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1. Community health/ med surg.

AED use:
1. Establish unresponsiveness
2. Check pulse and respirations in 10 seconds or less
3. Activate the response team
4. Start compressions
5. Defibrillate with the AED as soon as it is available
a. Turn on the device
b. It will give step by step instruction
c. Single shock is delivered instead of a sequential 3 shocks.
d. When it says analyzing the rhythm, any direct contact with the victim must stop
e. Once AED is charged, the instruction will state stand clear

Action for healthcare provider

Use as soon as possible. For an
out-of hospital, unwitnessed cardiac
arrest, EMS may initiate 1 to 3
min of CPR before attempting

2. Fundamentals Basic Nursing Skill, BP: steps on how to measure

Guidelines for measuring BP:
a. Have the pt. lie down or sit and rest for 5 minutes. If sitting the, the patient should keep the feet flat on the floor.
b. Use brachial artery in the elbow joint of either arm. The arm should be supported on a surface at a level of the heart.
Measuring BP in the

Uses properly
sized cuff for
Place midway
between the
elbow and the

over radial

Measuring BP in the thigh

Measuring BP in the calf

Place the pt. in a prone

position; alternatively
supine with knee
slightly bent
Uses the correct cuff
size; wraps the cuff so
lower edge is 1 in.
above the popliteal
fossa and centered over
the popliteal artery.
Auscultate and palpate
over the popliteal artery

Palpating the BP

Places the pt. in

supine position
Uses correct cuff
size; wraps the cuff
so the lower edge is
1 in. above the
malleoli or ankle
Place the
stethoscope over
the dorsalis pedis or
posterior tibial artery

Applies the cuff, and

palpates for the radial
or brachial pulse.
Inflate the cuff until the
pulse disappears, then
inflates for 30 mmHg
Release valve slowly
deflating the pulse.
Note manometer
reading when pulse was

3. Fundamentals Basic Nursing Skill, Elimination: Catheter insertion: Male

Action (rationale)
1. Check physicians order
2. Assess patients knowledge of
catheterization and whether pt.
is allergic to iodine or tape.

1. Perform hand hygiene.
2. Maintain sterile technique
3. Note date, time, size and type of
catheter inserted, amount of water
in balloon, any problems
encountered and amount and
character of urine obtained initially.

Special considerations
1. After urine starts to flow,
insert the catheter an
additional 1 to 2 inches and
then hold the catheter in

4. Fundamentals Basic Nursing Skill, Hygiene: safety contact precaution at home

Home care considerations:


Teach patients and families the importance of hand

hygiene. Stress that hands must be cleansed before/after
caring for patients. Gloves are needed in addition to hand
hygiene for tasks such as tracheal suctioning and
tracheostomy care, dressing changes and wound or drain
care, tube feedings, and cleansing of personal areas of
the body.

2. The bathroom should be cleaned daily with standard

household cleaning agent or 1:10 solution of chlorine
bleach and water.
3.Discard used dressings, tissues, wound cleaning
supplies, and any other item contaminated with body fluids
into a plastic bag, then seal the bag before placing it in the
household trash for pickup.

5. Fundamentals Basic Nursing Skill, Nutrition: clear liquid diet

a. Serves the primary function of
providing fluids and electrolytes

Nursing considerations:
a. Clear liquid are started when the patient has a return of bowel sounds
detected by auscultation. The goal is to introduce fluids that have low



to prevent dehydration
Initial feeding after complete
bowel rest
Used initially to feed
malnourished person or a
person who has not had any
oral intake for some time
Bowel preparation for surgery
or test
Postsurgical diet
Initial diet in gastroenteritis and



residue, easily digested, and have low risk of causing abdominal

Clear liquid diet are used short term because the diet is deficient in
most nutrients.
The patient progresses into full liquids when clear liquids are tolerated.
Grape, apple and cranberry juice, strained fruit juice, vegetable broth,
carbonated water (preferably clear), clear fruit-flavored drinks,
sweetened gelatin and ices, clear candies, popsicles, tea, coffee and
clear broth.
The nurse should limit the amount of caffeine consumed by the client,
because caffeine can cause an upset stomach and sleeplessness.
Client may have salt or sugar
Dairy products and fruit juices with pulp are not clear liquids.

6. Fundamentals Basic Nursing Skill, Nutrition: Protein diet

1. Amino acids, which make up proteins, are critical to all
aspects of the growth and development of body tissues
and provide 4 cal/g.
2. Proteins build and repair body tissues, regulate fluid
balance, maintain acid-base balance, produce
antibodies, provide energy, and produce enzymes and
3. Essential amino acids (EAA) are required in the diet
because the body cannot manufacture them.
4. High quality proteins are complete protein such as eggs,
dairy products, meat, fish, and poultry contain adequate
amount of EAAs.
5. Foods that do not contain EAAs in sufficient amounts are
lower-quality or incomplete proteins.
6. Inadequate protein intake can cause protein energy
malnutrition and severe wasting of fat and muscle tissue.

High calorie, high protein diet

Indications: Severe stress, burns, cancer, HIV
infection, AIDS, COPD, respiratory failure, or any
other type of debilitating disease.
Nursing Considerations:
a. Encourage nutrient dense, high calorie,
high protein foods such as whole milks and
milk products, peanut butter, nuts, seeds,
beef, chicken, fish, pork, and eggs.
b. Some high-calorie foods include sugar,
cream, gravy, oil, butter, mayonnaise, dried
fruit, avocados, and honey.
c. Encourage snack between meals, such as
milkshakes, instant breakfasts, and
nutritional supplements.

7. Fundamentals Basic Nursing Skill, Safety: standard precaution, CDC guidelines

Standard precautions must be practiced with all clients in any setting, regardless of the diagnosis or presumed
infectiousness. Promote hand washing and the use of gloves, masks, eye protection, and gowns, when appropriate during
client contact. These precautions apply to blood, all body fluids, secretions and excretions, regardless of whether they contain
blood, nonintact skin, or mucous membranes.

8. Fundamentals Basic Nursing Skill, Safety: sterile field

The field is considered sterile to within 1 inch of its horizontal, or flat border. The principles to observe when opening sterile
packages are as follows:
a. Perform hand hygiene
b. Open the sterile package away from the body
c. Touch only the outside of the wrapper.
d. Do not reach across the sterile field; go around the sterile field if necessary to reach the other side.
e. Always face the sterile field, even when moving to the other side.
f. Allow sufficient space (at least 6 inches) between the body and the sterile field.

9. Fundamentals Basic Nursing Skill, Safety: wrist restraint

The use of protective device must help the patient or be needed for the continuation of medical therapy
Use the least amount of immobilization needed for the situation
Obtain a written order for all devices that limit movement or immobilize the patient. Notify the physician as soon as
the device is no longer needed
Apply the device snugly but not so tightly as to interfere with blood circulation or nerve function, you should be able to
fit your index and middle fingers between the patient and the device.
Release the ties and change the patients position at least 2 hours (according to the agency policy). Perform active or
passive exercises for immobilized joints and muscles.
Check patient at least every 15 to 30 min as directed by your agency and observe neurovascular function
Place the ties under the armrest of a chair and secure at the back. This prevents the patient from sliding the tie up
and off the back of the chair.
Use half-bow knot to secure the device to the bed frame or chair.

10. Fundamentals Medication Administration, Refusal: documentation

When the patient refuses the medication, place a circle in medication administration record around the time the
medication was to be given and record an explanation for the refusal in the progress notes.
Any refusal of treatment are also recorded in the chart. The exact word the patient uses when refusing to comply with
the treatment regimen should be documented.

11. Fundamentals Medication Administration, Nasal gastric tube: medication administration

Tubes placed through the nose into the stomach
If medications cannot be crushed or if capsules cannot be opened, notify the physician so that the form can be
changed into liquid.
Flush the tube with 30 ml of water and add the dissolved medication. Follow the first meds with at least 15 to 30 mL
of water before administering the next one. Follow the last medication with 30 to 60 mL of water.
Leave the head of the bed elevated for at least 30 minutes, preferably for 60 minutes.
Safety alert! Evidence-based practice to prevent aspiration includes checking the placement of the feeding tube, elevating the
head of the bed, and allowing the patient to remain in an upright position for at least 30 minutes after instilling medications and
fluids through nasogastric tube.

12. Fundamentals Medication Administration, Topical application

Form of Drug


Lotions and liniments

(oily based)

Liquid suspension
Semisolid, thick preparation containing a
medicinal agent
Semisolid, thin preparation containing a
medicinal agent
Medication dissolved in alcohol
Liquid medication provided in a dropper
bottle with a detachable dropper






Adhesive substance with medication bonded

to it that is slowly absorbed into the skin
Liquid placed in a pressurized container or
squeeze bottle so that it will form an aerosol
when activated
Solid medication mixed with a viscous
substance that dissolves at body


Tinct, tr
Gt, gtt

This route is
for pt. who
are vomiting

Applied to the skin
Applied to the skin or mucous
Applied to the skin or mucous
Applied to the skin
Usually formulated for nose, eye or
ear, although infant vitamins and
other medications are made as
Applied to the skin for up 7 days for
transdermal absorption
Inhaled through the mouth or the
Placed in the vagina, rectum, or
urethra depending on the type of

Fundamental Medication Administration, Math: IM, ampule, mL

Fundamental Medication Administration, Math: PO, mg/kg, tabs/dose or tabs/day
Fundamental Medication Administration, Math: SubQ, international units/mL (insulin or heparin)
Fundamental Geriatrics, Basic Nursing Skill: Elimination constipation fluids
Fundamental Geriatrics, Basic Nursing Skill: Evaluate O2 effectiveness, O2 saturation

O2 Saturation device measures O2 saturation by determining the hemoglobin that is bound with the oxygen.
Finger or toe clip-on probe is most commonly used but adhesive sensors can be applied to the nose or the forehead.
A clip-on probe is available for use on an earlobe or an infants foot.
A pulse oximeter reading lower than 91% necessitates HCP notification; if the reading is lower than 85%, oxygenation
to the body tissues is compromised; and a reading lower than 70% is life threatening.

18. Fundamental Medical Surgical, Basic Nursing Skill: Rapid respirations

Tachypnea increased or rapid breathing, results from the presence of fever and a number of diseases. Breathing
rate increases about 4 breaths for each 1F increase in temperature.
Hyperventilation pattern of breathing in which there is an increase in rate and depth of breaths and carbon dioxide
is expelled, causing the blood level of CO2 to fall. The condition is seen after severe exertion, during high levels of
anxiety or fear, and with fever and condition such as diabetic acidosis.
Kussmaul fast deep respirations. Increased rate and depth with panting and long, grunting exhalation. Can be
seen on patients with diabetic acidosis and renal failure.
Biot fast deep respirations with abrupt pauses.
Cheyene-stokes respirations become faster and deeper, then slower and shallower with a period of apnea.

19. **
20. Fundamental Medical Surgical, Basic Nursing Skill: Elimination, Urine clean catch
Clean catch or midstream Urine Specimen to obtain specimen for culture and sensitivity test when
UTI is suspected. The purpose is to obtain a specimen that is relatively free form external contamination.

To obtain Midstream urine specimen:

a. Perform hand hygiene.
b. Clean the labia part for female (front to back) and for male the penis (opening of urinary meatus to
c. Void a small amount of urine to the toilet and catch the middle portion of the urine. Then finish voiding
into the toilet.
d. Rinse and dry the outside of the container and perform hand hygiene.
21. Fundamentals Medical Surgical, Basic Nursing Skill: Elimination Hygiene colostomy pouch
An ostomy appliance must be cut to the correct size or it will not fit correctly over the stoma.
Ostomy pouches should be emptied when one third to one half full to prevent pulling on the faceplate.
22. Fundamentals Medical Surgical, Basic Nursing Skill: Hygiene, hygiene and dyspnea (pneumonia, suction, oral

Actions to take to perform respiratory suctioning:

a. Explain the procedure to the client
b. Assist the client to an upright position
c. Perform hand hygiene and don protective garb.
d. Prepare suctioning equipment and turn on the suction.
e. Hyperoxygenate the client.
f. Once inserted, apply suction intermittently while rotating and withdrawing the catheter.
g. Hyperoxygenate the client.
h. Listen to breath sounds.

23. Fundamental Medical Surgical, Basic Nursing Skill: mobility ambulation safety
Guidelines for moving and Lifting: Body mechanics:
o Obtain help whenever possible
o Ask the patient to help if able
o Bend or flex knees
o Use the greatest number of muscles possible
o Use thigh, arm, leg muscles rather than back muscles
o Use wide base of support. Keep feet about shoulders width apart.
o Use smooth coordinated movement; avoid jerking or sudden pulling motions.
o Keep elbows and work close to your body.
o Work at the same level of height as the object to be moved.
o Remember that pulling actions require less effort than pushing or lifting
o Directly face the object or person to be moved
o Keep trunk straight; do not twist when lifting or pulling.
o Use arms as levers when pulling the patient toward you. Lock the elbows and rock back on your heels, using the
weight of your body to move the patient.

24. Fundamentals Medical Surgical, Basic Nursing Skill: Nutrition, diarrhea, intestinal flora



Foods to assist a patient with Diarrhea:

Patient who experienced diarrhea from antibiotics should be counseled to eat yogurt, drink buttermilk, or take
acidophilus when they begin taking antibiotics. Replacing the normal bacteria with those contained in these food
products reestablishes the right balance and stops diarrhea.
When diarrhea is thought to be caused by bacteria or a virus, the physician will let it run its course for at least 24 hrs.
Diarrhea from other causes simply leads to fluid and electrolyte loos and should not be allowed to continue for long
periods. Treatment involves placing the patient on clear liquid diet to rest the bowel, replacing fluids and electrolytes, and
seeking medication to stop the loose stools.
Observe for signs of dehydration when the patient has severe diarrhea: decreased skin turgor, dry mucous membranes
with thick saliva, and increased thirst. Self-medication for diarrhea should not be continue for more than 48 hours with
consulting the physician.

25. Fundamental Medical Surgical, Basic Nursing Skill: Nutrition, hypoglycemia diet
Hypoglycemia and Pt. able to swallow:
1. cup of juice
2. 1 cup of 2% skim milk
3. cup of regular soda
4. 6 or 7 hard candies such as life savers (not sugar free)
5. 1 small box of raisins
6. 3 glucose tablets
7. 1 tbsp of honey
8. 1 tbsp of sugar
9. 5 small cubes of sugar
10. 1 small tube of cake icing (2oz)

Hypoglycemia and pt. unable to swallow

1. Turn pt. onto the side
2. Administer 1g of glucagon by injection after mixing the
solution in the bottle until it is clear. Call 911 If unable to
give injection
3. Feed the pt. as soon as she is awake and able to
swallow. Give fast acting source of sugar and longeracting source such as crackers and cheese and or
meat sandwich
4. If the pt. does not awaken within 15 mins, give another

11. 1 small tube of glucose gel

12. Follow up with longer-acting source, such as crackers,
and cheese or a meat sandwich


dose of glucagon and inform HCP immediately

If HCP cannot be contacted, call 911

26. ***
27. Fundamental Medical Surgical, Basic Nursing Skill: Medication administration, allergy intranasal medication
Safety Alert! Nasal medication that are intended for local effect on the nasal mucosa, such as saline nose drops for seasonal
allergies, are administered in both nostrils. Nasal medications that are intended for systemic effects, such as sumatriptan
(Limitrex), should be given in one nostril only.

28. Fundamentals Medical Surgical, Basic Nursing Skill: Medication administration pillocarting instruction (eye drops,
self-administration medication) (p.656F)
Instilling Eye Medication:
o If patient has contact lenses or glasses, assist patient in storing it properly.
o Check medication with MAR, follow six rights and double check whether the instillation is for right eye, the left eye or
both eyes.
o Wash hands and remove cap from the bottle of medication; place it upside down on the table and cap must be sterile.
o Drop the directly into the conjunctival sac without touching the surface of the eye. Do not place drops on the cornea.
o Replace the cap on the bottle without contaminating the dropper tip or the rim of the top.

29. Fundamentals Medical Surgical, Medication Administration: Zofran


Prevention of
chemotherapy-induced and
postoperative nausea,
vomiting, hyperemesis in
pregnancy, bulimia, spinal
analgesia-or gallbladder
induced pruritus




8 mg
BID or
TID; 32
mg IV

The 5-hydroxytryptamine type 3 receptor

antagonists target serotonin receptors both at the
CTZ and peripherally at the nerve endings in the
stomach. This action reduces the non-GI adverse
effects that are often evident when nonspecific
cholinergic blocking drugs are used. This should
be used cautiously in patients with cardiac
conduction problems or electrolyte imbalance.

30. Fundamentals Medical Surgical, Physical Assessment: sleep assessment

o Conduct a thorough history of any sleep related problems that patient has had.
o Encourage pt. with sleep difficulties to keep a sleep diary. They should record the time they went to bed,
when they woke up, and any time they awoke during the night; usual diet, and all medications taken
including sleep aids. Also include information about where they sleep and anything that disturbs sleep,
such as neighborhood noise, a snoring partner, wakeful children, or pets.
31. Fundamentals Pathophysiology Medical Surgical, Basic Nursing Skill: Mobility risk skin breakdown
32. Fundamental Pediatrics Basic Nursing Skill, Nutrition: Obesity, pre-diabetic
33. Geriatrics Operative respiratory: Narcan
34. Geriatrics Medical Surgical Physical Assessment: Respiratory, pneumonia assessment
S/S: high fever accompanied by chills, cough that produce rusty or blood-flecked sputum, sweating, chest pain that is made
worse by respiratory movements and a general feeling of malaise and aching muscles.

35. Medical Surgical, Cardiovascular: Antilipidimics

Reduce serum levels of cholesterol, triglycerides, or low-density lipoproteins.

Statin drugs is used to lower cholesterol, remind pt. to have blood drawn periodically to determine if drug is effective
Statin drugs can injure muscle tissue and are toxic to the liver, blood should be drawn for levels of CK and for liver
Grapefruit juice should not be consumed when taking statin drug. Grapefruit juice interferes with the metabolism of
the drug which can lead to increased serum levels and risk of toxicity.

36. Medical Surgical, Cardiovascular: Coronary Artery Disease risk factor

Factors such as age (over 40), gender and race contribute to the disease.
Those who have one or more immediate family members die of coronary artery disease during middle age are
considered to be at high risk for disorder.
Postmenopausal women and women who use oral contraceptives or hormone replacement therapy are at greater risk
for CAD.

37. Medical Surgical, Cardiovascular: Hypokalemia with Digoxin

Digoxin (cardiac glycosides) inhibit the sodium-potassium pump, thus increasing intracellular calcium which causes
the heart muscle fibers to contract more efficiently.

These medications are contraindicated in those with ventricular dysrhythmias and second or third degree heart block
and should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia (because
hypokalemia can increase digoxin toxicity).
An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, or hypothyroidism.
Monitor the potassium level. If hypokalemia occurs (K lower than 3.5 mEq/L) notify HCP.
Hold the medication if apical pulse is <60 bpm or >120 bpm.

38. Medical Surgical, Cardiovascular: Physical Assessment

Physical assessment
Significant finding include abnormal or
extra heart sounds, crackles in the
lungs, or pink frothy sputum indicating
pulmonary edema.

Focused assessment of cardiovascular system:

1. Skin color, temperature, and texture.
2. Facial expression; signs of pain or anxiety
3. Vital signs
4. Heart sounds; S1 and S2, murmurs
5. Apical pulse rate and rhythm; presence of pulse deficit
6. Quality of peripheral pulses; compare them bilaterally
7. Breath sounds, presence of crackles in the lungs
8. Shape of fingers, presence of clubbing
9. Appearance of neck veins; presence of venous jugular vein distention
10. Abdomen, presence of distention; abdominal pulsation
11. Degree of body tension
12. Ankles and fee; presence of edema and degree
13. Weight gain of 2 lb. or more over a few days
14. Varicosities in lower extremities

39. Medical Surgical, Endocrine: Diabetes, Hyperglycemia action

Signs and symptoms




Blurred vision


Weight loss

*not enough insulin

Nursing action:

Encourage water intake

Check blood glucose frequently

Assess for ketoacidosis: Urine ketones, Urine glucose, Administer insulin as directed

Client/family teaching: regular non-strenuous exercise with health care providers

approval; Exercise should be done after mealtime; either exercise with someone; may
need snack before or during exercise; monitor blood glucose before, during and after
exercise when beginning a new regimen.

40. Medical Surgical, Endocrine: Diabetes, Low glucose

Signs and Symptoms:
Headache, nausea, sweating, tremors, lethargy, hunger,
confusion, slurred speech, tingling around mouth,
Anxiety, nightmares

Nursing Actions:
Usually occurs rapidly, and potentially life-threatening, treat immediately
with complex CHO. Example: graham cracker and peanut butter twice
and if no response, seek medical attention. Check blood glucose, may
seize if less than 40

41. Medical Surgical, Endocrine: Hyperthyroid

Hyperthyroidism (Graves disease, goiter) - excessive activity of thyroid gland resulting an elevated level of circulating
thyroid hormones. It can result from primary disease state, replacement hormone therapy; or from excessive thyroid
stimulating hormone (TSH) from anterior pituitary tumor.
Common treatment for hyperthyroidism are:
thyroid ablation with medication
Adenectomy of portion of anterior
pituitary whereTSH- producing tumor is

Nursing Assessment: Data Collection

Weight loss
Increased appetite
Heat intolerance
Tachycardia, palpitations,
Increased BP
Nervousness, insomnia
T3>220 ; T4>12

Nursing plans and Interventions

Recommended diet: high calorie,
high protein, low caffeine, low fiber,
diet if diarrhea is present.
Thyroid storm is life threatening. S/S
are: High fever, tachycardia, agitation,
anxiety and hypertension. Primary NI
include maintaining airway and
adequate ventilation. Propylthiouracil
(PTU) or methimazole (Tapazole) are
antithyroid drugs.

After thyroidectomy: check for bleeding, support the neck when moving, watch for laryngeal edema by assessing
for hoarseness or inability to speak clearly. Monitor serum calcium (8.5 to 10.9 mEq/L), check for tingling of toes,
fingers, and around the mouth, check for Chvostek or Trousseau sign.
42. Medical Surgical, GI: Hepatic, Tylenol and liver toxicity
The client should avoid alcohol and over the counter medications, particularly acetaminophen (Tylenol)
and sedatives because these medications are hepatotoxic.
43. Medical Surgical, GI: Hepatic, Ulcers
2 most common peptic ulcers:
a. Gastric ulcer Gnawing, sharp pain in or left of the
midepigastric region occurs 30 to 60 minutes after meal
(food ingestion accentuates the pain). Hematemesis is
common than melena.
b. Duodenal Ulcer Burning pain in the midepigastric are
1.5 to 3 hours after a meal and during the night (often
awakens the client). Melena is more common than
hematemesis. Pain is often relieved by the ingestion of

1. Monitor vital signs and for signs of bleeding.
2. Administer small, frequent bland feedings during
the active phase.
3. Administer H2 receptor antagonists or proton pump
inhibitors as prescribed to decrease the secretion
of gastric acid.
4. Administer antacids as prescribed to neutralize
gastric secretions.

44. Medical Surgical, GI: Hepatic, operative respiratory, post-op pain

45. Medical Surgical, Immune: Hematology, physical assessment, amino glycosides
46. Medical Surgical, Immune: Hematology, physical assessment, edema assessment

Assess for generalized edema by checking for weight gain over a short time. Ask about the shoe and ring tightness
and sock patterns left on the ankles when socks are removed.
Look for hand and eye puffiness and abdominal fullness.
To check for dependent edema, press the fingers into the tissue over the tibia just above the ankle. If an indentation
remains, pitting edema is present.

1+ barely perceptible pit 2mm (3/32 in)

2+ a deeper pit, rebounds in a few seconds 4mm (6/32in)

3+ A deep pit, rebounds in 10-20 seconds 6mm (1/4 in)

4+ A deeper pit rebounds in >30 seconds 8mm (5/16 in)

47. Medical Surgical, Immune: Hematology, respiratory penicillins

Penicillins - Antibiotics
Amoxcicillin, ampicillin, Penicillin

Adverse Effects: Gastrointestinal effects, including sore mouth and furry tongue
Superinfections, hypersensitivity reactions, including anaphylaxis

48. Medical Surgical, Integumentary: Prednisone dose schedule

49. Medical Surgical, Musculoskeletal: Cast care swelling

During the first 24 to 48 hours after any cast has been applied to an extremity, the extremity should be elevated to
minimize swelling.

50. Medical Surgical, Musculoskeletal: Compartment syndrome

Compartment syndrome restriction of blood flow that occurs in one or more muscle compartments of the extremities. It is
caused by external or internal pressure and seriously restricts circulation to the area. External pressure can occur from
dressings or casts that are too tight. Internal pressure occurs from excessive IV fluid infusion, inflammation, and edema (a
shifting of fluid from the vascular spaces to the intracellular spaces). The increased fluid puts pressure on the tissues, nerves,
and blood vessels, thereby decreasing blood flow.
o Elevation is the key to preventing compartment syndrome; toes and fingers should be higher than the trunk.
o The main sign of compartment syndrome is severe, unrelenting pain that is out of proportion to the injury and
unrelieved by narcotics. Assess the 6 Ps: pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia (cold
to touch).
o Dressings will be cut or replaced or surgical fasciotomy (linear incisions in the fascia down the extremity)
o Cast can be bivalve (split through all layers of material)

51. Medical Surgical, Musculoskeletal: Flexural

52. Medical Surgical, Musculoskeletal: Operative TENS unit
TENS utilizes a small electrical stimulator attached to the skin with electrodes placed around the area of
pain. A low current running between the electrodes acts to block pain sensation. Must be ordered by a
Biofeedback and transcutaneous electrical nerve stimulation (TENS) may be offered by a licensed
provider to help strengthen the pelvic floor muscles.
53. Medical Surgical, Neurological: CVA, pupils

54. Medical Surgical, Neurological: Valium Status Epilepticus

55. Medical Surgical, Neurological: Respiratory seizure precaution

Never try to pry open the patients mouth or insert something into it once the jaw is clamping down, as teeth may be
broken and the airway may become obstructed. If supplemental oxygen is near, it should be administered, if possible.
When the seizure is over, turn the patient to the side and suction the airway if needed. Check oxygen with pulse
oximeter. Stay with the patient until she is completely conscious.

56. Medical Surgical, Oncology Reproductive: Breast exam findings

Breast self-examination should be done monthly, about 1 week after menstruation begins, or on specific date each
month after menopause.
Mammography to screen the breast for abnormal growths, particularly cancer. Done in radiology department with
special radiographic equipment. A full filled digital mammography machine records images on a computer screen and
can computer enhance questionable images for increased accuracy. Nursing Implications: breast discomfort from
compression of tissue during the test, occasional mild bruising. Instruct patient to wear no deodorant or lotion on the
upper body and to wear clothing that allows top to be easily removed. Take acetaminophen and hour before the
scheduled test.
New test that may replace current mammography for breast cancer are currently being researched; these include the
cone-beam breast computed tomography scan.

57. Medical Surgical, Operative Renal: Nephrectomy Post-op

58. Medical Surgical, Operative Sensory: Pain assessment, non-verbal

Wincing, inability to sleep, restless movements, withdrawal from others.

59. Medical Surgical, Operative Trauma Emergency: Evisceration Action

Before reparative surgery, the patient should lie supine with the knees flexed. The wound should be covered with a
sterile towel or sterile dressings moistened with sterile normal saline.
In case of dehiscence or evisceration at home: moisten sterile gauze with sterile water (or fresh water is sterile is
unavailable and place over the expose bowel to keep the bowel membrane moist.

60. Medical Surgical, Renal: Nephrotoxic drug

Examples of substances that are potentially nephrotoxic:

Aminoglycosides (gentamicin, streptomycin)

Sulfonamides (trimethoprim-sulfamethoxazole)

Antifungals (amphotericin B)

Antitubercular (rifampin)

Cephalosporins (cefaclor)

Tetracyclines (doxycycline)

Miscellaneos (e.g. vancomycin)

Ace inhibitors (captopril)
Antineoplastic agents (cisplatin)
Immunosupressants (cyclosporine)
NSAIDs (salicylate, ibuprofen, indomethacin)
Other drugs (acetaminophen, furosemide, phenazopyridine HCL)
Contrast media dye (Gastrografin)
Anesthetics (halothane)
Heavy metals (lithium, gold salts, lead)
Industrial (carbon tetrachloride for cleaning)
Environmental (pesticides, snake venom)

61. Medical Surgical, Renal: UTI force fluids

Patient teaching: Drink at least 8 full glasses of water each day to prevent UTI
62. Medical Surgical, Reproductive: Impotence
Impotence also known as erectile dysfunction the inability to achieve or maintain an erection that is firm enough for
sexual intercourse more than 25% of the time. It also involve ejaculation problems, and it has psychological and organic
issues. Factors that interfere with the mechanisms of penile erection will cause erectile dysfunction like:

Condition that impairs blood supply to the penis like impairs pathology of the nervous system or hormonal supply or
impairs psychosocial responses.

Anxiety and depression

Organic causes include diabetes mellitus and other endocrine disorders, and disorder of urinary tract,

Chronic illness such as sickle cell anemia, hypertension, cardiovascular disease, liver disease and cancer.

Medications and drugs and alcohol abuse

Antihypertensive drugs, diuretics, tranquilizers, and medications used to prevent GERD

Anti-Parkinson medications can enhance sexual desire but not the ability to perform.
63. Medical Surgical, Respiratory: COPD risk

Includes 2 diseases: emphysema and chronic bronchitis

Exposure to air pollution and occupational exposures
Cigarette Smoker
Genetic susceptibility to the destruction of Alpha-antitrypsin (AAT), a serum protein which inhibits the activity of
enzyme elastase, which tends to breakdown lung tissue. In the absence of AAT, lung tissue is more easily destroyed
by the enzyme.

64. Medical Surgical, Respiratory: medication administration

Check the medication prescription
Compare the clients medication prescription with all the medications that the client was previously taking (medication

Ask the client about the history of allergies

Determine the clients current condition and the purpose of the prescribed medication or intravenous solution
Determine the clients understanding regarding the purpose of the prescribed medication or intravenous solution.
Plan to teach the client about the medication and about self-administration at home
Identify and address social, cultural, and religious concerns that the client may have about taking the medication.
Determine the need for conversion when preparing a dose of medication for administration to the client.
Check the six rights; right medication, right dose, right patient, right route, right time, and right documentation.
Check the clients vital signs before administering the medication.
Identify any food or medication interactions before administering the medication
Document the administration of the prescribed therapy and clients response to the therapy.
65. Medical Surgical, Respiratory: nasal cannula
Nasal Cannula (Nasal Prongs)
A nasal cannula is used at flow rates of 1 to 6 L/min, providing approximate oxygen concentrations of 24% (at 1
L/min) to 44% (at 6L/min)
Flow rates higher than 6L/min do not significantly increase oxygenation because the anatomical reserve or dead
space (oral and nasal cavities is full)
A nasal cannula is used for the client with chronic airflow limitation and for long term oxygen use.
Effective oxygen concentration can be delivered to nose breathers and mouth breathers with the use of nasal
A client who is hypoxemic and has chronic hypercapnia requires low levels of oxygen delivery at 1 to 2 L/min because
a low arterial oxygen level is the clients primary drive for breathing.

66. Medical Surgical, Respiratory: suctioning

Suctioning is a sterile procedure that involves the removal of respiratory secretions that accumulate in the tracheobronchial
airway when the client is unable to expectorate secretions; performed to maintain a patent airway.

67. Pathophysiology, Cardiovascular, Physical Assessment: Locate heart sounds

Heart sounds will be located at or close to the fifth intercostal space at the midclavicular line
S1 is the lub sound and S2 is the dub sound.
S1 is heard as the AV valves close and is heard loudest at the apex of the heart
S2 is heard when the semilunar valves close and is heard loudest at the base of the heart.
S3 is heard if ventricular wall compliance is decreased and structures in the ventricular wall vibrate; this can occur in
the conditions such as congestive heart failure or valvular regurgitation. However S3 sound may be normal in
individuals younger than 30 years.
S4 sound may be heard on atrial systole if resistance to ventricular filling is present, this is an abnormal finding, and
the causes include cardiac hypertrophy, disease, or injury to the ventricular wall.

68. Pathophysiology, Endocrine: Adrenal glands



Adrenal glands are located on the anterior upper surface of each kidney; each is composed of the cortex and the
medulla. It regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein metabolism; influences
the development of sexual characteristics; and sustains the fight or flight.
Adrenal cortex the outer shell of adrenal gland. It synthesizes glucocorticoids and mineralocorticoids; secretes
small amounts of sex hormones (i.e. androgens, estrogens)
Adrenal medulla the inner core of adrenal gland. It works as part of the sympathetic nervous system; produces
epinephrine and norepinephrine.

69. Pathophysiology, GI: hepatic, liver, exocrine gland

70. Pathophysiology, Physical Assessment

Physical Assessment physical data collection usually begins with measuring the patients blood pressure, pulse,
respiration, temperature, weight and height. Accuracy is essential. Data collection correlates current readings with the patients
current clinical status, and with medical care that has been provided. Such data yield significant information about the patients
condition and response to medication and other treatments. Complete assessment are performed daily.

71. ***
72. Pathophysiology, Renal: Micturition

Micturition (voiding) Urine passes from the bladder through the urethra during urination. Pathophysiology are urinary
incontinence (involuntary passing of urine), bladder capacity decreases to as little as 200 mL and frequent emptying is needed
when aging, nocturia (urination during night) and lowered estrogen levels in women results in tissue atrophy in the urethra,
vagina and trigone of bladder which predisposes to infection and incontinence.

73. Pathophysiology, Reproductive, mons pubis

Mons pubis is a rounded mound of fatty tissue that protects the symphysis pubis. The mons pubis is covered with pubic hair.

74. Pathophysiology, Respiratory alveoli

Alveolar ducts and alveoli

Alveolar ducts branch from the respiratory bronchioles.

Alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchange.

Type II alveolar cells in the walls of alveoli secrete surfactant, a phospholipid protein that reduces the surface tension
in the alveoli. Without surfactant the alveoli would collapse.

75. Pathophysiology, Sensory: Eustachian tube

Eustachian tube - connects the middle ear with the throat. It helps equalize pressure in the middle ear.

76. Pathophysiology, Sensory: Iris

Iris the third part of the middle layer of the eyeball; it is the colored portion of the eye and is a doughnut-shaped diaphragm
with the pupil as the central opening. The iris contains two groups of smooth muscles that constrict and dilate the pupil to
regulate the entrance of the light. Muscles in the iris control dilation and constriction of pupil. The changes occur in the eye
with aging is the ability of the iris to dilate decreases, causing difficulty for the older person in going from a bright area into a
darkened area.

77. Pathophysiology, Medical Surgical: Sensory, cataract, lens, opacity



The lens of the eye changes after age 40, gradually losing water and becoming harder. Cataracts may form.
Cataract is opacity of the lens that distorts the image projected onto the retina and that can progress to blindness.
Causes include aging process (senile cataracts), heredity (congenital cataracts). It can also result from another eye
disease (secondary cataracts). Cloudy appearance of lens.
Causes of secondary cataracts include diabetes mellitus, maternal rubella, severe myopia, ultraviolet light exposure
and medications such as corticosteroids.
Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or
adversely affects lifestyle.

Pediatrics, Professional issues: documentation, descriptive documentation

Pediatrics, Professional Issues: documentation, legal ethical EMR
Pediatrics, Professional Issues: legal ethical HIPPA breach
Professional Issues, Medical Surgical: documentation, pressure sore documentation
Professional Issues, Medical Surgical: Leadership, ascites
Psychiatric Mental Health: Depression, grief, communication, death and dying
Psychiatric Mental Health: Fundamentals, anxiety, communications, basic nursing skill, pain, back rub
Psychiatric Mental Health: Professional Issues, Med surgical, depression, grief, cultural, spiritual, client spirituality.