FUNDAMENTALS IN NURSING Never Leave the room!

Never Give false reassurance

PRACTICE
Never Ask Why?
1. “Why do you feel angry when”
THERAPEUTIC COMMUNICATION 2. “Why do you act this way?”
Open Ended Communication are not 3. “Why did you leave your child alone”
simply “yes or no” questions. It requires ASK QUESTIONS
an in depth answer. - Exploring emotions gather more
- What? information
- When? - Restating repeating patient words to
- Why? confirm what you understand
- How? STATING FACTS
Closed Ended Communication stating - Voicing doubt & presenting reality
facts used portray empathy, builds trust & refutes misconceptions or delusions
assess further. Answered by “yes” or “no”. - Suggesting resources or strategies
HOW TO BUILD TRUST WITH PATIENT helps offer guidance
A. Ask & Assess Emotions
1. “Tell me when you started noticing..”
ASEPSIS
2. “Tell me what concerns you have ...”
Asepsis is the absence of disease causing
3. “What are you feeling right now?”
organisms
4. “How are you feeling about your
KINDS OF ASEPTIC TECHNIQUE
Baby?”
1. Medical Asepsis or “clean technique”
B. State Facts
aims at reducing the number of bacteria
1. “You must be very upset after
or organisms.
experiencing this” a. Gloves, hand washing & normal PPE that
2. “I understand you are worried” personal protective equipment used for
3. “You sound very discouraged & giving meds, feeding, taking vital signs, and
scared.” most wound dressings.
4. “We have the vital signs under 2. Surgical Asepsis “sterile technique”
control” aims to eliminate bacteria or organisms.
a. Sterile field - Hospitals & nursing schools
5. “You sound angry. Anger is a normal
take this very seriously. Used for surgical
feeling associated with loss.” procedures, changing catheters, chest tubes,
C. Combination of A & B cervical checks. Working on parts of the
1. “This experience has been body that wouldn’t normally come into
contact with bacteria.
overwhelming for you. What are you
feeling right now?”
VITAL SIGNS
2. “Clients with cancer experience fear
Vital Signs measure various physiological
of dying, tell me about your
status; assess the most basic body
concerns.”
functions. When these values are not zero,
AVOID THE FOLLOWING
they indicate that a person is alive.
- Non-Therapeutic Communication
1. Body temperature (Temp).
Never Offer opinions, advice, or
2. Pulse / Heart rate.
personal experiences
3. Respiration.
“Everything is going to be alright”
4. Blood pressure (BP).
“I’m sure you will do the correct thing”

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WHEN TO ASSESS VITAL SIGNS - The average body temperature of an
1. Upon admission to any healthcare adult is between 36.7 C( 98 F) and 37 C
agency. (98.6 F).
2. Based on agency institutional policy and FACTORS AFFECTING BODY'S HEAT
procedures. PRODUCTION
3. Any time there is a change in the 1. Basal metabolic rate ( BMR) - The
patient’s condition. basal metabolic rate is the rate of
4. Before and after surgical or invasive energy utilization in the body to maintain
diagnostic procedures. essential activities such as breathing.
5. Before and after activity that may BMRs vary with age and sex.
increase risk. 2. Muscle activity - Including shivering,
6. Before and after administering can greatly increase metabolic rate.
medications that affect cardiovascular 3. Thyroxine output - Increased thyroxin
or respiratory functioning. output increases the rate of cellular
metabolism throughout the body.
PHYSIOLOGICAL BASIS OF BODY 4. Epinephrine and sympathetic
TEMPERATURE stimulation, these immediately increase
Body Temperature the balance between the rate of cellular metabolism in many
the heat production due to chemical body tissues.
activities by the body and heat lost from 5. Age - Very young and very old are more
the body through radiation, conduction, sensitive to change in environmental
convection, & vaporization (evaporation). temperature due to decreased
The normal range of the body temperature thermoregulatory controls
is between 36.2 to 37.2 C. 6. Gender - women tend to have more
TYPES OF BODY TEMPERATURE function in body temperature than men
1. Core temperature is the temperature of the increase in progesterone secretion
deep tissues of the body. e.g., cranium, at ovulation increases body
thorax and abdominal cavity. temperature.
- It remains relatively constant (37 C 7. Diurnal variation - body temperature
or 98.6 F). normally changes throughout the day,
- Can only be measured by invasive varying as much as I C ( I.8 F) between
means; placing a temperature probe the early morning and the late afternoon.
into the esophagus, pulmonary 8. Exercise - Hard work or strenuous
artery or urinary bladder. exercise can increase body temperature
- Non-invasive sites such as the to as high as 38.3C to 40 C( 101 to 104
rectum, oral cavity, axilla, temporal F) measured orally.
artery (forehead) and external ALTERATIONS IN BODY TEMPERATURE
auditory canal are accessible and Pyrexia, a body temperature above the
are believed to provide the best usual range.
estimation of the core temperature. - Hyperthermia = fever.
2. Surface temperature, the temperature - A very high temperature, e.g. 41 C (105
of the skin, the subcutaneous tissue and F) is called hyperpyrexia.
fat. It, by contrast, rises and falls in
response to the environmental changes. COMMON TYPES OF FEVERS

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1. Intermittent Fever - during this type of - Possible dehydration.
fever, the body temperature alternates at HYPOTHERMIA
regular intervals between periods of - A core body temperature below the
fever and periods of normal lower limit of normal.
temperatures. - Ability of hypothalamus to regulate
2. Remittent Fever - during this type of temperature
fever, a wide range of temperature SITES FOR ASSESSING BODY
fluctuations occurs over the 2 hour TEMPERATURE
period, all of which are above normal. 1. Orally
3. Relapsing Fever - In a relapsing fever, - 37 °C (3–5 min); Most common way.
short febrile periods of a few days are - Reliable when the thermometer is
interspersed with periods of 1 or 2 days placed posteriorly into the sublingual
of normal temperature. pocket.
4. Constant Fever - during a constant 2. Axillary
fever, the body temperature fluctuates - 36 C° + 0.5 C° (10 min); Safe way
minimally but always remains elevated. - Place the thermometer in the central
CLINICAL SIGNS OF FEVER position and adducting the arm close
1. Onset ( cold or chill stage) to the chest wall.
- Increased heart rate and respiratory - An unreliable site for estimating core
rate and depth. body temperature, there are no main
- Shivering due to increased skeletal blood vessels around the area
muscle tension and contraction. - Add 0.5C° to the actual reading.
- Cold skin due to vasoconstriction. 3. Rectal
- Cyanotic nail beds due to - 37 C°-0.5 C° (2-3 min); Accurate
vasoconstriction. way.
- Complaining of feeling cold. 4. Tympanic membrane.
- Gooseflesh appearance of the skin. - Used to estimate rapid fluctuations
- Rise in body temperature. in core temperature accurately
2. Course because the tympanic membrane is
- Skin feels warm. close to the hypothalamus.
- Increased pulse and respiratory rate. TYPES OF THERMOMETERS
- Increased thirst. 1. Electronic thermometer.
- Mild to severe dehydration. 2. Glass thermometer.
- Drowsiness, restlessness, or 3. Paper thermometer.
delirium and convulsions due to 4. Tympanic membrane thermometer.
irritation of the nerve cells. ALTERATIONS IN THERMOREGULATION
- Loss of appetite with prolonged 1. Heat exhaustion
fever. - An increase in body temperature in
- Malaise, weakness, and aching response to environmental
muscles due to protein breakdown. conditions causes Diaphoresis
3. Abatement stage (profuse perspiration).
- Flushed and warm skin . - Loss of excessive amounts
- Sweating. of water and sodium from
- Decreased shivering. perspiring leads to thirst,

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 nausea, vomiting, - A normal pulse rate for adults is
weakness, and between 60 and 100 beats per
disorientation. minute.
2. Heat stroke - Bradycardia is a heart rate less than
- A critical increase in body 60 beats per minute in an adult.
temperature - Tachycardia is a heart rate in excess
- Confused or delirious and of 100 beats per minute in an adult.
experiences thirst, abdominal 3. Pulse rhythm is the regularity of the
distress, muscle cramps, and visual heartbeat. It describes how evenly the
Disturbances, Dry, hot skin. heart is beating;
3. Hypothermia - Regular (the beats are evenly
- A lower temperature resulting from spaced).
cold weather exposure or artificial - Irregular (the beats are not evenly
induction. spaced).
- Decrease in metabolism leads to - Dysrhythmia (arrhythmia) is an
impaired mental functioning and irregular rhythm caused by an early,
depressed pulse, respiration, and late, or missed heartbeat.
blood pressure; can result in cardiac 4. Pulse volume is a measurement of the
arrest if untreated. strength or amplitude of force exerted by
4. Frostbite the ejected blood against the arterial
- Freezing of the body’s surface areas wall with each contraction.
(earlobes, fingers, and toes) in - It is described as normal (full, easily
extremely low temperatures. palpable).
CONVERSION FORMULAS - Weak (thready and usually rapid)
Fahrenheit to Celsius - Strong (bounding).
- N - 32 x 5/9 PULSE POINTS
Celsius to Fahrenheit 1. Temporal - Accessible ; Used routinely
- N x 9/5 - 32 in infants when radial pulse is
inaccessible.
PULSE 2. Carotid - Accessible ; Used routinely for
Pulse a wave of blood created by infants; During shock or cardiac arrest ;
contraction of the left ventricle when other peripheral pulses are too
of the heart. weak to palpate; also used to assess
Pulse assessment is the measurement cranial circulation.
of a pressure pulsation 3. Brachial - Used in cardiac arrest for
created when the heart contracts and infants ; Assess lower arm circulation,
ejects blood into the aorta. and to auscultate blood pressure.
CHARACTERISTICS OF PULSE 4. Radial - Accessible; used routinely in
1. Pulse quality refers to the ‘‘feel’’ of the adults to assess character of peripheral
pulse, its rhythm and forcefulness. pulse.
2. Pulse rate is an indirect measurement 5. Apical - Used to auscultate heart
of cardiac output obtained by counting sounds and assess apical-radial deficit.
the number of apical or peripheral pulse
waves over a pulse point.

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6. Popliteal - Used to assess circulation to 3. Hypoventilation - is characterized by
legs and to auscultate leg blood shallow respirations.
pressure. 4. Tachypnea - is a respiratory rate
7. Dorsalis Pedis - Used to assess greater than 24 breaths per minute.
circulation to feet. - 24b / min shallow
8. Femoral - Used to assess circulation to 5. Hyperventilation - is characterized by
legs and during cardiac arrest. deep, rapid respirations.
9. Ulnar - Used to assess circulation to the ALTERATIONS IN THE MOVEMENT OF
ulnar side of hand and to perform the THE CHEST
Allen's test. WALL
10. Posterior tibial - Used to assess 1. Costal breathing - occurs when
circulation to feet. external intercostal muscles and the
other accessory muscles are used to
RESPIRATION move the chest upward and outward.
Pulmonary ventilation (breathing) the - Thoracic Breathing
movement of air in and out of the lungs. 2. Diaphragmatic breathing - occurs
Inspiration (inhalation) is the act of when the diaphragm contracts and
breathing in. relaxes as observed by movement of the
Expiration (exhalation) is the act of abdomen.
breathing out. - Abdominal Breathing
ADVENTITIOUS BREATH SOUNDS 3. Dyspnea - refers to difficulty in
1. Crackles - Crackles can sound like salt breathing as observed by labored or
dropped onto a hot pan or like forced respirations through the use of
cellophane being crumpled or like velcro accessory muscles in the chest and
being torn open. neck to breathe.
2. Wheezes - Wheezes are continuous, 4. Apnea - respirations cease for several
coarse, whistling sound(s) produced in seconds. Persistent cessation is called
the respiratory airways during breathing. respiratory arrest.
3. Rhonchi - Rhonchi are continuous low 5. Cheyne-Stokes Respiration - irregular
pitched, rattling lung sounds that often respiration pattern, characterized by
resemble snoring. alternating periods of apnea and
4. Diminished/Absent - Absent or hyperventilation.
decreased sounds can mean: Air or fluid - The respiratory cycle begins with slow,
in or around the lungs (such as shallow breaths that gradually increase
pneumonia, heart failure, and pleural to abnormal depth and rapidity.
effusion). Gradually breathing slows and becomes
CHARACTERISTICS OF NORMAL AND shallower, climaxing in a 10 to 20
ABNORMAL BREATHING SOUNDS seconds period of apnea before
1. Eupnea - refers to easy respirations respiration resumes.
with a normal rate of breaths per minute 6. Kussmaul respiration - respirations are
that is age specific. abnormally deep but regular, similar to
2. Bradypnea - is a respiratory rate of 10 hyperventilation. Characteristics of
or fewer breaths per minute. clients with diabetic ketoacidosis.
- 10 b / min Regular

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7. Orthopnea - respiratory condition in
which a person must sit or stand in order
to breathe deeply or comfortably.

BLOOD PRESSURE
Blood pressure is the force required by
the heart to pump blood from the
ventricles of the heart into the arteries.
It is measured in systolic and diastolic
pressure.
Systolic pressure it is known as the
force to pump blood out
Diastolic pressure it is known as
relaxation period of the heart STERILE TECHNIQUE
pump (ventricles). Sterile Technique performed to
BLOOD PRESSURE ALTERATIONS drastically reduce and eliminate the threat
- Hypertension refers to a systolic blood of bacteria being introduced into patients.
pressure more than 120 mm Hg or 20 to Reduces the risk for post procedure
30 mm Hg more than the client’s normal infections, also called Nosocomial
systolic pressure. infections which means hospital acquired.
- Hypotension refers to a systolic blood PRECAUTIONS
pressure less than 90 mm Hg or 20 to - Gloves - Use when touching blood,
30 mm Hg below the client’s normal body fluids, secretions, excretions,
systolic pressure. contaminated items; for touching
FACTORS INCREASING BLOOD mucous membranes and non-intact skin.
PRESSURE - Gowns - Use during procedures and
1. Age patient care activities when contact of
2. Exercise clothing/exposed skin with blood/body
3. Stress fluids, secretions, or excretions is
4. Obesity anticipated.
5. Sex DROPLET PRECAUTIONS
6. Medication Surgical mask within 3 feet of patient
7. Disease Process S: Scarlet fever, strep
P: Pertussis, parvovirus,
PEDIATRIC VITAL SIGNS I: Influenza
D:Diphtheria
E: Epiglottitis
R: Rubella
M: Mumps, meningitis, mycoplasma,
meningeal pneumonia
AN: Adenovirus

- Pharyngeal Diphtheria

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- Epiglottitis, (caused by Haemophilus - Skin infection impetigo, lice, scabies,
influenzae type b) herpes simplex, chickenpox (airborne
- Flu (contact and droplet) and contact), skin diphtheria, shingles
- Meningococcal Disease: Meningitis (airborne and contact)
- Mumps (infectious parotitis) - Wound infections with excessive
- Mycoplasma Pneumonia drainage or staphylococci
- Parvovirus B19 (erythema infectiosum - Pulmonary infections RSV,
or 5th disease) parainfluenza
- Adenovirus (contact and droplet) - Eye infection conjunctivitis
- Streptococcal pharyngitis
- Rhinovirus DEATH, DYING GRIEF & LOSS
- Scarlet fever SOURCES OF LOSS
- Rubella (German Measles) - Aspect of self Loss of organs, loss of
AIRBORNE PRECAUTIONS independence, loss of a limb
N95 respirator - External objects – Money, house, pets
M: Measles - Familiar environment – Leaving home,
T: TB losing a home Moving to a new place,
V: Varicella Loved ones, divorce or death.
- Chickenpox (varicella) (Airborne and 5 STAGES OF GRIEF
Contact) 1. Denial
- Herpes Zoster (Varicella Zoster) 2. Anger
(disseminated) 3. Bargaining
- Shingles (Airborne and Contact) 4. Depression
CONTACT PRECAUTIONS 5. Acceptance
Gown and gloves for contact with patient or LOSS DEFINED
environment of care (e.g., medical 1. Actual loss – can be recognized by
equipment, environmental surfaces) others (death, divorce).
In some instances these are required for 2. Perceived loss – experienced by a
entering the patient’s environment. person but can not be verified by others
(Loss of freedom when becoming a stay
M: Multidrug resistant organism at home mom),
R: Respiratory infection 3. Anticipatory loss – Experienced before
S: Skin infections the loss has actually occurred (a family
W: Wounds member that is actively dying but has
E: Enteric c-diff not yet passed).
E: Eye infection UNHEALTHY GRIEF
- Medication-Resistant Organisms 1. Unresolved grief – Extended in length
MRSA, VRE. and severity, stages of grief may be the
- Diarrhea infections or of unknown same but the person grieves for an
origin C.diff, norovirus, rotavirus. extended period of time.
- Hepatitis A. (if patient is diapered or 2. Inhibited grief – Normal stages of
incontinent pt) remember it is spread grieving are suppressed
through stool

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3. Exaggerated grief – A person using
dangerous activities to lessen the pain
of grieving.
4. Complicated grief – Grieving period
lasts more than 6 months and leads to
an inability to perform daily activities.
EUTHANASIA
1. Active euthanasia – Actions that bring 2. Lateral Position – Right lateral means
about the client’s death directly, with or the right side of the patient is touching
without the client’s consent. the bed, left lateral indicates the left side
2. Assisted suicide – giving the clients of the patient is touching the bed.
the means to kill themselves if they - Uses – GI issues, and rectal surgery.
request. - Can be right or left sided.
3. Passive euthanasia: withholding life
sustaining therapy. Withdrawal of
extraordinary means of life support.

POSITIONING
Positioning ensures client comfort and
safety, while preventing complications 3. Lithotomy – lying flat on their back with
related to the client's condition, treatment, or knees elevated and hips level, often
procedure. supported by stirrups.
TYPES OF POSITIONING A PATIENT - Uses – Gynecological procedures
and childbirth.
- Most commonly seen in OB.

1. Fowler’s Position – A position in which

the head and trunk are raised 40-90
degrees. 4. Sim’s Position – A position in which the
- Uses – Cardiac issues, SOB, or NG patient lies on his side with his upper leg
tube. flexed and drawn in towards the chest,
- Includes semi fowler's position which and the upper arm flexed at the elbow.
is between 30-40 degrees and high - Uses – Administering enemas,
Fowler's which is 90 degrees. perineal examinations, and for
comfort in pregnancy.
- A prone/lateral.

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5. Prone Position – The patient lies on his
stomach with his back up. The head is
typically turned to one side. 8. Reverse Trendelenburg – Patient is in
- Uses – Drainage of the mouth after the supine position with the head of the
oral or neck surgery. It also allows bed elevated and the foot of the bed
for full flexion of knee and hip joints. down.
- On your tummy. - Uses – Used in surgery to help
promote perfusion in obese patients.
It can also be helpful in treating
venous air embolism and preventing
pulmonary aspiration.
6. Supine Position – A position where the - “Upside Down.”
patient is flat on his back.
- Uses – Used in surgery for OXYGEN
abdominal, facial, and extremity Oxygen saturation is the percentage of
procedures. hemoglobin in the blood that is bound to
- The most natural “at rest” position oxygen, compared to the percentage that
is not bound.
LEVELS OF HYPOXIA
Hypoxemia is defined as a decrease in the
partial pressure of oxygen in the blood.
7. Trendelenburg Position – This position 95-100% – Normal
involves a supine patient and sharply 91-94% – Mild hypoxia
lowering the head of the bed and raising 86-90% – Moderate Hypoxia
the foot. <85% – Severe hypoxia
- Uses – Used to treat hypotension, Brain Mental Status Change
during gynecological and abdominal - Restlessness
hernia surgeries, and for placement - Agitation “irritability”
and removal of central lines. - Confusion
- “Upside Down.” High Vitals Signs
- RR - Tachypnea (over 20 RR)
- HR - Tachycardia (over 100 bpm)
- BP - Hypertension (over 140 sys.)
Hypoxia is defined by reduced level of
tissue oxygenation.
Hypoxemia dominos into hypoxia, as low
oxygen in the blood means low oxygen
delivery to the tissues.

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DEVICES USED

1. Nasal Cannula
- 1 - 6 Liters per minute (LPM) 4. NRB non-rebreather
- 25 - 45% O2 Level - 10 - 15 LPM Medical Emergencies
- Short-term use – low oxygenation - 60 - 100% O2
after surgery Key Points:
- Long-term use – can dry out - Used during carbon monoxide
mucous membranes in the nose, so poisoning
we use humidification for long term - If the reservoir bag is fully
use. deflated on inspiration = Increase
oxygen flow.
Reminder:
- Do not open flutter valves
- Do not tighten face mask straps
first if the reservoir bag is fully
2. Simple Face Mask deflated.
- 6 - 10 LPM
- 40 - 60% O2
- Used in exchange to partial
rebreather & non-rebreather.

5. Venturi Mask
- 4 - 10 FiO2 Most precise oxygen
3. Partial Rebreather delivery device.
- 6 - 10 LPM Memory Trick:
- 35 - 60% - V - Venturi Mask
- Looks very similar to the - V - Very Accurate O2
non-rebreather - Typically used for patients with
- Key difference is the flutter valves on unstable COPD who can not
the sides tolerate changes in oxygen
concentration from other devices.

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 INTAKE & OUTPUT
- Monitored carefully while in
- the hospital
- Weighed daily
- At the same time every day and
wearing the same thing.
- Usually first thing in the morning
after the first void
6. Face Tent - All liquid intake is measured in mLs
- Used facial trauma & burns (1oz=30ml)
- High humidification COMMON DIET TYPES
1. NPO – nothing per oral / nothing by
NUTRITION mouth.
A nutritional assessment is very important - No food or water not even ice chips
because the needs will be different for every - Before surgery “12am midnight”
client. We need to take into account their 2. Clear liquid diet – any liquid that can
religious and cultural needs, illnesses, and be seen through (clear juice, jello, broth,
allergies. Consider how food is presented water)
when cared for in a hospital. 3. Full liquid diet – essentially a clear
BASIC NUTRIENTS liquid diet but add liquid dairy & all other
1. Carbs – break down into glucose for juices
fuel. 4. Pureed – clear and full liquid PLUS
- Simple Carbs: less fiber, FAST sugar pureed meats, eggs, fruits (anything that
level spikes can go in a blender)
- High Glycemic Index (Example: 5. Mechanical soft – clear and full liquid
white bread, white pasta, white PLUS chopped, diced or ground food
bagels) 6. Soft Diet – easy to digest foods that
- Complex Carbs: Most fiber, slow are low in fiber.
steady sugar levels 7. High fiber – beans, veggies, lots of
- Low Glycemic index (Example: whole grains
beans, whole grain bread, 8. Low sodium – no added salt, less than
potatoes). 2g of sodium
2. Fats – provide energy & vitamins 9. Low cholesterol – less than 300mg
(should be no more than 35% of caloric cholesterol
intake) 10. Diabetic – balance of protein and carbs
3. Protein – helps with growth, no added sugar (soda, pasta, white
maintenance, and tissue repair. This is a breads).
big one for healing patients
4. Vitamins – necessary for metabolism
5. Minerals – needed for chemical
reactions in the body
6. Water – critical for cell function and
replaces any fluid lost to sweating,
elimination, and respirations.

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FACTORS AFFECTING NUTRITION PATHOPHYSIOLOGY
1. Age 1. Nociceptors – Pain receptors on nerve
2. Gero considerations or elderly endings that respond selectively to
considerations painful stimuli.
3. Decreased metabolism 2. Nociception – The transmission of pain.
4. Decreased thirst mechanism Chemical substances: some increase
5. Increased need for fiber pain sensitivity some decrease pain
6. Financial constraints (fixed income) sensitivity.
7. Fluids 3. Cox 1 – Mediates prostaglandin
8. Religion formation, platelet formation, provides
gut protection from ulcers.
PAIN MANAGEMENT 4. Cox 2 – Present in inflammation, pain
Pain is very personal - both physical & and fever. Inhibition will reduce
emotional. While everyone experiences symptoms of fever inflammation and
pain, not everyone experiences it in the pain. Inhibits substance P.
same way. Something that may feel very 5. Decrease pain sensation – Endorphins
painful to one person may not feel painful to and enkephalins, act as endogenous
another. opioids.
FACTORS AFFECTING HOW PAIN IS PHARMACOLOGIC TREATMENTS
PERCEIVED 1. Non opioids
1. Ethnic and cultural variables - NSAIDS(Nonsteroidal anti-inflammatory drugs)
2. Developmental Stage Mild pain. Ketorolac, ibuprofen.
3. Environment and Support people - Acetaminophen: Can cause
4. Previous pain experience hepatotoxicity can be given with
TYPES & SOURCES OF PAIN NSAIDs.
1. Acute – Sudden, Severe, Short term. - Ofirmev: IV acetaminophen, newly
- Example: New bruise approved for short term use IV
2. Chronic – Long term, Recurring over an piggyback.
extended time. 2. Opioids
- Example: Back pain - Tramadol
3. Referred – The feeling of pain in one - Tylenol 3
part of the body is caused by pain or - Meperidine
injury in another part of the body. - Propoxyphene with tylenol
- Example: Chest pain from a heart - Oxycodone
attack could trigger pain in the jaw. - Fetanyl
4. Phantom – Pain that feels like it is - Morphine
coming from a body part that is no - Dilaudid
longer there. 3. Others
- Example: Amputations. - PCA pump & PRN medications
- Multi modal: use of one or more drug
- Routine admin: admin around the
clock
- Topical, Local anesthesia &
Intraspinal

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NON-PHARMACOLOGIC TREATMENTS CIRCADIAN RHYTHM
- Cutaneous stimulation – TENS machine The body’s sleep/wake cycle.
- Massage Stages of Sleep:
- Thermal therapies: Heat and cold 1. Stage 1 – Wakefulness to sleep (non
- Distraction REM) The body’s sleep/wake cycle.
- Relaxation Lasts a few minutes Loss of awareness,
- Guided imagery but easily aroused
- Hypnosis 2. Stage 2 –Light sleep (non REM) 10 - 20
- Music therapy minutes; Vitals & metabolism start to
- Alternative therapy – Acupuncture decrease
3. Stage 3 – Deeper sleep (non REM)
REST, SLEEP & STRESS Slow wave or delta sleep; Vitals
Sleep plays a critical role in how the body decrease further
functions. Chronic sleep loss can lead to 4. REM - Rapid Eye Movement Deepest
an increase in risk for high blood pressure, Sleep! (Delta Sleep) Eyes move
obesity, depression, diabetes, and stroke. “rapidly” side to side Vivid dreaming
5. Cognitive Restoration – Slow wave or
Stress can be good & bad. Good when it delta sleep Around 90 minutes after
helps us adapt to changes in our body and falling asleep & reoccurs every 90
the environment, but stress is often bad minutes 20 minute intervals
when chronic or persistent, when there are SLEEP DISORDERS
no periods of rest between stressful 1. Insomnia – Difficulty falling asleep,
occurrences. staying asleep, awakening too early, or
7 SLEEP HYGIENE not feeling rested when getting up.
1. Routine sleep schedule 2. Chronic Insomnia – 3 nights per week
2. Nighttime for more than 3 months ATI will often
3. Daytime ask questions related SAFETY
4. Reduce stimuli in the bedroom 3. Sleep Apnea – Breathing stops for
5. NO naps in the late afternoon & evening more than 10 seconds
6. Hospital Setting 4. Narcolepsy – Sudden “sleep attackss
7. Avoid these 4 - 6 hours before bed SIGNS & SYMPTOMS OF STRESS
- Caffeine (soda, coffee, tea, 1. Aches & pain
chocolate, “hot chocolate”) 2. Chest pain/ tightness
- Nicotine (cigarettes, chewing 3. GI upset
tobacco) 4. Changes in appetite
- Alcohol - “No routine glass of wine at 5. Exhaustion
night” 6. Trouble sleeping
- Exercise & strenuous activity 7. Decreased immunity
- Going to bed hungry
- Spicy food; Large meals or snack
right before bed

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 - Surgical – Excision/ removal of eschar
WOUND CARE: WET TO DRY and necrotic tissue, via surgery in a
DRESSING CHANGE sterile OR.
Purpose - Tangential – Excising very thin layers of
- To maintain skin integrity necrotic skin until bleeding occurs.
- To prevent infection. - Fascial – Necrotic tissue is removed
- Provide comfort. down to the superficial fascia, usually
- Maintain a moist environment. reserved for very deep and severe
- Remove necrotic tissue if burns.
appropriate.
- Prevent complications associated PRESSURE INJURY
with injury or surgery. Damage to the skin and/or the underlying
ASSESSMENT tissue over a bony prominence, common
- Assess the wound for color, excoriation, with bed-ridden clients who are not turned
odor, exudate or drainage, sinus tracts adequately or from a medical device
to tunneling. (oxygen therapy)
- Assess the client's pain level and Most common areas
administer analgesia 30-45 minutes - Lower back & buttocks (sacrum &
prior to dressing change. coccyx)
- Assess for allergies to latex, adhesive - Heels & ankles
and iodine. - Hip bones
RISKS - Shoulder area & elbows
- Risk for infection. 6 STAGES OF PRESSURE INJURIES
- Risk for impaired tissue integrity.
- Risk for pain.
- Risk for hypersensitivity reaction.
EDUCATION
- Educate the client to practice
- good hygiene.
- Educate the client to ask for analgesia
before the pain becomes unbearable.
- Educate the client on the signs and
symptoms of infection and when to
notify the HCP. 1. Stage 1 = 1 layer of damage (epidermis)
DEBRIDEMENT 2. Stage 2 = 2 layers of damage
- Mechanical – Done during Open wound: affecting both the
hydrotherapy, with washcloths or epidermis & dermis.
sponges to remove eschar. May include 3. Stage 3 = 3 layers of damage
wet to dry dressing changes. (epidermis, dermis, & subcutaneous).
- Painful and may cause bleeding. Full thickness skin loss into the
- Enzymatic – Application of a topical subcutaneous fat; the wound may tunnel
enzyme ointment such as santyl directly under the edges of the wound bed.
on the wound to remove necrotic tissue.

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4. Stage 4 = 4 layers of damage; Extends - Arrange for help prior to moving a client.
all the way down into muscle. - Encourage the client to assist.
5. Eschar (black / brown) dead necrotic - Avoid twisting, keep back, neck, pelvis
tissue bone, or tendon. and feet aligned.
Slough (yellow stringy) - Flex knees, keep feet wide apart.
6. The fatty tissue is injured below the skin - Position yourself close to the client or
(dark purple, & sometimes open wound). object.
CAUSES & RISKS - Use your arms and legs to lift, never
- Bed ridden your back.
- Incontinence - Slide the client towards yourself, use a
- Poor nutrition pull sheet.
- Diabetic neuropathy - Tighten abdomen and glutes before the
- Liver cirrhosis = Low Albumin move.
TREATMENTS - Person bearing the brunt of the load
- Assess skin & document (first 24 hours) coordinates the team on the count of
- Nutrition: Protein & Fluids (2 - 3 L / day) three.
- Urine output 30 mL/hr or Less = Kidney FACTORS THAT AFFECT MOBILITY
Distress - Age
- Turn every 1 - 2 hours - Attitudes and family values
- Albumin (norm: 3.5 - 5.0) - Developmental level
- Monitor: - Neuromuscular disorders and joint
- Stage, Size, Color disorders
- Braden Scale - Lifestyle, stress, environment
Memory Trick - Mental health, medications
- BS – Braden Scale – monitors for risk - Trauma to the musculoskeletal system
factors RANGE OF MOTION
- BS – Broken Skin - The full movement potential of a joint,
usually its range of flexion and
AMBULATION: BODY MECHANICS & extension.
MOBILITY - Active – Patients move their limbs by
Purpose themselves without assistance.
The safe practice of coordinated efforts to - Passive – Therapist or equipment
maintain balance, posture, and body moves the joint through the range of
alignment when ambulating,lifting, and motion with no effort from the patient.
moving clients. ASSESS
VARIABLES THAT LEAD BACK TO - Daily activity levels
INJURY - Endurance
- Uncoordinated lifts - Exercise goals
- Manual lifting - Mobility problems
- Lifting when tired - Physical or mental alterations
- Repetitive lifting, transferring, - External factors
repositioning and moving
- Prolonged standing
BODY MECHANICS ERGONOMICS

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 - Neuromuscular = High
- 1 -Increased DTR (deep tendon
reflexes)
- 2 - Paralysis & paresthesia
(tingling)
- 3 - Muscle weakness (general
feeling of heaviness)
- GI = HIGH PUMPS
- 1 - Diarrhea
- 2 -Hyperactive bowel sounds
CAUSES:
FLUID & ELECTROLYTE BASICS - Renal Failure
1. Potassium (K+) 3.5 - 5.0 - Low Aldosterone
- Pumps the heart !!ADDITION OF SODIUM LOWERS
a. Hypokalemia (below 3.0) POTASSIUM!!
MANIFESTATIONS: 2. Sodium (Na+) 135 - 145
- Heart = Low & Slow Pump Maintains:
- Flat T waves, ST Depressions & - Blood Pressure
Uwave - Blood volume
- Neuromuscular = Low & slow - pH balance
- 1 - Shallow Respirations ; Most a. Hyponatremia (below 135)
DEADLY MANIFESTATIONS:
- 2 - Decreased DTR (deep tendon - Brain = Low & slow
reflexes) - 1 - Headache = Cerebral edema
- 3 - Muscle cramping - 2 - Mental status changes
- GI = Low & slow - 3 - Seizures & Coma
- 1 - Constipation - Muscular = Low & slow
- 2 -HypOactive bowel sounds - Fatigue & muscle cramps
- 3 - Paralytic ileus (paralyzed - Respiratory = Low
intestine) - Respiratory Arrest
- Priority* risk for SBO (Acute small CAUSES:
bowel obstruction) - Sweating
CAUSES: - Excess water intake
- Fluid loss/electrolyte loss (running in the extreme heat)
“Where fluids flow, electrolytes goooo!” - SIADH (Excess ADH)
- Diarrhea, Diuretics, Diet, DKA, - Vomiting & diarrhea,
Aldosterone - Diuretics & Diuresis
b. Hyperkalemia (over 5.0) - Diet low in salt
MANIFESTATIONS: - Low aldosterone
- Heart = HIGH pumps b. Hypernatremia (over 145)
- 1 - Peaked T Waves & ST MANIFESTATIONS:
Elevation - Body = Big & Bloated
- 2 - Severe: V Fib & Cardiac Arrest - 1 - Edema (swollen body)
- 3 - Hypotension & Bradycardia - 2 - Flushed “red & rosey” skin

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 - 3 - Increased muscle tone - Hyporeflexia (decreased DTR)
- 4 - Swollen dry tongue - Lungs & GI = High Mellow
- 5 - Nausea & Vomiting - Depressed respirations
CAUSES: - Hypoactive bowel sounds.
- Low ADH (antidiuretic hormone) CAUSES:
- DI: Diabetes Insipidus - Renal failure
- Rapid respirations - Alcoholism
- Watery diarrhea - Malnourishment
- Loss of thirst 5. Calcium (Ca)
3. Chloride (Cl-) 97 - 107 Keeps the 3 Bs Strong
Maintains: B - Bone
- Blood Pressure B - Blood (clotting)
- Blood volume B - Beats (heart)
- pH balance INVERSE RELATIONSHIP WITH
a. Hypochloremia (below 97) PHOSPHATE
- Nearly Same As Low Sodium a. Hypocalcemia (below 9.0)
- 1 - Fatigue & muscle cramps MANIFESTATIONS:
- 2 - Fever (only difference) - Low Calm = Excited!
b. Hypercholermia (over 107) - 1 - T - Trousseau’s Sign
- Nearly Same As High Sodium Twerking arm when BP cuff on
Tetany: muscle spasms all over
- 1 - Swollen dry tongue
- 2 - Nausea & vomiting - 2 - C - Chvostek’s Sign
Cheeky smile when stroking face
- Metabolic Alkalosis - vomiting
- 3 - Diarrhea
4. Magnesium (Mg+) 1.3 - 2.1
- 4 - Weak B’s
- Mellows the muscles
- Weak Bones = Fractures
a. Hypomagnesemia (below 1.3)
- Weak Blood clotting = r/f bleeding
MANIFESTATIONS:
- Weak Beats = Cardiac
- Heart = Low Mellow
dysrhythmias
- 1 - Torsades de Pointes
CAUSES:
V Fib (ventricular fibrillation)
- DTR = Low Mellow - Excited! - Hypoparathyroidism
-
Hyperreflexia (increased DTR) - Low PTH = Low Calcium
- GI = Low Mellow - Excited! - Renal failure
- Diarrhea - Chronic kidney disease (CKD)
- Hyperactive bowel sounds b. Hypercalcemia (over 10.5)
CAUSES: MANIFESTATIONS:
- Crohn's disease - High Calm
- Celiac disease - 1 - Kidney stones, moans & groans
b. Hypermagnesemia (over 2.1) (Renal Calculi)
MANIFESTATIONS: - 2 - Constipation
- Heart = High Mellow - 3 - Bone pain
- 1 - Heart block - 4 - Severe muscle weakness &
- 2 - Hypotension, bradycardia lethargy.
- DTR = High Mellow

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 CAUSES: OSMOSIS
- Hyperparathyroidism - The movement of fluid from an area of
- High PTH = High Calcium LOWER concentration to an area of
- Cancer HIGHER concentration, leading to
- Immobility equalization.
6. Phosphate (PO43-) 9.0 - 10.5 - Example: Large intestines that absorb
CA HIGH = PHOSPHATE LOW high nutrients & balance fluids.
CA LOW = PHOSPHATE HIGH DIFFUSION
INVERSE RELATIONSHIP WITH - The movement of solutes from an area
CALCIUM of GREATER concentration to an area
a. Hypophosphatemia (below 3.0) of LESSER concentration, leading to
MANIFESTATIONS:: equalization.
- Think High Calcium signs - Example: exchange of O2 & CO2 inside
- 1 - Kidney stones, moans & groans the lungs.
(Renal Calculi) FILTRATION
- 2 - Constipation - The movement of BOTH fluid & solutes
- 3 - Bone Pain from an area of HIGH hydrostatic
- 4 - Severe muscle weakness & pressure to an area of low pressure.
lethargy. - Example: Kidneys that filter the blood.
CAUSES: OSMOLALITY
- Hyperparathyroidism - The concentration of a solution.
High PTH = High Calcium - Higher osmolality = Higher solutes
- Genetics (heavy)
- Cancer - Lower osmolality = Lower solutes (light
b. Hyperphosphatemia (over 4.5) & dilute)
MANIFESTATIONS:: - Examples:
- Think Low Calcium signs - Isotonic solutions – Equal osmolality
- 1 - Trousseau’s & Tetany 270 - 300 millimoles / kg (same as
- 2 - Chvostek's blood concentration)
- 3 - Weak B’s (bones, blood, beats) - Hypertonic solutions – High
CAUSES: osmolality (heavy & thick
- Renal failure TEST TIP concentration) OVER 300 millimoles
- Chronic kidney disease (CKD) / kg
- Hypotonic solutions – Lower
FLUID & ELECTROLYTE osmolality (lighter & dilute) Less than
FACTORS THAT AFFECT FLUID 300 millimoles / kg
BALANCE EDEMA
- Muscle (more fluid) - The swelling of soft tissues as a result of
- Body Fat (less fluid) excess fluid accumulation.
- Gender (men retain more fluid) - Fluid Volume Excess
- Age - Hypervolemia
- FVO (Fluid Volume Overload)

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 FLUID & ELECTROLYTE BASICS
FVD is a common manifestation of
dehydration, where there is a deficit or
decrease in body fluid.
Clients present sucked in, shriveled up &
very weak.
DRY
Dehydration
Deficit of fluid
4 CAUSES DEHYDRATION
- Urination & 3Ds
- DI (Diabetes Insipidus)
- DKA (Diabetic Ketoacidosis)
- Increased sugar concentration in the blood
(hyperglycemia)
- Typically caused by infection
- Kussmaul respiration (insensible losses)
4 MAIN CAUSES OF EDEMA - Diuretics (Furosemide,
1. Increased hydrostatic pressure Hydrochlorothiazide)
- Increased volume - Severe burns
Manifestations: - Hot body & Sweating
- High blood pressure (BP) - Fever, Heat Stroke, Thyroid Crisis
- Pitting edema - Vomiting & Diarrhea
Examples: COMPENSATION OF FVD &
- Renal Failure DEHYDRATION
- Heart Failure - Increased thirst
2. Decreased colloid osmotic pressure - Holding on to urine (concentration)
- Increased capillary permeability - Increased HR & Vasoconstriction
- Low Albumin (Low plasma proteins)
- A - Albumin = A - Attracts fluid
Examples:
- Cirrhosis (liver disease)
- Starvation
3. Increased capillary permeability
Examples:
- Bacteria (infection)
- Burns
4. Obstruction of the lymphatic system
- Cancer (tumor blockage)
- Infection (big lymph nodes)

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 CRUTCH & CRANE TRAINING
UPstairs
1. UP with Strong leg
2. Cane moves nexT
3. Weak leg last
Downstairs
1. Descend with Cane
2. Weaker leg down
3. Strong leg
!!UP WITH THE GOOD LEG
DOWN WITH THE BAD LEG!!

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