Fundamentals Review Notes

NCLEX Test Plan:

 Integrate advanced directives into client plan of care
o Advanced Directives
 Living Will
 Durable Power of Attorney
 DNR
 DNI
 Delegate and supervise care of client provided by others
o Delegation: the person delegating still is responsible for it
 Initiate, evaluate, and updated plan of care
o Nursing Process- ADPIE
 Client rights and responsibilities
 Provide and receive hand off care (report) on assigned clients
o SBAR
 Use approved terminology when documenting care
 Prioritize the delivery of client care based on acuity
o Prioritizations- ABCs; 123; Umbrella
 Safety and Infection Control
o Assess for allergies and intervene as needed
 NKDA
 Latex Allergies
o Assess client care environment
 Culture of Safety
o Promote staff safety
o Protect client from injury
o Properly identify client when providing care
o Follow procedures for handling biohazardous and hazardous materials
o Acknowledge and document practice errors and near misses
o Apply principles of infection prevention
 Hand hygiene
 Aseptic technique
 Isolation
 Sterile technique
 Universal/standard enhanced barrier precautions
o Restraints
 Health Promotion and Maintenance
o Provide care and education for the newborn, infant, and toddler client from birth
to 2 years
o Provide care and education for the adult client ages 18 through 64 years
o Provide care and education for the adult client ages 65 years and over
o Assess client’s readiness to learn, learning preferences, and barriers to learning
 o Educate client about preventative care and health maintenance
recommendations
o Provide targeted screenings assessments
o Educate client about prevention and treatment of high risk health behaviors
o Perform comprehensive health assessment
 Basic Care and Comfort
o Assist client to compensate for a physical or sensory impairment
 Assistive devices
 Positioning
o Perform skin assessment and implement measures to maintain skin integrity
 Turn q2 hours
o Implement measures to promote circulation
 ROM
 Positioning
 Mobilization
o Assess client for pain and intervene as appropriate
o Complementary therapies
o Non-pharmacological comfort measures
o Evaluate client’s nutritional status and intervene as needed
o Provide nutrition through tube feedings
o Evaluate intake and output
o Assess performance of ADLs
o Post-mortem care
o Assess client sleep/rest pattern and intervene as needed
 Reduction of Risk Potential
o Assess and respond to changes and trends in client vital signs
 Normal Vital Signs
o Perform testing (ecg, glucose monitoring)
o Insert, maintain, or remove a NG tube
o Insert, maintain, or remove a urinary catheter
o Apply and/or maintain devices used to promote venous return
 TEDs/SCDs
o Perform focused assessments
o Educate client about treatments and procedures

Fundamentals Review:
 Commonly Used Abbreviations
o https://nurseslabs.com/nursing-abbreviations/
 Do NOT use abbreviations
o U, u
o IU
o Q.D.; WD; q.d; qd
 o Q.O.D.; QOD; q.o.do; qod
o Trailing zero 1.00000
o Lack of leading zero .123
o MS; MS04: MgSO4
 Documentation
o If you didn’t document it, you didn’t do it!!!!!!!
o Include factual subjective and objective data
o Be accurate and concise
o Complete and current
o Organized
o Box 6.13 p. 62
o We document to communicate; provide accurate billing; audit; research
 Legal Requirements for Documentation
o Begin entry with date and time
o If hand written, correct error with single line, error, and initials
o Sign all documentation with name and title
o Documentation should reflect assessments, interventions, and evaluations
o Leave out opinions and criticism
 Subjective Data
o What the patient says
o Support it with objective data
o Patient complains of….
o Pain, nausea; itching; burning; headache; pain scale
 Objective Data:
o What the nurse sees, feels, hears, smells
o Non judgmental
o Patient’s vital signs are…
o Patients bp is; patients pupil reactivity is sluggish; hand grasp diminished
 SOAP
o Subjective Data, Objective Data, Assessment, Plan
 PIE
o Problem, Intervention, Evaluation
 SBAR
o Situation, Background, Assessment, Recommendation
 Verbal and Telephone Orders:
o Try to avoid these, but if necessary remember…
 Have a 2nd nurse listen o telephone prescriptions
 Repeat it back, make sure to include medications name (spell it, if
needed), dosage, time, and route
 Question anything that seems inappropriate
 Make sure the providers signs w/in 24 hours
 Legal and Ethical Review
o Ethical Principles
 Autonomy- right to self determination and making own decision
 Non maleficence- to do no harm
 Beneficence- duty to do good
 Justice- equitable distribution of benefits and tasks
 Veracity- the obligation to tell the truth
 Fidelity- the duty to do what is promised
o Examples of negligence box 6.2 p. 56
o Assault- putting another person in fear of a harmful or offensive contact
 Threatening a patient
 Be careful not to say do this or this ____ will happen
o Battery- intentional touching of another’s body without the person’s consent
 Always ask permission before touching a patient
o Invasion of privacy- violating confidentiality
 Follow HIPAA guidelines
 Don’t share information without a need to know
o False imprisonment- holding a patient against their will
 Not allowing a patient to leave
 Restraining a patient
 AMA- clients have the right to leave, document well, don’t be guilty of
threatening
o Defamation- communication that threatens someone’s reputation
 Libel- written
 Slander- verbal
o How to Comply with HIPPA
 Protect personal health information (PHI)
 Lock computer screens
 don’t leave chart documents laying out
 Watch what you say and who you say it to
o Use an interpreter if unable to communicate with patient properly
o Consents
 legal document that indicates permission
 Types of consents box 6.4
 Informed consent: risks and benefits of surgery or treatment,
consequences of not having surgery, treatment option, healthcare
provider performing procedure
 Can be signed with the next of kin over the phone with a second nurse
witnessing
 Medication that alters cognitive ability makes a patient unable to give
consent
 Informed consent can be waived for urgent medical or surgical
interventions, if within facility policy
 Client can withdraw consent at any time
 o Advanced Directives
 On admission: MUST ask do you have an advanced directive; DOCUMENT
IF THEY HAVE ONE
 Instructional directive- list of medical tx’s the patient chooses to omit or
refuse if unable to make decision or terminally ill
 Durable power of attorney- health care proxy who is appointed to make
healthcare decisions on the client’s behalf
 DNR- client and provider have made the decision not to undergo CPR
 You must offer to get them assistance if they want one
 Isolation/Infection Control
o What is considered infectious material?
 Body Fluids
 https://www.osha.gov/bloodborne-pathogens/hazards#:~:text=Other
%20potentially%20infectious%20materials%20(OPIM)%20means%3A
%20(1),with%20blood%2C%20and%20all%20body
o Reportable Diseases:
 https://www.alabamapublichealth.gov/infectiousdiseases/report.html
o Donning PPE
 Gown
 Mask
 Goggles
 Gloves
o Doffing PPE
 Gloves
 Goggles
 Gown
 Mask
o Review Standard Precautions pg 170
o Airborne:
 Measles, chicken pox, pulmonary tb, Covid-19
 Private room with negative pressure
 Must wear N95
 Client must wear a surgical mask when leaving the room
o Droplet:
 Adenovirus, diphtheria, epiglottitis, flu, meningitis, mump, mycoplasma
pneumonia, parvo, pertussis, rubella, scarlet fever, sepsis, strep
pharyngitis
 Private room
 Surgical mask within 3 feet
 Mask on client when leaving the room
o Contact
 C- Diff; multidrug resistant organisms; RSV; Wound infections; skin
infections; conjunctivitis;
  Private room
 Gloves and gown when in room (must wash hands with soap and water
for c-diff)
 No sharing of equipment
o Reverse (Neutropenic)
 Immunocompromised; low wbc; stem cell transplant; chemotherapy
 Private room
 Mask when leaving the room
o Keep door closed except to enter and exit
 Health Promotion
o Screening/Time Frames
o Routine Physical Exam
 Q1-3 years for females
 Q5 years for males
o Dental Screening
 Q6months
o Tb screening
 Every 2 years (health care workers, immune compromised, and drug
users every years)
o BP screening
 Q 2 years; every year if elevated
o Cholesterol
 Starting at age 20 q5years
o Blood glucose
 Starting at age 45; q3 years
o Vision screening
 <40 q 3-5 years; 40-64 q2 years;
 > 65 annually
o Skin assessment
 20-40 q3years; >40 annually
o Digital rectal exam
 Annually if life expectancy >10 years
o Colorectal
 Fecal occult blood annually age 50-75; colonoscopy q10 years
o Women
 Cervical Cancer Screening (Pap Smear)- 21-65 q3 years (may decrease to
q5 after age 35 if no hx of positive)
 Breast Cancer Screening- 20-39 exam q3 years; age 40 begin annual
mammography
o Men
 Testicular exam- at each routine health care visit starting a puberty
 Prostate-specific antigen- begin at age 50 with each routine health
screening
 Pain Management
o Where is your patient (have pt point; use anatomical terms and landmarks to
describe)
1. What does the pain feel like (quality: sharp, dull, aching, burning, stabbing,
pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting,
sickening, terrifying, torturing, nagging, annoying, intense, unbearable)
2. Rate your pain on a scale of 0 to 10.
3. When did it start, how long does it last, how often does it occur, is it constant or
intermittent (onset, duration, frequency)
4. How does the pain affect your ADLs
5. What other symptoms do you have with the pain (fatigue, depression, nausea,
anxiety)
6. What makes the pain better
7. What makes the pain worse
8. Are you taking anything for the pain?
o Look for cues (facial expressions, grimacing, restlessness, pacing, guarding,
moaning, crying, decreased attention span)
o Vital Sign changes are temporary with acute pain (BP, Pulse, Resp increase)- may
not be a good indicator
o Persistent pain- schedule pain interventions around the clock and supplement
with prns
o Note order may say for mild, moderate, severe pain- you must assess the pain
and treat accordingly
o Nonpharmacological Interventions
 Keep bed linens clean and smooth
 Position to relieve pressure/pain
 TENs unit, heat, cold, therapeutic touch and massage
 Cold for inflammation
 Heat to increase blood flow and reduce stiffness
 Distraction (deep breathing, visitors, games, music)
 Relaxation (meditation, yoga)
 Guided imagery
 Acupuncture/acupressure
 Elevate edematous extremities
 Calculating intake and output
o Important to monitor when fluid or electrolyte imbalances exist
o Measure is ml (1oz= 30mL)
o Intake- liquids (oral fluids, food that liquefies at room temp, IV fluids, flushes,
and meds, enteral feedings, catheter irrigations)
o Output- all liquids (urine, blood, emesis, diarrhea, tube drainage, wound
drainage)
o Weigh at the same time each day, after voiding, and while wearing same type of
clothes
  Daily Weights: 2.2lbs= 1 liter of fluid gained or lost
 Heart Failure patients need daily weights
o Compare 24 hour intake with 24 hour output: should be approximately equal
 Rest and Sleep:
o Common sleep disorders
 Insomnia
 the inability to get an adequate amount of sleep and to feel
rested. Difficulty falling asleep, awakening too early, or not getting
refreshing sleep
 Women and older adults are more prone to insomnia
 Sleep apnea
 >5 breathing cessations lasting longer than 20 second per hour
during sleep, results in decreased O2 sat
 central- brain fails to trigger breathing during sleep
 obstructive- structures in mouth and throat relax and occlude
airway
 Narcolepsy
 sudden attacks of sleep that are often uncontrollable
 Hypersomnolence disorder
 excessive daytime sleepiness that impairs social or vocational
activities and increases risk for accidents or injuries
o Routines are important
o Promote quiet environment
o Perform ADLs and back rub prior to sleep
o CPAP
o OTC (melatonin, velarian, chamomile)
o Meds (benzodiazepine for insomnia)
o Match home routines as much as possible when in the hospital
 Identifying a patient:
o Must use at least 2 patient identified (joint commission)
 Patient’s name
 Medical record number assigned by facility
 Or telephone number
o Never use identifiers
 Room number
o Compare the patient’s identifiers to their armband
o https://www.jointcommission.org/standards/standard-faqs/home-care/
national-patient-safety-goals-npsg/000001545/
o If the ID band is smudged or messed up get another one
 Administering tube feedings (pg 1035-1039)
o When utilized
o Check for residual (usually less than 100mL)
o Hold feeding if bowel sounds are absent
 o Assess tube placement per agency protocol
o Feedings should be room temperature
o Maintain pt. in high fowlers for 30 minutes after feedings
o Continuous feeding- maintain semi-Fowler’s at all times
o Change the feeding container and tubing every 24 hours
o Do not hang more than 4 hours worth of feedings
o Flush with 30-50mL of water or NS after feeding
o Gi tract disturbance; swallowing problems, burns, major trauma, liver or organ
failure, severe malnutrition, >100 mL residual can indicate delayed gastric
emptying and place the client at risk for aspiration (check orders)
o Remember to return residual contents- helps maintain electrolyte imbalances
o Not room temp- diarrhea and cramps
 Health Assessment
o Ensure privacy and comfort
o Types of assessments
 Complete- head to toe, all health history and baseline data
 Focused- focused on a limited or short term problem, such as patient
complaint
 episodic/follow-up- evaluating progress
 Emergency- rapid collection of data for lifesaving measures
 o
o Visual Acuity Test (P. 570)
 Near vision- read printed material under adequate lighting
 Patient wears their glasses during the assessment
 Distant vision- Snellen chart
 Test without lenses first
 Patient stands 20 feet away from the chart and tries to read all
the letters beginning with any line with both eyes open
 The smallest line the patient can read correctly and record
 Use E chart or object chart if unable to read
 Chest Physiotherapy (p. 993-994 Fundamentals)
o external chest wall manipulation using percussion, vibration, and high frequency
chest wall compression to help mobilize pulmonary secretions
o Perform respiratory assessment first
o Be careful with diuretics and anti hypertensives and long term steroid use
o Postural changes are contraindicated with spinal cord injury, increased ICP, or
abdominal aneurysm resection
 o https://www.cff.org/managing-cf/chest-physical-therapy#:~:text=Chest
%20physical%20therapy%20(CPT%20or,breathing%2C%20and%20huffing%20or
%20coughing
o Diuretics and antihypertensives- decrease tolerance to postural changes
o Long term steroid use increases risk for rib fractures and contraindicates use of
vibration
 Delegation:
o https://www.youtube.com/watch?v=11hP8FOywiY
 Patient Positioning
o Fowlers- HOB 45-60
o semi-fowlers - HOB 30
o High fowler's- HOB 90
o Orthopneic- HOB 90 and overbed table
o Lateral- side lying
o Prone- on abdomen, head to side
o Sims- semi prone
o Supine- back with head and shoulders on pillow
o Moving a patient in bed- elevating the head of bed allows the patient o slide
down due to gravity; move patients up in bed
o Turning- protect patient’s skin and prevent other complications of immobility;
use pillows and positioning devices
o Moving out of bed- use transfer boards; lifts; gait belts
o Fowler’s- increases respiratory function
o Lateral- relieves pressures on heels and sacrum; creates pressure on scapula,
ilium, and trochanter
o Prone- helpful for unconscious patient; allows for secretions to drain
o Sims- enema
 o
 Restraints:
o Used for safety only
o must try alternatives first, and must use least restrictive type of restraint to
maintain safety
o Risk associated with restraint use
o All staff must receive training
o Involve family in decision to use restraints
o Health care provider must do a face to face assessment in 24 hour period (60
minutes if restraints are being used for violence)
o Orders must be renewed every 24 hours
o Monitor violent patient every 15 minutes; all others minimum of every 2 hours
o Risk associated with restraint use: pressure injuries; pneumonia; constipation;
incontinence; loss of self-esteem; humiliation; death
o Monitoring: vital signs, skin integrity, nutrition, hydration, circulation, ROM,
hygiene, elimination, cognitive function, psych
o Box 27.12 p. 433 fundamentals book
OTHER:
** PHARM Questions all from PPT
** Fundamentals Questions all from PPT and some from BOOK

Urinary Catheter
 Sterile Technique
 Insertion
o Women position in dorsal recumbent, men in supine with thighs slightly
abducted
o Clean gloves, wash perineal area, discard dirty gloves
o Open kit away from you, place sterile drape under the buttocks, don sterile
gloves, lubricate tip, attach syringe to balloon port, swab sticks to clean area
o Gloved hands must be above waist, never turn back, and 1 inch border is not
sterile
o Women: spread labia and don’t let it go with nondominant hand, with dominant
hand wipe right, left, middle then insert catheter until urine appears
o Men: Grasp at the shaft, dominant hand take swab and cleanse from urethral
meatus down to the base of glans and repeat twice. Advance until urine and
then advanced an additional 2.5- 5cm
o Inflate balloon fully and pull back until resistance is felt; secure tubing to inner
thigh; record type/size, amount of fluid used, characteristics and amount of
urine drained. Specimen collection if appropriate; client’s response and
education complete
 Removal:
o Position in same way as insertion
o Remove securing device
o Insert 10-ml syringe and pull back to deflate balloon
o Explain may feel burning as it is withdrawn, pull slowly and smoothly
o Assess the urinary function by noting the first void after removal and document
the time and amount of voiding for the next 24 hours

Sterile Technique:
 Everything used in the care of the client is free from microorganisms
 Confirm sterility of pack, open pack away from your body and touch only the outside of
the kit, open sterile drape and drop sterile items onto sterile field, all items placed 1.5 in
from edge, don’t reach over the field
 Gloves: grasp folded cuff of first glove with nondominant hand and glove dominant hand
first, place fingers of gloved hand under cuff and glove nondominant hand
 Removal of gloves: grasp glove at cuff edge without touching skin pull off turning wrong
side out and then grasp second glove

NG Tube:
  Position in high-fowlers
 Measure tube from the bridge of the nose to earlobe to xiphoid process and indicate
length with piece of tape
 Have client swallow or drink water
 Lubricate tip with lubricant
 Insert into nasopharynx and advance tube once enters back of throat have them sip
water; if resistance is met slowly rotate and aim the tube downward and toward the
ear; tilt head forwards to aid in insertion
 Obtain x-ray after
 Check residual every 4 hours, before feeding and giving medications. After measuring
put back contents. Withhold feeding if greater than 100 ml. pH needs to be 3.5 or lower
 Warm feedings
 Assess bowel sounds
 Change feeding container and tubing every 24 hours
 Flush tube before and after
 Remove Tube: irrigate tube with 10 ml NS, untape tube from nose, clamp the tube to
prevent drainage, instruct to hold their breath to close epiglottis then withdraw tube
gently

PHARM
 S/S and pick right med
 What are adverse effects