FUNDAMENTALS OF NURSING REVIEWER

 Disease- detectable alternation in normal tissue functions

ASEPSIS AND INFECTION CONTROL  Signs and symptoms – can be occurred
 Asymptomatic/Subclinical – no clinical evidence of disease

 Microorganisms
 Pathogenicity of Pathogen- the ability to produce or cause
Resident flora – is a collective vegation in each area. (it is a normal microorganisms that can cause disease.
microorganism)  Communicable disease – can be transmitted to an individual.
Ex. E-colli (1 part of body area only is affected) (From one person to another person)
Ex. UTI (if its travels to another body area that can cause infection)  Opportunistic pathogen – can cause diseases only in
susceptible individuals.
 Transient flora- microbial species that can be cultured from
body surfaces under certain circumstances. (obstate from that  Asepsis – freedom or absence from diseases causing
area for hours/days) microorganisms.
 Medical asepsis – practices intended to confine specific
 Four major microorganisms cause infections in humans. microorganisms to a specific area (not 100% free from
 Bacteria microorganisms)
 Viruses CLEAN – (absence of microorganisms)
 Fungi these are common resident MO’s DIRTY/SOIL/CONTAMINATED – (presence of
 Parasites microorganism)

 Infections- growth of microorganisms in body tissue where they are  Surgical asepsis – practices that keep an area or object free from
not usually found. microorganisms.
STERILE TECHNIQUE – (to free from all microorganisms)
 FUNDAMENTALS OF NURSING REVIEWER

 MAINTAINING ASEPSIS
 organisms’ mode of transmission determines isolation
precautions
 barrier used to break the chain of infection between the mode
of transmission and susceptible host
 sterile items can be only stored for 1 -2 months
 handwashing not less than 30 seconds
 autoclave – kills all microbes including spores –penetrate
thick linen
 patient in isolation – need sensory stimulation
 soaps and detergents – remove bacteria – lower surface
tension of water and act as emulsifying agents
 antiseptic – inhibit growth
 bactericides and disinfectants – destroy pathogens
 exudate – clear protein-rich fluid
 good nutrition - crucial in the healing of pressure ulcers
 FUNDAMENTALS OF NURSING REVIEWER

Most common
 Types of Infections Causes
microorganisms
1. Colonization – the process by which microorganism strains
URINARY TRACT INFECTION Improper catheterization technique
become resident flora.
 Escherichia colli contamination of closed drainage
2. Local infection - limited to specific body parts where  Enterococcus species system
microorganisms remain.  Pseudomonas aeruginosa Inadequate hand hygiene
3. Systematic infection – microorganisms spread and damage
different parts of the body.
4. Bacteremia (Septicemia) – the culture of the individual’s blood
reveals a microorganism. SURGICAL SITES
 HEALTHCARE – ASSOCIATED INFECTIONS or Ais  Staphylococcus aureus
(Including methicillin-resistant Inadequate hand hygiene
(In hospital setting// nosocomial infections) strains; MRSA)
- an infection that originates in any healthcare setting.  Enterococcus aureus
(including vancomycin- Improper dressing change technique
 ENDOGENOUS (ENDO means inside of the patient) infection resistant strains VRE
originates from the client themselves pseudomonas aeruginosa
 EXOGENOUS (EXO means outside of the patient) -from the BLOODSTREAM
hospital environment and hospital personnel. (Other causes of  Coagulase-negative Inadequate hand hygiene
infections) staphylococci
 Staphylococcus aureus Improper intravenous fluid, tubing,
- infections that occur as a result of being under the care of healthcare  Enterococcus species and site care technique
professionals. PNEUMONIA
- high-risk individuals include individuals that are poorly nourished,  Staphylococcus aureus Inadequate hand hygiene
older, and have weakened immune systems or multiple illnesses.  Pseudomonas aeruginosa Improper suctioning technique
 Enterobacter species
 FUNDAMENTALS OF NURSING REVIEWER
 BEST WAY TO BREAK THE CHAIN OF INFECTION
 CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION Infectious agent (bacteria, viruses, etc.)
(CLABSI) Reservoir
-a serious infection that occurs when microorganisms enter the
bloodstream through a large catheter placed in larger veins.
 CATHETER-ASSOCIATED URINARY TRACT INFECTION “WASH HANDS” Portal exit
(CAUTI) Soap and water only
-any infection involving any part of the urinary system (urethra,
bladder, ureters, or kidneys acquire in the hospital) HOST Portal entry Mode of transmission
 SURGICAL SITE INFECTION (SSI) (ex: airborne, contact, droplet)
- an infection that occurs after surgery in the part of the body
where the surgery took place.
 TRANSMISSION BASED PRECAUTIONS
 VENTILATOR-ASSOCIATED PNEUMONIA (VAP)
-a lung infection that develops in a person on a machine used to
AIRBORNE
help the client breathe.
M- MEASLES
T- TUBERCULOSIS
V- VARICELLA
 CHAIN OF INFECTION
 Invasion – a disease-causing agent like bacteria, viruses, yeast,
Private room- negative pressure with 6-12 air changes/hr
fungi, or other microorganisms.
MASK or N95 mask – Health worker wears
 Multiplies – reacts with host tissue to cause a reaction and disease.
 FUNDAMENTALS OF NURSING REVIEWER

CONTACT SKIN INFECTION

DROPLET M-MULTIDRUG RESISTANT ORGANISM V- VARICELLA ZOSTER

S- SEPSIS R- RESPIRATORY INFECTIONS C- CULTANEOUS DIPHTHERIA
S- SCARLET FEVER S- SKIN INFECTIONS H- HERPES SIMPLEX
S- STREPTOCOCCAL
P- PARVOVIRUS B19 W- WOUND INFECTIONS I- IMPETIGO
P- PNEUMONIA E- ENTERIC INFECTIONS P- PEDICULOSIS
P- PERTUSSIS (CLOSTRIDIUM DIFFICILE)
AN- ADENOVIRUS
I INFLUENZA E- EYE INFECTION (CONJUNCTIVITIS) S- SCABIES
D- DIPTHENIA
E- EPIGLOTTITIS
Patient transport is limited and disinfection of the room is prioritized.
R- RUBELLA
M- MUMPS
M- MENINGITIS
M- MYCOPLASMA OR MENINGEAL PNEUMONIA

Private room or cohort

Patient is encouraged to wear a mask.
FUNDAMENTALS OF NURSING REVIEWER

PRINCIPLES OF MEDICATION ADMINISTRATION

I - “Six Rights” of drug administration

1. The Right Medication – when administering medications, the nurse

compares the label of the medication container with medication form.
The nurse does this 3 times:
a. Before removing the container from the drawer or shelf
b. As the amount of medication ordered is removed from the
container
c. Before returning the container to the storage
2. Right Dose –when performing medication calculation or conversions,
the nurse should have another
qualified nurse check the calculated dose
3. Right Client – an important step in administering medication safely is
being sure the medication is
given to the right client.
a. To identify the client correctly:
b. The nurse checks the medication administration form against the
client’s identification bracelet and asks the client to state his or
her name to ensure the client’s identification bracelet has the
correct information.
4. RIGHT ROUTE – if a prescriber’s order does not designate a route of
administration, the nurse consult the prescriber. Likewise, if the specified
route is not recommended, the nurse should alert the prescriber
immediately.
5. RIGHT TIME
 FUNDAMENTALS OF NURSING REVIEWER
a. the nurse must know why a medication is ordered for certain e. To received labeled medications safely without discomfort in
times of the day and whether the accordance with the six rights of medication administration
time schedule can be altered f. To receive appropriate supportive therapy in relation to medication
b. each institution has are commended time schedule for therapy
medications ordered at frequent interval g. To not receive unnecessary medications
c. Medication that must act at certain times are given priority (e.g
insulin should be given at a II – Practice Asepsis – wash hand before and after preparing the
precise interval before a meal) medication to reduce transfer of microorganisms.
6. RIGHT DOCUMENTATION –Documentation is an important part III – Nurse who administer the medications are responsible for their own
of safe medication administration action. Question any order that you considered incorrect (may be unclear
a. The documentation for the medication should clearly reflect the or appropriate)
client’s name, the name of the ordered medication,the time, dose, IV – Be knowledgeable about the medication that you administer
route and frequency
b. Sign medication sheet immediately after administration of the “A FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION
drug IS: “NEVER ADMINISTER AN UNFAMILIAR MEDICATION”

V – Keep the Narcotics in a locked place.

CLIENT’S RIGHT RELATED TO MEDICATION VI– Use only medications that are in clearly labeled containers.
ADMINISTRATION Relabeling of drugs are the responsibility of the pharmacist.
VII – Return liquid that are cloudy in color to the pharmacy.
A client has the following rights: VIII – Before administering medication, identify the client correctly
a. To be informed of the medication’s name, purpose, action, and IX – Do not leave the medication at the bedside. Stay with the client until
potential undesired effects. he actually takes the medications.
b. To refuse a medication regardless of the consequences X – The nurse who prepares the drug administers it.. Only the nurse
c. To have a qualified nurses or physicians assess medication history, prepares the drug knows what the drug is. Do not accept endorsement of
including allergies medication.
d. To be properly advised of the experimental nature of medication
therapy and to give written consent for its use XI – If the client vomits after taking the medication, report this to the
nurse in-charge or physician.
 FUNDAMENTALS OF NURSING REVIEWER
XII – Preoperative medications are usually discontinued during the d. Suspension: water-based liquid medication. Shake bottle before
postoperative period unless ordered to be continued. use of medication to properly mix it.
XIII- When a medication is omitted for any reason, record the fact e. Emulsion: oil-based liquid medication
together with the reason. f. Elixir: alcohol-based liquid medication. After administration of
XIV – When the medication error is made, report it immediately to the elixir, allow 30 minutes to elapse before giving water. This allows
nurse in-charge or physician. To implement necessary measures maximum absorption of the medication.
immediately. This may prevent any adverse effects of the drug.
“NEVER CRUSH ENTERIC-COATED OR SUSTAINED
MEDICATION ADMINISTRATION RELEASE TABLET”
Crushing enteric-coated tablets – allows the irrigating medication to
1. Oral administration come in contact with the oral or gastric mucosa, resulting in mucositis or
Advantages gastric irritation.
a. The easiest and most desirable way to administer medication Crushing sustained-released medication – allows all the medication to
b. Most convenient be absorbed at the same time, resulting in a higher-than-expected initial
c. Safe, does not break skin barrier level of medication and a shorter than expected duration of action
d. Usually less expensive 2. SUBLINGUAL
Disadvantages a. A drug that is placed under the tongue, where it dissolves.
a. Inappropriate if client cannot swallow and if GIT has reduced b. When the medication is in capsule and ordered sublingually, the
motility fluid must be aspirated from the capsule and placed under the
b. Inappropriate for clients with nausea and vomiting tongue.
c. A drug may have an unpleasant taste c. A medication given by the sublingual route should not be
d. Drugs may discolor the teeth swallowed, or desire effects will not be achieved
e. A drug may irritate the gastric mucosa Advantages:
f. Drugs may be aspirated by seriously ill patients. a. Same as oral
Drug Forms for Oral Administration b. Drug is rapidly absorbed in the bloodstream
a. Solid: tablet, capsule, pill, powder Disadvantages
b. Liquid: syrup, suspension, emulsion, elixir, milk, or other alkaline a. If swallowed, drug may be inactivated by gastric juices.
substances. b. Drug must remain under the tongue until dissolved and absorbed
c. Syrup: sugar-based liquid medication 3. BUCCAL
 FUNDAMENTALS OF NURSING REVIEWER
a. A medication is held in the mouth against the mucous membranes e. Apply only thin layer of medication to prevent systemic
of the cheek until the drug dissolves. absorption.
b. The medication should not be chewed, swallowed, or placed under 2. Opthalmic - includes instillation and irrigation
the tongue (e.g sustained release nitroglycerine, a. Instillation – to provide an eye medication that the client requires.
opiates,antiemetics, tranquilizer, sedatives) b. Irrigation – To clear the eye of noxious or other foreign materials.
c. Client should be taught to alternate the cheeks with each c. Position the client either sitting or lying.
subsequent dose to avoid mucosal irritation d. Use sterile technique
e. Clean the eyelid and eyelashes with sterile cotton balls moistened
Advantages: with sterile normal saline from the inner to the outer canthus
a. Same as oral f. Instill eye drops into lower conjunctival sac.
b. Drug can be administered for local effect g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if
c. Ensures greater potency because drug directly enters the blood and additional drops need to be administered. This is for proper
bypass the liver absorption of the medication.
h. Avoid dropping a solution onto the cornea directly, because it
Disadvantages: causes discomfort.
 If swallowed, drug may be inactivated by gastric juice i. Instruct the client to close the eyes gently. Shutting the eyes tightly
causes spillage of the medication.
5. TOPICAL – Application of medication to a circumscribed area of j. For liquid eye medication, press firmly on the nasolacrimal duct
the body. (inner cantus) for at least 30 seconds to prevent systemic
absorption of the medication.
1. Dermatologic – includes lotions, liniment and ointments, powder. 3. Otic
a. Before application, clean the skin thoroughly by washing the area Instillation – to remove cerumen or pus or to remove foreign body
gently with soap and water, soaking an involved site, or locally a. Warm the solution at room temperature or body temperature,
debriding tissue. failure to do so may cause vertigo, dizziness, nausea and pain.
b. Use surgical asepsis when open wound is present b. Have the client assume a side-lying position ( if not
c. Remove previous application before the next application contraindicated) with ear to be treated facing up.
d. Use gloves when applying the medication over a large surface. (e.g c. Perform hand hygiene. Apply gloves if drainage is present.
large area of burns) d. Straighten the ear canal:
 0-3 years old: pull the pinna downward and backward
 FUNDAMENTALS OF NURSING REVIEWER
 Older than 3 years old: pull the pinna upward and backward medication more accurately into the bronchial tree rather than
e. Instill eardrops on the side of the auditory canal to allow the drops being trapped in the oropharynx then swallowed
to flow in and continue to adjust to body temperature d. Instruct the client to hold breath for 10 seconds. To enhance
e. Press gently bur firmly a few times on the tragus of the ear to assist complete absorption of the medication.
the flow of medication into the ear canal. e. If bronchodilator, administer a maximum of 2 puffs, for at least 30
e. Ask the client to remain in side lying position for about 5 minutes second interval. Administer bronchodilator before other inhaled
e. At times the MD will order insertion of cotton puff into outermost medication. This opens airway and promotes greater absorption of
part of the canal. Do not press cotton into the canal. Remove cotton the medication.
after 15 minutes. f. Wait at least 1 minute before administration of the second dose or
4. Nasal – Nasal instillations usually are instilled for their astringent inhalation of a different medication by MDI
effects (to shrink swollen mucous membrane), to loosen secretions and g. Instruct client to rinse mouth, if steroid had been administered.
facilitate drainage or to treat infections of the nasal cavity or sinuses. This is to prevent fungal infection.
Decongestants, steroids, calcitonin. 6. Vaginal – drug forms: tablet liquid (douches). Jelly, foam and
a. Have the client blow the nose prior to nasal instillation suppository.
b. Assume a back lying position, or sit up and lean head back. a. Close room or curtain to provide privacy.
c. Elevate the nares slightly by pressing the thumb against the client’s b. Assist client to lie in dorsal recumbent position to provide easy
tip of the nose. While the client inhales, squeeze the bottle. access and good exposure of vaginal canal, also allows suppository
d. Keep head tilted backward for 5 minutes after instillation of nasal to dissolve without escaping through orifice.
drops. c. Use applicator or sterile gloves for vaginal administration of
e. When the medication is used on a daily basis, alternate nares to medications.
prevent irritations Vaginal Irrigation – is the washing of the vagina by a liquid at low
5. Inhalation – use of nebulizer, metered-dose inhaler pressure. It is also called douche.
a. Simi or high-fowler’s position or standing position. To enhance a. Empty the bladder before the procedure
full chest expansion allowing deeper inhalation of the medication b. Position the client on her back with the hips higher than the
b. Shake the canister several times. To mix the medication and ensure shoulder (use bedpan)
uniform dosage delivery c. Irrigating container should be 30 cm (12 inches) above
c. Position the mouthpiece 1 to 2 inches from the client’s open d. Ask the client to remain in bed for 5-10 minute following
mouth. As the client starts inhaling, press the canister down to administration of vaginal suppository, cream, foam, jelly or
release one dose of the medication. This allows delivery of the irrigation.
 FUNDAMENTALS OF NURSING REVIEWER
7. RECTAL – can be use when the drug has objectionable taste or odor.  Scapular areas of the upper back
a. Need to be refrigerated so as not to soften.  Ventrogluteal
b. Apply disposable gloves.  Dorsogluteal
c. Have the client lie on left side and ask to take slow deep breaths a. Only small doses of medication should be injected via SC route.
through mouth and relax anal sphincter. b. Rotate site of injection to minimize tissue damage.
d. Retract buttocks gently through the anus, past internal sphincter c. Needle length and gauge are the same as for ID injections
and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in d. Use 5/8 needle for adults when the injection is to administer at 45
children and infants. May need to apply gentle pressure to hold degree angle; ½ is use at a 90 degree angle.
buttocks together momentarily. e. For thin patients: 45 degree angle of needle
e. Discard gloves to proper receptacle and perform hand washing. f. For obese patient: 90 degree angle of needle
f. Client must remain on side for 20 minute after insertion to promote g. For heparin injection:
adequate absorption of the medication. h. do not aspirate.
8. PARENTERAL- administration of medication by needle. i. Do not massage the injection site to prevent hematoma formation
Intradermal – under the epidermis. j. For insulin injection:
a. The site are the inner lower arm, upper chest and back, and beneath k. Do not massage to prevent rapid absorption which may result to
the scapula. hypoglycemic reaction.
b. Indicated for allergy and tuberculin testing and for vaccinations. l. Always inject insulin at 90 degrees angle to administer the
c. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½” medication in the pocket between the subcutaneous and muscle
d. Needle at 10–15 degree angle; bevel up. layer. Adjust the length of the needle depending on the size of the
e. Inject a small amount of drug slowly over 3 to 5 seconds to form a client.
wheal or bleb. m. For other medications, aspirate before injection of medication to
f. Do not massage the site of injection. To prevent irritation of the check if the blood vessel had been hit. If blood appears on pulling
site, and to prevent absorption of the drug into the subcutaneous. back of the plunger of the syringe, remove the needle and discard
Subcutaneous – vaccines, heparin, preoperative medication, insulin, the medication and equipment.
narcotics. Intramuscular
The site: a. Needle length is 1”, 1 ½”, 2” to reach the muscle layer
 outer aspect of the upper arms b. Clean the injection site with alcoholized cotton ball to reduce
 anterior aspect of the thighs microorganisms in the area.
 Abdomen
 FUNDAMENTALS OF NURSING REVIEWER
c. Inject the medication slowly to allow the tissue to accommodate Vastus Lateralis
volume. a. Recommended site of injection for infant
Sites: b. Located at the middle third of the anterior lateral aspect of the
Ventrogluteal site thigh.
a. The area contains no large nerves, or blood vessels and less fat. It c. Assume back-lying or sitting position.
is farther from the rectal area, so it less contaminated. Rectus femoris site –located at the middle third, anterior aspect of thigh.
b. Position the client in prone or side-lying. Deltoid site
c. When in prone position, curl the toes inward. a. Not used often for IM injection because it is relatively small
d. When side-lying position, flex the knee and hip. These ensure muscle and is very close to the radial nerve and radial artery.
relaxation of gluteus muscles and minimize discomfort during b. To locate the site, palpate the lower edge of the acromion process
injection. and the midpoint on the lateral aspect of the arm that is in line with
e. To locate the site, place the heel of the hand over the greater the axilla. This is approximately 5 cm (2 in) or 2 to 3
trochanter, point the index finger toward the anterior superior iliac fingerbreadths below the acromion process.
spine, and then abduct the middle (third) finger. The triangle IM injection – Z tract injection
formed by the index finger, the third finger and the crest of the a. Used for parenteral iron preparation. To seal the drug deep into the
ilium is the site. muscles and prevent permanent staining of the skin.
Dorsolateral site b. Retract the skin laterally, inject the medication slowly. Hold
a. Position the client similar to the ventrogluteal site retraction of skin until the needle is withdrawn
b. The site should not be use in infant under 3 years because the c. Do not massage the site of injection to prevent leakage into the
gluteal muscles are not well developed yet. subcutaneous.
c. To locate the site, the nurse draw an imaginary line from the GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION
greater trochanter to the posterior superior iliac spine. The OF MEDICATIONS
injection site id lateral and superior to this line. 1. Check doctor’s order.
d. Another method of locating this site is to imaginary divide the 2. Check the expiration for medication – drug potency may increase or
buttock into four quadrants. The upper most quadrant is the site of decrease if outdated.
injection. Palpate the crest of the ilium to ensure that the site is 3. Observe verbal and non-verbal responses toward receiving injection.
high enough. Injection can be painful. client may have anxiety, which can increase
e. Avoid hitting the sciatic nerve, major blood vessel or bone by the pain.
locating the site properly. 4. Practice asepsis to prevent infection. Apply disposable gloves.
 FUNDAMENTALS OF NURSING REVIEWER
5. Use appropriate needle size. To minimize tissue injury. 2. By injection of a bolus, or small volume, or medication through an
6. Plot the site of injection properly. To prevent hitting nerves, blood existing intravenous infusion line or intermittent venous access
vessels, bones. (heparin or saline lock)
7. Use separate needles for aspiration and injection of medications to 3. By “piggyback” infusion of a solution containing the prescribed
prevent tissue irritation. medication and a small volume of IV fluid through an existing IV
8. Introduce air into the vial before aspiration. To create a positive line.
pressure within the vial and allow easy withdrawal of the medication. a. Most rapid route of absorption of medications.
9. Allow a small air bubble (0.2 ml) in the syringe to push the b. Predictable, therapeutic blood levels of medication can be obtained.
medication that may remain. c. The route can be used for clients with compromised gastrointestinal
10.Introduce the needle in quick thrust to lessen discomfort. function or peripheral circulation.
11.Either spread or pinch muscle when introducing the medication. d. Large dose of medications can be administered by this route.
Depending on the size of the client. e. The nurse must closely observe the client for symptoms of adverse
12.Minimized discomfort by applying cold compress over the injection reactions.
site before introduction of medicati0n to numb nerve endings. f. The nurse should double-check the six rights of safe medication.
13.Aspirate before the introduction of medication. To check if blood g. If the medication has an antidote, it must be available during
vessel had been hit. administration.
14.Support the tissue with cotton swabs before the withdrawal of the h. When administering potent medications, the nurse assesses vital signs
needle. To prevent the discomfort of pulling tissues as the needle is before, during and after infusion.
withdrawn.
15.Massage the site of injection to haste absorption. Nursing Interventions in IV Infusion
16.Apply pressure at the site for a few minutes. To prevent bleeding. a. Verify the doctor’s order
17.Evaluate the effectiveness of the procedure and make relevant b. Know the type, amount, and indication of IV therapy.
documentation. c. Practice strict asepsis.
Intravenous d. Inform the client and explain the purpose of IV therapy to alleviate
The nurse administers medication intravenously by the following client’s anxiety.
method: e. Prime IV tubing to expel air. This will prevent air embolism.
1. As mixture within large volumes of IV fluids. f. Clean the insertion site of IV needle from center to the periphery
with alcoholized cotton ball to prevent infection.
g. Shave the area of needle insertion if hairy.
 FUNDAMENTALS OF NURSING REVIEWER
h. Change the IV tubing every 72 hours. To prevent contamination.  Apply warm compress. This will absorb edema fluids and
i. Change IV needle insertion site every 72 hours to prevent reduce swelling.
thrombophlebitis. 2. Circulatory Overload -Results from administration of excessive
j. Regulate IV every 15-20 minutes. To ensure administration of volume of IV fluids.
proper volume of IV fluid as Assessment:
ordered.  Headache
k. Observe for potential complications.  Flushed skin
Types of IV Fluids  Rapid pulse
Isotonic solution – has the same concentration as the body fluid  Increase BP
a. D5 W  Weight gain
b. Na Cl 0.9%  Syncope and faintness
c. plain Ringer’s lactate  Pulmonary edema
d. Plain Normosol M  Increase volume pressure
Hypotonic – has lower concentration than the body fluids.  SOB
a. NaCl 0.3%  Coughing
Hypertonic – has higher concentration than the body fluids.  Tachypnea
a. D10W  shock
b. D50W Nursing Interventions:
c. D5LR  Slow infusion to KVO
d. D5NM  Place patient in high fowler’s position. To enhance breathing
Complication of IV Infusion  Administer diuretic, bronchodilator as ordered
1. Infiltration – the needle is out of nein, and fluids accumulate in the 3. Drug Overload – the patient receives an excessive amount of fluid
subcutaneous tissues. containing drugs.
Assessment: Assessment:
 Pain, swelling, skin is cold at needle site, pallor of the site,  Dizziness
flow rate has decreases or stops.  Shock
Nursing Intervention:  Fainting
 Change the site of needle Nursing Intervention
 Slow infusion to KVO.
 FUNDAMENTALS OF NURSING REVIEWER
 Take vital signs Nursing Intervention
 Notify physician  Do not allow IV bottle to “run dry”
4. Superficial Thrombophlebitis – it is due to o0veruse of a vein,  “Prime” IV tubing before starting infusion.
irritating solution or drugs, clot formation, large bore catheters.  Turn patient to left side in the Trendelenburg position. To allow air
Assessment: to rise in the right side of the heart. This prevent pulmonary
 Pain along the course of vein embolism.
 Vein may feel hard and cordlike 6. Nerve Damage – may result from tying the arm too tightly to the
 Edema and redness at needle insertion site. splint.
 Arm feels warmer than the other arm Assessment
Nursing Intervention:  Numbness of fingers and hands
 Change IV site every 72 hours Nursing Interventions
 Use large veins for irritating fluids.  Massage the are and move shoulder through its ROM
 Stabilize venipuncture at area of flexion.  Instruct the patient to open and close hand several times each hour.
 Apply cold compress immediately to relieve pain and  Physical therapy may be required
inflammation; later with warm compress to stimulate circulation Note: apply splint with the fingers free to move.
and promotion absorption. 7. Speed Shock – may result from administration of IV push medication
 “Do not irrigate the IV because this could push clot into the rapidly.
systemic circulation’  To avoid speed shock, and possible cardiac arrest, give most IV
5. Air Embolism – Air manages to get into the circulatory system; 5 ml push medication over 3 to 5 minutes.
of air or more causes air
embolism.
Assessment:
 Chest, shoulder, or backpain
 Hypotension
 Dyspnea
 Cyanosis
 Tachycardia
 Increase venous pressure
 Loss of consciousness
FUNDAMENTALS OF NURSING REVIEWER

FACTORS AFFECTING RESPIRATION

1. Increased altitude
2. Stress
3. Environment
a. Increase temp = decreased RR
b. Decreased temp = increased RR
c. Mountain climbers bring portable oxygen for high altitudes to
facilitate breathing
4. Exercise
5. Medications
a. Narcotics = decrease RR

ALTERATIONS IN RESPIRATIONS
A. RATE
1. Apnea
 Cessation of breathing
 FUNDAMENTALS OF NURSING REVIEWER
 In newborns, periods of apnea in newborns is considered 2. CHEYNE STOKES
NORMAL  Shallow, fast then labored, deep then episodes of apnea
2. Bradypnea (low RR)  Rapid waxing and waning with periods of apnea
3. Tachypnea (high RR)  E.g. in ICP patients, Drug toxicity patients
3. KAUSSMAUL’S
 Hyperventilation
B. VOLUME  Labored breathing
1. Hyperventilation  Very deep breathing
 Deep rapid respirations  E.g. DKA, severe metabolic acidosis, kidney failure
 CO2 excessively inhaled 4. APNEUSTIC
2. Hypoventilation  Prolonged gasping (inspiration) followed by very short
 Decreased RR and decreased depth expiration
 CO2 excessively retained
PROMOTE OXYGENATION
1. Sit straight and Erect
2. Exercise
3. Breathe through the nose
C. EASE OF EFFORT 4. Breathe in to expand chest fully
1. Dyspnea 5. Avoid smoking
 DOB
6. Eliminate/reduce use of chemicals
2. Orthopnea 7. Support a pollution-free environment

PULSE OXIMETRY
D. RHYTHM
 Measures O2 saturation
1. BIOT’S RESPIRATIONS
 Percentage of Oxygenated Hgb in arterial blood
 Regular, deep followed by apnea
 NORMAL = 95-100%
 Cluster respiration
 91-94% = MILD hypoxia
 Very shallow breathing
 86-90% = MODERATE hypoxia
 E.g. meningitis, severe brain damage
 <85% = SEVERE hypoxia
 FUNDAMENTALS OF NURSING REVIEWER
 <70% = LIFE-THREATENING  LIFE:
 SITES:  Loosens secretions
a. FINGERTIPS  Improve ventilation
b. TOES  Facilitates gas exchange
c. EARLOBE  Expands the collapsed alveoli
d. NOSE BRIDGE  Ball goes up in INHALATION, Ball goes down in EXHALATION
e. FOREHEAD  STEPS:
1. Place UPRIGHT
2. EXHALE comfortably.
3. OPTION 1: HOLD MDI 1-2 INCHES from open mouth
OPTION 2: LIPS TIGHTLY around MOUTHPIECE
 Factors Affecting the Accuracy of Pulse Oximeter: 4. INHALE SLOWLY and DEEPLY through the
1. Nail Polish MOUTHPIECE (2-6 seconds)
 Advise to remove nail polish 5. HOLD FOR 2 SECONDS (gradually increase on every repetition
 Use other sites if patient does not want to remove nail until you reach a maximum of 6 seconds)
polish 6. REMOVE mouthpiece
2. Direct Sunlight 7. EXHALE SLOWLY
 Cover the site with cloth 8. COUGH 2 times
 Avoid sunlit areas 9. REPEAT 5-10 times if ordered.
3. Carbon monoxide poisoning 10.Perform q hour.
 Do not use pulse oximeter!  Do THIS BEFORE MEALS
4. Arterial Disorders (Raynaud’s & Buerger’s Disease)
 Avoid using fingertips and toes
 Use other sites

INCENTIVE SPIROMETRY
 Measures the flow of air inhaled through mouthpiece
 Also called SUSTAINED MAXIMAL INSPIRATION (SMI)
devices
 FUNDAMENTALS OF NURSING REVIEWER
CHEST PHYSIOTHERAPY c. ALTERNATE FLEX AND EXTEND THE WRISTS RAPIDLY
 DEPENDENT NURSING INTERVENTION (needs DOCTOR’s TO SLAP THE CHEST
ORDERS) d. PERCUSS 1-2 MIN/SEGMENT
 CONSIDERATIONS FOR PERFORMING CPT (STEPS):  HAND IS IN C-SHAPE FORM
1. POSTURAL DRAINAGE: DRAINAGE BY GRAVITY  When done correctly produce a hollow popping sound
OF SECRETIONS FROM VARIOUS LUNG SEGMENTS.  Avoid:
 ONLY USE SPECIFIC POSITIONS ON SPECIFIC  Breast
AFFECTED AREAS TO BE DRAINED IN THE  Sternum
PROCEDURE  spinal column
 IF PATIENT FELTS PAIN, STOP THE PROCEDURE  kidneys
 EACH POSITION: 5-20 MINUTES 3. VIBRATION:
 FLOWER LOBES REQUIRE DRAINAGE MOST  VIBRATE ON EXHALATION
FREQUENTLY BECAUSE THE UPPER LOBES  5x in each lung segment
DRAIN BY GRAVITY. A. PLACE HANDS, PALMS DOWN, ON THE CHEST AREA TO
 BEFORE PD: BE DRAINED, ONE HAND OVER THE OTHER
 GIVE BRONCHODILATOR OR B. INHALE DEEPLY AND EXHALE SLOWLY THROUGH THE
NEBULIZATION THERAPY NOSE OR PURSED LIPS
 SCHEDULE: C. EXHALATION: VIBRATE THE HANDS
 2-3 TIMES DAILY 4. DEEP BREATHING + COUGHING
 BEFORE BREAKFAST, BEFORE LUNCH, 5. AUSCULTATE LUNG SOUNDS
LATE AFTERNOON, BEFORE BEDTIME
 AVOID: OXYGEN THERAPY
 HOURS SHORTLY AFTER MEALS
 TIRING AND CAN INDUCE VOMITING
 DEPENDENT NURSING INTERVENTION
2. PERCUSSION: mechanically dislodge tenacious secretions from  Primary care provider specifies: concentration, method of
the bronchial walls delivery, and liter of flow rate.
a. COVER THE AREA WITH A TOWEL OR GOWN  EMERGENCY: RN MAY INITATE therapy, CONTACT
b. BREATHE SLOWLY AND DEEPLY physician after.
 OXYGEN DELIVERY SYSTEMS:
 FUNDAMENTALS OF NURSING REVIEWER
1. NASAL CANNULA
 24-45%
 2-6 L/min 6. FACE TENT
 COMFORTABLE  For BURN patients
 Does not interfere with eating/talking  30-50%
2. SIMPLE FACE MASK  4-8 L/min
 FOR EMERGENCIES
OXYGEN THERAPY PRECAUTIONS:
 40-60%
 5-8 L/min 1. POST NO SMOKING SIGNS
3. PARTIAL REBREATHER 2. STAY AT LEAST 6 FT AWAY FROM AN OPENFLAME
 40-60% 3. DO NOT EXPOSE TO ELECTRICAL APPLIANCES
 6-10 L/min 4. BE SURE TO HAVE A FUNCTIONING SMOKE
 Oxygen reservoir bag allows the client to rebreathe DETECTOR AND FIRE EXTINGUISHER
exhaled air 5. OXYGEN CYLINDER MUST BE SECURED AT ALL
 When inhalation/exhalation, the bag must not be fully TIMES
deflated and fully inflated. 6. AVOID MATERIALS THAT GENERATE STATIC
4. NON-REBREATHER ELECTRICITY (WOOLEN, BLANKETS AND
 90-100% SYNTHETIC FIBERS).
 10-15 L/min 7. COTTON BLANKETS SHOULD BE USED
 HIGHEST CONCENTRATION 8. BE SURE THAT ELETRIC DEVICES ARE ALL
 One-way valve prevents the room air and exhaled air GROUNDED
from re-entering. 9. AVOID USE OF VOLATILE, FLAMMABLE
5. Venturi Mask MATERIALS (OILS, GREASES, ALCOHOL AND
 APPROPRIATE for COPD pts ACETONE)
 24-40% or 50%
 4-10 L/min Guidelines in ET Suctioning:
 MOST ACCURATE CONCENTRATION
 Purpose: Removal of secretions
 Blue: 24% on 4 L/min
 HYPEROXYGENATE before and after.
 Green: 35% on 8 L/min
 FUNDAMENTALS OF NURSING REVIEWER
 INSERT CATHETER into trachea WITHOUT SUCTION. INTERVAL 20-30 SECONDS 20-30 SECONDS 30 SECONDS
 Once RESISTANCE is felt, PULL BACK for 10mm to 1cm O2 SIMPLE FACE SIMPLE FACE MASK HYPER OXYGENATE WITH
MASK 100% O2
 Intermittent, rotating motion of suction catheter
 Total suction time = must not exceed 5 minutes
 Interval between each suction 20-30 seconds
 Assess effectiveness after.
4 D’s TO WARRANT OF SUCTIONING:
1. DYSPNEA
2. DROOLING
3. DECREASED O2 SATURATION
4. DECREASED BREATH SOUNDS

ORO NASO TRACHEO PAIN

PHARYNGEAL PHARYNGEAL STOMY  Subjective
 Best way to know the pain of the patient:
POSITION SEMI-FOWLERS SEMI-FOWLERS SEMI-FOWLERS  INTERVIEW
NECK SLIGHLT HYPER
EXTENDED
LENGTH 3-5 IN 3-5 IN 2-3 IN
LUBRICAN TAP WATER KY JELLY NSS  <6 months (Acute) = Fast Pain
T  >6 months (Chronic)
DURATION 5-10/15 20-30 SECONDS 10 SECONDS  Slow Pain
SECONDS
 Exceeded expected time of healing
 FUNDAMENTALS OF NURSING REVIEWER
 Pain is protective and preventive mechanism - Pain that feels like it's coming from a body part that's no
 ALGOLOGY = study of pain management longer there.
 Pain Threshold
 Amount of pain stimulation required to feel pain.
 Awareness of pain stimulus  PQRST Pain Assessment:
 Pain Tolerance a. Precipitating/Predisposing –WHY?
 Amount of duration of pain  What triggers the pain or what makes it worse?
 Person no longer accepts pain b. Quality – WHAT?
 Types of Pain  Tell me what the pain feels like
a. Radiating Pain  Stabbing (e.g. Angina)
- Pain that travels from the nearby tissues  Crushing (e.g. Myocardial Infarction)
b. Referred Pain  Pounding (e.g. Hypertension)
- The pain you feel in one remote part of your body is  Gnawing (e.g. Peptic Ulcer Disease)
caused by pain or injury in another part of your body.  Knife-like (e.g. AAA, ruptured appendix, ectopic
c. Intractable Pain pregnancy)
- Pain is constant and excruciating c. Region/Radiation – WHERE?
- Type of pain that cannot be controlled with standard  Where else do you feel pain?
medical care. d. Severity – HOW PAINFUL?
d. Cutaneous pain  Does it interfere with ADLs?
 Superficial areas of the body (skin)  How does it rate on a severity scale of 1 to 10?
e. Deep somatic pain  Use of Pain Scale (MOST IMPORTANT)
 Bones, muscles 1. 1-3 = Mild pain
 E.g. bone cancer 2. 4-7 = Moderate pain
f. Malignant pain 3. 8-10 = Severe pain
 Cancer-related pain e. Time – WHEN?
g. Visceral pain  Onset; Frequency
 Body cavity  When did it begin?
h. Phantom Pain  How often does it occur?
 FUNDAMENTALS OF NURSING REVIEWER
Pretended Pain = phantom pain

PAIN MANAGEMENT
A. NON-INVASIVE
1. RELAXATION/DBE
2. REFRAINING EXERCISES
3. DISTRACTION
4. GUIDED IMAGERY
5. HUMOR
6. CUTANEOUS STIMULATION
7. HOT & COLD APPLICATION