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Fundamentals HESI
1. Edema Lower Leg: excess of watery fluid collecting in the cavities or tissue of the extremity.
Grading scale:
➢ 1+ barely detectable
➢ 2+ indentation of less than 5mm
➢ 3+ indentation of 5 to 10mm
➢ 4+ indentation of greater than 10mm
2. Blood pressure: the pressure of blood in the circulatory system measured by systolic over diastolic
Average blood pressure readings:
Newborn: (1 year): 65-90/30-60mm Hg; (6 years): 87-117/48-64mm Hg
Adolescent: (12 years): 110/65mm Hg; (16 years): 119/75mm Hg
➢ Adult: (18-60 years): <120/80mm Hg
Checking Orthostatic or Postural hypotension changes: Take blood pressure and pulse with
patient SUPINE (lying down forward). Then have patient sit and stand for 1 minute. Retake
blood pressure and pulse. Record both sets of numbers. If patient is orthostatic, pressure will
decrease (20 to 30mm Hg) and pulse will increase (5 to 25 beats per minute) when sitting or
standing. Observe for dizziness, fainting, lightheadedness. Remember patient safety. Record
what was found
Korotkoff sounds: sounds of blood pressure
Phase I Systole : sharp thud
Phase II Systole : Swishing sound
Phase III Systole : low thud or knocking
Phase IV Diastole : begins fading
Phase V Diastole: silence
Cuff should be 20% wider than the diameter of the limb
Creating a FALSE HIGH reading
Having the cuff that is too narrow
Having a cuff that is too loose
Deflating the cuff to slowly
Having the arm below the heart
Having the arm unsupported
Creating a FALSE LOW reading
Having a cuff that is too wide
Having a cuff that is too tight
Deflating the cuff too quickly
Having the arm above the heart
Technique for taking BP in the leg- use popliteal artery. Systolic usually 10-40mm HG higher
than using brachial; diastolic remains the same.
3. Rectal Temperature: insert lubricated thermometer probe with probe cover in place into rectum 1-1 ½
(2.5-3.5 cm) toward umbilicus. Reading is usually 0.9oF lower than oral temperature.
Advantage: Very reliable
Disadvantage: may lag behind core temperature during rapid changes
➢ Should not be used for those with diarrhea or who have had rectal surgery
4. Sleep:
A patient’s sleep history:
➢ Have the patient describe his or her specific problem
➢ Have the patient describe his or her symptoms and alleviating factors
➢ Assess the patient’s normal sleep pattern
➢ Assess the patient’s normal bedtime rituals
➢ Assess for current or recent physical illnesses
➢ Assess for current or recent emotional stress
➢ Assess for possible sleep disorders
➢ Assess the patient’s current medications and their possible effects on sleep
Sleep disorders:
➢ Bruxism: tooth grinding during sleep
➢ Insomnia: chronic difficulty with sleep patterns
Initial insomnia: difficulty remaining asleep
Intermittent insomnia: difficulty remaining asleep
Terminal insomnia: difficulty going back to sleep
➢ Narcolepsy: difficulty in regulating between sleep and awake states; person may fall
asleep without warning
➢ Nocturnal enuresis: bedwetting
➢ Sleep apnea: intermittent periods of cessation of breathing during sleep. Use risk
assessment, alcohol at bedtime increase risk for sleep apnea
➢ Sleep deprivation: decrease in the amount and quality of sleep
➢ Somnambulism: sleepwalking, night terrors or nightmares
Drugs and their adverse effects on sleep
➢ Hypnotics
Interfere with reaching deep sleep stages
Only temporary increase in quality of sleep
May cause hangover during day
Excess drowsiness, confusion decreased energy
May worsen sleep apnea in older adults
➢ Diuretics
Cause nocturia
➢ Antidepressants and stimulants
Suppress rapid eye movement (REM) sleep
➢ Alcohol
Speeds onset of sleep
Disrupts REM sleep
Awakens person during night and causes difficulty returning to sleep
➢ Caffeine
Prevents person form falling asleep
May cause person to awaken during night
➢ Nonbenzodiazepines
Anxiety and irritability
Sleep walking, eating, or driving
➢ Digoxin
Causes nightmares
➢ Beta-Blockers
Causes nightmares
Cause insomnia
Cause awakening from sleep
➢ Valium
Decreases stages 2 and 4 and REM sleep
Decreases awakenings
➢ Narcotics (Morphine/Meperidine {Demerol})
Suppress REM sleep
If discontinued quickly, can increase risk of cardiac dysrhythmias because of
rebound REM periods
Cause increased awakenings and drowsiness
Sedation scale
➢ S= Sleepy, but easy to arouse
➢ 1= Awake and alert
➢ 2= Slightly drowsy but easy to arouse
➢ 3=Drowsy, drifts to sleep during to arouse
➢ 4= Somnolent, minimal or no response to physical stimulation
Exercise and Sleep- exercise 2 hours before bedtime allows cold down period and fatigue that
promotes relaxation. Should not exercise closer to bedtime
36.4% sleep problems; altered sleep-pain. Treat underlying problem of pain, not sleep
Normal sleep patterns and interventions to help return patient to normal sleep patterns;
types pf nonpharmacologic interventions before giving meds.
5. Wound cleansing:
54.5% Braden scale- risk assessment tool for pressure ulcers; interpretation of Braden score(
lower score is greater risk for pressure ulcers) reassess if something changes
Wound drainage- abnormal
Wound irrigation fluid- wound cleansing (routinely use normal saline if no order for specific fluid)
Lab values to monitor : serum albumin & prealbumin
90.9% pressure ulcer assessment
➢ Stages of pressure ulcer:
1. Stage I: Nonblanchable
2. Stage II: Partial thickness
3. Stage III: Full thickness Skin loss
4. Stage IV: Full thickness tissue loss
Lab assessments: protein (albumin, prealbumin)
Stasis ulcer- inflammation
72.7% skin rash
Hydrogel, hydrocolloid dressings are types of dressing for wounds
Hemovac or other vacuum drain, Jackson- Pratt: postop care with drain (compress, close seal)
If dressing saturated and no order to change, can reinforce dressing
6. Enemas: a procedure in which liquid or gas is injected into the rectum
Types of Enemas: Carminative: used to expel flatus
➢ Cleansing: stimulates peristalsis; irritates bowel by distention
➢ Colonic irrigation: used to expel flatus
➢ Hypertonic: tap water; avoid with cardiac patients
➢ Medicated: contains a therapeutic agent
➢ Retention: oil given to soften stool
➢ Saline: draws fluid into the bowel
➢ Soapsuds: irritates and distends bowel; use only castile soaps
7. Impaction: hard dry stool embedded in rectal folds; may have liquid stool passing around impaction
Causes: poor bowel habits, immobility, inadequate food or fluids, or barium in rectum
Remedies: digitally remove impaction, increase fluids and fiber, increase exercise and
institute bowel program
Impaction removal requires physician order
8. Voided specimen: a urine specimen obtained after the external urethral area is washed with a liquid
soap and rinsed well; then the patient starts a urinary stream, stops it, and voids into a sterile specimen
container. The purpose of obtaining such a specimen is to minimize contamination by external
- Normal void- 30ml/hr
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills
of personal hygiene in order to:
Assess the client for personal hygiene habits/routine
Assess and intervene in client performance of activities of daily living
Provide information to the client on required adaptations for performing activities of daily living (e.g.,
shower chair, hand rails)
Perform post-mortem care
Personal hygiene, which is one of the basic activities of daily living, includes:
Bathing, showering and washing
Foot care
Hair care
Nail care
Perineal care
Mouth and oral care
Denture care
General considerations-Many patients are sensitive or embarrassed about wearing dentures; therefore, the
patient’s privacy should be respected when the dentures are cleaned.Dentures must be handled carefully; they
are fragile and expensive, and the patient is handicapped without them.
If the dentures are left out of the mouth for any period of time, place them in a covered opaque container
with the patient’s name on the container.
Dentures must be kept in water to preserve their fit and general quality; the color may change if they
become dry.
You may avoid breaking the dentures while cleaning them by holding them over a basin of water with a
washcloth folded in the bottom.
Dentures are brushed in the same way as natural teeth; be sure to rinse them well.
The denture cup should be labeled with the patient’s name and room number.
Never use hot water to rinse the dentures as it could warp them; use cool or lukewarm water.
The patient’s gums and soft tissues should be cared for at least twice per day while the dentures are out of the
mouth; a soft-bristled toothbrush, swab, or gauze-covered tongue blade dipped in mouthwash should be used to
cleanse the gums, tongue, and soft tissues.
a. General.
Follow procedures outlined in paragraph 2-3 a through h. Use only acetone or alcohol to clean injection site and
allow the area to dry before injection is administered.
b. Select Injection Site and Prepare Patient.
(1) Selecting site. Usually palmer (inner) forearm or subscapular region of the back is selected. The site selected
should be an easily obtainable area and relatively free from being rubbed by clothing.
(2) Position patient. To position the patient, proceed as follows:
(a) Place arm in a relaxed position, elbow flexed.
(b) Place palm up, exposing palmer or inner arm area.
c. Prepare Injection Site.
Refer to paragraph 2-3a.
d. Remove Needle Guard.
Pull the guard straight off.
e. Stabilize Injection Site.
(1) Using your nondominant thumb, apply downward pressure, directly below and outside the prepared
injection site. (Do not draw the skin back or move the skin to the side because the skin will return to its normal
position when pressure is released and will cause the needle bevel to either go deeper into the skin or to leave
the skin, depending upon which direction the skin moves.)
(2) Hold the skin taut until the needle bevel has been inserted between the skin layers (see figure 2-10).
f. Insert Needle.
(1) Using your dominant hand, hold syringe, bevel up, with fingers and thumb resting on the sides of the barrel.
If you insert the needle at a 20 degree angle, lower it at once to 15 degrees. Do not place thumb or fingers under
syringe because this will cause the angle of insertion to exceed 15 degrees causing the needle to insert beyond
the dermis.
(2) Insert needle, bevel up, just under the skin at an angle of 15 to 20 degrees until the bevel is covered (see
figure 2-11). Continue stabilizing thumb pressure. You should feel some resistance. If the needle tip moves
freely, you have inserted the needle too deeply. At this point, withdraw needle slightly and check again for
Figure 2-11. Position of needle. Proper angle and depth for an
intradermal (ID) injection.
g. Inject Medication.
It is not necessary to aspirate the syringe since no large vessels are commonly found in the superficial layer of
the skin. Inject the medication as follows:
(1) Continue holding syringe with same hand.
(2) Release skin tension with other hand.
(3) With free hand, push plunger slowly forward until the medication is injected and a wheal appears at the site
of the injection. The appearance of a wheal indicates that the medication has entered the area between the
intradermal tissues. If a wheal does not appear, withdraw the needle and repeat the procedure in another site.
h. Withdraw Needle.
To withdraw the needle, quickly withdraw it at the same angle that it was inserted.
i. Cover Injection Site.
Without applying pressure, quickly cover injection site with a dry sterile small gauze.
j. Perform Postinjection Patient Care.
Refer to paragraph 2-3u.
k. Evaluate Reaction of Medication.
Usually you, as the medical specialist, will not evaluate the reaction of a suspected allergic reaction or a
tuberculin test, but will record the reaction. For a tuberculin test, the patient will wait 48 to 72 hours and then
return to have an evaluation to determine if the patient has been exposed to tuberculosis. If the intradermal
injection is done to determine if the patient is allergic to dust, pollen, or similar substances, a reaction will take
place in a few minutes after the substance has been placed under the skin.
(1) Instruct the patient to wait or return to have the test read according to local SOP.
(2) Caution patient not to rub, scratch, or wash injection site. Rubbing, scratching, or washing may spread or
dilute the medication, causing a false reading at a later time.
l. Dispose of Equipment.
Dispose of equipment according to local SOP.
m. Record Administration of Intradermal Injection.
Record the injection information on the patient’s chart or record.
Oral administration is a route of administration where a substance is taken through the mouth. ...
Many medications are taken orally because they are intended to have a systemic effect, reaching different parts
of the body via the bloodstream, for example.
Nurses adhere to "seven rights" of medication administration: right medication, right client, right dose, right
time, right route, right reason and right documentation.
● Easiest and most desirable route.
● Food sometimes affects absorption.
● Aspiration precautions.
● Enteral or small-bore feedings:
➢ Verify that the tube location is compatible with medication absorption.
➢ Use liquids when possible.
➢ If medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding.
Risk of drug-drug interactions is higher.
● Integrate knowledge from nursing and other disciplines.
● Have understanding of sex practices and risks associated with sexual problems.
● Apply the nursing process and use a critical thinking approach in your care of patients.
● Provides a clinical decision-making approach to help you develop and implement an individualized plan
of care.
● Assess all relevant factors, including physical, psychological, social, and cultural, to determine a
patient’s sexual well-being.
This review describes the fact that many elderly people enjoy an active sex life and examines the evidence
against the general perception of an ‘asexual’ old age. It offers an overview of the evidence for healthcare
professionals who had not previously considered the sexuality of their older patients. It also describes some of
the sexual problems faced by older people, especially the difficulties experienced in disclosing such problems to
healthcare professionals. It examines why healthcare professionals routinely avoid discussing sexual problems
with older patients, and how this can be improved. It also offers some recommendations for future research in
the area, as well as a word of caution regarding the temptation of over-sexualising the ageing process.
Adjustment sleep disorder (acute insomnia), Inadequate sleep hygiene, Behavioral insomnia of
childhood, Insomnia caused by medical condition
Most cases of insomnia are related to poor sleep habits, depression, anxiety, lack of exercise, chronic
illness, or certain medications.
Symptoms may include difficulty falling or staying asleep and not feeling well-rested.
Treatment for insomnia consists of improving sleep habits, behavior therapy, and identifying and
treating underlying causes. Sleeping pills may also be used, but should be monitored for side
● Through the patient’s eyes
➢ Ask the patient’s pain level
➢ Use ABCs of pain management
➢ Pain is not a number
● In selecting a tool to be used with a patient, be aware of the clinical usefulness, reliability, and validity of
the tool in that specific patient population.
Be aware of possible errors in pain assessment
● Patient’s expression of pain
➢ Pain is individualistic
● Characteristics of pain
➢ Timing
➢ Location
➢ Severity
● Characteristics of pain (Cont.)
➢ Quality
➢ Aggravating and precipitating factors
➢ Relief measures
● Effects of pain on the patient
➢ Behavioral effects
➢ Influence on activities of daily living (ADLs)
● Concomitant symptoms
➢ Usually increases pain severity
The normal range for serum potassium is narrow (3.5 to 5.5 mEq/L), and minor departure from this range (by
less than 1.0 mEq/L) is associated with significant morbidity and mortality.
A potassium test checks how much potassium is in the blood. Potassium is both an electrolyte and a mineral. It
helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the
body. Potassium is also important in how nerves and muscles work.
This test measures the amount of potassium in the fluid portion (serum) of the blood. Potassium (K+) helps
nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.
Potassium levels in the body are mainly controlled by the hormone aldosterone
(17-32 handwritten)
33) Medication Administration/Cultural/Spiritual –
Routes: Oral – Buccal, Sublingual – easy to administer, economical, often produce local or systemic
effects, rarely cause anxiety for patient. Oral medications are not given if patient is unable to swallow, has
gastric upset, nausea, vomiting
Parenteral: Subcutaneous, Intramuscular, intravenous, intradermal – can be used when oral medications
are contraindicated. More rapid absorption than with topical or oral routes, intravenous (IV) infusion provides
medication delivery when patient is critically ill or long-term therapy is necessary.
Topical: applied to skin – primarily provides local effect, painless, limited side effects
Transdermal: Prolonged systemic effects with limited side effects – Prolonged systemic effects with
limited side effects. Medication leaves oily or pasty substance on skin and sometimes soils clothes.
Mucous Membranes – Therapeutic effects provided by local application to involved sites. Aqueous
solutions readily absorbed and capable of causing systemic effects. Potential route of administration when oral
medications are contraindicated.
Inhalation – Provides rapid relief for local respiratory problems. Used for introduction of general
anesthetic gases. Some local agents cause serious systemic effects.
Intraocular Disk – route advantageous because it does not require frequent administration as eyedrops
do. Local reactions possible; expensive. Patients must be taught to insert and remove disk. Contraindicated in
eye infections.
Cultural/Spiritual – assess cultural beliefs, attitudes, and values when administering medications and teaching
patients abut self-administration. Establish trust with patients and resolve conflicts between medications and
cultural beliefs to achieve optimal patient outcomes. Investigate if the patient practices any alternative therapies
or is taking any herbal preparations.
Consider cultural influences on drug response, metabolism, and side effects if a patient is not responding to drug
therapy as expected. Confer with health care provider because a change in the patient’s medications is
sometimes necessary. Assess food preferences that may interfere with patients medication therapy.
34) Medications/Math/Nursing process/Documentation – electronic medication-incorrect - dose – To
administer medications safely, you need to understand basic mathematics skills to calculate medications doses,
mix solutions, and perform a variety of other activities. This is important because medications are not always
dispensing the unit of measure in which they are ordered. Medication companies package and bottle
medications in standard dosages. Always double check your math and always read back the order to the Health
Care Provider when taking phone orders. You must have a general knowledge of the medication and its dosages
give to adults, pediatrics, or certain ethnic groups to prevent mistakes.
35) Nursing process – Compare data: Is a critical thinking five-step process (Assessment, Diagnosis,
planning, implementation, and evaluation) that professional nurses use to apply the best available evidence to
caregiving and promoting human functions and responses to health and illness. It is the fundamental blueprint
for how to care for patients. A patient-centered care approach is holistic and essential when applying the
nursing process. Such an approach enhances patient assessment and education, family centeredness, patient
adherence to interventions, and patient outcomes.
36) Nursing process – Pain-outcome POC – Successful management of pain depends on establishing a
relationship of trust among health care providers, patient, and family. Pain management extends beyond relief,
encompassing the patient’s quality of life and ability to work productively. During the assessment process
thoroughly assess each patient and critically analyze finds to ensure that you make patient-centered clinical
decisions required for safe nursing care. A comprehensive assessment of pain aims to gather information about
the cause of a person’s pain and determine its effect on his or her ability to function. POC (Plan of Care)
37) Nursing process – Cultural/Spiritual – agnostic: Agnostic is the philosophy that underscores universal
ethics and rejects the divisive differences between religions. It doesn’t matter which religion you might follow,
nor does it matter whether or not you believe in God. What matters is what you do, not what you believe
38) Nursing process – Chronic Pain – Chronic pain is not protective and thus serves no purpose, but it has a
dramatic effect on a person’s quality of life. Chronic pain is any pain that lasts for more than three months. The
pain can become progressively worse and reoccur intermittently, outlasting the usual healing process. After
injured tissue heals, pain is expected to stop once the underlying cause is treated, according to conventional
ideas of pain.
39) Nursing process – Shearing force – Shearing force is when one part of a body in part in one specific
direction, and another part of the body in the opposite direction. When the forces are aligned into each other,
they are called compression forces. Usually when a bed-bound patient is being moved, and results in soft-tissue
damage and ischemic changes. For patients at risk for skin breakdown who are able to sit in a chair, limit the
amount of time they sit to 2 hours or less at any given time. Teach patient to shift weight every 15 minutes.
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