Summary
Summary Fundamentals of nursing - Hesi study guide
- Course
- UPNS MISC
- Institution
- Duquesne University
This is a comprehensive and detailed note for fundamentals of nursing is HESI based. U'll need it!!
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Fundamentals HESI Study GuideVital Signs:
August 22
Temperature, pulse, respiration, blood pressure, pulse ox
Temperature: lower in the morning, highest in the evening,
98.6 F-100.4 F, 36-38 C
Pulses: carotid, brachial, radial, ulnar, femoral, popliteal,
dorsalis pedis, posterior tibial
Loudest heart sounds heard at apical pulse
Normal heart rate:
o Infants: 120-160
o Toddler: 90-140
o Adolescent: 60-90
o Adult: 60-100
Tachycardia vs. bradycardia
o Tachycardia: greater than 100
o Bradycardia: less than 60
Strength of pulse: 0: absent, 1: weak, 2: normal, 3: full, 4:
bounding
Amplitude: volume of blood pushed against the wall of an
artery during ventricular contraction
Ox saturation: usually 95% to 100%
Systolic: force exerted as left ventricle contracts and pumps
blood into aorta MAX PRESSURE
Diastolic: force exerted during ventricular relaxation, when
heart is filling MINIMUM PRESSURE
Blood pressure ranges
o Normal: <120, <80
o Prehypertension: 120-139, 80-89
o Stage 1 Hypertension: 140-159, 90-99
o Stage 2 Hypertension: >160, >100
Blood pressure cuff…
o Too wide: false low
o Too narrow: false high
Patient Safety and Quality:
August 22
, Fall risk: age, medication, post op, confusion, previous
history, repeated falls, bone fractures, etc.
Make sure patient is aware of environment items at reach,
call light, phone, etc.
Restraint:
o Last resort – try all other options first ** all other
possibilities have been tried and failed, benefits
outweigh the risks
o Behaviors that result: wandering, restlessness,
violence, agitation, pulling out tubes, resisting care
o Alternatives: treat pain, rule out physical causes for
agitation, involve family, reduce stimulation, noise,
light, environmental factors, use therapeutic touch,
discontinue bothersome treatment
o NEED ORDER WITHIN 1 HOUR AFTER APPLICATION
o RENEWED EVERY 24 HOURS
o Only one restraint at a time (physical or chemical – no
two at once)
o REMOVE EVERY 2 HOURS FOR ASSESSMENT AND
NEEDS (skin integrity, ROM, circulation)
Fire Safety
o RACE
Rescue, alert, contain, extinguish
o PASS
Pull, aim, squeeze, sweep
Hygiene:
August 24
Wash legs from distal to proximal to promote venous return
Observe skin for warmth, redness, swelling, rashes,
tenderness, pain, etc. while bathing
Do not massage reddened areas on client’s skin
Wear gloves when: washing perineum, anal areas, skin
infections, skin not intact, open wounds, draining, oozing
skin, performing oral care
Female: front to back
Male: retract foreskin, wash from urethral meatus and
outward, return foreskin to natural position
Apply lotion skin barriers especially on pressure points
, Empty urine drainage bag at least every 8 hours
Keep catheter bag lower than patient to prevent backflow of
urine
Condom catheter: check for skin irritation, change in 24
HOURS
Infection Prevention and Control
August 24
Infectious agent reservoir portal of exit mode of
transmission portal of entry susceptible host
Susceptible host for germs: strength in numbers, impaired
nutritional status, chronic disease, trauma
Blood borne pathogens: HEP B, HEP C, HIV
Transmission: accidental injuries (needle pricks, sharps,
blood/fluid splashes), sharing needles, blood and blood
product transfusion, sexual contact
Universal precaution treat all patients as if they were
infectious
Hand hygiene: wash for 15 seconds, GLOVES DO NOT TAKE
PLACE OF HAND HYGIENE
PPE:
o PUT ON: 1: gown, 2: mask, 3: goggles, 4: gloves
o TAKE OFF: 1: gown, 2: gloves, 3: goggles, 4: mask, 5:
wash hands
Precautions:
o Airborne
Mask
Negative pressure (door shut)
Common: TB, measles
o Droplet
Mask
Gloves
Common: meningitis, pneumonia, influenza,
rubella
o Contact
Gown
Gloves
Common: MRSA, VRE, lice, major draining wounds,
e-coli
, o Contact (C. Diff)
Gown
Gloves
WASH HANDS NO HAND SANITIZER
o Airborne/Contact
Mask
Gown
Gloves
Common: varicella, herpes, SARS, small pox
o Droplet/Contact
Gown
Gloves
Mask
Common: flu, MRSA, pneumococcus, VRSA, ESBL
Nutrition
August 29
Digestion: begins in mouth ends in small and large intestine
Absorption: small intestine is primary site
Enteral tube feeding:
o Orogastric mouth to stomach
o Nasogastric nose to stomach
o Nasointestinal nose to intestines
o Gastrostomy stomach tube from outside
o Jejunostomy intestine tube from outside
NG Tube: measure from nose to ear lobe to xiphoid process
NG tube placement: pH of 1 to 4 is good indication
Continuous feeding: always going
Intermittent or bolus feeding: nurse gives food at certain
time through tube
Complications
o Clogged tube: flush 30 mL of water every 4 hours after
checking residual volume, flush med flush
o Develops nausea and vomiting: withhold feeding, notify
physician, check patency of tube, aspirate for gastric
residual, for cramping and nausea, decrease the
administration rate
o Gastric residual exceeds normal volume: notify
physician, elevate to at least 30 degrees, reassess
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