Fundamentals Everything you need to know, all in one place! Hi all! Understanding and applying nursing fundamentals is critical for laying a good foundation of nursing skills. We all took the class and thought we’d never see this stuff again, right?! WRONG! Fundamentals are integrated into every field of nursing, and we’ll never get away from it! But don’t let this scare you. I have condensed all important fundamentals information in one neat, organized PDF for your enjoyment and review. Take a deep breath, and go through it at your own pace. You got this! Table of Contents Acid/Base Balance Fluid and Electrolytes Positioning Patients Nutrition Isolation Precautions IVs and Gauges Labs Pain Assessment Hemodynamic Values O2 Administration Leadership and Delegation Nursing Process Culturally Competent Care Page # 2 4 10 11 15 15 16 17 18 19 20 22 24 Acid/Base Balance Maintaining a proper balance between acids and bases in the body is vital for homeostasis and optimal cell function. Recall that the normal pH level in the body is 7.35 to 7.45. If the pH is lower than 7.35, the serum is acidic, and if the pH is higher than 7.45, the serum is too alkaline. The pH of the body is measured by Hydrogen ions (H+), therefore, an increase in H+ ions will decrease the pH, and a decrease in H+ ions will increase pH. The body's way of keeping the pH in an appropriate range is through compensatory mechanisms and buffering. But what happens when the body is unable to keep this balance? Four major changes are likely, and we’ll review them below. Respiratory Acidosis Alkalosis pH -Less than 7.35 pH -Higher than 7.45 ABGs -↓ pH -↑ PaCO2 -HCO3 normal ABGs -↑ pH -↓ PaCO2 -HCO3 normal What does the patient look like? -Slowed breathing/hypoxic -Dizziness, palpitations, muscle twitching, convulsions What does the patient look like? -ineffective breathing/too fast -tachypnea, anxiety, tetany, palpitations, chest pain Risks -respiratory depression, pneumothorax, airway obstruction, inadequate ventilation Risks -hyperventilation, hypoxemia, altitude sickness, asphyxiation, asthma, pneumonia Treatment -Increase respiratory rate, decrease metabolism, sedation -NO BICARB Treatment -Decrease respiratory rate, anxiety, pain Remember, the arrows will always be flipped for RESPIRATORY problems; the pH will be opposite of the PaCO2. Metabolic Acidosis Alkalosis pH -Less than 7.35 pH -Higher than 7.45 ABGs -↓ pH - PaCO2 normal -↓ HCO3 ABGs -↑ pH -PaCO2 normal - ↑ HCO3 What does the patient look like? -Too many H+ ions What does the patient look like? -Not enough H+ ions (usually from fluid volume loss) Risks -diarrhea, fever, hypoxia, starvation, seizures, overdose, renal failure, DKA, dehydration Risks -ingestion of antacids, GI suction, hypokalemia, TPN, blood transfusions, prolonged vomiting Treatment -Decrease diarrhea, remove toxin, give bicarb Treatment -IV NaCl, KCl if fluid overloaded, dialysis Remember, the arrows will always be the same for METABOLIC problems; the pH will match the bicarb (HCO3). Easy way to remember: ROME R- Respiratory O- Opposite (arrows in opposite directions) M- Metabolic E- Equal (arrows in same direction) But what about compensation? Here’s what our ABGs will look accordingly: Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis -↓ pH -↑ PaCO2 -HCO3 normal -↑ pH -↓ PaCO2 -HCO3 normal -↓ pH - PaCO2 normal -↓ HCO3 -↑ pH -PaCO2 normal - ↑ HCO3 Uncompensated: CO2 or HCO3 is normal Partially compensated: Nothing is normal Compensated: pH is normal Fluid & Electrolytes In this section, we will review fluid volume excess/deficit, as well as IV fluids and major electrolytes imbalances and the intervention appropriate for each one. Fluid Volume Deficit ● Fluid intake is less than what is required by the body ● Causes ○ Excess GI/renal loss ○ Diaphoresis ○ Fever ○ Long term NPO ○ Hemorrhage ○ Insufficient intake ○ Burns ○ Diuretic therapy ○ Advanced age ● Symptoms ○ Weight loss ○ Dry mucous membranes ○ ↑ HR and RR ○ Thready pulse ○ Cap refill less than 3 seconds ○ Weak, fatigue ○ Orthostatic hypotension ○ Poor skin turgor ○ LATE SIGNS: oliguria, decreased CVP ● How to diagnose ○ Serum electrolytes, BUN, Cr, Hct, urine osmolality and specific gravity ● Interventions ○ Monitor vitals, skin turgor ○ Maintain strict I&O, aim for an output approx. 0.5mL/kg/hr ○ Weight patient, correct underlying cause ○ Fluid replacement via oral rehydration and IV solutions ○ Electrolytes replacement and IV fluids IV Fluids Isotonic Hypotonic Hypertonic Used for fluid deficit Used for intracellular dehydration Used when serum osmolality is critically low Concentration is = to plasma Lower osmolality than ECF, the fluid will shift from ECF to ICF Higher osmolality than ECF, the fluid will shift from ICF to ECF -0.9% normal saline (NS) -Lactated ringer's (LR) -5% dextrose in water (D5W) -0.45% normal saline (NS) -2.5% dextrose in 0.45% saline -10% dextrose in water (D10W) -50% dextrose in water (D50W) -5% dextrose in 0.9%/0.45% NS -5% dextrose in LR Fluid Volume Excess ● Fluid intake is far greater than body requirements ● Causes ○ Late stages of kidney failure ○ Heart failure ○ Cirrhosis ○ Interstitial to plasma fluid shifts (hypotonic fluids, burns) ○ Excessive water intake ○ Long term corticosteroid therapy ● Symptoms ○ Cough, dyspnea, crackles in lungs ○ ↑ BP, HR, RR ○ Bounding pulse ○ Weight gain ○ Jugular vein distention ○ Increased CVP ○ Pitting edema ● How to diagnose ○ Serum electrolytes, BUN, Cr, Hct ○ Urine specific gravity, osmolality ○ CXR if respiratory sx are present ● Interventions ○ Monitor RR and work of breathing ○ Monitor for pulmonary edema, edema in bilateral lower extremities ○ ○ ○ ○ ○ Monitor for ascites, abdominal weight gain Weight patient daily and maintain strict I&O Limit fluid intake Maintain skin integrity Restrict sodium intake Electrolyte Imbalances Intracellular ● Potassium ● Phosphorous ● Magnesium Extracellular ● ● ● ● Sodium Calcium Chloride Bicarbonate Function of electrolytes: Maintenance of homeostasis, fluid volume, Promote neuromuscular excitability, Distribute water between fluid compartments, Maintain cardiac stability, Regulate acid/base balance Potassium (K+) 3.5-5.0 mEq/L “The number of bananas that usually come in a bunch” Hypokalemia Less than 3.5 Hyperkalemia More than 5.0 Risks ● Adverse effects of corticosteroids, diuretics, digitalis, laxatives ● Body fluid loss via vomiting, diarrhea, wound drainage, NG suction ● Excessive diaphoresis, kidney disease, dietary deficiency, alkalosis Risks ● Renal failure, adrenal insufficiency ● Acidosis, excessive K+ intake ● Potassium sparing diuretics, ACE inhibitors Symptoms ● Muscle weakness, fatigue, cramping, N/V, irritability, confusion, decreased bowel motility, paresthesias, dysrhythmias, flat/inverted T waves on EKG Symptoms ● Peaked T waves on EKG, ventricular dysrhythmias, paresthesias, ascending muscle weakness, increased bowel motility Interventions ● Initiate fall precautions, monitor K+ levels, initiate K+ replacement (MUST Interventions ● Monitor EKG, bowel sounds ● Initiate dialysis DILUTE VIA IV, NEVER IV PUSH) ● Monitor EKG, I&O, HCO3 and pH levels ● Kayexalate, 50% glucose with insulin ● Calcium gluconate ● Bicarbonate, loop diuretics *Potassium replacement must be via dilution through IV, NEVER PUSH K+ *If patient is not urinating, never give potassium Sodium (Na+) 135-145 mEq/L “The number of salt crystals you shake onto your fries” Hyponatremia Less than 135 Hypernatremia More than 145 Risks ● GI loss, SIADH, adrenal insufficiency ● NPO status, restricted sodium diet, water intoxication, excessive diaphoresis ● Medications such as diuretics, anticonvulsants, SSRIs, lithium, demeclocycline Risks ● Dehydration, GI loss, hyperaldosteronism ● Hypertonic tube feedings ● Diabetes insipidus ● Kidney failure ● Burns, heatstroke, corticosteroids Symptoms ● Weakness, lethargy, confusion, seizures, headache, N/V, muscle cramps/twitching ● Hypotension ● Tachycardia ● Weight gain, edema Symptoms ● Fever, swollen/dry tongue, sticky mucous membranes, hallucinations, lethargy, restlessness, seizures ● Hypertension ● Tachycardia ● Hyperreflexia, twitching ● Pulmonary edema Interventions ● Sodium replacement via orally or IV/G tube ● Restrict oral fluid intake ● Daily weight and I&O ● Conivaptan hydrochloride if needed ● Seizure precautions Interventions ● Daily weight and I&O ● Seizure precautions ● IV infusion of hypotonic or isotonic fluids ● Diuretics ● Dietary sodium restriction and education ● Increased oral fluid intake ● *hypertonic solutions can cause cerebral edema, be cautious Calcium (Ca++) 8.5-10.5 mEq/L “The number of cows seen in a field at once” Hypocalcemia Less than 8.5 Hypercalcemia More than 10.5 Risks ● Hypoparathyroidism, hypomagnesemia ● Kidney failure ● Vitamin D deficiency, inadequate calcium intake ● GI loss ● Celiac disease, lactose intolerance, crohn's disease, ETOH Risks ● Hyperparathyroidism, malignant disease ● Prolonged immobilization, dehydration ● Vitamin D excess, thiazide diuretics, lithium ● Glucocorticoids ● Digoxin toxicity ● hyperthyroidism Symptoms ● Tetany, cramps, paresthesias, dysrhythmias ● Trousseau’s and chvostek’s signs ● Seizures, hyperreflexia, impaired clotting time Symptoms ● Muscle weakness, hypercalciuria/kidney stones ● Dysrhythmia, lethargy, hyporeflexia, pathologic fx, flank pain, deep bone pain ● Polyuria, polydipsia, dehydration ● Hypertension ● N/V Interventions ● Seizure precautions ● IV calcium replacement ● Daily calcium vitamins, vitamin D therapy ● Monitor for orthostatic hypotension Interventions ● Increase mobility, isotonic IVF ● Dialysis, cardiac monitoring ● Furosemide, calcitonin, glucocorticoids, bisphosphonates, calcium chelators *IV calcium must be given slowly and diluted in D5W, never in NS *Ca++ levels are opposite of Phosphorous levels: when one is elevated the other is decreased Magnesium (Mg++) 1.6-2.6 mEq/L “You need MAGnum condoms for six (six=sex)” Hypomagnesemia Less than 1.6 Risks Hypermagnesemia More than 2.6 Risks ● GI loss, alcoholism, hypocalcemia, hypokalemia, DKA, hyperparathyroidism, malabsorption, TPN, laxative abuse, acute MI ● Medications such as cisplatin, cyclosporine, aminoglycosides, diuretics, amphotericin B ● ● ● ● Renal failure, excessive Mg++ therapy Adrenal insufficiency, laxative overuse Lithium toxicity Excessive soft tissue injury or necrosis Symptoms ● Paresthesias, dysrhythmias ● Trousseau’s and chvostek's signs ● Agitation, confusion, hyperreflexia ● Hypertension ● Insomnia, irritability, N/V ● Dysphagia Symptoms ● Hypotension, drowsiness, bradycardia ● Bradypnea, coma, cardiac arrest ● Hyporeflexia, N/V, facial flushing Interventions ● Seizure precautions, monitor swallowing ● IV mag sulfate, PO mag salts ● Monitor urine output and respirations Interventions ● Mechanical ventilation ● IV fluids such as LR or NS ● IV calcium gluconate, loop diuretics ● Monitor respirations and BP *Monitor for Mag toxicity with IV replacement, if suspected, treat with Calcium Gluconate Phosphorus 3.0-4.5 mEq/L “Phorus- 4 us” Hypophosphatemia Less than 3.0 Hyperphosphatemia More than 4.5 Risks ● Vitamin D deficiency, refeeding after starvation ● Alcohol use disorder ● DKA ● Alkalosis, hypomagnesemia, hypokalemia ● Excessive loss of body fluids ● Burns. TPN Risks ● Renal failure, chemotherapy, acute pancreatitis ● High vitamin D, high phosphorus intake ● Hypoparathyroidism ● Excessive enema use, acidosis Symptoms ● Paresthesias, muscle weakness, bone pain, chest pain, confusion, seizures, Symptoms ● Tetany, cramps, paresthesias, dysrhythmias nystagmus Interventions ● Oral phosphate replacement ● Careful IV replacement (only used in severe cases) ● Gradual introduction or solution for TPN patients ● Protection from infections ● Seizure precautions ● Trousseau’s and chvostek's signs ● Hyperreflexia, anorexia, N/V ● Soft tissue calcifications Interventions ● Vitamin D, aluminum hydroxide, diuretics, IV NS, dialysis, dietary management and education *Phosphorus levels are opposite of calcium levels: when one is elevated the other is decreased Positioning Patients While it may seem silly, the position of your patient can drastically affect their health status and hinder their recovery. It is important to recognize the types of positions, as well as which disease processes require specific positions. ● Flat with patient prone (face down) ○ Helps drainage in patients with COVID-19 ● Flat with patient supine (face up) ○ Post lumbar puncture patients ● Side-lying or lateral position ○ Hemorrhoidectomy ○ After liver biopsy ○ During lumbar puncture ● Sim’s position (Patient prone with one knee flexed and head turned to same side) ○ Rectal enemas and irrigations ● Trendelenburg (Head of bed is decreased while foot of bed is elevated) ○ Circumferential burns to allow extremities to be positioned above level of the heart ○ Postural drainage ● Reverse trendelenburg (Head of bed is elevated while foot of bed is decreased) ○ GERD ● Fowler’s (90 degree angle) ○ Burns of face, head, neck ○ Hypophysectomy, thyroidectomy ○ Insertion of NG tube ○ Irrigation/tube feedings ○ COPD with patient leaning forward onto pillow in lap ○ Laryngectomy, bronchoscopy post-procedure ○ Autonomic dysreflexia patients ● Semi fowler’s (30-45 degree angle) ○ Burns of face, head, neck ○ Hypophysectomy, thyroidectomy ○ Irrigation/tube feedings ○ Mastectomy patients ○ Paracentesis procedure, place patient in position of comfort following procedure ○ Abdominal aneurysm resection post procedure ○ No more than 30 degrees is used following catheterization, especially with a femoral approach ○ After cataract surgery with the patient on the unaffected side to prevent edema from forming ○ Cerebral aneurysm and IICP patients ○ Stroke patients ○ Craniotomy post procedure ● Lithotomy positioning ○ Perineal and vaginal procedures ● Others ○ Heart failure and pulmonary edema should have their legs dangle on the side of the bed to decrease venous return and lung congestion ○ PAD patients should elevate their legs when resting, but NOT above the level of the heart ○ Suspected or confirmed spinal injury patients all require log rolling ○ Total hip arthroplasty patients require a wedge or pillow between the legs to prevent adduction of the hips Nutrition ● Overview ○ 1 gram of protein is 4 calories ○ Processed and canned foods are high in sodium ○ Fresh fruits and vegetables are low in sodium ○ The order of fuel use ■ Carbohydrates, fat, and then proteins Special Diets Clear Liquid Diet High-fiber Diet -Gelatin, broth, apple juice, cranberry juice, tea -Ordered to provide bulk in the stool and bring water into the colon for patients with constipation for diverticulitis -Raw fruits and vegetables and whole grains Sodium-restricted Diet -Ordered for patients with kidney, cardiovascular disease, or hypertension in order to control the retention of sodium and water and lowering blood pressure -Avoid canned prepared foods, table salt, prepared seasoning -Used in patients with ascites, edema-associated advanced liver and renal disease, congestive heart failure, essential hypertension, and pts receiving adrenocorticoids Low-residue Diet -Ordered to reduce fiber for patients with crohn's disease, colon surgery, esophagitis, and diarrhea -Clear liquids, fat, eggs, white potatoes -Avoid dairy products High-residue Diet -Foods that contain skins, seeds, leaves Bland Diet -Excludes foods that are chemically and mechanically stimulating or irritating to the GI tract -Small, frequent meals -Usually for patients with ulcers and post-op patients -Avoid fried foods, meat extracts, pepper, and chili powder Low-fat Diet -Limits foods containing cholesterol and saturated fatty acid -Increases foods high in polyunsaturated fatty acids including skim milk, egg whites, lean meats, and fat-free soup Low-purine Diet -Recommended for patients with gout -Avoid organ Meats, shellfish, oily fish Low-oxalate Diet -Avoid leafy greens, nuts/seeds, beets, raspberries -For kidney stones, gout BRAT Diet Gluten-free Diet -Banana, rice, Apple, tea -Ordered for patients with malabsorption syndrome such a Celiac disease Special Populations and Considerations Maintaining cholesterol levels -Levels of 200+ associated with increased risk for CAD -Avoid foods with cheese and eggs Vitamin K -A deficiency in this may affect blood coagulation -Green leafy vegetables are high in vitamin K and should be avoided in patients on coumadin -Foods high in potassium also include baked potatoes, avocados, cantaloupe, tomatoes, and orange juice Gout -Avoid foods such as organ meats, sardines, beans, and lentils, foods high in protein Kidney stones -To reduce the risk of stone formation, increase intake of fluids -Maintain low oxalate diet 12 Amino acids -Non-essential -The liver is able to synthesize these acids 8 amino acids -Essential -The liver is unable to synthesize these Vitamin B12 -Found only in animal food -Needed after a gastrectomy in the form of injections because the intrinsic factor that is necessary for the absorption of B12 is founded a stomach -Strict vegetarians should include fortified breakfast cereal as their reliable source of vitamin B12 -Treatment of pernicious anemia also requires B12 injections for their life Vitamin D -Considered a nutrient of concern in elderly patients because they're synthesist is decreased -Deficiency includes osteomalacia, which is weakening and softening of the bones Calcium -Green leafy vegetables are a great source of calcium -Patients at risk for renal calculi should adhere to a low calcium diet -Pregnant mothers must maintain an adequate calcium intake to prevent from losing stores of calcium -Cow’s milk is not suitable for infants under 1 year of age because it is high in protein and calcium that can lead to pediatric dehydration Iron -Must increase consumption of iron during pregnancy because of maternal red blood cell volume and iron storage in the fetus -Increase consumption of spinach, beef, liver, prunes, pork, broccoli, whole bread, and whole cereal MAOIs -Patient’s who consume foods high in tyramine may experience a hypertensive crisis, advise patients to avoid avocados, figs, bananas, fermented and aged Meats, pepperoni, salami, cheese, foods containing yeast (beer and wine) Older adults -Those who are bedridden or inactive need small meals with high fiber to prevent constipation -Dehydration often is missed because they have diminished sense of thirst Cancer and chemotherapy -May contribute to the development of malnutrition as a result of the effect on basal metabolism and symptoms such as nausea and decreased food intake -Recommendations include eggs and cottage cheese in place of meat Pulmonary disorders -Encourage rest periods before meals Dialysis patients -Routinely supplemented with calcium, vitamin B6, and folic acid -Nephrotic syndrome -Hypoalbuminemia, and hyperlipidemia -Chronic renal failure -Requires supplementation of water soluble vitamins -Low protein, low potassium diet Congestive heart failure -Offer smaller meals throughout the day due to the frequent fatigue -The goal is to minimize cardiac workload and reduce edema -Daily weights are the best indicator of fluid balance Type 2 diabetes mellitus -The more body fat that the client has, the more resistant to body cells are to insulin Islamic & Orthodox Judaism -Both exclude pork from the diet -Kosher -If meat is consumed, 3-6 hours must pass before dairy can be consumed Isolations and Precautions Standard Precautions ● Used when in contact or handling blood, bodily fluids, tissues, mucous membranes, or areas of open skin ● Includes gloves, masks, goggles, gown ● Order of putting on PPE ○ Gown ○ Mask (if needed) ○ Goggles ○ Gloves ● Order of removing PPE ○ Gloves ○ Gown ○ Goggles ○ Mask Transmission Based Precautions ● Followed in addition to standard precautions ● Airborne ○ Germs that float in air or travel long distances ○ Chickenpox, measles, TB, etc. ○ Patient is placed in a negative pressure room ○ Special considerations ■ N95 mask/respirator is required, surgical masks are not ● Contact precautions ○ Germs that are spread by touching ○ C. Diff, norovirus ○ Special considerations ■ Gown and gloves are required ● Droplet precautions ○ Prevention of contact with germs in or around the secretions and mucus from nose, sinuses, throat, airway, and lungs ○ Influenza, pertussis, mumps, respiratory illness, COVID-19 ○ Special considerations ■ Surgical mask is required IVs and Gauges The smaller the number, the larger the needle will be! Recognizing the types of needles and IV sizes, as well as the size required for IM/subQ/ID injection is so important. 16 Gauge -Most commonly used in ICU/surgical areas -Large size allows for blood administration, rapid fluid administration, etc. 18 Gauge -Same tasks as 16 -Blood administration, rapid IV push 20 Gauge -Better for patients with small veins 22 Gauge -Smaller size is more ideal for patients who will not need an IV for long, not critically ill -Usually NO blood is administered through these 24 Gauge -Used in pediatrics -Used as a last resort in adult populations Intramuscular Injections, Adults SubQ Injections, Adults Length 1-1 ½ Length ½-⅝ Gauge 22-25 Gauge 23-25 Locations -Deltoid -Vastus lateralis and rectus femoris -Ventrogluteal -Posterior aspect of upper arm -Abdomen, 2 inches around umbilical area -Thigh region -Lower flank Important Lab Values RBC 4.5-6.1 million WBC 4,500-11,00 0 Hgb 12-18 Hct 38-54% Plt 150-450,000 PTT 35-45 sec PT 10-15 sec aPTT 25-35 sec INR 2-3 Bleeding time 1-10 min Na 135-145 K 3.5-5.1 Mg 1.6-2.6 Ca 8.5-10.5 BUN 10-20 Creat 0.5-1.5 Lithium 0.5-1.5 Dig 0.5-1.5 Cholesterol 160-190 CKP 25-175 AST 8-20 Prostate antigen 0.18-0.89 Glucose 70-110 A1C 4-6% pH 7.35-7.45 CO2 35-45 >45: acid O2 80-100 HCO3 22-26 <22: acid PaO2 95-100% <35: alkaline >26: alkaline Pain Assessment We like to think that pain is the 6th vital sign (HR, RR, BP, Temp, O2, and pain). It is important in the assessment of the patient that we frequently ask about their pain, and asking in an appropriate way is even more important. ● Numerical rating scales use numbers to rate pain ○ 0 being no pain at all, 10 being the worst pain they’ve ever felt ● Visual analog scales typically ask a patient to mark a place on a scale that aligns with their level of pain ● Categorical scales use words as the primary communication tool and may also incorporate numbers, colors, or relative location to communicate pain ● Wong Baker FACES scale ○ Can be used in children above 3 years and in adults ● FLACC scale ○ Can be used in children who are too young or in adults who are unable to communicate Hemodynamic Values In addition to electrolyte levels and our CBC, the hemodynamic status of our patient can tell us a lot about their current condition. Familiarize yourself with these properties and their values. SVO2 (Mixed venous oxygen saturation) -60-75% -The percentage of oxygen bound to hemoglobin in blood returning to the right side of the heart This reflects the amount of oxygen "left over" after the tissues remove what they need Stroke Volume -50-100 mL -The volume of blood ejected from each ventricle due to the contraction of the heart -The difference between end diastolic volume (EDV) and end systolic volume (ESV) -Three primary factors that regulate SV- preload, afterload, contractility Stroke Index -25-45 mL/M2 -Relates SV to body surface area (BSA), thus relating heart performance to the size of the individual -The unit of measurement is millilitres per square metre (ml/m2) SVI-SV/BSA Cardiac Output Cardiac Index -4-8 L/min -The amount of blood the heart pumps from each ventricle per minute -CO=HR x SV -Impaired regulation of SV (preload, afterload, contractility) can have a negative effect on CO -2.5-4.0 L/min/M2 -The cardiac output proportional to the body surface area (BSA) -CI= CO x BSA MAP -60-100 mmHg -Average pressure in arteries during one cardiac cycle -Considered a better indicator of perfusion to vital organs -Can only be determined by invasive monitoring CVP -2-6 mmHg -The blood pressure in the venae cavae, near the right atrium of the heart This reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system PAP -20-30 mmHg -One of the most commonly measured parameters during a cardiac catheterization -Determined by visually marking the waveform output by a transducer PAOP (wedge) SVR -8-12 mmHg -Pressure within the pulmonary arterial system when catheter is wedged in a branch of one of the pulmonary arteries -900-1300 dynes/sec/cm2 -Reflects changes in the arterioles, which can affect emptying of the left ventricle -If the blood vessels tighten or constrict, SVR increases, resulting in diminished ventricular compliance, reduced stroke volume -The heart must work harder against an elevated SVR to push the blood forward, increasing myocardial oxygen demand Oxygen Administration Even though our atmosphere only contains 17% oxygen, it is crucial for survival. If any one or more of the systems that deliver and circulate oxygen fails, hypoxia will occur, and reversing hypoxia is one of the main indications for oxygen therapy. We can measure oxygen saturation through pulse ox monitoring. Normal O2 levels are 95-100%, however, there are special populations who will have a lower saturation including COPD/emphysema patients, neurmuscular and chet wall disorders, cystic fibrosis patients, and obese patients. Let’s work through some types of oxygen administration devices and when they would be appropriate to use. Note: The type of oxygen delivery device will be chosen based on the required oxygen flow rate prescribed, the patient’s inspiratory volume, respiratory rate, etc. Low-Flow Systems Nasal Cannula -Oxygen Concentration: 24%-40% O2 -O2 Delivery: 1-6L/min -Anything above 6L should be humidified Simple Face Mask -Oxygen Concentration: 40%-60% O2 -O2 Delivery: 6-10L/min -Prongs placed in either nostril supply oxygen direction from a flow meter/humidified oxygen to the patient -Used for short term therapy (long term therapy in COPD patients) -Best used in stable patients who require low amounts of oxygen -Mask fitting over nose and mouth, has exhalation ports to release CO2 -Mask held in place by elastics around patient’s head -May cause claustrophobia -efficiency depends on how well it fits Face Tent -Oxygen Concentration: 28%-100%% O2 -O2 Delivery: 15L/min + -Mask covers nose and mouth, does NOT create a seal around face -Provide a controlled concentration of oxygen and increase moisture High-Flow Systems Non-Rebreather Mask -Oxygen Concentration: 60%-80% O2 -O2 Delivery: 10-15L/min Partial Rebreather Mask -Oxygen Concentration: 80%=90% O2 -O2 Delivery: 10-12L/min Venturi Mask -Oxygen Concentration: 24%-60% O2 -O2 Delivery: 4-12L/min -Simple mask with reservoir bag attached to O2 tubing, connected to flow meter -No re-breathing of exhaled air -Bag should never totally deflate -Bag should always remain partially inflated -Does not have one-way valves, so expired air mixes with inhaled air -Sterile water is connected via corrugated tubing and a drainage bag; oxygen/air ratio nebulizer also attached -Can be an aerosol mask, tracheostomy mask, T piece, or face tent -Flow of oxygen exceeds peak inspiratory flow rate of the patient Leadership and Delegation Essential Components of Leadership ● Effective communication, conflict manager, competence, role model, delegation, identified goals, motivation, proactive, flexible ● Therapeutic Communication ○ Used to help build and maintain relationships with patients, families, coworkers, etc. ○ Patient-centered, purposeful, planned, and goal-directed Delegation ● NEVER delegate what you can EAT: evaluate, assess, teach ● Rights ○ Right person, task, circumstance, direction/communication, supervision ● Roles of UAPs ○ Basic hygiene care/grooming, report to LPN/RN, assistance with ADLs, vital signs, calculating I&O ○ Basic skills that are non-invasive and do not require sterility ● Roles of LPNs ○ Cares for stable patients, chronic patients, and those whose outcome can be expected ○ Reinforcement teaching ○ Contributes to the care plan but does not create the plan ○ Calculates and monitors IV flow rate ○ Administer IVPB medications ○ Monitors IV fluids ● Roles of RNs ○ Advanced clinical skills, including the care of acute and critically ill patients ○ Follows nursing process and communicates with team if there are changes Prioritization ● Prioritize systemic before local ● Prioritize acute before chronic ● Prioritize actual problems before potential future problems ● Prioritize according to Maslow’s hierarchy of needs ● Prioritize and respond to trends versus transient findings ● ABCs! ○ Airway, breathing, circulation ○ If a patient was hemorrhaging but you notice they are not breathing, which problem do you address first? Breathing! Nursing Process Overview ● Systemically a collection of data and clearly identifies the patient's strengths and problems ● The process offers improved quality of nursing care ● Encourages client participation in care and decision-making ● Always individualized ● ADPIE ○ Assessment, nursing diagnosis/analysis, planning, implementation, and evaluation ■ Always use the five steps in chronological order ○ Remember that assessment always comes before planning or implementation 1) Assessment ● Begins as soon as the patient walks in ● ● ● 2) ● ● ● ○ Involves establishing the database of a client, collection and organization of physical and psychosocial assessment data ○ Collection of physical assessment data Verify the data ○ Whenever there is a doubt, verify the data ■ ex; if a patient wants to urinate, assess the symphysis pubis for dissension or swelling. If this tension is present, it confirms the Dell ○ Always question orders you do not agree with ■ ex; ordering Demerol for head injury patient, needs questioning because Demerol depresses the respiratory center ○ Before the administration of any pain medication, ask the patient to rate the pain ■ If the pain is 0-4, try diversional therapies first ■ If the pain is 5-10, give pain meds Subjective Data ○ Information perceived only by patient, what they feel ○ Symptoms: patient is nauseous, with chills and pain Objective Data ○ Observed by nurse ○ Body temperature, blood pressure, cyanosis Diagnosis & Analysis Formulated nursing diagnosis used NANDA Analysis ○ To identify the actual potential problems, the cause, or etiological factors ○ Analyzes lab results ○ Identifies immediate needs ○ Determine cause of symptoms, strengths, weaknesses Ability to Make Predictions ○ If a nurse administers Demerol, the nurse should expect it to start to relieve pain within 30 minutes ○ Regular insulin works within the first 30 minutes, therefore, if a nurse administers regular insulin, they should expect that the medication will start working within 30 minutes ■ Ability to synchronize meal times ○ If you remove CSF during a lumbar puncture, it will cause fluid loss and a headache ■ Remember, the positioning for this procedure is the fetal position/knee to chest position at the edge of the bed ■ The first four hours after the lumbar puncture, the nurse then places the patient in a prone position to allow the process of coagulation to take place ■ After this, the nurse places the patient in supine or flat position to apply pressure on the puncture site 3) ● ● ● ● 4) ● 5) ● ○ When taking care of a patient with rheumatoid arthritis, a systemic and autoimmune disease that if left untreated, will affect the heart (carditis) ■ Therefore, the nurse can predict that bed rest will be needed Planning Set priority first, short term goals before long term ones Consult with family and patient in developing plan of care Short-term goals ○ Immediate actions ○ Ex; f a patient is in a state of anxiety due to pain, the best solution is to relieve anxiety by relieving the pain ○ Ex; if a patient is bleeding from a surgical incision site, stop the bleeding by reinforcement of a wound dressing or apply pressure Long-term goals ○ Takes longer to achieve ○ Sets up priority or prioritizes the goals by using Maslow's hierarchy of needs, ABCs, and safety Implementation Carrying out the planning or accomplishing a defined goal, involves implementation of care, reporting significant changes in client's condition, documentation, communicating patient needs to others of the healthcare team ○ Ex; give me orange juice with iron for better absorption ○ Ex; Not giving diuretics at night Evaluation Determining the extent at which the goals have been achieved ○ Comparing patient responses to the expected outcome ○ Revising the goal of care to accommodate patient values, Customs, culture, and beliefs ○ Gathering data to indicate effectiveness of each intervention ■ Ex; an evaluation of an anemic woman on iron medication after 3 months showed that her hemoglobin improved effectively Culturally Competent Care As nurses, we strive to treat all of our patients with the same care and respect, regardless of their background. However, sometimes we aren’t always sensitive to the needs of different populations. Let’s take a look at some ways we can provide culturally competent care in the healthcare setting. Eleven Standards for Providing Culturally Competent Care: ● Social justice ● ● ● ● ● ● ● ● ● ● Critical reflection Knowledge of cultures Culturally competent practice Cultural competence in health care systems Patient advocacy and empowerment Multicultural workforce Education and training in culturally competent care Cross-cultural communication and leadership Policy development Evidence-based practice and research How to Assess Culture ● Find out patient’s cultural affiliation and how it impacts their daily life ● Does the patient read, speak, and write in English? ○ If not, have you made an effort to get an interpreter? ○ If using an interpreter, ensure you speak to the patient ● Does the patient have specific dietary restrictions? ○ If so, have you made an effort to change their diet with dietary? ● Are there any rituals that the patient requests as it pertains to life and death? ○ If so, have you made an effort to ensure those rituals happen? ● Does the patient wish for family to be included in care and ADLs? Language and Communication ● Speak in a low, calm voice ○ Those who are blind can still hear, do not shout ○ Those who are deaf are not going to hear a louder voice ○ Have you made reservations to find an alternative way for the patient to communicate? ● Eye contact and touch are sensitive for specific cultures. Ask before you assume! ○ This also applies to personal space ● Address the patient by their last name, and as them what name they’d like to be called Blind Patients ● Those who are blind may have a specific way of performing ADLs and may or may not need assistance ○ Ensure that you find out the patient’s preference before assuming they are helpless ● When delivering their meal tray, explain the location of items in a clock formation ○ Ex; the water cup is at 1 O’clock and the pudding is at 5 O’clock, and so on You made it to the end! If there is anything that was not covered in this study guide, feel free to reach out to me! I’d love to make changes, add topics, etc. I am here for YOU!
