diastolic
- Thorax, heart, abdomen: auscultating closure to the Aortic Valve
o Beginning of ventricular diastole and produces the S2 sound (Dub). Place the diaphragm
of the stethoscope at the aortic area.
Adult Med-Surg
- Cancer treatment options: Discharge teaching for myelosuppression
o Monitor the client’s temperature and WBC
o Fever greater than 100*F (37.8*C) should be immediately reported to the provider.
o If WBC drops below 1000/mm3, place client in a private room and initiate neutropenic
precautions.
o Place mask during transport
o Protect client from possible sources of infection.
o Frequent hand hygiene, have no ill visitors
o Avoid invasive procedures that can cause a break in tissue unless necessary (rectal temp,
injections are a no no)
o Avoid crowds
o Avoid yard work, gardening, or changing a pet’s litter box
o Avoid fresh fruits
o Wash toothbrush daily in dishwasher or rinse in bleach solution
o Avoid fluids that have been sitting out for over 1 hr
- Meningitis: appropriate actions for bacterial meningitis
o Isolate the client as soon meningitis is suspected.
o Droplet precautions which requires a private room or a room with cohorts, wearing of a
surgical mask when within 3 feet of the client, appropriate hand hygiene, and the use of
- Rest and sleep: interventions to promote sleep
o Establish a routine bedtime
o Limit waking clients during the night
o Help with personal hygiene needs or a back rub prior to sleep to increase comfort
o Instruct client to:
Exercise regularly at least 2 hours before bedtime
Arrange the sleep environment for comfort
Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
Limit fluids 2-4 hr before bedtime
- Pharmacokinetics and routes of administration: selecting intramuscular site
o Ventrogluteal, dorsogluteal, deltoid, and vastuc lateralis (pediatric)
1-3 mL otherwise it needs to be divided into separate syringes.
- NG intubation and enteral feedings: evaluating proper function of NG tube
o Aspirate and x-ray
o pH up to 4.5
- Mobility and immobility: appropriate use of crutches
o Do not alter crutches after fitting
o Follow the prescribed crutch gait
o Support body weight at the hand grips with the elbows flexed at 30*
o Position the crutches on the unaffected side when sitting or rising from a chair
- Urinary elimination: performing closed intermittent irrigation
o 50 cc sterile solution
- Nutrition and oral hydration: findings to report
o Nausea, vomiting, diarrhea, constipation
o Flaccid muscles
o Mental status changes
o Loss of appetite
o Change in bowel pattern
o Spleen, liver enlargement
o Dry, brittle hair
o Loss of subcutaneous fat
o Dry, scaly skin
o Inflammation, bleeding of gums
o Poor dental health
o Dry, dull eyes
o Enlarged thyroid
o Poor posture
- Pressure ulcers, wounds, and wound management: preventing delays in healing
o Encourage intake of 2,000 to 3,000 mL of fluids/day
o Provide education about good resource of protein
o Lack of protein increases the risk for a delay in wound healing and infection
o Provide nutritional support
o Clean wounds from least contaminated towards the most contaminated
o Use gentle friction when cleansing or applying solution to the skin
, o Use a piston syringe or a sterile straight cath for deep wounds with small openings 30-60
mL syringe with a 19 gauge needle.
- Nursing Process – Family Concerns
- Infection Control: Contact Precautions
o Person to person, object to person, fecal oral route
o Protect visitors and caregivers when they are within 3 ft of the client (Respiratory
synctytial virus, shigella, wounds, herpes simplex, impetigo, scabies.
o Private room or a room with other client with the same infection.
o Gloves and gowns
o Infectious dressing material into a single, nonporous bag without touching the outside
bag
- Mobility and Immobility: benefits of applying ice to extremity
o Decreases inflammation
o Prevents swelling
o Reduces bleeding
o Reduces fever
o Diminishes muscle spasms
o Decrease pain
o Assess every 5-10 minutes
- Vital Signs – Calculating pulse pressure
o Systolic – Diastolic
- Thorax, heart, abdomen: auscultating closure to the Aortic Valve
o Beginning of ventricular diastole and produces the S2 sound (Dub). Place the diaphragm
of the stethoscope at the aortic area.
Adult Med-Surg
- Cancer treatment options: Discharge teaching for myelosuppression
o Monitor the client’s temperature and WBC
o Fever greater than 100*F (37.8*C) should be immediately reported to the provider.
o If WBC drops below 1000/mm3, place client in a private room and initiate neutropenic
precautions.
o Place mask during transport
o Protect client from possible sources of infection.
o Frequent hand hygiene, have no ill visitors
o Avoid invasive procedures that can cause a break in tissue unless necessary (rectal temp,
injections are a no no)
o Avoid crowds
o Avoid yard work, gardening, or changing a pet’s litter box
o Avoid fresh fruits
o Wash toothbrush daily in dishwasher or rinse in bleach solution
o Avoid fluids that have been sitting out for over 1 hr
- Meningitis: appropriate actions for bacterial meningitis
o Isolate the client as soon meningitis is suspected.
o Droplet precautions which requires a private room or a room with cohorts, wearing of a
surgical mask when within 3 feet of the client, appropriate hand hygiene, and the use of
