FUNDAMENTALS
CPR STEPS
ALWAYS ESTABLISH RESPONSIVENESS FIRST, activate rescue team, place client on
a firm surface, open airway and check for breathing, if not breathing administer 2
breaths, then start compressions
Chest compressions are ONE FINGER BENEATH NIPPLE LINE DIRECTLY OVER
STERNUM
...
fundamentals cpr steps always establish responsiveness first
place client on a firm surface
open airway and check for breathing
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FUNDAMENTALS
CPR STEPS
ALWAYS ESTABLISH RESPONSIVENESS FIRST, activate rescue team, place client on
a firm surface, open airway and check for breathing, if not breathing administer 2
breaths, then start compressions
Chest compressions are ONE FINGER BENEATH NIPPLE LINE DIRECTLY OVER
STERNUM
IV INFILTRATION
Seepage of IV fluid out of the vein and into surrounding tissues occurs when it is
dislodged or perforates the wall of vein.
PREVENTION: Avoid puncture over area of flexion, secure with tape, use splint if pt is
active/restless, monitor for decrease or cessation of flow
S/S: pallor, cool to touch, swelling
N/I: Remove IV immediately, Notify HCP, compress and elevation, do not rub affected
area can cause hematoma
INFORMED CONSENT
Client’s permission to perform surgery, procedure or give information to a third party
Must be informed of the type of procedure, risk and benefits, consequences if not done,
treatment options and name of HCP doing procedure. Questions must be answered
before signing consent. Must be signed freely without threat/pressure to client and
MUST BE WITNESSED. It can be waived for urgent medical/surgical intervention.
CONCEPT: pt heavily sedated/medicated which affects the cognitive ability cannot sign
consent forms. A CLIENT MAY WITHDRAW CONSENT ANYTIME.
Surgical consent: HCP/surgeon/anesthesiologist who performs operative procedure is
responsible for explaining procedure/risks/benefits/alternative options.
Incompetent clients: next of kin/appointed guardian/power of attorney must sign
Minors: may NOT give legal consent. Must come from parent/legal guardian.
Exceptions are made for minors who are emancipated, in an emergency,
treatments related to substance abuse/STDs & AIDs/HIV testing/birth
control services/pregnancy/psychiatric services/court orders.
Witness: Nurse only witnesses the signature of the client on the informed
consent. They verify the correct person signing the consent and that it
was done voluntarily.
INFORMED CONSENT FOR FOSTER CHILD
PARENT/GUARDIAN still is the only one with a right to sign informed
consent even with a foster family. If unable to contact parent/
guardian, COURT ORDER must be obtained.
LIVING WILL/ADVANCED DIRECTIVE
Addresses the withdrawal/withholding of life-sustaining interventions that unnaturally
prolong life. It is witnessed and signed by two people who are UNRELATED to the client
through family or care.
Nurse acts as a witness. Nurse must document the event and circumstances (who was
present, significant comments from pt, client’s conduct).
MUST BE ANNUALLY REVIEWED WITH HCP.
,CRUTCH WALKING
N/I: elbows should be slightly flexed, STAND ON THE AFFECTED SIDE OF PT, never
rest axilla on arm rests, place crutches 6-10 inches diagonally in front of the foot
CANES
N/I: stand at affected side, elbow should be flexed, HOLD CANE ON UNAFFECTED
SIDE, MOVE CANE WITH AFFECTED LEG
CONCEPT: CANE AND WEAKER LEG WORK TOGETHER.
ABOVE THE KNEE AMPUTATION
POST- OP: mark bleeding/drainage if occur, explain sensation of phantom limb pain, DO
NOT ELEVATE ON PILLOWS, wash limb with mild soap and water and dry completely,
massage skin TOWARD suture line
N/I: prevent edema, DO NOT ALLOW LIMB TO HANG OVER EDGE OF BED, avoid
long periods of sitting, exercise should begin DAY AFTER SURGERY to maintain muscle
tone of remaining limb
G-TUBE FEEDING
N/I: if residual is less than 100mL allowed to administer feeding, hold feedings if bowel
sounds are absent, position in HIGH FOWLERS, check tube placing by ASPIRATING
and measuring pH, make sure to return aspirated contents, warm feeding to room
temperature
MEDS THRU G-TUBE (IN ORDER)
CHECK HCP PRESCRIPTION, prepare meds, crush meds, dissolve meds in water,
verify right patient and explain procedure, check presence of bowel sounds, check tube
placement and residual, draw up meds in syringe, insert meds into tube, flush with
30-50mL of water, clamp tube, document
NG TUBE INTUBATION (IN ORDER)
Explain procedure and discomfort pt might feel, position pt, determine which nostril is
more patent, measure length of tube from BRIDGE OF NOSE TO THE EARLOBE TO
XIPHOID PROCESS, swallow/drink water, when tube hits back of the throat instruct pt to
swallow or drink sips of water, immediately withdraw tube if respiratory changes, secure
tube with tape, check residual volumes q4hours/before feeding/after meds, aspirate and
measure stomach contents, always replace tape.
ACNE VULGARIS FACTORS IN TEENS
heredity, increased hormone levels, growth of bacteria
24-HOUR URINE COLLECTION
Void first then throw out first sample. Keep all specimen on ice. At end of 24 hour
collection period empty last void and add to the collection.
BLOOD PRESSURE IN THIGH
SYSTOLIC BP is HIGHER in the thigh by 10-40.
DIASTOLIC BP stays the same
,HOW TO ASSESS RASHES IN A DARK SKINNED PERSON: palpitations of warmth and
induration of rather than observation, mucous membranes
PITTING EDEMA
1+: barely perceptible pit
2+: deeper pit, rebounds in a few seconds
3+: deep pit rebounds in 10-20 seconds
4+: a deeper pit rebounds in more than 30 seconds
HALLUCINATIONS
when one of the five senses are used in perception without any actual external stimuli
to prove it existed
N/I: ask pt directly about hallucination, avoid reacting to it, decrease stimuli, move pt
from area, do not respond negatively, focus on reality based topics, avoid touching client
DELUSIONS
false belief held to be true even when there’s evidence to the statement
N/I: ask pt do describe delusion, be honest to prevent suspicions, focus on reality based
topics, encourage to express feelings, set firm limits on amount of time to talk about
delusions, do not try to convince pt that delusions are false
DELIRIUM
change in consciousness that occurs rapidly over time this can occur at any age
S/S: reduced awareness, reduced attention to surroundings, disorganized thinking,
sensory misinterpretations, irrelevant speech, disturbed sleep patterns
can occur for hours.
ADVENTITIOUS SOUNDS
CRACKLES
Can be fine, medium or coarse. Heard during the end of inspiration and not
cleared by coughing
Can be heard by pneumonia, HF, asthma and restrictive pulmonary diseases,
pulmonary edema
WHEEZE
High pitched musical sound similar to a squeak. Heard during expiration
occurs in small airways like asthma
RHONCHI
low pitched coarse loud snoring or moaning tone. SOUNDS LIKE SNORING.
May clear by coughing. Heard in disease that obstruct the trachea or bronchus
like bronchitis
PLEURAL FRICTION RUB
superficial low pitched coarse rubbing or grating sound. Sounds like two surfaces
rubbing together. Not cleared by cough. Heard in pleurisy.
Z-TRACK INJECTION
type of IM injection technique used to prevent leakage of the medication into the
subcutaneous layer. Pulling skin before injecting leaves a “Z” shape which prevents
leakage. Usually given through vastus laterus or ventrogluteal
, STEPS: Clean injection site, relax muscle, draw air into syringe, instill air into vial,
withdraw med, remove air bubbles, change needle, use one hand to PULL
DOWNWARD/ AWAY on skin and hold firmly, insert at 90 DEGREE ANGLE, aspirate for
blood return before injecting, wait 10 seconds, simultaneously withdraw needle and
release skin, apply GENTLE PRESSURE DO NOT MASSAGE
PAIN WHILE VOIDING
N/I: sit in a warm sits bath when trying to void because warm water relieves pain and
encourages increased circulation to the perineal area and relies the muscles
SPICA CAST
considered a body cast. Pillows should not be used for this kind of cast because it will
thrust the chest against the cast causing discomfort and respiratory difficulty. Neuro
checks are critical b/c it ensures the cast is not causing circulatory compromise.
STRAINS/SPRAINS
STRAINS: excessive stretching of muscle/tendon.
SPRAINS: excessive stretching of a ligament caused by twisting movement.
Characterized by pain and swelling. RICE (rest, ice, compression bandage
and elevation).
FRACTURES
a breaking the continuity of the bone caused by trauma Signs include pain/tenderness,
deformity, edema, muscle spasms
OBTUNDED
patient sleeps unless aroused and once aroused has limited interaction with the
environment. Easily aroused.
POISON IVY
when an individual comes in contact with poison ivy, the sap is invisible on the skin.
Patient should take several showers lathering the skin multiple times and rinse in
running water. DO NOT LEAVE HOUSE
RECEPTIVE APHASIA
Affects the wernickes in the temporal. Can say the word but does not understand
EXPRESSIVE APHASIA
Affects the brocas which is in the frontal. Brochas can understand but CANT say
ANTIEMBOLISM STOCKINGS
used to prevent or reduce edema in the legs or feet by promoting venous return
therefore increasing venous and arterial blood circulation to the legs and feet
MUSCLE STRAIN
Apply ice pack the first 24-48 hours then heat packs after.Ice first to reduce swelling then
heat to in ease discomfort/promote reabsorption of blood and circulation/speed healing.
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