FOUNDATIONS FINAL EXAM REVIEW
HEALTHCARE DELIVERY SYSTEM:
1. 6 LEVELS OF HEALTH CARE:
 PREVENTIVE CARE “PRIMARY PREVENTION”
 FOCUSES MORE ON DISEASE RISK & CONTROL
 “WELL VISITS”
 ADULT SCREENING “ BP, PAP, SMOKING, CANCER”
 PEDS SCREENING “ HEARING, VISIONS, DEVELOPMENTAL”
 HIV SCREENING
 IMMUNIZATIONS
 DIET COUNSELING
 MENTAL HEALTH COUNSELING/CRISIS PREVENTION
 COMMUNITY HEALTH LEGISLATIONS (SEAT BELT/ CAR SEAT SAFETY)
(DISEASE PREVENTION”
 PRIMARY CARE “HEALTH PROMOTION”
 FOCUSES IS ON IMPROVED HEALTH OURCOMES FOR AN ENTIRE
POPULATION
 PROMOTION IS SUPPOSED TO DECREASE OVERAL HEALTH COST BY
DECREASING DISEASE INCIDENCE MINIMIZING COMPLICATIONS
 DX & TRMT OF COMMON ILLNESS
 CHRONIC HEALTH MANAGEMENT
 PRENATAL CARE
 WELL-BABY CARE
 FAMILY PLANNING
 PT – CENTERED MEDICAL HOME
 SECONDARY CARE “ ACUTE CARE/CURING CARE”
 SERVICE PROVIDED UPON REFERRAL FROM HCP
 REQUIRES MORE SPECIALIZED KNOWLEDGE
 URGENT CARE/ER
 ACUTE MED/SURG, OUTPT SX, AMBULATORY
 RADIOLOGICAL PROCEDURES
 TERTIARY “ HIGHLY SPECIALIZED/REDUCING COMPLICATIONS”
 REFERALL FROM SECONDARY HCP
 CONSULTIVE CARE
 ICU
 INPT PSYCHIATRIC
 SPECIALTY CARE (ONCOLOGY)
 RESTORATIVE
 REHAB PROGRAMS (PULMONARY, CARDIO, ORTHOPEDIC)
 SPORTS MEDICINE
 SPINAL CORD INJURY
 HOME CARE
 CONTINUING CARE
 LONG TERM (NURSING HOMES)
 PSYCHIATRIC
 OLDER ADULT DAY CARES
 ASSISTED LIVING FACILITIES
PROMOTING SAFETY
1. FIRE SAFETY: “RACE” & “PASS”
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RESCUE CLIENTS IN IMMEDIATE DANGE
ACTIVATE THE FIRE ALARM
CONFINE THE FIRE
EXTINGUISH THE FIRE
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OBTAIN THE FIRE EXTINGUISHER
PULL THE PIN ON THE FIRE EXTINGUISHER
AIME AT THE BASE OF THE FIRE
SQUEEZE THE EXTINGUISHER HANDLE
SWEEP THE EXTINGUISHER FROM SIDE TO SIDE TO COAT THE AREA OF THE
FIRE EVENLY
2. POISON SAFETY
 IN ALL CASES OF SUSPECTED POISONING CALL POISON CONTROL
IMMEDIATELY BEFORE ATTEMPTING ANY INTERVENTION
 REMOVE ANY OBVIOUS MATERIAL FROM MOUTH, EYES, OR BODY
IMMEDIATELY
 IDENTIFY THE TYPE & AMOUNT OF SUBSTANCE INGESTED
 DON’T INDUCE VOMITING IN AN UNCONSCIOUS PERSON; FOLLOWING
INGESTION OF LYE, HOUSEHOLD CLEANERS, GREASE, OR PETROLEUM
3. NEEDLESTICK SAFETY
 DISPOSE OF IN SHARPS CONTAINER
 DON’T RECAP
FACILITATING HYGIENE:
1. IDENTIFY PRIORITY PROBLEMS/ ASSESSMENTS:
 ASSESS ALL AREAS: SKIN, HAIR, SCALP, EYES, EAR, NOSE, FEET & NAILS
 HEALTH MAINTENANCE
 SKIN INTEGRITY
 INFECTION
 ASSESS PT’S EXPECTATION ON HYGIENE
 ASSESSMENT OF SELF-CARE ABILITY
 MOBILITY
 LIMITED: BEDREST, WEAKNESS, DECREASE ROM
2. BE MINDFUL OF FACTORS:
 DEVELOPMENTAL STAGE
 HEALTH STATUS
 PAIN: LIMITS MOBILITY & ENERGY
 SENSORY DEFICITS
 DECREASED INDEPENDENCE & INCREASED SAFETY CONCERNS
 COGNITIVE IMPAIRMENT
 CANT DETERMINE NEED FOR HYGIENE
 CAN’T PROBLEM SOLVE ADL PROCESSES
 FORGOT LAST PERFORMED HYGIENE & ADL
 EMOTIONAL
 LACK OF ENERGY FOR ADL
 ALTERED REALITY DOESN’T INCL. HYGIENE
 SOCIAL PRACTICES,
 FINANCIAL FACTORS,
 PERSONAL PREFERENCES,
 CULTURAL DIFFERENCES,
 BODY IMAGE,
 PHYSICAL CONDITION
 SOCIOECONOMIC STATUS,
 HEALTH BENEFITS & MOTIVATION
3. COMMON DX ASSOCIATED W/HYGIENE:
 ACTIVITY TOLERANCE/INTOLERANCE
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IMPAIRED DRESSING & GROOMING
IMPAIRED MOBILITY
IMPAIRED HEALTH MAINTENANCE
IMPAIRED SKIN INTEGRITY
RISK FOR INFECTION
4. APPLYING CLINICAL JUDGEMENT TO COMMON HYGEINE RELATED
PROBLEMS:
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INTEGRATE NURSING KNOWLEDGE
CONSIDER DEVELOPMENTAL & CULTURAL INFLUENCE
BE NON-JUDGEMENTAL & CONFIDENT
DRAW ON OWN EXPERIENCES
RELY ON PROFESSIONAL STANDARDS
RESPECT
5. SAFETY CONSIDERATIONS & PROCESS/STEPS WHEN PROVIDING A BATH
 TYPES OF BATH:
 ASSIST
 HARD TO REACH AREAS
 COMPLETE
 PARTIAL
 ONLY AREAS ABSOLUTELY NECESSARY INCL. PERINEUM
 TOWEL BATH
 BAG/PACKAGED BATH
 SHOWER
 TUB
 THERAPEUTIC
 CONSIDERATIONS/TRIGGERS THAT MAY AFFECT:
 UNMANAGED PAIN
 ADMINISTER ANALGESIC 30 MIN PRIOR
 BEING COLD
 MAINTAIN WARMTH
 KEEP PT’S BODY WARM W/WARM TOWEL
 ENSURE ROOM TEMP IS COMFORTABLE
 FEELING FRIGHTENED, VULNERABLE, EXPOSED, EMBARASSED, LOST OF
CONTROL,
 MAKE SURE ALL SAFETY DEVICES ARE AVAILABLE
 PROMOTE INDEPENDENCE
 ASK PERMISSION TO GIVE BATH
 USE COMFORTING WORDS
 PROVIDE PRIVACY
 MAINTAIN SAFETY
MEDICATION ADMINISTRATION
1. FACTORS & CONTRAINDICATIONS INFLUENCING MEDICATION ACTIONS
 THERAPEUTIC EFFECT
 EXPECTED/PREDICTED PHYSIOLOGICAL RESONSE CAUSED BY A
MEDICATION
 ADVERSE EFFECT
 UNDESIRED, UNINTENDED, UNPREDICTABLE RESPONSES TO A
MEDICATION
 SIDE EFFECT
 PREDICTABLE, UNAVOIDABLE ADVERSE EFFECT PRODUCED AT THE
USUAL THERAPEUTIC DOSE
 TOXIC EFFECT
 OCCURS AFTER PROLONGED MEDICATION USE; MEDICATION
ACCUMULATES IN THE BLOOD BECAUSE OF IMPAIRED
METABOLISM/EXCRETION
 IDIOSYNCRATIC RESPONSE
 PT OVERREACTS/UNDERREACTS TO A MEDICATION; OR HAS A REACTION
DIFFERENT FROM NORMAL
 ALLERGIC REACTION
 UNPREDICTABLE RESPONSES TO A MEDICATION
 MEDICATION INTERACTION W/OTHER MEDS
 MEDICATION TOLERANCE
 MEDICATION DEPENDENCE
 PHYSICAL: PHYSIOLOGICAL ADAPTATION TO A MEDICATION THAT
MANIFESTS BU INSTENCE PHYSICAL DISTURBANCE WHEN THE
MEDICATION IS W/DRAWN
 PSYCHOLOGICAL: PT DESIRES FOR MED OTHER THAN INTENDED USE
2. HOW TO ADMINISTER
 SUBLINGUAL: UNDER TONGUE TO DISSOLVE
 NO SWALLOWING/DRINKING UNTIL DISSOLVED COMPLETELY
 BUCCAL: PLACE MED IN MUCOUS MEMBRANES OF CHEEK UNTIL DISSOLVED
 NO SWALLOWING/DRINKING UNTIL DISSOLVED COMPLETELY
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ORAL: GIVEN BY MOUTH & SWALLOWED
INTRADERMAL: INTO DERMIS, UNDER EPIDERMIS
SUBCUT: INTO TISSUES BELOW DERMIS
IM: INTO MUSCLE
IV: INTO VEIN
TRANSDERMAL: TOPICAL APPLICATION LEFT FOR AS LITTLE AS 12HRS OR UP TO 7
DAYS
 LIQUID/OINTMENT
 INSERTION INTO A BODY CAVITY (I.E SUPPOSITORY)
3. LANDMARKS & ANGLES
 SUBCUT: OUTER POSTERIOR OF UPPER ARMS (TRICEPS), ABDOMEN, ANTERIOR
THIGH, SCAPULAR AREA/UPPER BACK, UPPER VENTRAL.DORSAL GLUTEAL AREAS
 45 DEGREES: 25 GAUGE, 5/8 INCH NEEDLE
 90 DEGREES: 25 GAUGE, 1/2 INCH NEEDLE
 INSULIN/ANTICOAGS
 IM: VENTROGLUTEAL, VASTUS LATERALIS, DELTOID
 90 DEGREES
 VACCINES, REG MEDS (ANALGESICS/ANTIEMETICS)
 ASPIRATE NEEDLE AFTER INSERTION; ENSURE NO BLOOD
 INTRADERMAL: INTO DERMIS; INNER (VENTRAL) FOREARM, UPPER CHEST, UPPER
BACK
 5-15 DEGREES
 TB & ALLERGY TESTING
INFECTION PREVENTION
1. ISOLATION PROCEDURES
 CONTACT:
 DIRECT: CARE & HANDLING OF CONTAMINATED BODY FLUIDS (INCL. BLOOD)
 INDIRECT: TRANSFER OF AN INFECTIOUS AGENT THROUGH A
CONTAMINATED INTERMEDIATE OBJECT (I.E CONTAMINATED NEEDLE OR
HANDS)
 REQUIRE: GOWN & GLOVES
 DROPLET:
 DISEASES THATED ARE TRANSMITTED BY LARGE DROPLETS EXPELLED INTO
THE AIR & W/IN 3FT OF A PERSON
 REQUIRE: MASK WHEN W/IN 3FT OF PERSON, PROPER HAND HYGIENE, &
DEDICATED CARE EQUIPMENT; PT NEEDS MASK WHEN LEAVING ROOM
 AIRBORNE:
 DISEASES THAT ARE TRANSMITTED BY SMALLER DROPLETS THAT REMAIN IN
THE AIR FOR LONG PERIOD OF TIME
 REQUIRES ROOM W/ NEGTIVE AIRFLOW (AIR FLOWS THROUGH HIGHEFFICACY PARTICULATE AIR FILTER, AND EXHAUSTED DIRECTLY OUTSIDE)
 DOOR REMAINS CLOSED
 REQUIRES: RESPIRATORY MASK WHEN W/IN 3 FT OF PT; PT NEEDS MASK
WHEN LEAVING ROOM
2. S/S OF LOCALIZED & SYSTEMIC INFECTION
 LOCALIZED: PAIN, TENDERNESS, WARMTH, & REDNESS AT SITE; WOUND
INFECTION
 SYSTEMIC: INFECTION AFFECTS ENTIRE BODY
 FATAL IF LEFT UNDETECTED/UNTREATED
WOUNDS
1. FACTORS THAT AFFECT SKIN INTEGRITY & WOUND HEALING:
 SKIN PRESSURE
 SKIN SHEARING & FRICTION
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IMMOBILITY
MALNUTRITION
INCONTINENCE
DECREASED SENSORY PERCEPTION
2. DIFFERENT FORM OF WOUND DEBRIDEMENT:
 DEBRIDEMENT: THE REMOVAL OF NECROTIC TISSUE
 CHEMICAL:
 TOPICAL ENZYME PREP
 DIGESTS/DISSOLVES TISSUE
 MED/STERILE MAGGOTS
 INGEST DEAD TISSUE
 DAKIN’S SOLUTION
 AUTOLYTIC
 DEAD TISSUE REMOVAL W/LYSIS OF NECROTIC TISSUE BY WBCs &
NATURAL BODY’S ENZYMES
 MECHANICAL:
 HIGH PRESSURE WOUND IRRIGATION
 PULSATILE HIGH PRESSURE LAVAGE
 WHIRLPOOL TREATMENTS
 SURGICAL:
 DEAD TISSUE REMOVAL W/ SCALPEL, SCISSORS, OR OTHER SHARP
INSTRUMENTS
URINARY ELIMINATION
1. FACTORS THAT AFFECT URINARY ELIMINATION
 PHSYIOLOGICAL/PATHOLOGICAL FACTORS:
 BLADDER/KIDNEY INFECTIONS
 BLADDER INFLAMMATION
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KIDNEY STONES
PROSTATE HYPERTROPHY
MOBILITY ISSUES
DECREASED BLOOD FLOW THROUGH GLOMERULI
 NEUROLOGIC CONDITIONS
 NUEORGENIC BLADDER
 PSYCHOSOCIAL CONDITION/DIAGNOSTIC TRMT/INDUCED FACTORS
 PERSONAL
 IMMOBILITY
 COMMUNTICATION/COGNITION IMPAIRMENT
 ALZHEIMERS/DEMENTIA
 SOCICULTURAL
 ENVIRONMENTAL
 NUTRITION
 HYDRATION
 ACTIVITY LEVEL
 MEDICATION
 SX & ANESTHESIA
2. CLIENTS AT HIGHEST RISK FOR UTI:
 USE OF INDWELLING/INTERMITTENT CATHETERS
 CAUTI
 URINARY RETENTION
 URINARY/FECAL INCONTINENCE
 URINARY DIVERSION/UROSTOMY/URETEROSTOMY/NEPHROSTOMY
 POOR PERINEAL HYGIENE PRACTICE
3. INTERVENTIONS TO PREVENT UTIS:
 MAINTAIN FLUID INTAKE
 PROMOTE PERINEAL HYGIENE
 WOMEN: WIPE FRONT TO BACK
 AVOID PERFUMED ITEMS, TIGHT CLOTHES
 VOID AT REGULAR INTERVALS
 AVOID LONG PERIODS OF WETNESS
4. S/S OF UTI:
 DYSURIA: BURNING PAIN W/URINATION
 CYSTITIS
 BLADDER INFLAMMATION/IRRITATION
 URGENCY
 FREQUENCY
 INCONTINENCE
 SUPRAPUBIC TENDERNESS
 FOUL-SMELLING CLOUDY URINE
 ELDERLY PRESENTS W/:
 DELIRIUM/CONFUSION
 FATIGUE
 LOSS OF APPETITE
 DECLINE IN MENTAL STATUS FUNTION
 INCONTINENCE
 FALLS
 SUBNORMAL TEMPS
5. URINARY RETENTION:
 INABILITY TO PARTIALLY/COMPLETELY EMPTY THE BLADDER
 ACUTE/RAPID ONSET
 BLADDER STRETCHES BUT NO URINE OUTPUT OR SMALL VOLUME VOIDING
 CHRONIC/SLOW, GRADUAL ONSET
 DECREASE IN VOIDING VOLUME
 STRAINING TO VOID
 FREQUENCY/URGENCY/INCONTINENCE W/VOIDING VOL.
 SENSATION OF INCOMPLETE EMPTYING
6. URINARY INCONTINENCE:
 INVOLUNTARY LOSS OF URINE
 URGE INCONTINENCE
 INVOLUNTARY LEAKAGE ASSOC. W/URGENCY
 STRESS INCONTINENCE
 INVOLUNTARY LOSS OF URINE ASSOC. W/ EFFORT/EXERTION ON
SNEEZING/COUGHING
 MIXED INCONTINENCE
 URGE + STRESS
 FUNCTIONAL INCONTINENCE
 FACTORS THAT PROHIBIT/INHIBIY ACCESS TO TOILET/RECEPTACLE
 MULTIFACTORAL INCONTINENCE
 INCONTINENCE W/MULTIPLE RISK FACTORS (W/IN URINE TRACT & N OT)
 MULTIPE CHRONIC ILLNESSES
 MEDS
 AGE
 ENVIRONMENT
 TRANSIENT INCONTINENCE
 CAUSED BY A MEDICAL CONDITION
 TREATABLE & REVERSIBLE
 REFLEX/UNCONSCIOUS INCONTINENCE
 INVOLUNTARY LOSS AT RANDOM TIMES WHEN SPECIFIC BLADDER
VOLUME IS REACHED
 PERSON IS UNWARE OF NEED TO URINATE
7. NURSING INTERVENTIONS TO FACILITATE BLADDER
CONTINENCE/INCONTINENCE:
 ASSIST W/POSITIONING
 HIGH FOWLERS FOR THOSE ON BEDREST
 IMPLEMENT BLADDER TRAINING/COMPLETE BLADDER EMPTYING
 ASSIST W/POSITIONING
 FACILITATE TOILET ROUTINES; IDENTIFY PT’S PATTERN
 ASSIST/WTOILETING
 KEGEL EXERCISES
 USE ANTI-INCONTINENCE DEVICES AS NEEDED
 STRATEGIES TO PROMOTE INDEPENDENT URINATION
 PHARMOLOGICAL/SX INTERVENTIONS
 PARENTAL TEACHING FOR ENEURESIS
 MAINTAIN ADEQUATE FLUID INTAKE
 PROVIDE FLUIDS
ANURIA- FAILURE OF THE KIDNEYS TO PRODUCE URINE
POLYURIA- VOIDING EXCESSIVE AMOUNTS OF UREA
HIGH VOL. OF FLUID INTAKE
UNCONTROLLED DM
DIABETES INSIPIDUS
DIURETIC THERAPY
DYSURIA: PAIN, BURNING, DISCOMFORT WHEN URINATING
UTI, PROSTITIS, URETHRITIS, LOWER URINARY TRACT TRAUMA, URINAR TRACT TUMORS
ENURESIS: CHILDREN WHO WET THE BED AT NIGHT
CAPUTI/CLINICAL JUDGEMENT MODEL/FRAMEWORK
1. COMPONENTS OF THE CAPUTI & TANNER MODEL
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NOTICING ( WHAT WAS NOTICED)
INTERPRETING (WHAT DOES IT MEAN)
RESPONDING (WHAT WILL BE DONE)
REFLECTING (WHAT WAS THE EFFECT/OUTCOME)
2. NURSING PROCESS
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ASSESS
DIAGNOSE
PLANNING
INTERVENTION
EVALUATION
3. DR. BENNER’S NOVICE TO EXPERT MODEL
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NOVICE
ADVANCE BEGINNER ( CORRELATES W/NEW GRADUATES)
COMPETENT
PROFICIENT
EXPERT
PHYSICAL ACTIVITY & IMMOBILITY
1. FACTORS THAT AFFECT BODY ALIGNMENT & ACTIVITY:
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DISEASE
INJURY
PAIN
PHYSICAL DEVELOPMENT (AGE)
LIFE CHANGES (PREGNANCY)
MEDICATIONS
NURSING PROCESS
1. PURPOSE & PROCESS FOR EVALUATING THE EFFECTIVENESS OF NURSING
PLAN OF CARE:
 PURPOSE:
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o EVALUATE PT’S PROGRESS TOWARDS GOALS,
o EFFECTIVENESS OF THE CARE PLAN
o & QUALITY OF CARE IN THE HEALTHCARE SETTING
PROCESS:
o REVIEW ASSESSMENT
o REVIEW DX
o REVIEW PLANNING OUTCOMES
o REVIEW PLANNING INTERVENTION
o REVIEW IMPLEMENTATION
EVALUATION OUTCOME SHOULD BE OBSERVABLE & MEASURABLE
OUTCOME:
o MANNER IN WHICH CARE IS GIVEN RELEVANT? APPROPRIATE?
COMPLETE? TIMELY? CORRECT SETTING?
EVALUATIONS CAN BE:
o ONGOING: DURING IMPLEMENTATION, IMMEDIATELY AFTER
INTERVENTION & AT EACH PT CONTACT
o INTERMITTENT: PERFORMED AT SPECIFIC TIMES
o TERMINAL: AT DISCHARGE
2. TYPES OF NURSING INTERVENTIONS
 INDEPENDENT: NURSE INITIATED IN RESPONSE TO A DX
o SUPERVISION, DIRECTION, OR ORDER FROM OTHERES ARENT NEEDED
 I.E POSITIONING PT, INITIATING AMBULATION/MOBILITY
PROTOCOLS, TEACHING
 DEPENDENT: HCP INITIATED; REQUIRES ORDER FROM HCP; BASED ON HCP
CHOICE FOR TREATING/MANAGING A MEDICAL DX
o NURSES CARRY OUT THESE WRITTEN/VERBAL ORDERS
 I.E: ADMIN MEDS, INSERTING A FOLEY CATHETER, STARTING AN
IV INFUSION, PREPPING PT FOR DIAGNOSTIC TESTING
 INTERDEPENDENT: (COLLABORATIVE) COMBINED KNOWLEDGE, SKILL, &
EXPERTISE OF MULTIPLE HCP
FLUID & ELECTROLYTES
1. NURSING ASSESSMENT
 OBTAIN HX
o
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AGE, DIETARY INTAKE[ FLUIDS, FOODS W/SALT, CALCIUM, POTASSIUM,
MAGNESIUM], LIFESTYLE [ALCOHOL], MEDS, MEDICAL HX [SX, ILLNESS
(ACUTE & CHRONIC), TRAUMA, BURNS, RESPIRATORY DISORDERS
HEAD TO TOE ASSESSMENT
VITAL SIGNS
DAILY WEIGHT
o > 2.2 = FLUID EXCESS
o < 2.2 = FLUID DEFICIT
I/O
o INTAKE: ALL LIQUIDS EATEN, DRUNK, OR RECEIVED VIA IV
o OUTPUT: URINE, DIARRHEA, VOMIT, GASTRIC SUCTION, WOUND DRAINAGE
LAB STUDIES
2. FOR CLIENTS W/ F & E IMBALANCE…..
 ASSESS FLUID BALANCE/VOLUME, ELECTROLYTE/ACID-BASE IMBALANCE,
 ASSESS POSTURAL BP & PULSE
 ASSESS URINE ELIMINATION
o OUTPUT, COLOR, ODOR
 ASSESS MUCOUS MEMBRANES
o DRY= ELECTROLYTE/FLUID DEFICIT (DEHYDRATION)
 ASSESS FULLNESS OF NECK (JUGULAR?) VEINS
o FLAT= DEFICIT
o FULL=EXCESS
 ASSESS CAPILLARY REFILL
o SLOW= DEFICIT
 ASSESS LUNG SOUNDS
o CRACKLES= EXCESS
 ASSESS SKIN TURGOR
o NO RECOIL= DEFICIT (DEHYDRATION)
3. NURSING INTERVENTIONS FOR CORRECTING F&E IMBALANCE
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DIETARY TEACHING
ORAL ELECTROLYTE SUPPLEMTS
LIMITING/FACILITATING ORAL FLUID INTAKE
PARENERAL REPLACEMENT OF F & E
o ADMIN PRESCRIBED IV FLUIDS BASED ON PT’S CONDITION (ISOTONIC,
HYPER/HYPO TONIC)
4. S/S OF PHLEBITIS, INFILITRATION, & EXTRAVASATION
 PHLEBITIS: INFLAMMATION OF A CEIN THAT RESULTS FROM CHEMICAL,
MECHANICAL, OR BACTERIAL CAUSES
o SIGNS OF INFLAMMATION: HEAT, ERYTHEMA/REDNESS, TENDERNESS
 INFILTRATION: FLUID ENTERS SUBCUTANEOUS TISSUE
o SIGNS: COOLNESS, PALENESS, & SWELLING OF THE AREA, EDEMATOUS
 EXTRAVASATION: FLUID W/ADDITIVES (VESICANT) ENTERS TISSUES & CAUSE
NECROSIS
o SIGNS: COOLNESS, PALENESS, & SWELLING OF AREA, EDEMATOUs
5. CONSIDERATION FOR APPROPRIATE GAUGE FOR IV CATHETER
 USE THE SMALLEST-GAUGE CATHETER OR NEEDLE POSSIBLE (22-24 GAUGE)
o FOR RAPID FLUID REPLACEMENT: 16-20 GAUGE
 AVOID BACK OF HAND
 AVOID PLACEMENT IN VEINS THAT ARE EASILY BUMPED
 AVOID VIGOROUS FRICTION WILE CLEANING A SITE
6. FLUID COMPARTMENTS WITHIN THE BODY:
 INTRACELLULAR (K, MG, PHOS)
o W/IN CELLS
o APPROX 40% OF B DY WEIGTH
o ESSENTIAL FOR CELL FX & METABOLISM
 EXTRACELLULAR (NA, CH, HCO3)
o OUTISDE CELLS
o INTERSTITIAL,
 LOCATED BTWN CELLS & OUTSIDE BLOOD VESSELS
o INTRAVASCULAR,
 PLASMA; LIQUID PART OF BLOOD
o TRANSCELLULAR
 GASTRIC , CEREBROSPINAL, PLEURAL, PERITONEAL & SYNOVIAL
FLUIDS
 EXCRETED BY EPITHELIAL CELLS
o THIRD SPACING
 EXCESS INTERSTITIAL FLUID= EDEMA
7. RASHID AHMED (VSIM)..DEVELOPING A SIMILAR PLAN OF CARE:
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NEUROLOGIC ASSESSMENT
I/O ASSESSMENT
FALL PREVENTION
MED ADMIN
IV SOLUTION CHANGE
o CALCULATE & SET IV DRIP RATE
o IV BAG PREP
 ABG ANALYSIS & ELECTROLYTE LAB LEVELS
OXYGEN, CIRCULATION, & PERFUSION
1. ADEQUACY OF OXYGENATION , BREATHING & GAS EXCHANGE:
 FACTORS:
o PHYSIOLOGICAL
 FACTORS AFFECTING CARDIOPULMONARY FUNCTION
(HYPER/HYPO VENTILATION, HYPOXIA, CARDIAC DISORDERS,
IMPAIRED VALVULAR FX)
 ANEMIA (DECREASED OXYGEN-CARRYING CAPACITY)
 INCREASE IN METABOLIC DEMAND (FEVER)
 MUSCULAR DYSTROPHY; CHEST WALL MOVEMENT IMPAIRMENT
o DEVELOPMENTAL
o LIFESTYLE
o ENVIRONMENTAL
2. NURSING ASSESSMENT:
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
RESPIRATORY RATE & PATTERN
PRESENCE OF COUGH &/OR SECRETIONS
BREATH SOUNDS
FATIGUE
DYSPNEA
WHEEZING
CHEST PAIN
OXYGEN SATURATION
S/S OF RESPIRATORY INFECTION
S/S HYPOXEMIA (CLUBBED FINGERS/BARREL CHEST)
3. OUTCOMES:
 LUNGS CLEAR; NO ADVENTITIOUS LUNG SOUNDS PRESENT
 NO DYSPNEA OR SHORTNESS OF BREATH
 EXPECTORATES SECRETIONS EFFECTIVELY
4. VAP [ VENTILATOR ASSOCIATED PNEMONIA]
 HAI THAT DEVELOPS W/IN 48 HRS OR MORE AFTER ENDOTRACHEAL INTUBATION &
MECHANICAL VENTILATION
 ADHERENCE TO VAP BUNDLE [DECREASES RATES OF VAP]:
o ELEVATE HEAD OF BED GREATER THAN 30-45 DEGREES
o DAILY “ SEDATION VACATION” & ASSESSMENT OF READINESS TO EXTUBATE
o PEPTIC ULCER DISEASE & VENOUS THROMBOEMBOLISM PROPHYLAXIS
o DAILY ORAL CARE W/CHLORHEXIDINE
o MONITOR FOR DELIRIUM
o
EARLY MOBILIZATION
5. PULSE OXIMETRY:
 ESTIMATE OF ARTERIAL BLOOD OXYGEN
 NORMAL VALUES: 95-100%
6. STRATEGIES TO MAINTAIN A CLIENT’S AIRWAY
 NON-INVASIVE VENTILATION (NOT W/IN NURSING SCOPE)
o CONTINOUS POSITIVE AIRWAY PRESSURE (CPAP)
o BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP)
 ARTIFICIAL AIRWAYS (NOT W/IN NURSING SCOPE)
o TRACHEAL
o OROPHARANGEAL
o NASOPHARNGEAL
o ENDOTRACHEAL
 POSITIONING, MEDS, OXYGEN ADMIN, RESPIRATORY MUCLE TRAINING, & AIRWAY
SUCTIONING
7. DELEGATION TO UAP
 OROPHARYNGEAL, & TRACHEOSTOMY TUBE SUCTIONING; ONLY AFTER PT IS STABLE
8. FIO2
 FRACTION OF INSPIRED OXYGEN (PERCENTAGE/CONCENTRATION
 PARTIAL NON-BREATHER W/RESERVOIR BAG DELIVERS HIGHEST CONCENTRATION OF
OXYGEN @ 6-10 L/MIN TO PROVIDE 40-70 % FIO2
CULTURAL AWARENESS
1. MUSLIMS CANT HAVE….
 PORK, ALCOHOL, CAFFEINE
2. MUSLIMS OBSERVE….
 RAMADAN (FASTING SUNRISE TO SUNSER FOR A MONTH)
3. MUSLIMS HAVE….
 ..RITUALIZED METHODS OF ANIMAL SLAUGHTER REQUIRED FOR MEAT INGESTION
DELEGATION
1. MAJOR CONCEPTS OF SAFE & EFFECTIVE DELEGATION AS THEY APPLY TO
NURSING PRACTICE….
 ACCOUNTABILITY & RESPONSIBILITY
 **EVEN IF ONE DELEGATES A TASK; THEY’RE STILL HELD ACCOUNTABLE, AS WELL AS
THE PERSON WHO ASSUMES RESPONSIBILITY**
2. 5 RIGHTS
 RIGHT TASK
o BE FAMILIAR WITH PERSON’S EXPERIENCE, JOB DESCRIPTION, SCOPE OF
PRACTICE, AGENCY POLICY & PROCEDURES, & STATE NURSE PRACTICE
ACT
 RIGHT PERSON
 RIGHT CIRCUMSTANCE
 RIGHT DIRECTION & COMMUNICATION
o PROVIDE CLEAR DIRECTION ABOUT THE TASK & ENSURE
UNDERSTANDING
o CLARIGY PT’S SPECIFIC NEEDS
o CLEAR & CONSTANT COMMUNICATION
** NEVER GIVE TASK/COMMUNICATION THROUGH SOMEONE ELSE**
 RIGHT SUPERVISION & EVALUATION
o DETERMINE DEGREE OF SUPERVISION THAT MAY BE NEEDED
o EVALUATE PT’S OUTCOME
o PROVIDE FEEDBACK REGARDING PERFORMANCE
 PROBLEMS/CONCETNS/SPECIFIC MISTAKES THAT OCCURRED
 HOW TO AVOID MISTAKES/BETTER WAY TO HANDLE
** FEEDBACK SHOULD BE DONE IN PRIVATE; PROFESSIONAL & PRESERVES DIGNITY, & ALLOWS TO FOCUS
ON ONE ISSUE @ A TIME**