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www.anurseinthemaking.com www.etsy.com/shop/nurseinthemaking @Kristine_nurseinthemaking @NurseInTheMaking @nurseinthemakingkristine SCAN ME! @anurseinthemaking [email protected] By purchasing this material, you agree to the following terms and conditions: you agree that this ebook and all other media produced by NurseInTheMaking LLC are simply guides and should not be used over and above your course material and teacher instruction in nursing school. When details contained within these guides and other media differ, you will defer to your nursing school’s faculty/staff instruction. Hospitals and universities may differ on lab values; you will defer to your hospital or nursing school’s faculty/staff instruction. These guides and other media created by NurseInTheMaking LLC are not intended to be used as medical advice or clinical practice; they are for educational use only. You also agree to not distribute or share these materials under any circumstances; they are for personal use only. © 2021 NurseInTheMaking LLC. All content is property of NurseInTheMaking LLC and www.anurseinthemaking.com. Replication and distribution of this material is prohibited by law. All digital products (PDF files, ebooks, resources, and all online content) are subject to copyright protection. Each product sold is licensed to an individual user and customers are not allowed to distribute, copy, share, or transfer the products to any other individual or entity, they are for personal use only. Fines of up to $10,000 may apply and individuals will be reported to the BRN and their school of nursing.

TABLE OF CONTENTS Head-To-Toe Assessment...........................................................................5 Dosage Calculation..................................................................................9 Lab Value Cheat Sheet with Memory Tricks.......................................................... 21 Electrolyte Imbalances........................................................................... 25 Fundamentals.......................................................................................31 Mental Health......................................................................................51 Mother Baby....................................................................................... 61 Pediatrics........................................................................................... 79 Med-Surg Renal / Urinary System.................................................................102 Cardiac System........................................................................... 112 Endocrine System........................................................................ 133 Respiratory Disorders...................................................................145 Hematology Disorders................................................................... 155 Gastrointestinal Disorders.............................................................160 Neurological Disorders.................................................................. 166 Critical Care (Burns & Shock).......................................................... 171 ABGs........................................................................................ 177 Musculoskeletal.......................................................................... 181 Pharmacology..................................................................................... 185 Templates & Planners........................................................................... 217 Note from Kristine..............................................................................227 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

NOTES © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. Every accomplishment starts with the decision to try. 4

HEAD-TO-TOE ASSESSMENT BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 5

HEAD-TO-TOE ASSESSMENT 1 INSPECT Introduction Orientation \"Normal\" Vital Signs 2 PALPATE ✹ Knock ✹ What is your name? ✹ Pulse: 60-100 bpm 3 PERCUSS ✹ Introduce yourself ✹ Do you know where you are? ✹ Blood Pressure: 120/80 mmHg 4 AUSCULTATE ✹ Wash hands ✹ Do you know what month it is? ✹ O2 Saturation: 95 -100% ✹ Who is the current U.S. president? ✹ Temperature: 97.8-99.1°F ✹ Provide privacy ✹ What are you doing here? ✹ Respirations: 12-20 breaths per min ✹ A&O X4 = Oriented to Person, ✹ Verify client ID and DOB Place, Time, and Situation ✹ Explain what you are doing (using non-medical language) Head & Face pulse scale otfhetAhssesterpsesunilngsgeth HEAD 0 pulse is absent 1+ diminished ✸ Inspect head/scalp/hair VII: Facial 2+ normal 3+ full ✸ Palpate head/scalp/hair • Raise eyebrows 4+ bounding, strong • Smile FACE • Frown Neck, Chest (Lungs) & Heart • Show teeth ✸ Inspect • Puff out cheeks ✸ Check for symmetry • Tightly close eyes ✸ To assess Cranial Nerve 7, check.... NECK EYES ✸ Inspect and palpate ✸ Palpate carotid pulse ✸ Inspects external eye structures ✸ Check skin turgor (under clavicle) ✸ Inspect color of conjunctiva and sclera POSTERIOR CHEST ✸ PERRLA ✸ Inspect • Pupils Equal, Round, Reactive to Light, ✸ Auscultate lung sounds in posterior and lateral chest & Accommodation • Note any crackles or diminished breath sounds assess the depth of the respirations ANTERIOR CHEST effort note if it’s Labored or unlabored ✸ Inspect: rhythm note if it’s regular or irregular • Use of accessory muscles 5 Areas for Listening to the Heart • AP to transverse diameter • Sternum configuration All Aortic People Pulmonic ✸ Palpate: symmetric expansion Enjoy Erb’s Point ✸ Auscultate lung sounds → anterior and lateral Time Tricuspid Magazine • Note any crackles or diminished breath sounds Mitral HEART © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. ✸ Auscultate heart sounds (A, P, E, T, M) with diaphragm and bell • Note any murmurs, whooshing, bruits, or muffled heart sounds 6

HEAD-TO-TOE ASSESSMENT Peripherals Spine UPPER EXTREMITIES SHOULDER ✸ Have the client stand up (if able) ✸ Inspect the skin on the back ✸ Inspect and palpate ✸ Inspect, palpate, and assess ✸ Inspect: spinal curvature ✸ Note any texture, lesions, temperature, ELBOWS (cervical/thoracic/lumbar) moisture, tenderness, & swelling ✸ Inspect, palpate, and assess ✸ Palpate spine ✸ Palpate radial pulses bilaterally ✸ Note any lesions, lumps, HANDS AND FINGERS 0 pulse is absent or abnormalities 1+ diminished ✸ Inspect hands/fingers/nails 2+ normal ✸ Palpate hands and finger joints If we were to percuss + palpate before 3+ full ✸ Check muscle strength of listening (auscultating), we would alter 4+ bounding, strong hands bilaterally the bowel sounds. This would lead to • Does each hand grip evenly? inaccurate results. Lower Extremities (hips, knees, ankles) Abdomen LOWER EXTREMITIES ✸ Inspect: Assess in different order: 1 INSPECT ✸ Inspect: • Skin color • Overall skin coloration • Contour 2 AUSCULTATE • Lesions • Hair distribution • Scars 3 PERCUSS • Varicosities • Aortic pulsations • Edema 4 PALPATE ✸ Auscultate bowel sounds: ✸ Palpate: Check for edema (pitting or non-pitting) all 4 quadrants (start in RLQ and go clockwise) ✸ Check capillary refill bilaterally ✸ Light palpation: all 4 quadrants HIPS capillary refill time (CRT) Absent: Must listen for at least 5 minutes to chart absent bowel sounds ✸ Inspect and palpate Time taken for capillary bed to regain its color after pressure Hypoactive: One bowel sound every 3-5 minutes KNEES Normoactive: Gurgles 5-30 times per minute has been applied Hyperactive: Can sometimes be heard without a ✸ Inspect and palpate stethoscope. Constant bowel sounds ANKLES Normal <2-3 seconds (> 30 sounds per minute) ✸ Inspect and palpate ✸ Posterior pulse ✸ Dorsal pedis pulse bilaterally OVERALL • Check strength bilaterally ☞ Positions and drapes client appropriately • Dorsiflexion flexion against resistance during exam (gave client privacy) 0 pulse is absent ☞ Gave client feedback/instructions 1+ diminished ☞ Exhibits professional manner during exam, 2+ normal 3+ full treated client with respect and dignity 4+ bounding, strong ☞ Organized: exam followed a logical sequence (order of exam “made sense”) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 7

NOTES © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. It’s a beautiful thing when a career and a passion come together. 8

DOSAGE CALCULATION BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 9

ABBREVIATIONS TIMES OF MEDICATIONS EXAMPLE A patient is receiving 1 mg tid. question: How many mg will they receive in one day? ac before meals Remember: tid = 3X a day pc after meals Answer: If they are receiving 1 mg for 3X a day, daily every day bid two times a day that’s 1 mg x 3 = 3 mg per day tid three times a day qid four times a day ROUTES OF ADMINISTRATION qh every hour ad lib as desired PO by mouth stat immediately IM intramuscularly q2h every 2 hours PR per rectum q4h every 4 hours SubQ subcutaneously q6h every 6 hours SL sublingual prn as needed ID intradermal hs at bedtime GT gastrostomy tube IV intravenous IVP intravenous push IVPB intravenous piggyback NG nasogastric tube DRUG PREPARATION METRIC APOTHECARY & HOUSEHOLD tab, tabs tablet g (gm, Gm) gram gtt drop cap, caps capsule mg milligram min, m, mx minim gtt drop mcg microgram tsp teaspoon EC enteric coated kg (Kg) kilogram pt pint CR controlled release L liter gal gallon susp suspension mL milliliter dr dram el, elix elixir mEq milliequivalent oz ounce sup, supp suppository T, tbs, tbsp tablespoon SR sustained release qt quart © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 10

CONVERSIONS BASED ON VOLUME 1 mg = 1,000 mcg THE METRIC SYSTEM 1 g = 1,000 mg 1 oz = 30 mL Large unit to small unit → move decimal to the right 8 oz = 1 cup small unit to Large unit → move decimal to the left 1 tsp = 5 mL 1 dram = 5 mL Moving to a larger unit? larger unit 1 tbsp = 15 mL lMEMORY 1 tbsp = 3 tsp Move the decimal place to the left 1 L = 1,000 mL (Ex: mcg → mg) TRICK think eft 1500 mcg = mg EXAMPLE A mg is larger than a mcg Therefore you move decimal 3 places to the left 1500. mcg = 1.500 mg (1.5 mg) BASED ON WEIGHT lb → kg kg → lb divide by 2.2 MULTIPLY by 2.2 1 kg = 2.2 lbs EXAMPLE 120 lbs = _____ kg EXAMPLE 45.6 kg = ______ lbs 1 lb = 16 oz 120 lbs / 2.2 = 54.545 kg 45.6 kg x 2.2 = 100.32 lbs © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 11

DOSAGE CALC RULES 1 Show ALL your work. ! Medication error kills, prevention is crucial! 2 Leading zeros must be placed before any decimal point. The decimal point may be missed without the zero EXAMPLE .2 mg should be 0.2 mg WHY? .2 could appear to be 2 (0.2 mg of morphine is VERY different than 2 mg of morphine!) 3 No trailing zeros. EXAMPLE 0.7 mL NOT 0.70 mL 1 mg NOT 1.0 mg WHY? 1.0 could appear to be 10! 4 Do not round until you have the final anwser! HOW TO ROUND YOUR FINAL ANSWER →If the number The # in the hundredth place is rounded up in the thousands place is 5 or greater 1.995 mg is rounded to 2 mg DECIMAL EXAMPLES 1.985 mg is rounded to 1.99 mg REFERENCE GUIDE 3 4 .7 3 2 →If the number The # is dropped tens thousandths ones hundredths in the thousands place is 4 or less tenths EXAMPLES 0.992 mg is rounded to 0.99 mg 5 Most nursing schools, if not all, do not give partial credit. 12 This means every step must be done correctly! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

FORMULA METHOD For Volume-Related Dosage Orders D xV=A H D =Desired ! Some medications like heparin and Example: “The physician orders 120 mg...” insulin are prescribed in units/hour H =Dosage of medication available Example: “The medication is supplied as 100 mg/5 mL” V = Volume the medication is available in Example: “The medication is supplied as 100 mg/5 mL” A = Amount of Medication required for administration You should assume that all questions Your answer ! are asked “per dose” unless the question gives a timeframe (example: “how many tablets will you give in 24 hours?”) EXAMPLE 1 EXAMPLE 2 Ordered: Drug C 150 mg Ordered: Drug C 10,000 units SubQ Available: Drug C 300 mg/tab Available: Drug C 5,000 units/mL How many tablets should be given? How many mL should be given? D xV= A D xV= A H H What’s our desired? Drug C 150mg PO What’s our desired? Drug C 10,000 SubQ What do we have? Drug C 300mg/tab What do we have? Drug C 5,000 units What’s our quantity/volume? tablets What’s our quantity/volume? 1 mL 150 mg 300 mg x 1 tab = 0.5 tabs 10,000 units 5,000 units x 1 mL = 2 mL 150 300 = 0.5 x 1 = 0.5 tabs 10,000 5,000 = 2 x 1 = 2 mL FINAL ANSWER: 0.5 tabs FINAL ANSWER: 2 mL © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 13

IV FLOW RATES mL of solution What if the question total hours is given in Minutes? = mL/hr Since there are 60 minutes in one hour, use this formula: mL of solution 60 = mL/hr min (minutes) mL / hour ! If the question is asking for flow rate and you’re given mL/hr is always rounded to the nearest whole number! units of mL, you need to write the answers in mL/hr! EXAMPLE #1 EXAMPLE #2 Ordered: 1000 mL D5W to infuse over Ordered: Infuse 3 grams of Penicillin in 3 hours. What will the flow rate be? 50 mL normal saline over 30 minutes. 1000 mL 333.333 mL/hr 50 mL 60 min 100 mL/hr 3 hr 30 min ANSWER: 100 mL/hr ANSWER: 333 mL/hr (rounded to the nearest whole number) mL of solution drop = gtt/min What if the question total minutes factor is given in hours? ! If a drop factor is included, the question Remember our Since there are 60 minutes is asking for flow rate in gtt/min. abbreviations: in one hour, use this formula: You need to write the answers in gtt/minute! gtt means “drop”! Convert hours to minutes! examples: 1 hour = 60 minutes 2.5 hours = 150 minutes gtt / min EXAMPLE #1 EXAMPLE #2 Ordered: 1000 mL of Lactated Ringer’s to Ordered: 100 mL of Metronidazole to infuse infuse at 50 mL/hr. Drop factor for tubing is over 45 minutes. The tubing you are using a 5 gtt/mL. (Convert: 1 hour = 60 min) has a drop factor of 10 gtt/mL. 50 mL 5 gtt/mL 4 gtt/min 100 mL 10 gtt/mL 22 gtt/min 60 min 45 min 50 ÷ 60 = 0.833 x 5 = 4.166 100 ÷ 45 = 2.222 x 10 = 22.222 Round to the nearest whole number → 4 Round to the nearest whole number →22 FINAL ANSWER: 4 gtt/min ! Remember Rule #4 FINAL ANSWER: 22 gtt/min ! Remember Rule #4 Don’t round till the end! Don’t round till the end! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 14

PRACTICE QUESTIONS Do all 10 questions without looking at the correct answers on the following pages. Don’t forget to show all your work. After you are done, walk through each question…even the questions you got correct! 1 ORDERED: Rosuvastatin 3000 mcg PO ac 6 250 mL normal saline over 5 hours. AVAILABLE: Rosuvastatin 2 mg tablet (scored) Tubing drop factor of 10 gtt/mL. How many tabs will you administer in 24 hours? 2 ORDERED: Tylenol supp 2 g PR q6h 7 Humulin R 200 units in 100 mL of normal AVAILABLE: Tylenol supp 700 mg saline to infuse at 4 units/hr. How many supp will you administer? Round to nearest tenth. 3 ORDERED: Potassium chloride 0.525 mEq/lb PO 8 Dopamine 600 mg in 200 mL of normal saline to dissolved in 6 oz of juice at 0930 infuse at 10mcg/kg/min. Pt weight = 190 lbs. AVAILABLE: Potassium cholride 12 mEq/mL How many mL of potassium chloride will you add to the juice for a 66.75 kg patient? Round to nearest tenth. 4 1000 mL D5W to infuse over 4 hours. 9 2.5 L normal saline to infuse over 48 hours. 5 150 mL Cipro 250 mcg 10 ORDERED: Morphine 100 mg IM q12h prn pain to infuse over 45 minutes. AVAILABLE: Morphine 150 mg/2.6 mL How many mL will you administer? Round to nearest hundredth. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 15

COMPREHENSIVE REVIEW 1 2 ORDERED: Rosuvastatin 3000 mcg PO ac ORDERED: Tylenol supp 2 g PR q6h AVAILABLE: Rosuvastatin 2 mg tablet (scored) AVAILABLE: Tylenol supp 700 mg How many supp will you administer? How many tabs will you Round to nearest tenth. administer in 24 hours? STEP 1: CONVERT DATA STEP 1: CONVERT DATA mcg → mg g → mg 3000 mcg = 3 mg 2g = 2000 mg REMEMBER Small to big: REMEMBER big to small: move the decimal point 3 to the left move the decimal point 3 to the right unit is getting larger think left STEP 2: READY TO USE DATA STEP 2: READY TO USE DATA Ordered: 3 mg Ordered: 2000 mg Available: 2 mg Available: 700 mg Volume: 1 tab Volume: 1 supp Administered ac: before each meal Question is asking: dosage in 24 hours STEP 3: IRRELEVANT DATA STEP 3: IRRELEVANT DATA N/A N/A STEP 4: FORMULA USED STEP 4: FORMULA USED D xV= A D xV=A H H SHOW YOUR WORK SHOW YOUR WORK 3 mg = 1.5 ! Don’t forget to check 2000 mg = 2.857 2 mg times of medication! 700 mg 1.5 x 1 tab = 1.5 The medication is ordered ! Remember Rule #4 to be given AC, which Don’t round till the end! 1.5 x 3 = 4.5 tabs per day means before each meal. 2.857 x 1 supp = 2.857 supp Since there are 3 meals ROUND: No rounding necessary ROUND: Nearest tenth in a day (24 hours), the answer must be →2.857 supp 2.9 supp multiplied by 3. FINAL ANSWER: 4.5 tabs FINAL ANSWER: 2.9 supp © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 16

COMPREHENSIVE REVIEW 3 4 ORDERED: Potassium chloride 0.525 mEq/lb PO dissolved in 6 oz of juice at 0930 1000 mL D5W to infuse over 4 hours. AVAILABLE: Potassium chloride 12 mEq/mL How many mL of potassium chloride will STEP 1: CONVERT DATA you add to the juice for a 66.75 kg patient? Round to nearest tenth. N/A STEP 1: CONVERT DATA STEP 2: READY TO USE DATA kg → lb 1000 mL 4 hr 66.75 kg x 2.2 (lb/kg) = 146.85 lb mEq/lb → mEq ! In this case, ordered amount depends on patient weight ( 0.525 mEq/lb x 146.85 lb = 77.096 mEq ) STEP 2: READY TO USE DATA Ordered: 77.096 mEq Available: 12 mEq Volume: 1 mL STEP 3: IRRELEVANT DATA ! STEP 3: IRRELEVANT DATA Dissolved in 12 oz of juice at 0930 Question asked for N/A “per dose” because no STEP 4: FORMULA USED timeframe was given mL of solution = mL/hr STEP 4: FORMULA USED total hours D xV= A H SHOW YOUR WORK SHOW YOUR WORK 77.096 mEq = 6.424 ! Remember Rule #4 1000 mL = 250 mL/hr ! 12 mEq Don’t round till the end! 4 hr mL/hr is always 6.424 X 1 mL = 6.424 mL rounded to the nearest ROUND: Nearest tenth whole number! →6.424 mL 6.4 mL ROUND: No rounding necessary FINAL ANSWER: 6.4 mL FINAL ANSWER: 250 mL/hr © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 17

COMPREHENSIVE REVIEW 5 6 150 mL Cipro 250 mcg to infuse 250 mL normal saline over 5 hours. over 45 minutes. Tubing drop factor of 10 gtt/mL. If the question is asking for flow rate (“to infuse”) and you’re given mL ! of solution, you need to write the answer in mL/hours! STEP 1: CONVERT DATA STEP 1: CONVERT DATA N/A hr → min 1 hour = 60 minutes STEP 2: READY TO USE DATA 5 hr x 60 min = 300 min 1 hr mL of solution: 150 mL total hours: 45 min STEP 3: IRRELEVANT DATA STEP 2: READY TO USE DATA Cipro 250 mcg mL of solution: 250 mL total minutes: 300 min Important: don’t let this information lead you to use Drop factor: 10 gtt/mL the wrong formula. In this example, we’re asked for a flow rate which requires mL of solution and total time. STEP 3: IRRELEVANT DATA N/A STEP 4: FORMULA USED STEP 4: FORMULA USED mL of solution x 60 = mL/hr mL of IV solution x drop factor = gtt/min total minutes time in minutes SHOW YOUR WORK SHOW YOUR WORK ! Remember Rule #4 250 mL = 0.8333 mL/min ! Remember Rule #4 Don’t round till the end! 300 min Don’t round till the end! 150 mL = 3.333 x 60 = 200 mL/hr 0.8333 mL/min x 10 gtt/mL = 8.3333 gtt/min 45 min ! ROUND: gtt/mL is always rounded to the nearest whole number! ROUND: No rounding necessary mL/hr is always →8.3333 gtt/min 8 gtt/min The question may not rounded to the nearest ! specify to round the final answer to a whole number; whole number! FINAL ANSWER: 8 gtt/min you are expected to know this with gtt/min units. FINAL ANSWER: 200mL/hr © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 18

COMPREHENSIVE REVIEW 7 8 Dopamine 600 mg in 200 mL of normal Humulin R 200 units in 100 mL of normal saline saline to infuse at 10 mcg/kg/min. to infuse at 4 units/hr. Pt weight = 190 lbs. STEP 1: CONVERT DATA If the question is asking for flow rate (“to infuse”) and you’re given mL N/A ! of solution, you need to write the STEP 2: READY TO USE DATA answer in mL/hours! Desired: 4 units/hr STEP 1: CONVERT DATA Available: 200 units Volume: 100 mL mcg → mg REMEMBER STEP 3: IRRELEVANT DATA 10 mcg = 0.010 mg Small to big: move the decimal point 3 to the left N/A lb → kg unit is getting larger think left 190 lb / 2.2 = 86.363 kg mg/kg mg ! In this case, ordered amount min → min depends on patient weight 0.010 mg/kg/min x 86.363 kg = 0.863 mg/min STEP 2: READY TO USE DATA Desired: 0.863 mg/min Available: 600 mg Volume: 200 mL STEP 3: IRRELEVANT DATA N/A STEP 4: FORMULA USED STEP 4: FORMULA USED D xV=A D xV=A H H SHOW YOUR WORK SHOW YOUR WORK 4 units/hr = 0.02 /hr 0.863 mg/min = 0.00143 /min 200 units 600 mg WAIT! 0.02 /hr x 100 mL = 2 mL/hr ! 0.00143 /min x 200 mL = 0.2878 mL/min This is in mL/min ... we need mL/hr is always 0.2878 mL/min x 60 min = 17.2727 mL/hr units of mL/hr! rounded to the nearest ROUND: No rounding necessary ROUND: mL/hr is always rounded to nearest whole number! whole number! →17.2727 mL/hr 17 mL/hr FINAL ANSWER: 2 mL/hr FINAL ANSWER: 17 mL/hr © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 19

COMPREHENSIVE REVIEW 9 10 2.5 L normal saline to infuse over 48 hours. ORDERED: Morphine 100 mg IM q12h prn pain AVAILABLE: Morphine 150 mg/2.6 mL If the question is asking for flow rate How many mL will you administer? (“to infuse”) and you’re given mL Round to nearest hundredth. ! of solution, you need to write the STEP 1: CONVERT DATA answer in mL/hours! N/A STEP 1: CONVERT DATA L → mL REMEMBER big to small: move the decimal point 3 to the right 2.5 L = 2500 mL STEP 2: READY TO USE DATA STEP 2: READY TO USE DATA mL of solution: 2500 mL Ordered: 100 mg total hours: 48 hr Available: 150 mg Volume: 2.6 mL STEP 3: IRRELEVANT DATA STEP 3: IRRELEVANT DATA ! Question asked for N/A IM q12h prn pain “per dose” because no timeframe was given STEP 4: FORMULA USED STEP 4: FORMULA USED mL of solution = mL/hr D xV=A total hours H SHOW YOUR WORK SHOW YOUR WORK 2500 mL 100 mg = 0.6666 48 hours 150 mg = 52.0833 mL/hr 0.6666 x 2.6 mL = 1.7333 mL ROUND: mL/hr is always rounded to nearest whole number! ROUND: nearest hundredth →52.0833 mL/hr 52 mL/hr →1.7333 mL 1.73 mL FINAL ANSWER: 52 mL/hr FINAL ANSWER: 1.73 mL © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 20

hgb wbc hct plt LAB VALUE CHEAT SHEET WITH MEMORY TRICKS BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 21

LAB VALUE CHEAT SHEET vital signs renal BLOOD PRESSURE SYSTOLIC 120 mmHg Calcium 9 - 11 mg/dL Magnesium 1.5 - 2.5 mg/dL DIASTOLIC 80 mmHg Phosphorus 2.5 - 4.5 mg/dL Specific gravity 1.010 - 1.030 HEART RATE 60 – 100 bpm GFR 90 - 120 mL/min/1.73 m2 BUN 7 - 20 mg/dL RESPIRATIONS 12 – 20 breaths/min Creatinine 0.6 – 1.2 mg/dL TEMPERATURE 97.8 – 99°F (36.5 - 37.2°C) OXYGEN 95 – 100% OXYGEN IN COPD PT. as low as 88% COPD pts are expected to have low O2 levels pancreas WBCs complete blood count (cbc) Amylase 30 - 110 U/L Lipase 0 - 150 U/L 4,500 - 11,000 /µL RBCs 4.5 - 5.5 x106 /µL basic metabolic panel (bmp) PLTs 150,000 - 450,000 /µL Sodium 135 – 145 mEq/L Hemoglobin (Hgb) Female: 12 - 16 g/dL Potassium 3.5 – 5.0 mEq/L Male: 13 - 18 g/dL Chloride 95 - 105 mEq/L Hematocrit (HCT) Female: 36% - 48% Calcium 9 - 11 mg/dL Male: 39% - 54% BUN 7 - 20 mg/dL hba1c liver function test (lft) Creatinine 0.6 – 1.2 mg/dL non-diabetic 4 - 5.6% ALT 7 - 56 U/L Albumin 3.4 - 5.4 g/dL pre-diabetic 5.7 - 6.4% AST 5 - 40 U/L Total protein 6.2 - 8.2 g/dL diabetic > 6.5% ALP 40 - 120 U/L coags Bilirubin 0.1 - 1.2 mg/dL Goal for diabetic: < 7% 10 - 13 sec 25 - 35 sec bmi ABGs PT NOT ON heparin: 30-40 secs PTT ON heparin: 47-70 secs underweight <18.5 PH 7.35 - 7.45 ªPTT NOT ON Warfarin: < 1 sec 35 - 45 mmHg ON Warfarin: 2 - 3 sec healthy weight 18.5 - 24.9 PªCO2 80 - 100 mmHg INR PªO2 22 - 26 mEq/L overweight 25.0 - 29.9 HCO3 obesity > 30.0 lipid panel other Total cholesterol <200 mg/dL MAP (mean arterial pressure) 70 - 100 mmHg ICP (intracranial pressure) 5 - 15 mmHg Triglyceride <150 mg/dL Glasgow coma scale Best = 15 Mild: 13-15 Moderate: 9-12 Severe: 3-8 LDL <100 mg/dL ldl bad cholesterol - we want low levels HDL >60 mg/dL hdl happy cholesterol - we want high levels Lab values, instruments, and institutions differ based on the facility. Local policy should supersede. Author & publisher intend this reference to be free of errors but no guarantee can be made & assume no responsibility for any outcomes resulting from its use. 22 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

LAB VALUE MEMORY TRICKS SODIUM: 135 - 145 POTASSIUM: 3.5 - 5 PHOSPHORUS: 2.5 - 4.5 *Commit to memory! BANANAS: PHOR: 4 tfh*oedrgo.5ent’t There are about 3-5 in every US: 2 (me + you = 2) CALCIUM: 9 - 11 bunch & you want them half ELECTROLYTES ripe (½) CALL 911 So, think 3.5 - 5.0 MAGNESIUM: 1.5 - 2.5 CHLORIDE: 95 -105 MAGnifying glass Think of a chlorinated pool that you see 1.5 - 2.5 you want to go in when it’s bigger than normal SUPER HOT: 95 - 105 °F COMPLETE • Hemoglobin (Hgb) To remember HCT, 12 X 3 = 36 (Female) BLOOD COUNT (CBC) Female: 12 - 16 g/dL multiply Hgb by 3 16 X 3 = 48 Male: 13 - 18 g/dL 13 X 3 = 39 (Male) • Hematocrit (HCT) 18 X 3 = 54 Female: 36% - 48% Male: 39% - 54% BASAL METABOLIC BUN: 7 - 20 mg/dL CREATININE: 0.6 – 1.2 mg/dL PANEL (BMP) Think hamburger BUNs... This is the same value as Hamburgers can cost anywhere LITHIUM’s therapeutic range (0.6 - 1.2 mmol/L) Lithium is excreted almost solely by the kidneys... from $7 - $20 dollars And creatinine is a value that tests how well your kidneys filter © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 23

NOTES It doesn’t get easier, you just get stronger! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 24

ELECTROLYTE IMBALANCES BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 25

SODIUM (Nª+) IMBALANCE Sodium is a major ELECTROLYTE found in ECF. Essential for acid-base, fluid balance, active & passive transport 135 - 145 mEq/L mechanism, irritability & CONDUCTION of nerve-muscle tissue > 145 mEq/L = < 135 mEq/L = HYPERNATREMIA HYPONATREMIA SIGNS & SYMPTOMS big & bloated HYPOVOLEMIC HYPERVOLEMIC HYPONATREMIA: HYPONATREMIA: “fried salt” ↓ of fluid & sodium ↑ body water that is F flushed skin S Skin flushed & dry greater than Na+ “salt loss” R Restless, anxious, A agitation S Stupor/coma L Limp muscles confused, irritable L Low-grade fever A anorexia (nausea/vomiting) (muscle weakness) T thirst L Lethargy (weakness/fatigue I increased BP T tachycardia (thready pulse) O Orthostatic hypotension (dry mucous membranes) S seizures/headache & fluid retention S stomach cramping E Edema (pitting) (hyperactive bowels) D decreased urine output • Increased sodium intake • Increased sodium excretion • Excess oral sodium ingestion • Diaphoresis (ex: high fever) • Excess administration of • Diarrhea & vomiting RISK FACTORS IV fluids w/ sodium 4 D’S • Drains (NGT suction) • Hypertonic IV fluids • Diuretics (thiazide & loop diuretics) • LOSS OF FLUIDS! • SIADH • Fever • Watery diarrhea hemoconcentration • Adrenal insufficiency (adrenal crisis) • Diabetes insipidus • Excessive diaphoresis = • Inadequate sodium intake • Infection • Fasting, NPO, Low-salt diet Increased sodium! • Decreased sodium excretion • Kidney disease • Kidney problems • Heart failure MANAGEMENT • If due to fluid loss: “add salt” • Administer IV infusions A ADMINISTER IV sodium chloride infusions • If the cause is inadequate (only if due to hypovolemia) renal excretion of sodium: • Give diuretics that promote sodium loss D DIURETICS (If due to hypervolemia) Hyponatremia → high fluids & low salt = hemodilution • Restrict sodium & fluid intake as prescribed D Daily Weights Where sodium goes, water FLOWS Potassium & sodium = opposites S Safety (orthostatic hypotension AKA risk for falls) A Airway protection (NPO) Don’t give food to a lethargic, confused client (Increased Risk For Aspiration) L Limit water intake Hypervolemic hyponatremia (high fluid & low salt) T Teach about foods high in sodium (canned food, packaged/processed meats, etc.) Example: ↑ Na = ↓ K+ © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 26

POTASSIUM (K) IMBALANCE Potassium imbalance plays a vital role in cell METABOLISM, 3.5 - 5 mEq/L and TRANSITION of nerve impulses, the functioning of cardiac, lung, muscle tissues, & acid-base balance. > 5 meq/L = < 3.5 meq/L = HYPERKALEMIA HYPOKALEMIA • Muscles contract for TOO long • Not enough contraction = Weak = Tight & Contracted SIGNS & SYMPTOMS • Thready, weak, irregular pulse “murder” • Orthostatic hypotension M muscle cramps & weakness • Shallow respirations U urine abnormalities • Anxiety, lethargy, confusion, coma R Respiratory distress • Paresthesias • Hyporeflexia D decreased cardiac contractility (↓HR, ↓BP) • Hypoactive bowel sounds (constipation) E eCG changes • Tall peaked T waves • Nausea, vomiting, abdominal distention R Reflexes (↑ DTR ) • Flat P waves • Widened QRS complexes • ECG changes • ST depression • Prolonged PR intervals • Shallow or inverted T wave • Prominent U wave • Medication • Potassium-sparing diuretics (Spironolactone) RISK FACTORS • Ace inhibitors • Actual total body potassium loss • NSAIDs • Inadequate potassium intake • Excessive potassium intake • Fasting, NPO (Example: rapid infusion of potassium-containing IV solutions) • Movement of potassium from the • Kidney disease or those on Dialysis Potassium imbalance extracellular fluid to the intracellular fluid • Decreased potassium excretion can cause cardiac • Alkalosis • Hyperinsulinism • Adrenal insufficiency (Addison’s disease) dysrhythmias • Tissue damage • Dilution of serum potassium • Acidosis that can be • Water intoxication • Hyperuricemia • IV therapy with potassium-deficient solutions • Hypercatabolism life-threatening! MANAGEMENT • Monitor EKG • Oral potassium supplements • Discontinue IV & PO potassium • Initiate a potassium-restricted diet • Liquid potassium chloride • Potassium-excreting diuretics • Prepare the client for dialysis • Potassium-retaining diuretic • Prepare for administration: • Potassium is NEVER administered • IV calcium gluconate & IV sodium bicarb by IV push, IM, or subQ routes • IV potassium is always diluted & • Avoid the use of salt substitutes or administered using an infusion device! other potassium-containing substances Potassium & sodium = opposites Example: ↑ Na = ↓ K+ © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 27

CALCIUM (Cª+) IMBALANCE Calcium is found in the body’s cells, bones, and teeth. Needed for proper functioning of the CARDIOVASCULAR, NEUROMUSCULAR, 9 - 11 mg/dL ENDOCRINE systems, blood clotting & teeth formation SIGNS & SYMPTOMS > 11 mg/dL = < 9 mg/dL = HYPERCALCEMIA HYPOCALCEMIA “backme” “cats go numb” B bone pain C Convulsions A Arrhythmias C cardiac arrest (bounding pulses) A Arrhythmias K kidney stones M muscle weakness ↓ (DTR) T Tetany E Excessive urination S spasms & stridor • Increased calcium absorption GO NUMB Numbness in fingers, face, limbs • Decreased calcium excretion • Kidney disease POSITIVE CHVOSTEK’S Think “C” • Thiazide diuretics SIGNS: for Cheesy smile • Increased bone resorption of calcium TROUSSEAU’S: Contraction of facial • Hyperparathyroidism / Hyperthyroidism Carpal spasm caused muscles w/ light tap • Malignancy by inflating a over the facial nerve. (bone destruction from metastatic tumors) blood pressure cuff • Hemoconcentration RISK FACTORS • Inhibition of calcium absorption from the GI tract • D/C IV or PO calcium • D/C Thiazide diuretics • Increased calcium excretion • Administer phosphorus, calcitonin, • Kidney disease, diuretic phase • Diarrhea & steatorrhea bisphosphonates, & prostaglandin • Wound drainage synthesis inhibitors (NSAIDs) • Avoid foods high in calcium • Conditions that decrease the ionized fraction of calcium A client with a calcium imbalance is at risk for a pathological fracture. Move the client carefully and slowly MANAGEMENT • Adm. calcium PO or IV • For IV, warm before & adm. slowly • Adm. aluminum hydroxide & Vit D • Initiate seizure precautions • 10% calcium (acute calcium deficit) • Consume foods high in calcium Calcium & phosphate = Inverse Example: ↑ Ca+ = ↓ Po4 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 28

MAGNESIUM (Mg) IMBALANCE Most of the magnesium found in the body is found in the bones. 1.5 - 2.5 mg/dL Regulates BP, blood sugar, muscle contraction & nerve function. > 2.5 mg/dL = Magnesium < 1.5 mg/dL = is a HYPERMAGNESEMIA HYPOMAGNESEMIA SEDATIVE! Low (↓) everything, AKA sedated SIGNS & SYMPTOMS • ↓ energy (drowsiness / coma) high (↑) everything, AKA not sedated • ↓ HR (bradycardia) • ↑ HR (tachycardia) • ↓ BP (hypotension) • ↑ BP (hypertension) • ↓ RR (bradypnea) • ↑ deep tendon reflex (hyperreflexia) • ↓ Respirations (shallow) • ↓ Bowel sounds • Shallow respirations REMEMBER • ↓ DTRs (deep tendon reflex) • Twitches, paresthesias • Tetany & seizures hCtyAaopalg&snoeodcMtahsfleagceleerlr!nmisiiena. • Irritability & confusion POSITIVE CHVOSTEK’S Think “C” SIGNS: for Cheesy smile TROUSSEAU’S: Contraction of facial Carpal spasm caused muscles w/ light tap by inflating a over the facial nerve. blood pressure cuff RISK FACTORS • Increased magnesium intake • Insufficient magnesium intake • Magnesium-containing antacids (TUMS) • Malnutrition/vomiting/diarrhea & laxatives • Malabsorption syndrome • Excessive adm. of magnesium IV • Celiac & Crohn’s disease • Renal insufficiency • Increased magnesium excretion • ↓ renal excretion of Mg = ↑ Mg in the blood • Diuretics or chronic alcoholism • DKA (Diabetic Ketoacidosis) • Intracellular movement of magnesium • Hyperglycemia & Insulin adm. • Sepsis MANAGEMENT • Diuretics • Magnesium sulfate IV or PO • IV adm. calcium chloride or calcium gluconate • Restrict dietary intake of Mg containing foods • Seizure precautions • Avoid the use of laxatives & antacids • Instruct the client to increase containing magnesium magnesium-containing foods • Hemodialysis Magnesium & Calcium = SAME Example: ↑ Mg = ↑ Ca+ © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 29

NOTES You are closer than you were yesterday. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 30

FUNDAMENTALS BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 31

BLOOD TYPES Before a blood transfusion happens, a patient’s blood should be sent to the lab to be typed & cross-matched. If a patient receives blood that is not a compatible type, it can lead to a transfusion reaction and potentially death. → Plasma Water Centrifuge 55% of total blood Ions Proteins A device that uses force to separate Nutrients components of fluids. It separates Waste Gases fluids of different densities. This is how labs separate blood. → White Blood Cells & Platelets > 1% of total blood → Erythrocytes 45% of total blood URNEICVIEPRIESNALT UNDIVOENROSRAL o think universal donor ANTIGENS antigen A B A&B NONE ∙ Proteins that elicit immune responses ANTIGEN ∙ Identifies the cell B A A&B PLASMA ANTIBODIES antibody NONE ANTIBODIES ∙ Protects body from “invaders” (think ANTI) ∙ Opposite of the type of antigen RECIPIENT A, O B, O ALL O that is found on the RBC DONOR A, AB B, AB AB ALL donor blood types A person who can Compatible with receive blood of any type any blood type O- O+ A- A+ b- b+ ab- ab+ O- RH FACTOR Recipient blood types O+ A- Rhesus (Rh) factor is an inherited protein A+ found on the surface of red blood cells. b- b+ If your blood has does not have ab- has the protein, Rh on surface. Rh on surface. ab+ you're Rh positive. can receive can receive Always check with your hospital’s protocol about blood product administration If your blood lacks the protein, 32 you're Rh negative. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

ABBREVIATIONS AAA Abdominal Aortic Aneurysm BX Biopsy DX Diagnosis NPO Nothing by Mouth SOB Shortness of Breath Abd Abdomen CABG Coronary Artery Bypass Graft ECG or EKG Electrocardiogram NKA No Known Allergies SBAR Situation, Background, Ac Before Meals C/O Complaining Of ED Emergency Department O2 Oxygen Assessment, Recommendation ACLS Advanced Cardiac Life Support CAD Coronary Artery Disease EENT Eye, Ears, Nose and Throat OB Obstetrics SSE or S.S.E. Soap Suds Enema AD Admitting Diagnosis CBC Complete Blood Count ETT Endotracheal Tube OOB Out of Bed Stat At Once, Immediately A&D Admission and Discharge CCU Cardiac Care Unit / Coronary Care Unit FBS Fasting Blood Sugar OR Operating Room SLE Systemic Lupus Erythematosus Ad lib As Desired C&S Culture & Sensitivity Fx Fracture OA Osteoarthritis STD Sexually Transmitted Disease ALL Acute Lymphocytic Leukemia CF Cystic Fibrosis Gtt or G.T.T. Glucose Tolerance Test Ortho Orthopedics SIADH Syndrome of Inappropriate Antidiuretic ADL Activities of Daily Living CHF Congestive Heart Failure HOB Head of Bed OT Occupational Therapist Hormone Secretion Adm. Admission CKD Chronic Kidney Disease HS Bedtime Pc After Meals Tid Three Times a Day Amb Ambulation CPR Cardiopulmonary Resuscitation Hx History Prn or p.r.n. As Needed T&S Type and Screen AKA Above-the-Knee Amputation COPD Chronic Obstructive Pulmonary Disease ICU Intensive Care Unit Pre op Before Surgery TPN Total Parenteral Nutrition AV Atrioventricular CVA Cerebrovascular Accident (stroke) LMP Last Menstrual Period PFT Pulmonary Function Test TIA Transient Ischemic Attack AP or A.P. Appendectomy CVC Central Venous Catheter LOC Level of Consciousness PLT Platelets TB Tuberculosis Bid Twice a Day D/C Discontinue or Discharge LES Lower Esophageal Sphincter PTCA Percutaneous Transluminal TURP Transurethral Resection of the Prostate BLS Basic Life Support D&C Dilatation and Curettage LP Lumbar Puncture Coronary Angioplasty UA Urinalysis BM Bowel Movement DI Diabetes Insipidus I&O Intake and Output PRBC Packed Red Blood Cells UTI Urinary Tract Infection BP Blood Pressure DIC Disseminated Intravascular Coagulation MAP Mean Arterial Pressure PVC Premature Ventricular Contraction US Ultrasound BKA Below-the-Knee Amputation DKA Diabetic Ketoacidosis MRI Magnetic Resonance Imaging Rom/R.O.M. Range of Motion VS Vital Signs BUN Blood Urea Nitrogen DM Diabetes Mellitus MVA Motor Vehicle Accident RBC Red Blood Cell WBC White Blood Count BPH Benign Prostatic Hyperplasia DVT Deep Vein Thrombosis NGT Nasogastric Tube RT Respiratory Therapist WNL Within Normal Limits RA Rheumatoid Arthritis DO NOT USE POTENTIAL PROBLEM INSTEAD, WRITE: U Mistaken for “0” (zero) or “cc” unit IU Mistaken for IV (intravenous) \"international unit\" or the number 10 (ten) \"daily\" or \"every other day\" Q.D., QD, q.d., qd, Mistaken for each other Q.O.D.,QOD, q.o.d, qod \"X mg\" \"0.X mg\" Decimal point is missed \"morphine sulfate\" \"magnesium sulfate\" Trailing zero (X.0 mg) Can mean morphine sulfate Lack of leading zero (.X mg) or magnesium sulfate MS, MSO4, MgSO4 @ Mistaken for the number “2” (two) “at” cc Mistaken for U (units) when poorly written “mL” or “milliliters” THE NURSING PROCESS \"A Delicious PIE\" SUBJECTIVE DATA ASSESS What the client tells the nurse OBJECTIVE DATA • Gather information • Verify the information Data the nurse obtains through their assessment collected is clear & accurate & observation EVALUATE DIAGNOSE Set SMART Goals • Determine the outcome of goals • Interpret the information collected Specific • Evaluate client's compliance • Identify & prioritize the problem • Document client's response to pain • Modify & assess for needed changes through a nursing diagnosis (be sure it's NANDA approved) Measurable IMPLEMENT PLAN Achievable Relevant • Reaching those goals through • Set goals to solve Time frame performing the nursing actions the problem •\"Implementing\" the goals set • Prioritize the above in the planning stage outcomes of care © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 33

VITAL SIGNS BLOOD SYSTOLIC Hypotension = low blood pressure PRESSURE 120 mmHg Hypertension = high blood pressure (BP) DIASTOLIC 80 mmHg HEART RATE (HR) Bradycardia = <60 bpm 60 – 100 bpm Tachycardia = >100 bpm RESPIRATION 12 – 20 Bradypnea = <12 breaths/min RATE (RR) breaths/min Tachypnea = >20 breaths/min TEMPERATURE 97.8 – 99°F Hypothermia = <95 °F (<35 °C) (T) (36.5 - 37.2°C) Hyperthermia = >104 °F (>40 °C) OXYGEN 95 – 100% Low oxygen levels = hypoxemia (O2) Pain is subjective Can be measured in various ways: PAIN data given to you by The numerical scale, Wong-Baker Faces®, the patient or verbal rating scale Wong-Baker FACES® Pain Rating Scale © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 34

PRIORITY QUESTIONS ! You know you are being asked a MoaifqsmWulNmeohesetwedeinioda’nsytssoe,HualyyinseodeturheAiasnthBrhkoCceuosslhefd!y PRIORITY QUESTION when the question asks: C Circulation • What is the most important ? #3 circulation • What is the initial response ? • Which action should the nurse take first ? Can they circulate blood through their body and are ABC S B breathing their organs being perfused? A Airway #2 breathing Ask yourself: #1 Patent Airway Gas exchange taking Is there a reason that the place inside the lungs blood isn't pumping/circulating Patent means \"open\"; the airway is clear! Ask yourself: in the body? (Example: The heart is working to Ask yourself: Can gas exchange pump the blood to the vital organs) successfully happen in Can they successfully breathe oxygen in and their lungs? breathe CO2 out? MASLOW'S HIERARCHY OF BASIC NEEDS This shows the 5 levels of human needs, Self-fulfillment SELF- • Hope Physiological needs • Spiritual well-being being the most important needs ACTUALIZATION • Enhanced growth (oxygen, fluids, nutrition, shelter). ABCs fall into Maslow's Physiological need! • Control • Competence • Positive regard Psychological SELF-ESTEEM • Acceptance/worthiness LOVE & BELONGING NCLEX needs SAFETY & SECURITY • Maintain support systems TIP PHYSIOLOGICAL NEEDS • Protect from isolation Pain is considered • Protection from injury “psychological” • Promote feeling of security meaning it does • Trust in nurse-client relationship not take priority. • Airway *Pain rarely kills basic • Respiratory effort people needs • Heart rate, rhythm, and strength of contraction • Nutrition • Elimination © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 35

NURSING ETHICS & LAW ETHICAL PRINCIPLES PATIENT RIGHTS AUTONOMY The right to... → Privacy Respect for an individual’s right → Considerate & respectful care to make their own decisions → Be informed → Know the names & roles of the NONMALEFICENCE persons who are involved in care Obligation to do & cause no harm to others → Consent or refuse treatment → Have an advance directive BENEFICENCE → Obtain their own Duty to do good to others medical records & results JUSTICE CONSENT Distribution of benefits & services fairly TYPES OF CONSENT: • Admission agreement VERACITY • Immunization consent • Blood transfusion consent Obligation to tell the truth • Surgical consent • Research consent FIDELITY • Special consents Following through with a promise → Treatment can not be done without a client's consent HIPAA → In the case of an emergency when a The Health insurance client cannot give consent, then consent is portability & accountability act implied through emergency laws → Clients records are private & they have the right to ensure the medical → Minors (under 18), consent must be information is not shared without obtained from a parent or legal guardian permission → All health care professionals must ! inform the client how their health Before signing the consent, the client must be informed information is used of the following: risks & benefits of surgery, treatments, → The client has the right to obtain procedures, & plan of care in layman's terms so the a copy of their personal health client understands clearly what is being done. information 36 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

INFECTION CONTROL PPE PERSONAL PROTECTIVE EQUIPMENT DONNING DOFFING Putting on PPE Removing PPE • Put on PPE before entering the client's room • Remove PPE at the client's doorway or • Do not touch your face while wearing PPE • Minimize contact with items in the client's room outside the room • If hands become soiled while removing PPE, stop & perform hand hygiene • After hand hygiene, continue with PPE removal 1 HAND 1 REMOVE HYGIENE GLOVES 2 GOWN 2 REMOVE 3 MASK / PROTECTIVE EYEWEAR RESPIRATOR 3 REMOVE GOWN 4 GOGGLES / 4 REMOVE & FACE SHIELD DISCARD RESPIRATOR 5 GLOVES 5 PERFORM HAND HYGIENE HOSPITAL-ASSOCIATED INFECTIONS (HAIS) CAUTI........ Catheter-associated urinary tract infection Meticulous hand hygiene practices SSI ............. Surgical site infection and use of chlorhexidine washes CLABSI ...... Central line-associated blood infection VAP ........... Ventilator-associated pneumonia helps in preventing HAIs © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 37

INFECTION CONTROL Susceptible Causative Reservoir STAGES OF Host Agent INFECTION • Human Leaves the host • Bacteria • Animal Incubation more susceptible • Virus • Surfaces • Fungus • Food Interval between the pathogen to infections • Prion • Soil entering the body & the presentation • Parasite • Insects of the first symptom Portal  Of Entry Chain Portal Prodromal Stage of Of Exit Onset of general symptoms to more distant Infection • Skin (wound) symptoms; the pathogen is multiplying • Mouth (vomit, saliva) • How it gets to the host Mode Of • Blood (cuts on the skin) Illness Stage • Same as portal of exit Transmission • Respiratory tract Symptoms specific to the infection appear • Contact • Droplet Convalescence • Airborne • Vector borne Acute symptoms disappear and total recovery could take days to months TRANSMISSION BASED PRECAUTIONS Airborne droplet contact • Single room under negative pressure • Private room or a client whose body • Private room or cohort client • Door remains closed cultures contain the same organism • Use gloves & a gown whenever • Health care workers wear a • Wear a surgical mask entering the client's room respiratory mask • Place a mask on the client (N95 or higher level) • Colonization or whenever they leave the room infection with a multidrug-resistant Measles Think • Adenovirus organism When in contact with T uberculosis \"Mtv\" • Diphtheria (pharyngeal) C. Diff, patient’s hands • Epiglottitis • Enteric infections • Influenza (flu) (Clostridium difficile) must be washed • Meningitis with soap & water • Mumps • Respiratory infections when performing • Parvovirus B19 (RSV, Influenza) • Pertussis hand hygiene • Pneumonia V aricella (Chickenpox) • Rubella • Wound & skin infections & Disseminated • Scarlet fever (cutaneous diphtheria, herpes simplex, herpes-zoster (Shingles) wplhohraneevgcn*eoaAeavucrilerrtlnbuiroleeosntesrenidiodseenndso • Streptococcal pharyngitis impetigo, pediculosis, scabies, staphylococci, & varicella-zoster) • Eye infections (conjunctivitis) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 38

IV THERAPY: TYPES OF IV SOLUTIONS HYPERTONIC \"Enter the vessel from the cells\" 1 EXAMPLES: USED FOR: 2 3 5% saline Cerebral edema Hyponatremia 3% saline (low levels of sodium) 5% dextrose in 0.9% saline (D5NS) Metabolic alkalosis 1 IV administration 5% dextrose in 0.45% saline (D5 ½ NS) Maintenance fluid 5% dextrose in LR (D5LR) Hypovolemia 2 effects of the solution 10% dextrose in water (D10W) 3 homeostasis after MORE salt in the solution, MEMORY ↓MONITOR FOR: LESS water in the solution. The vessel TRICK becomes MORE concentrated than the cell. Fluid Volume Overload hypertonic think Water then LEAVES the cell. high numbers 5% dextrose in water (D5W) Therefore, the cells will shrink. starts as isotonic and then * The only exception to this memory trick is changes to hypotonic 5% dextrose in water (D5W) when the dextrose is metabolized. mEISeQOaUnAsL iIsSoOtToONniIcC \"stays where I put it\" USED FOR: vionlturmfalvEeuaXi&sdPcuAlrolNeaspsrDlSaflcueisd Same osmolality as body fluids EXAMPLES: Blood loss (Equal water & particle ratio) 0.9% sodium chloride (NS) (normal saline) (hemorrhage, burns, surgery) hypotonic 5% dextrose in water (D5W)* Lactated Ringers (LR) Dehydration Use with (vomiting & diarrhea) BLOOD PRODUCTS Fluid maintenance NORMAL SALINE is the only solution compatible to use with blood or blood products \"go out of the vessel\" + into the cell 3 EXAMPLES: USED FOR: 1 1 IV administration 0.45% saline (1/2 NS) Diabetic ketoacidosis (DKA) 2 2 effects of the solution 0.33% saline (1/3 NS) 3 homeostasis after 0.225 saline (1/4 NS) Helps kidneys excrete 5% dextrose in water (D5W)* excess fluids LESS salt in the solution, MORE water in the solution. Hypernatremia thsoeInmceDuwllcKash,Ate,gtrhltu!ehcyeorsneeeeiisnd The vessel becomes LESS concentrated than the cell. Water then ENTERS the cell. Therefore, the cells will SWELL. (high levels of sodium) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. DO NOT GIVE WITH: ↑ ICP Burns Trauma 39

IV THERAPY: BASICS Fluid in our body is found in 2 places: iSf Intracellular & Extracellular icf IV (ICF) (eCF) iSf iSf IV fluid INSIDE the cell fluid OUTSIDE the cell icf icf (Millions of these cells in our body) icf iSf Interstitial fluid (ISF) Intravascular (IV) fluid that surrounds the cell plasma/fluid in AKA fluid in the tissues the blood vessels the cells & homeostasis Sodium & Water The cells love to have everything equal (homeostasis). MEMORY where sodium But when fluids/solutes shift, diffusion/osmosis TRICK goes water flows! occurs to get back to homeostasis again. Sodium is the cool kid, diffusion osmosis so water wants to be his friend. the movement of a the movement of water said Let's play Okay, solute from a through a semipermeable another way... over here! I'm coming! TIP higher membrane from a from a sodium water Sodium concentration lower higher is a solute! to a solute concentration water concentration to a to a EXAMPLE: If sodium shifts into lower the cell (intracellular space) higher lower water will follow and leave the concentration extracellular space (the vessel) solute concentration water concentration (until there is equal concentration) (until there is equal concentration) (until there is equal concentration) Colloids & Crystalloids Colloids EXPPALNASDMEARS! Crystalloids Large molecules Small molecules Colloids have LARGE molecules making it more Crystalloids have Small molecules. efficient at increasing fluid volume in the blood. They are less expensive than colloids and provide immediate fluid resuscitation. EXAMPLES: USED FOR: EXAMPLES: Albumin Shock Pancreatitis Hypertonic solution Fresh frozen Burns plasma (FFP) Excessive bleeding Isotonic solution Hypotonic solution © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 40

IV THERAPY: COMPLICATIONS Pathology Symptoms treatment AIR Air enters • Tachycardia • Clamp the tubing EMBOLISM the vein through • Chest pain • Turn client on the • Hypotension the IV tubing • ↓ LOC left side & place in • Cyanosis Trendelenburg position • Notify the HCP IV fluid • Pain • Remove the IV leaks into • Elevate the extremity INFILTRATION surrounding THEATSITE: • Swelling • Apply a warm or • Coolness tissue cool compress • Numbness • Do not rub the area • No blood return INFECTION Entry of • Tachycardia • Remove the IV microorganism • Redness into the body • Swelling • Obtain cultures • Chills & fever via IV • Malaise • Possible antibiotic • Nausea & vomiting administration CIRCULATORY Administration • ↑ blood pressure • ↓ flow rate OVERLOAD of fluids • Distended neck veins (keep-vein-open rate) • Dyspnea too rapidly • Wet cough & crackles • Elevate the head (Fluid Volume of the bed Overload) • Keep the client warm • Notify the HCP Inflammation THEATSITE: • Heat • Remove the IV of the vein PHLEBITIS • Redness • Notify the HCP Can lead • Tenderness to a clot • Restart the IV on (thrombophlebitis) • ↓ flow of IV the opposite side HEMATOMA Collection THEATSITE: • Blood • ELEVATE the extremity of blood in • Hard & • Apply pressure & ice the tissues painful lump • Ecchymosis © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 41

BLOOD TRANSFUSIONS ADMINISTRATION OF BLOOD TRANSFUSION FACTS ABOUT BLOOD TRANSFUSIONS 1 Insert an IV line using a 16g*, 18g, or 20g IV needle *commonly used for trauma patients ∙ Administered by the RN ∙ Only normal saline (NS) can be 2 Run it with normal saline 0.9% (keep-vein-open-rate) used in conjunction with blood Blood is transfused with a special Y-tubing with an inline-filter ∙ Type & screen and a cross match 3 Begin the transfusion slowly If you use too are good for 72 hours A The first 15 min are the MOST CRITICAL, small of a needle Blood must be hung (started) within the RN must stay at bedside (i.e. 24 gauge needle) 30 minutes from the time the blood when administering B Vital signs are monitored blood products, it is picked up from the blood bank every 30 min - 1 hr can cause the All blood must be transfused C After 15 min, the flow can be increased blood to LYSIS. within 4 hours of the time the (unless a transfusion reaction has occurred) blood was hung (started) 4 Dispose the bag into a red biohazard bag STOP the transfusion if you 5 Document the patient's tolerance to the suspect a transfusion reaction administration of the blood product TRANSFUSION REACTION Red blood cells Normal saline A transfusion reaction is an adverse reaction that happens as a result of receiving blood transfusions SIGNS OF TRANSFUSION REACTIONS ∙ Fast heart rate Immediate transfusion reaction ∙ Itching/urticaria/skin rash ∙ Wheezing/dyspnea/tachypnea Chills, diaphoresis, aches, chest pain, rash, hives, itching, ∙ Anxiety swelling, dyspnea, cough, wheezing, or rapid, thready pulse ∙ Flushing/fever ∙ Back pain Circulatory overload NURSING ACTIONS: Infusion of blood too rapid for the client to tolerate 1 STOP the transfusion 2 Change the IV tubing down to the IV site Cough, dyspnea, chest pain, headache, hypertension, 3 Keep the IV open w/ normal saline tachycardia, bounding pulse, distended neck vein, wheezing 4 Notify the HCP & blood bank 5 Do not leave the patient alone Septicemia Blood that is contaminated with microorganisms (monitor the patient's vital signs & continue to assess) Rapid onset of chills, high fever, vomiting, diarrhea, hypotension & shock Iron overload Complication that occurs in client's who receive multiple blood transfusions Vomiting, diarrhea, hypotension, altered hematological values *Always check with your hospital’s protocol about IV and blood product administration © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 42

MEDICATION ADMINISTRATION 6 RIGHTS OF MED ADMIN TYPES OF ORDERS COMMON MEDICATION ERRORS RIGHT CLIENT ☞ ROUTINE RIGHT TIME Given on a regular schedule with ! Medication error kills, RIGHT DOSE or without a termination date. prevention is crucial! RIGHT MED RIGHT ROUTE ☞SINGLE \"ONE-TIME\" ✘ Wrong medication RIGHT DOCUMENTATION Used for a single case. Not a routine medication. ✘ Incorrect dose ☞ STAT ✘ Wrong... Only for administration once • Client and given immediately. • Route • Time ☞ PRN \"As needed\" must have an ✘ Administer a medication the indication for use such as pain, client is allergic to nausea & vomiting. ✘ Incorrect D/C of Medication ✘ Inaccurate prescribing SCOPE OF PRACTICE RN LPN/LVN UAP ✸ Post-op assessment ✸ Stable client ✸ Routine, stable vital signs ✸ Initial client teaching ✸ Monitor RN’s findings ✸ Documenting input and output ✸ Starting blood products ✸ Can get blood from the ✸ Sterile procedures & gather data ✸ IVs & IV medications ✸ Specific assessments blood bank ✸ Discharge education ✸ Reinforce teaching ✸ Activities of daily living (ADLs) ✸ Clinical assessment ✸ Routine procedures ADLs NOTE: (catheterization, ostomy care, wound care) ☞ Feeding When a registered nurse ✸ Monitors IVFs & blood products (not with aspiration risk) delegates tasks to others, ✸ Administer injections & narcotics responsibility is transferred (not IVs meds & 1st IV bag) ☞ Positioning but accountability for patient ✸ Tube potency & enteral feedings ☞ Ambulation ✸ Sterile procedures ☞ Cleaning care is not transferred. ☞ Linen change The RN is still responsible! SPECIFIC ASSESSMENTS ☞ Hygiene care Lung sounds, bowel sounds, & neurovascular checks RN = Registered Nurse LPN = Licensed Practical Nurse LVN = Licensed Vocational Nurse UAP = Unlicensed Assistive Personnel © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 43

PHARMACOKINETICS Adme\" \" some medications Pharmacokinetics: The study of how drugs are moved throughout the body A Absorption ORAL SubQ & IM IV Medication going from the location of Takes the Depends on the site Quickest administration longest of blood perfusion. absorption to the bloodstream to absorb More blood perfusion time = rapid absorption d Distribution Influencing factors: Transportation by bodily • Circulation fluids of the medication • Permeability of the cell membrane to where it needs to go • Plasma protein binding m Metabolism Influencing factors: How is the medication going to be broken down? Age• (Infants & elderly have a limited med-metabolizing capacity) • Medication type Most Liver • First-pass effect common the liver or gut. It may need to be site: A drug given orally gets metabolized administered via parenteral route and its effects are greatly reduced (subQ, IM, or IV) because this route before it reaches the systemic bypasses the liver and gut. circulation. It's generally related to • Nutritional status e Excretion Influencing factors: If the kidneys aren't How is the medication going to working/excreting waste, be eliminated from the body? • Kidney dysfunction the medication will stay Leads to an increase in the in the body which leads Most duration and intensity of a medication response to toxic levels cdoomnmeobnyly: Kidneys © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 44

PARENTERAL ADMINISTRATION Any route of administration that does not involve drug absorption through the GI tract SLOWEST ABSORPTION 10-15° INTRADERMAL (ID) Should Angle form a \"BLEB\" needle Usual USES: size: site: • TB testing 25 - 27 gauge Inner forearm • Allergy sensitivities Normal to Thin 45° SUBCUTANEOUS (SUBQ) overweight clients Angle clients 90° Angle USES: needle Usual size: site: non-irritating, water-soluble medication (insulin & heparin) 23 - 25 gauge • Abdomen • Posterior upper arm • Thigh Giving a malnourished/thin client a medication at a 90° angle could lead to accidental intramuscular injury! 90° INTRAMUSCULAR (IM) MZEUTTsReHAtOChDeK Angle usual QUICKEST ABSORPTION Do not inject more than USES: needle site: 3 mL (2 mL for the deltoid) size: Divide larger volumes into two Irritating, • Deltoid syringes & use two different sites solutions in oils, 22 - 25 gauge • Vastus lateralis and aqueous • Ventrogluteal suspensions 25° INTRAVENOUS (IV) Angle USES: needle Usual size: site: Administering medications, fluids, 16 gauge: • Hand & blood products clients who have trauma • Wrist • Cubital fossa 25° angle used when starting an IV 18 gauge: • Foot surgery & blood administration • Scalp GAUGES & IV USES 22 - 24 gauge: thetthgThehaeueIgVlsaemrbgonareullermerber, children, older adults, & clients who have medical issues or are stable post-op 16 G 18 G 20 G * 22 G 24 G *Some hospitals allow blood to be administered with 20 G Trauma, surgery, rapid Administering blood, Medications, routine IV fluids, medications Pediatric patients, Always check with your hospital’s protocol fluid administration (bolus) rapid infusions (bolus), therapies, IV fluids elderly patients, about IV and blood product administration CT scans with IV dye very fragile/small veins LARGEST SMALLEST © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 45

PRESSURE INJURIES (ULCERS) \"Decubitus Ulcer\" \"Bed Sores\" WHAT IS A PRESSURE INJURY?The break down of skin integrity due to unrelieved pressure seeinnpcciaoaontnmniMbedtmine/onotdosesrtrnnidltyden BRADEN SCALE Asses your client's skin EVERY shift for Type 1 pressure injuries using the Braden Scale! • Skin is intact (unbroken) Looks at 6 categories • Nonblanchable redness • Swollen tissue • Sensory Perception • Moisture • Darker skin → may appear blue / purple • Activity Interpretation • Mobility Type 2 • Nutrition Low risk: 22 - 23 • Skin is NOT intact • Friction & shear Less risk: 19 - 21 • Partial thickness loss High risk: <18 • No fatty tissue is visible • Superficial ulcer NURSING Type 3 CONSIDERATIONS • Skin is NOT intact As a nurse, it's important to prevent • Full thickness SKIN loss pressure injuries while in the hospital! → Damage to or necrosis of subQ tissue RELIEVE PRESSURE → No bone, muscle, or tendon exposed ∙ Apply pressure relieving devices • Ulcer extend down to the underlying fascia, (overlays, specialty beds, air cushions, but not through it foam-padded seat cushions, etc.) • Deep crater with or without tunneling Type 4 ∙ Do not use donut-type devices or synthetic sheepskins • Skin is NOT intact • Full thickness TISSUE loss PROPER NUTRITION promhpoertaoeltisnewginound → Destruction of tissue ∙ ↑ protein intake → Bone, muscle, or tendon exposed ∙ Adequate hydration ∙ Possible enteral nutrition • Deep pockets of infection & tunneling deep tissue injury (dti) SKIN HYGIENE • Skin is intact (unbroken) ∙ Clean skin with mild soap • Tissue beneath the surface is damaged • Appears purple or dark red ∙ Clean incontinent patients ∙ Do not scrub or rub bony prominences ∙ Barrier for incontinence Unstageable ∙ Moisturizer for hydration Stage cannot be determined due to eschar REPOSITIONING or slough covering the visibility of the wound Turn/reposition patient every 2 hours while in the bed RISK FACTORS \"AVOIDS PRESS\" ∙ LIFT, don't PULL a Aging skin p Poor nutrition ∙ Pulling could cause shearing r Reduced RBCs (anemia) & friction from force v Vascular disorders o Obesity e Edema monitor: i Immobility & incontinence s Sensory deficits ∙ Size & color of the wound d Diabetes s Sedation ∙ Braden Scale s Skin friction (tool for anticipating the risk of pressure ulcers) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 46

NONPARENTERAL ADMINISTRATION Absorbed into the system through the digestive tract ORAL OR ENTERAL rectal SUPPOSITORIES → CONTRAINDICATIONS: vomiting, → Lateral or sims' position aspiration precautions/absence of a gag → Use lubrication reflex, decreased LOC, difficulty swallowing → Insert beyond the internal sphincter → Leave it in for 5 minutes → Have client sit at 90 angle to help with swallowing vaginal → Supine with knees bent & feet flat on the bed, close to hips → NEVER crush enteric-coated or time-release medications → Insert the suppository along the posterior wall of the vagina (3 - 4 inches deep) → Break or cut scored tablets only! → Stay supine for at least 5 minutes TRANSDERMAL INSTALLATION (DROPS, OINTMENTS, SPRAYS) → Place the patch on a dry and clean area of skin (free of hair) eyes → If there is dried section use a moisten sterile gauze and wipe from inner to outer canthus to → Rotate the sites of the patch to prevent prevent bacterial from entering the eye skin irritation → Have the client tilt their head back slightly → Always take off the old patch before placing a new one on → Pull lower eye lid down gently to expose the conjunctival sac INHALATION → Hold the dropper 1 - 2 cm above the → Rinse mouth after the use of steroids conjunctiva sac & drop medication → 20 - 30 seconds between puffs directly into the sac → 2 - 5 minutes between different medications → Use a spacer if possible to prevent thrush → Close eye lid & apply gentle pressure on the nasolacrimal duct for 30 - 60 seconds SUBLINGUAL & BUCCAL ears → Have client tilt their head Sublingual: Under the tongue Buccal: Between the cheek & the gum → Warm the solution before adm. to prevent vertigo & dizziness → Adults: pull ear upward & outward → < 3 years of age: pull ear down & back Do not swallow! Ad u lt nose → Have client lie supine p → Do not blow nose for 5 min Keep the medication under the tongue (sublingual) or in between the cheek chil d after drop instillation and gum (buccal) until it has completely o absorbed w n © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 47

INTEGUMENTARY (SKIN) OVERVIEW arCeotlmcdooliaroenrrncokehtteadsircniwefgsifkiteinihcsnult INSPECTION OF THE SKIN Pallor Description Indication Locations The best way to assess for Loss of color Lack of blood flow, Face, conjunctiva, nail beds, anemia, shock palm, lips, mucous membranes Jaundice Erythema Redness Inflammation, localized vasodilation, Skin is to press gently on sun exposure, rash, hyperthermia the forehead or nose. can be blanchable (areas of trauma or pressure) or non-blanchable If the skin looks yellow where you applied pressure, it indicates jaundice. Jaundice Yellow to orange Liver-dysfunction Skin, sclera, Peripheral Cyanosis Cyanosis mucous membranes Cyanosis of the peripherals Bluish Hypoxia (not enough oxygen) Lips, mucous membranes, (fingertips, palms, toes) or impaired venous return nail beds, skin Rarely a life-threatening medical emergency Central Cyanosis Cyanosis around the mouth, Edema is accumulation of piwtftlifeAunrrigeodempaeosdiutntethhmegdaaistrekcehiadcnatnveleylmeaak tongue or mucous membranes excess fluid in the body's tissues that Medical emergency! causes swelling of the skin TYPES OF → Non-pitting WOUND DRAINAGE edema can be: → Pitting Serous Clear, watery plasma. bIlneadecitdciiavnetges Sanguineous Grading Pitting is when you Bright red blood. Pitting press the edematous area Edema for a few seconds and it Serosanguineous Pale, pink, watery. dimples or pits Mixture of clear and red fluid. +1 = +2 +3 +4 Purulent Thick, yellowish-green. ininfdeMicctaaiyotne Trace = == Foul odor. Mild Moderate severe PRIMARY LESION SECONDARY LESION Develops as a result of a disease process Results from a primary lesion or due to a client's actions (scratching, picking) MACULE PAPULE NODULE FISSURE SCAR Flat discoloration Solid, slightly Solid & elevated Linear crack/tear with abrupt edge Normal tissue is lost & replaced of the skin <1 cm elevated lesion <1cm lesion >1cm Example: freckles Example: anal fissures, with connective tissue causing a scar Example: moles Example: lipomas athletes foot Example: healed area after surgery/injury PUSTULE WHEAL VESICLE EROSION SCALE Enclosed Superficial, Elevated cavity Scooped-out, shallow depression Compact, flaky skin pus-filled cavity raised lesion containing clear fluid Example: (silvery or white) Example: acne Example: psoriasis Example: Example: severe pressure injuries allergic reactions chickenpox, shingles © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 48

HYPOVOLEMIA VS. HYPERVOLEMIA HYPO VSSC. AHVNIYDPFEEOORRVOLEMIA HYPOVOLEMIA HYPERVOLEMIA ↓↓ ↓ ↓ ↓↓ \"LOW\" \"VOLUME\" \"IN THE BLOOD\" \"HIGH\" \"VOLUME\" \"IN THE BLOOD\" CAallsloed Dehydration  Fluid volume deficit (FVD)  Hypovolemic shock CAallsloed Over-hydration  Fluid volume excess  Loss of fluid from ANYWHERE  Heart failure • Thoracentesis • Trauma • Paracentesis • GI losses • Hemorrhage  Kidney dysfunction • Vomiting • NG tube • Diarrhea • Can't filter the blood = back up of fluids CAUSES  Third spacing  Cirrhosis • Burns • Ascites shiftsTthhierdflusipdascfirnogm the  ↑ Sodium intake  Polyuria (peeing a lot) intravascular space (the vein) Let's play Okay, • Diabetes into the over here! I'm coming! • Diuretics • Diabetes insipidus interstitial space (third space). where sodium goes water flows! This causes a drop sodium water in the circulating Sodium is the cool kid, so blood volume water wants to be his friend. SIGNS & SYMPTOMS  Distended neck vein (JVD)  Edema  Flat neck veins  ↓ CVP  ↑ HR (bounding)  Polyuria  ↓ Weight  ↑ HR (weak & thready)  ↓ Skin turgor  ↑ BP MMOOREREPR=VEOSLSUUMREE • Kidneys are trying  ↓ Urine output  ↑ Weight to get rid of the  ↑ Respirations  Dry mucous membranes excess fluid  Thirst  ↑ Urine specific gravity  ↑ CVP  ↓ BP LELSESSSPRV=EOSLSUUMREE  Wet lung sounds • Crackles / dyspnea • Due to back flow of fluid from the heart LABS Concentrated  ↑ Urine specific gravity Diluted  ↓ Urine specific gravity (dehydrated)  ↑ Hematocrit (%) (over-hydrated)  ↓ Hematocrit (%) makes the #  ↑ Serum sodium  ↓ Serum sodium  ↑ BUN makes the #  ↓ BUN go up go down NURSING CONSIDERATIONS  Fluid replacement fmlouoviendritvloooalrudfmoer  Low sodium diet / TREATMENT • Fluids (PO or IV)  Daily I&O + weights  Safety precautions  Diuretics where sodium goes • Risk for fall due to water flows! orthostatic hypotension  High-Fowler's or Semi-Fowler's position  Daily I&O + weights • Easier to breathe © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 49

OXYGEN DELIVERY SYSTEM There are many types of oxygen delivery systems, but they all have the same goal: They are used to administer, regulate, and supplement oxygen. MASK TYPE FLOW RATE FiO2 DESCRIPTION Nasal 2 - 6 L/min 24 - 44% Low-flow device cannula 6 - 10 L/min 40 - 60% Used for non-acute situations Simple masks irarsiCtahtatouniom↓bnid/endiafigrsyeiavndleenassir Low-flow device Used for non-acute situations Non-rebreather 10 - 15 L/min 80 - 90% Low-flow device mask Used for acutely ill patients High-flow Up to 21 - 100% High-flow oxygen Most oxygen therapy 60 L/min Often a high flow pdreecliivseerOy 2 without Venturi mask 2 - 15 L/min 24 - 50% nasal cannula intubation High-flow device Face tent at least 24 - 100% Best for patients with venturi mask 10 L/min chronic lung disease think High-flow device Great for those who don’t very accurate O2 tolerate masks well © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 50