Nursing Practice:

● Nurse Practice Act

○ Explains the function and responsibilities of a professional nurse
○ Differs from state to state
○ Identifies conditions for licensure and scope of practice
○ Definition of nursing
○ Minimum education for required certifications
○ Regulates nursing practice within the state and identifies a regulatory body for the
state (ex. State Board of Nursing)
● Transitioning from Novice to Expert nurse
○ Dr. Patricia Benner → created the novice-to-expert model for nursing competence in
1982; categorizing the different levels of skills acquisition
○ Novice → no previous experience; not able to make decisions
○ Advanced Beginner → can recognize patterns and recurrent situations
■ Begins to pull information from previous experiences, but still needs clinical
support to set priorities
○ Competent → can prioritize tasks by drawing in past experiences
■ Does not function as fast as Proficient nurse, but has mastery in a lot of areas
■ Recognizes patterns more quickly than the Advanced Beginner
○ Proficient → can understand the bigger picture and has a greater overall
understanding in a variety of areas
○ Expert → has been in the field for many years and can be referred to form nurses at
the lower levels
● What is the code of ethics for nurses?
○ It guides the nurse with ethical decision making
○ Incorporates nurse’s value system, duty, obligation to client, and call to uphold
professional ideal
○ NSNA creates one for students→ Advocacy, Leadership and Autonomy,
Professionalism, Care, Diversity, Quality Education
■ Focused more on students and quality education
■ Helps students build leadership skills and be informed as they learn and grow as
a nurse
○ ANA → standard of nursing care for actual nurses
■ Advocates for nurses and guides to carry out ethical obligations
■ Maintaining human dignity
● What is the scope & standards of nursing practice?
○ Established by the ANA and NPAs
○ Scope → explains the services or activities that licensed professionals are deemed
competent and permitted to perform
■ How is it defined ?
● State legislature passes law to regulate nursing practice within the state
● State legislature identifies a regulatory body (ex. State Board of Nursing,
BONN)
 ○ Standards of practice → explanatory statements that describe a competent level of
care for all RNs (*Sets the Standard*); corresponds to the nursing process
○ *Standards of Professional Practice → establish expectations for professional
behavior and also to protect nurse, client, and the facility where client care is
rendered
● What is evidence-based practice?
○ Ensuring that practice is based on the most current evidence, rather than just a
nurse’s education/experiences or the policies of their health care agencies

Communication
● 5 levels of communication
○ Verbal → what is said
■ Therapeutic communication
■ Gender, stress level, and communication style can affect how a message is
perceived
○ Energetic → how the person project themselves
■ Maintaining a caring and compassionate attitude
■ Demonstrating empathy
■ Bioelectric energy in the body → client’s emotional state affects physical health
status → emotions have an effect on the body’s electrical impulses
● HeartMath → using biofeedback through monitoring devices to teach the
client how the heart’s electrical impulses are affected by positive/negative
emotions
○ Emotional → speaker’s emotional state when conveying a message
■ Can be transferred to the receivers and affect how the message is accepted
■ Negative or condescending emotions → will not be well received by listener
■ Use an empathetic frame of mind → build trust and positive rapport
● Especially important with difficult conversations → imminent end-of-life
issues → fear/anxiety
○ Physical → body language; can be intentional but is often an unconscious display of
the person’s feelings
■ In situations with mixed/confusing messages, nonverbal/physical messages
tend to outweigh what is being said verbally
○ Auditory → what the receiver hears when the sender speaks a message
■ The speed and tone of voice that the receiver perceives
■ Can be affected by many factors → physical/intellectual disabilities or outside
disruptors (ex. Noise from medical equipment)
■ Be aware of limitations that the client has with auditory communication → adjust
methods → assess for hearing/cognitive deficits that would prevent
understanding → use hearing aids or other tools
● Other levels of communication
○ Intrapersonal → also called self-talk; thoughts and inner communications that
influence perceptions, feelings, behavior, and self-esteem
■ Be aware of the nature/content of your own thinking
 ■ Positive self-talk → mental rehearsal for difficult tasks/situation; diminish
cognitive distortions
■ Used to develop self-awareness and a positive self-esteem to enhance
appropriate self-expression
○ Interpersonal → one-on-one interaction between a nurse and another person that
most often occurs face-to-face
■ Most frequently used in nursing situations → lies at the heart of nursing practice
■ Includes all the symbols/cues used to give and receive meaning
■ “Meaning resides in people and not in words” → received messages can be
different from intended messages → important to validate a meaning or mutually
negotiate it between participants
■ Assess understanding and clarify misinterpretations when educating patient
○ Small group → occurs when a small number of people meet
■ Goal directed and requires an understanding of group dynamics
■ Nurse committees or patient care conferences
■ Organized, concise, complete communication → all disciplines should contribute
○ Public → interaction with an audience
■ Speaking with groups of consumers about health-related topics, presenting
scholarly work to colleagues at conferences or leading classroom discussions
with peers/students
■ Special adaptations in eye contact, gestures, voice inflection, and use of media
materials to communicate messages effectively
■ Increases audience knowledge about health-related topics, health issues, and
other issues related to nursing profession
○ Electronic → Use of technology to create ongoing relationships with patients and
their health care team
■ Secure messaging → frequent/timely communication via a patient portal
■ Allows patients to stay engaged/informed → empathetic aspect of relationship
may be more challenging
● What are the types of communication styles?
○ Passive → avoid conflict, expressing feelings/opinions, or standing up for yourself
when boundaries are crossed
■ Worried about how others perceive them
■ Novice nurses may demonstrate this when confronting a provider or authority
figure → lack of confidence
■ Anxious
○ Assertive → most effective type → cooperative and straightforward
■ Communicate clearly/honesty
■ Advocate for opinions/rights/needs without violating the rights of others
■ Fundamental for good communication, mental health, and healthy relationships
■ Uses “I” statements
■ Fair and receptive → confident in their message
○ Aggressive → pattern of expression that is verbally, and sometimes physically,
abusive
 ■ Uses “you” statements to blame the receiver
■ Interrupt other speakers, are controlling, become antagonistic or hostile when
challenged
■ Quick to react and do not take the time to work through misunderstandings
○ Passive Aggressive → appear passive only on the surface but act out anger in a
subtle, indirect, or secretive way
■ Stems from feelings of powerlessness or resentment → use sarcasm or other
witty responses
■ Rarely interrupt others
● Modes of Communication
○ Verbal
○ Nonverbal
○ Written
○ Electronic
● Read the section on “overcoming communication barriers” in the ATI module for
communication
○ Nurse needs to be skilled in identifying and developing more effective
communication strategies → avoid medical errors and other poor client outcomes
○ Communication barriers
■ Language differences → popular languages in US are Spanish, Mandarin,
Cantonese, and Russian (still underrepresented in nurses)
● How to overcome → qualified medical interpreter available in person or via
telephone
● Do not use family members or nonprofessional phone apps as medical
interpreters → may change or leave out information OR client may not want
them to know; apps may be inaccurate and are not HIPAA compliant
■ Cultural diversities → develop cultural competence
● Learning about behaviors that are acceptable and unacceptable for the client
population commonly cared for
● Showing respect and compassion for different beliefs and customs
● Active listening, therapeutic communication skills, using respectful touch,
helping to relieve suffering
■ Speech or hearing impairments
■ Developmental or cognitive disorders
● Dementia, stroke, autism
● Use uncomplicated words, avoid medical terms, and speak clearly at a
slower pace
● Providing well-lit supportive environment with limited noise and other
distractions
● Be aware of the client’s body language to determine if there is more to the
message that the client cannot or is choosing not to communicate
● Make sure client can see and hear who is speaking to them is essential →
face client, ensure assistive devices are present and in use (hearing aids
and eyeglasses)
 ■ Medication effects → can cause cognitive deficits
● Wait for effects to fade
■ Effects of recreational drugs
■ Emotional distress
■ Environmental factors
○ No matter the barrier → show respect/empathy, don’t interrupt, exhibit supportive
body language, convey simple/honest messages
■ Use communication enhancers like reflecting or summarizing

Clinical judgment
● Nursing process
○ Assessment → recognize cues; data collection
■ Objective data → observe using senses → inspection, auscultation, smelling,
palpation
■ Subjective data → from client’s self-report or form family member
○ Analysis/Diagnose → analyze cues, prioritize hypothesis
■ Data classification, identify the nursing diagnoses
■ May need to repeat this step and assessment space
○ Planning (or delegate) → generate solutions; goal-setting with outcome criteria
■ Interventions → individualized actions to use in the client’s plan of care to assist
with attaining goals
■ Goals → realistic, measurable, and attainable in a timely manner → short-term
or long-term
■ No two clients are alike
■ Holistic interventions → physical, spiritual, emotional, social needs
○ Implementation → take nursing actions, treatments, medications
■ Sometimes the best action is no action at all → continuous monitoring
■ Prescribed meds or therapies
■ Reassess after giving treatment
○ Evaluation → evaluate outcomes → review goals and outcome criteria
■ Document client’s response and effectiveness of interventions
■ Determine if the client’s plan of care should be continued, discontinued, or
modified
■ Reassess and adapt plan of care to reflect new assessment data
■ Identify if client adhered to plan of care → investigate why not
○ *Benefits of the Nursing Process → decreased length of stay, decreased health care
costs, decreased patient suffering, increased communication, increased flexibility,
individualization of patient care, and increased patient/RN satisfaction
■ Focused on designing creative, goal-directed nursing care focused on quality
and efficiency
○ *Importance of Outcome Criteria → setting the standards for what outcome you want
■ Ex. Outcome is Patient comfort → criteria is what that would look like → patient
in comfortable position, lowered bed, call light within reach
● Steps of Clinical Judgment
 ○ *What is clinical judgment?
■ The observed outcome of critical thinking and decision making
■ Process that uses nursing knowledge to observe/assess presenting situations,
identify a prioritized client concern and generate the best possible
evidence-based solutions in order to deliver safe client care
■ Must consider both environmental (setting/situation → safety considerations,
equipment, staffing, supplies, health records, time pressures) and individual
factors (nurse factors like knowledge/skills, attitudes, prior experiences, level of
experience, cognitive load)
○ Clinical Judgment Action Model (CJAM)
■ *Has relationship with the nursing process
■ Recognize Cues (Assessment)
● Filter information from different sources → signs, symptoms, health history,
environment
■ Analyze Cues (Analysis)
● Link cues to a client’s clinical presentation and establish probable client
needs, concerns, or problems
■ Prioritize Hypotheses (Analysis)
● Establish priorities of care based on client’s health problems →
environmental factors, risk assessment, urgency, signs/symptoms,
diagnostic test, lab values
■ Generate Solutions (Planning)
● Identify expected outcomes and related nursing interventions to ensure
clients’ needs are met
■ Take Actions (Implementation)
● Appropriate interventions based on nursing knowledge, priorities of care,
and planned outcomes to promote, maintain or restore a client’s health
■ Evaluate Outcomes (Evaluation)
● Evaluate client’s response to nursing interventions and reach a nursing
judgment regarding the extent to which outcomes have been met
■ *incorporates critical thinking → higher-order thinking, use of logic/reasoning to
identify areas of client needs while considering alternatives as well
■ *incorporates clinical reasoning → analyzing all data pertaining to a clinical
situation; guides nurse through process of assessing/compiling data,
selecting/discarding pieces of information based on relevance, and making
decisions about client care based on nursing knowledge

Vital signs (Definitions and Normal/Abnormal Values)

● *Vital Signs → reflection of body’s essential functions
○ Serves as baseline, helps identify trends, guides treatment
● Blood Pressure Categories (ADULT)
○ *Definition of Blood Pressure: amount of pressure exerted by the blood within the
circulatory system
 ■ Systolic blood pressure → maximum amount of pressure exerted when the
heart contracts and forces blood into the aorta
■ Diastolic blood pressure → minimum amount of pressure exerted when the
heart is relaxes
○ Orthostatic Hypotension: drop in BP after change in position (ex. sitting to standing);
drop in systolic of at least 20 mm Hg and diastolic of at least 10 mm Hg within 1
minute after moving
○ Hypotension: Less than 90 mm Hg systolic or diastolic less than 60 mm Hg
○ Normal: less than 120/80
○ Elevated: Systolic: 120-129 AND Diastolic: less than 80
○ High Blood Pressure (Hypertension) Stage 1: Systolic: 130-139 OR Diastolic: 80-89
○ High Blood Pressure (Hypertension) Stage 2: Systolic: 140 or higher, OR Diastolic:
90 or higher
○ Hypertensive crisis (contact provider): Systolic: Higher than 180 and/or Diastolic:
Higher than 120
● Pulse Categories (ADULT)
○ *Definition of Pulse: rhythmic dilation of the arteries and pulsation of blood flow that
occurs with each contraction of the left ventricle
○ Bradycardia → pulse less than 60 bpm
○ Normal → 60-100 bpm
○ Tachycardia → pulse greater than 100 bpm
○ *Rhythm can be Regular or Irregular (stop and tell provider if it's irregular)
● Body Temperature Categories
○ *Definition of Body Temperature: measurement of the balance of heat produced by
the body and the heat lost to the environment
○ Hypothermia → decrease in core body temperature due to extended exposure to
cold or the inability of the body to produce heat; below 86.8 degrees F
○ Normal → 96.8 degrees F - 100.4 degrees F
○ Fever → increase in body temperature above expected ref. range due to an upward
shift of the body's natural set point in the hypothalamus gland; greater than 100.4
degrees F
○ Hyperthermia → increase in temperature due to the body's inability to stop heat
production or to stimulate heat loss; the inability of the hypothalamus to maintain
temperature regulation; above 100.4 degrees F
● Respiration Categories
○ *Definition of Respirations: Number of sets of inspirations (intake of air) and
expirations (expelling waste products of air) per minute
○ Bradypnea → RR lower than expected reference range
○ Eupnea → RR within the expected range (12-20)
○ Tachypnea → RR rate higher than expected reference range
○ Apnea → cessation of respirations due to opioid toxicity, trauma, or neurologic
dysfunction
● Pulse Oximetry
 ○ *Definition of Oxygen Saturation: amount of oxygen bound to the hemoglobin
molecule in red blood cells
○ Measures oxygen saturation via ear lobe/finger
○ Dyspnea → shortness of breath or difficulty breathing; alteration in heart/lung
function combined with a low oxygen saturation level
○ Hypoxia → not enough oxygen being supplied to the body’s tissues
○ Normal: 91-100%
○ Low: <90%

Meds
● Reading med labels
○ Each medication label has:
■ Generic name, brand name, dosage, National Drug Code (NDC) number, total
number of tablets in the bottle, expiration date, type of tablets/administration
○ Drug can be ordered by either generic name (one) or trade name (multiple)
○ *Do not confuse dosage and total number of tablets
○ Generic labeling → occurs with drugs that have been in use for generations
■ Ex. Metoprolol, Phenobarbital
○ Two dosages on the label can signify the amount of each drug within a combo
medication (ex. Oxycodone/Acetaminophen → 5 mg/325 mg)
■ Different from concentration in solution → ex. 5 mg/5mL
○ Oral Medications:
■ Unit-dose system → each dose of medication (unit) is packaged separately and
labeled with the medication name and expiration date (some have barcode)
■ Pharmacy bulk system → labeled container holds multiple doses of a
medication
○ Powdered Medications:
■ Label a vial when you reconstitute medication → dosage strength, date/time of
preparation/expiration, storage method, and initials
■ Label has route of administration, dosage strength, amount and type of fluid to
add for reconstitution, expiration time after reconstitution
■ Label indicates medication concentration following reconstitution → **Use this
when doing dose calculations! (NOT the amount of diluent you mixed in)
○ Injectable Medications:
■ Label has route of administration (IV, IM, SQ
■ Label tells if medication needs refrigeration after opening
■ Ex. Iron Dextran
● IV administration preferred → fewer adverse effects
● IM route → use Z-track technique
● Ampule → small glass/plastic bottle with a constricted neck (break neck to
access it)
■ Some labels have space to write day/time first opened
■ Some labels have table of equivalents for different dosages
○ Parenteral Medications:
 ■ IV tubing should always be labeled with date/time of first use and nurse initials
■ Must attach label to volume control fluid chamber if a medication is added
■ Label has diluent, route, and total volume
○ Safety → label all medications, especially before a procedure
● Syringe Sizes (And Syringe Use Generally)
○ Calibrated syringes → ensure accurate measurements; calibrated by tenths or
hundredths of mL
○ Luer-lock tip → securely holds a parenteral needle in place or helps administer
medications as part of a needleless system
■ Can attach to a hub on IV tubing or saline lock for medication administration →
reduces risk of needlestick injuries
○ Syringe sizes → use calibration closest to volume of medication you will administer
and that will allow for more accurate measurement
■ 3-5 mL → subcutaneous, IM, IV
● 3 mL syringe → calibrated in tenths of a ML (long mark is 1 mL)
○ Amounts less than 3 ML
● 5 mL syringe → used for dose greater than 3 mL
■ Tuberculin and insulin syringes → 0.3-1 mL of fluid
● Tuberculin → narrow and calibrated in hundredths of a mL each long mark
is 1/10 of a mL); used for very small medication volumes
● Insulin Syringe → calibrated in units
○ Preventing needlestick injuries (*SAFETY*)
■ Use needleless devices whenever possible
● Safety syringes → active/passive devices
○ Active → activate by pushing lever upward
○ Passive → no action required by nurse
■ 1. When device has been used, needle retracts into the barrel
■ 2. Prefilled syringes with a needle guard that activates when the
medication is injected
● Safe Disposal
○ Place needles into sharps container immediately after use → do not force
it in and get a new container if this one is full
○ Never leave needles/syringes at the bedside or place in a pocket or trash
can
○ Never recap, bend, or break a used needle
○ Needle Sizes → measured in gauge and length
■ Ex. 21 G ½ = 21 gauge, ½ inch needle
■ The smaller the gauge, the larger the diameter of the opening
■ Length of needle varies depending on its use
● Med calc X 2
● IV Meds
○ Goals → restore and maintain fluid/electrolyte balance with use of fluid infusion
and/or provide medium for med delivery directly into the bloodstream
○ Advantages
 ■ Medication effect almost immediately
■ Precise amounts of meds and large volumes of fluid infusion
■ Use of meds that irritate tissues and can’t be administered by other routes
■ Prevent discomfort of subQ or IM injection
○ Risks
■ Local Reactions
● Phlebitis → localized vein inflammation
○ Mechanical → inserting IV catheter in area of flexion, using excessively
large catheter, inadequately stabilizing catheter
○ Chemical → infusion of irritating solutions, rapid infusion rates
○ Bacterial → break in asepsis or integrity of dressing covering insertion site
○ *Observe IV sites for signs of complications → every 4 hours for alert
adults, every 1-2 hours for all other clients
○ Manifestations → redness/warmth/swelling at insertion site, report of
discomfort from IV, increased firmness along cannulated vein
○ What to do → stop infusion and remove catheter (can insert new one at a
different proximal site or another extremity)
■ Apply warm/cool compress to inflamed area and document
appearance
● Infiltration and Extravasation
○ IV catheter slips out of vein or fluid leaks into tissues from another
puncture site close to the IV catheter
○ Infiltration → pallor, swelling, pain at IV site
■ What to do → stop IV immediately and remove cannula from vein,
elevate extremity and apply warm/cold/moist compresses
● Document size of infiltrated area, estimate
amount of fluid and monitor site
○ Extravasation → solution that leaked contains a vesicant (blister-inducing
medications) → chemotherapeutic medications, vancomycin, dopamine,
digoxin
■ Similar findings to infiltration → also blistering of skin, tissue necrosis,
ulceration
■ What to do → depends on which medication leaked
● May leave peripheral IV catheter in palace
to allow for antidote med to be instilled
■ Systemic Reactions
● Speed shock → IV med is administered too rapidly → blood levels can rise
to possibly toxic levels
○ Manifestation → chest pain or discomfort, lightheadedness, palpitations,
tachycardia, and even shock/cardiac arrest
○ What to do → stop med, change IV fluid to isotonic solution, notify
provider, treat effects, and monitor vitals
 ○ Prevention → use controlled pump, administer IV bolus at least over 1
min, check med references to see which ones require slow administration,
dilute IV bolus meds
● Fluid Overload → rate of IV fluid administration is faster than the client can
tolerate
○ Manifestation → shortness of breath, intake > urine output, increased
BP/HR/RR, crackles in lungs, neck vein distention, extremity edema
○ What to do → slow infusion rate, raise head of bed, administer oxygen
(As prescribed), notify provider, anticipate diuretic prescription, document
and monitor vital signs
● Catheter Embolism → part of IV catheter breaks off in vein → caused by
catheter damage during insertion or too much force when flushing or
administering medication
○ Embolism can travel to heart, lungs, or elsewhere
○ Occurs with peripheral IV, central IV, or PICC line
○ Manifestation → pain in extremity proximal to IV insertion site, signs of
shock (shortness of breath, cyanosis, tachycardia), cardiopulmonary
arrest → depends on where the fragment lodges
○ What to do → remove IV catheter and inspect it for damage to the tip,
apply tourniquet above IV site if broken piece can be palpated, notify
provider and anticipate obtaining X-Ray
○ Prevention → inspect catheters for damage prior to insertion, never
reinsert needle into IV cannula after removing, inspect catheter after
removing to ensure it is intact before discarding
● Allergic Reactions → hypersensitivity to a medication
○ Mild to moderate reactions
■ Generalized rash (hives/vesicles), pruritus (itchy skin), edema, rhinitis,
excessive tearing, nausea, vomiting, diarrhea, wheezing, and
dyspnea
■ Can occur few minutes to 2 weeks after med administration
■ What to do → stop med infusion, replace IV tubing, infuse 0.9% NaCl,
and notify provider
○ Severe reactions
■ Can precipitate anaphylactic shock
■ Manifestation → feeling of apprehension/weakness, generalizing
itching/hives, erythema, angioedema of eyes/lips/tongue, respiratory
distress, increased mucus production, hypotension, tachycardia, and
diaphoresis → respiratory/cardiac arrest within minutes of med admin.
■ What to do → stop medication and initiate oxygen at 90-100% (while
another nurse calls rapid response team), replace IV tubing and
infuse 0.9% NaCl, elevate client’s bed to 45 degrees (only to 10 if
hypotension is present), anticipate administering epinephrine and
diphenhydramine, and prepare for resuscitation
○ Osmolarity of Solutions
■ Concentration of dissolved particles within a solution, milliosmoles per liter
■ Isotonic IV solutions
● Similar in composition to body fluids → maintain/increase volume within
vascular system
● Stay in veins and interstitial tissues → does not move into cells → can cause
fluid overload
● Examples:
○ 0.9% NaCl (Normal Saline;NS) → mixture of sodium and water; preferred
diluent for mixing with IV medications and when administering blood
products
○ Lactated Ringer’s → electrolytes, sodium, chloride, potassium, calcium
and lactate; liver metabolizes lactate to form bicarbonate → used to treat
acidosis

■ Hypotonic IV solutions
● Less concentrated than blood and other body fluids
● Moves water into cells → treats fluid/electrolyte imbalance
○ Continued infusion can cause hemolysis → cell rupture
○ Can cause cerebral edema for clients at risk for increased intracranial
pressure
● Examples:
○ 0.45% NaCl (½ NS)
○ D5W → dextrose 5% in water → isotonic but becomes hypotonic after it
enters the body
■ Used as a solution to add meds for intermittent IV bolus
■ Combined with isotonic IV solutions to provide calories for clients
■ Can be contraindicated for DM clients → increase blood glucose
■ Hypertonic IV solutions
● More concentrated than blood and other body fluids
● Pulls fluid from interstitial spaces and cells into the veins → corrects
fluid/electrolyte imbalances
○ Caution with clients at risk for fluid volume overload → heart/renal failure,
older adults, young children
● Examples:
 ○ 3% NaCl solution
○ D10W
○ D5LR and D5NS → hypertonic in bag but becomes isotonic after body
metabolizes dextrose
○ IV Equipment
■ Label all tubing with date/time of first use and nurse initials
■ Primary → drip chamber, injection port, or ports and a roller clamp
● Usually for continuous IV infusion
● Regulate by gravity drip or electronic infusion pump
● Long enough to attach to IV catheter in vein
■ Secondary → drip chamber, roller clamp
● Short and attached to primary tubing at upper Y-port
● Used for small IV bag or medication bottle
■ Volume-controlled administration sets
● Small fluid container attached just below primary infusion bag/bottle → then
primary tubing connected below
● Holds up to 150 mL
● Used in precise controlled volume administration → young children, older
adults
● Can also be used to dilute IV medications
■ Electronic Infusion Devices
● Deliver accurate fluid infusion rate and amount
● Internal detectors that sound alarm if → air in tubing, remaining volume is
low, infusion is complete, low battery, occlusion
● Syringe pump → administer meds in small amount of solution
○ Types of IV Administration
■ Intermittent IV bolus
● Meds contained within smaller volumes of solution → 50-250 mL
● Piggyback infusion → secondary higher than primary bag, connecting tubing
at upper Y-port of primary tubing, regulate flow rate with roller clamp or
electronic infusion device
■ IV bolus
● Use syringe to administer meds directly into existing IV lines or an
intermittent venous access (ex. Saline lock or IV lock)
● Rapid serum concentration and immediate effect
● Flush port of IV with 0.9% NaCl before admin. To ensure patency →
administer med within time frame → follow with flush of 0.9% NaCl
■ Tandem Administration
● Primary and secondary bags infuse at the same time → hung at same level
→ secondary tubing plugged into lower port on primary tubing
● Flow rate controlled with roller clamp or electronic infusion device
○ Flow Rate
■ Too fast → fluid overload and electrolyte imbalances
■ Too slow → delayed client recovery
 ■ Factors that influence flow rate → position of forearm, flexion of wrist/elbow,
kinked/occluded tubing, back pressure from an infiltrated IV
■ Order tells the type of IV fluid, volume that client receives, and rate at which to
infuse
● Large-volume IV infusions → continuous basis
● Large-volume IV bolus → one-time prescription
● Intermittent IV bolus infusion → medication mixed in 50-250 mL of solution,
given over less than 1 hr
● IV bolus → small amount of medication (concentrated or diluted) injected
over a short time (typically 1-2 minutes)
■ Calculating manual IV pump rates → use a roller clamp, count number of drops
that fall into the drip chamber during 1 minute and then calculate flow rate using
drop factor on package
■ Macrodrip → 10, 15, 20 gtt/mL
■ Microdrip → 60 gtt/mL

Documentation
● Documentation guidelines → Documentation should be/have:
○ Factual
○ Accurate
○ Appropriate use of abbreviations
○ Current
○ Organized
○ Complete
○ *FACT → Factual, Accurate, Complete, Timely
● MAR vs. EMR vs. EHR
○ MAR → Medication Administration Record (Paper)
■ Name, dose, route, frequency, date, time of administration, expiration of
prescription, and whether it should be taken with food
● Client’s identifying information and current date
○ EMR → Electronic Medical Record
■ The record for an individual health care visit
○ EHR → Electronic Health Record
■ An individual’s lifetime computerized record → comprehensive health records of
a person’s health history
■ Means of communication for all health care providers involved in client’s care
■ Also important for financial reimbursement
○ CPOE → Computerized Provider Order Entry
■ Allow providers to write and transmit prescriptions electronically
■ Can eliminate errors caused by illegible handwriting, inconsistent abbreviations,
and lack of knowledge → increases client safety
● Case management model → incorporates an interprofessional approach to delivery and
documentation of patient care
 ● Critical Pathways → interprofessional care plans that identify patient problems, key
interventions, and expected outcomes within an established time frame
● Acuity Rating System → used to determine hours of care and number of staff required or
a group of patients every shift or every 24 hours
○ Patient’s acuity level → based on type/number of nursing interventions required by
that patient over a 24-hour period

Mobility
● Proprioception → awareness of body movement and position → difficulties in older
patients or post-brain surgery patients
● Principles of Body Mechanics → Body Alignment, Balance (bending legs lowers center
of gravity), Body Movements
● Effects of Immobility: Immobility and the Body Systems
○ Immobility and Muscles
■ Prolonged bed rest and limb immobilization → muscle atrophy (smaller and
weaker), poor coordination, reduced ADLs
■ Sarcopenia → loss of lean muscle mass→ deterioration of twitch fibers (help
with speed of contraction and ability to resist fatigue)
○ Immobility and Joints
■ Changes in tissue tension/elasticity/shape → joint stiffness and decreased ROM
■ Joint contracture → abnormal fixations of the joints that occur as a result of
changes to muscle/connective tissues (deteriorated cartilage)
● Foot Drop → partial/total inability of dorsiflexion
○ Shortening of calf muscles and Achilles tendon
○ Foot is left arches with toes pointing downward
○ Unable to place heel on the floor → toes drag while walking
○ Immobility and Cardiovascular System
■ Body fluids redistributed to head, abdomen, and chest area → increase blood
volume returning to heart → release hormones for fluid balance regulation
■ Diuresis and dehydration → decrease circulating blood volume and increase
blood viscosity → decreases amount of blood ejected when heart contracts →
cardiac deconditioning (atrophy of the heart muscle)
■ Reduced blood volume and cardiac deconditioning → orthostatic hypertension
● Systolic decrease by 20 mm Hg or more
● Diastolic decrease by 10 mm Hg or more
● Within 3 minutes of changing to sitting or standing position
■ Increased blood viscosity and atrophy of heart muscle → DVT
● Could lead to pulmonary embolism, cerebrovascular accident, ot heart attack
○ Immobility and Respiratory System
■ Supine positioning → decreased ribcage expansion and abdominal organ shift
towards diaphragm → decrease depth of breaths and decreased coughing
effectiveness
■ Dehydration → thickens mucus secretions in lungs → difficult to expel
 ● Atelectasis → partial or complete collapse of lung → due to shallow
breathing
○ Use incentive spirometer to promote lung expansion
● Pneumonia → infection → due to shallow breathing, thickened mucus,
decreased coughing → Reduced ability to remove pathogens/irritants from
lungs
○ Immobility and GI system
■ Decreased appetite and overall food intake
■ Malnutrition (lower blood protein levels), harder stools (slow of peristalsis),
constipation (can lead to fecal impaction), gastroesophageal reflux (backflow via
lower esophageal sphincter causing damage to esophageal lining)
○ Immobility and GU (Genitourinary) System
■ Supine positioning (lack of gravity aid) → urinary retention → incomplete
emptying of the bladder
● Formation of renal calculi → increase risk of bacterial growth and UTI
■ Overdistention of the bladder → damages the lining
○ Immobility and Integumentary System
■ Altered skin integrity
■ Compression of skin and tissue between bone and firm surface → restriction of
blood flow and lymph to those areas
● Reposition every 2 hours for bed-bound patients
○ Left side 2 hours → back 2 hours → right side 2 hours
○ Pillow between knees and ankles
○ Offload heels with a pillow
■ Most susceptible areas → bony prominences with thinner skin and skin exposed
to moisture from perspiration, wound drainage, or incontinence
■ Pressure injuries → range from intact skin with non-blanchable redness to deep
wounds with exposed bone and necrotic tissue
○ Immobility and Psychosocial Effects
■ Increased dependence on others, loss of privacy, inability to participate in work
and hobbies
■ Negative impact on self-concept/self-esteem → frustration, anxiety, depression
■ Social isolation
■ Try to promote self care
● Rating of Perceived Exertion (RPE) Scale → evaluating activity tolerance → target zone
is 12-14 → somewhat hard to strong effort
■ 6 → resting or sitting that is effortless
■ 20 → maximal effort required to perform action
● Kyphosis → outward curvature of the thoracic area of the spine → most commonly
occurs in older adult females due to weakening/breakage of vertebra → impact ability to
ambulate and rise from seated position
● Mobility Assessment → performed prior to initially mobilizing and repeated every 24
hours → evaluates how well a client can move and what aides may be needed
○ MAT → objective determination of mobility level
 ■ Four-step process → tests client’s ability and provides recommended level of
assistance (ex. Maximum assistance with two or more caregivers, no
assistance)
■ Ability to move, stand, walk, step; balance, strength, posture, activity intolerance
■ Implementation → right equipment is used
■ Level 1 → maximum assistance
○ Timed Up and Go (TUG) → client stands up from a seated position, ambulates 10
feet, turn and ambulate back to chair, and becomes seated
■ Monitor how long it takes → observe balance, stride, posture, gait
■ Older patient → >12 seconds → increase fall risk
● Support → gait belt, cane, walker, crutches
○ Top of walker should be at level of wrist
○ Crutches → elbows bent at 15-30 degree angle when holding hand grips, rest
crutches 5 cm below axilla
● ROM → Passive vs. Active
○ Helps with increased joint function and flexibility, improved posture, reduced
stiffness, and lower risk of injury
○ Passive → done for the client by the nurse
○ Active → taught to the client by the nurse and done by the client themselves
● ROM → types of movement (adduction vs. abduction, etc.)
○ Flexion and extension
■ Flexion: bend → reduce angle between bones
■ Extension → straighten the limb
○ Abduction and adduction
■ Abduction → move away from baseline
■ Adduction → bring closer to baseline
○ Pronation and supination
■ Pronation → turning to face backward
■ Supination → turning to face forward
○ Circumduction → circular motion
■ Putting a circle on a paper
○ Rotation → side–to-side
■ Can be internal or external → like putting a dot on a paper
○ Inversion and eversion
■ Inversion → turn inward
■ Eversion → turn outward

Nutrition
● Nursing interventions
○ Nutritional assessment → collection/review of client’s dietary habits to determine if all
the necessary nutrients are being consumed and if there are any health issues
related to nutritional intake
○ 24-hour recall→ see what client has consumed in the last 24 hours –. Different food
and portion sizes
○ Food frequency questionnaire → determine client’s typical food consumption based
on a list of foods
○ Dietary preferences → cultural, religious, likes/dislikes
○ Assess ability to chew and swallow → often done by speech therapist
○ Inspect client’s teeth, hair, and skin while checking the client’s weight
○ Determine BMI
○ Ask about digestion issues
○ Obtaining BP and cholesterol levels; other vital signs
○ Lab data
○ Document intake and output
○ Looking at medical history for risk factors → lack of appetite, decreased hunger,
illness, medications, eating disorders
○ If you are assisting a patient with feeding/drinking and they start coughing (or
showing other signs of aspiration), STOP the feeding, keep the patient NPO and
notify the provider
○ Thickened liquids → help to prevent aspiration
■ Nectar thick → fluid runs freely off the spoon but leaves a mild coating on the
spoon
■ Honey thick → fluid slowly drips in dollops off the end of the spoon
■ Spoon thick → fluid sits on the spoon and does not flow off it
○ Enteral Nutrition
■ Dietary intake via a medical device → feeding tube
■ For clients who do not have adequate oral intake or nutrition that can meet their
metabolic needs
■ Used for clients who cannot eat safely due to dysphagia
■ Can provide total sustenance or be used to supplement the diet
○ Types of Feeding Tubes
■ Nasogastric Tube (NG) → thin plastic tube placed via nostril, down the
esophagus and the stomach
● Can be used to provide nutrition and meds to client but also to remove
contents from stomach (with suction)
● Inserted by RN or PN
● Taped to nose to secure it
■ Gastrostomy Tube (G-tube)
● Inserted by PEG technique, laparoscopic or open surgery technique →
inserted by surgeon
● Must be NPO for at least 8 hours prior to procedure
■ Nasoduodenal tube (ND): inserted into the nasal passage, with the tip placed
past the stomach and in the duodenum (more long term)
● Primarily for feedings
● Fluoroscopic assistance can aid positioning during insertion and x-ray
confirms placement after
■ Nasojejunal (NJ) tube: thin, soft tube that is inserted through the nostril and
stomach, ending in the jejunum of the small intestine
 ● Used for clients who are unable to consume enough nutrition, cannot
tolerate foods/liquids in their stomach, or have delayed gastric emptying
● Food, liquids, and meds placed directly into the client’s intestines
● Taped to cheek to secure
● Placed by provider using guided radiology → placement verified by x-ray
○ Preventing tube feeding aspiration
■ Verify tube placement with an x-ray before initial use
■ Check tube placement every 4 hours by checking pH of gastric contents
■ Measure the residual every 4 hours to check tube feeding tolerance → should
be less than 250 mL
■ Maintain head of the bed at 30-45 degrees during feeding and for at least 1 hour
following bolus feedings
■ *Indications of tube feeding aspiration → difficulty or painful breathing,
wheezing, productive cough, or a fever
○ Feed/offer liquids with the patient sitting in the High Fowler's position
○ Offer assistive devices → help client perform activities or tasks more easily
■ Goal → provide nutritional support and prevent any complications
■ Utensils with easy-to-grip handles
■ Cut food into bite-sized pieces, unwrap packets/lids
■ Position client at 90 degree angle
■ Ensure dentures/hearing aids in place, free of clutter surrounding, washed
hands, restroom use beforehand
○ Swallowing Techniques

○ Blood Glucose Monitoring

■ Fasting blood glucose → taken after client has been NPO for at least 8 hours
■ Hypoglycemia → less than 70 mg/dL
■ Hyperglycemia → greater than 100 mg/dL
○ Parenteral Nutrition
■ Dietary intake administered intravenously
■ Prevents or corrects malnutrition
 ■ Liquid nutrients → proteins, fats, carbohydrates, minerals, electrolytes, and
vitamins
■ Clients with digestive system that cannot absorb/tolerate adequate food eaten
by mouth
■ Administered into a large vein through a venous access device
■ PPN (Partial Parenteral Nutrition) → provides a patient with part of their nutrition
needs
■ TPN (Total Parenteral Nutrition) → provides a patient with their total nutrition
needs
● Types of Diets
○ Correct diet based on prescription and promotion of adequate nutritional intake
○ NPO → nothing by mouth → may be due to lack of safety while eating/drinking,
scheduled surgery, or diagnostic test that requires fasting
■ Verify if extends to meds as well
■ Includes water
■ Prevents aspiration during surgery
■ Dysphagia → inability to swallow
○ Regular diet → healthy foods from all of the food groups → fruits, vegetables, grains,
protein, and dairy sources
■ No significant health concerns
■ No salt/sugar restrictions
■ No issues with chewing/swallowing
■ Increase water intake; limit sugar, alcohol, saturated/trans fats
○ Soft diet → foods that are soft, easy to digest, low in fiber, swallowed without
difficulty
■ Short or long-term
■ For clients recovering from jaw/mouth/abdomen surgeries, having swallowing
difficulty due to narcotics/muscle relaxants/anxiety medications, dysphagia
■ Foods that are bland without a lot of seasoning → well-cooked vegetables,
low-fiber cereals, easy-to-chew proteins
● Plain cake, fruit juices without pulp, tender beef cuts, creamy nut butters,
and cooked fruit without skin/seeds
○ Pureed diet → soft and smooth foods that do not need to be chewed
■ For clients with difficulty chewing/swallowing, recent oral surgery, or numbness
in the mouth
■ Pudding, mashed potatoes yogurt, juices without pulp, baby food, pureed meats,
broths, and ice cream
○ Full liquid diet → only fluids, foods that are liquids, foods that are liquid at room
temperature
■ Postoperative abdominal surgery patient, experiencing dysphagia, prior to
certain procedures
■ Ice cream, juices, pudding, milkshakes, tea, strained soups, protein shakes,
gelatin
■ Solid foods not allowed
 ○ Clear liquid diet → only clear liquids → broth, gelatin, water
■ Foods that are see through, partly or completely melt at room temperature
■ Also tea, fruit juices without pulp, sports drinks
■ Do not leave undigested residue in intestinal tract→ decrease strain on digestive
system while keeping the body adequately hydrated
■ Before/after certain procedures, following surgery, due to digestive issues
■ Restricted to no more than a few days due to limited amount of
calories/nutrients
■ Avoid red-colored liquids/gelatin → avoided for colon procedures and
tonsillectomies
■ Also good for clients experiencing n/v/d
○ Diet for Cardiovascular Health
■ Controlling portions, consuming more fruits/vegetables, increasing whole grains,
limiting unhealthy fats, eating low-fat protein sources, and decreasing sodium
intake
■ Limit fast foods and processed foods
■ Whole-grain foods contain fiber promote heart health and blood pressure
regulation → over white bread
■ Controlling sodium → can lead to HTN and increased risk for heart disease
● Healthy adult → no more than 2300 mg of salt a day
● Substitute no-salt-added versions of soups and vegetables
○ Renal Diet
■ Monitor and limit intake of minerals such as potassium, phosphorous, and
sodium
■ Avoiding table salt, not adding salt to foods while cooking, avoiding processed
meats, consuming “no salt added” foods, avoiding soups unless low sodium
■ High potassium → heart dysrhythmias → increase risk of myocardial infarction
■ Avoiding potassium-rich foods → bananas, grapefruit juice, honeydew melons,
cantaloupe, dried beans, prune juice, tomatoes, tomato sauce, tomato juice,
oranges, orange juice, greens (spinach)
● Avoiding salt substitutes
● Small amounts of potatoes, granola, bran cereals, molasses
■ High phosphorus → increase risk for bone disease → calcium pulled from bones
→ increases risk for fractures

● Factors that affect nutrition

 ○ Gender → women need less calories than men
○ Age → older clients need less calories
○ Activity Level → more active people need more calories than sedentary persons
○ Daily dietary intake for adults → 2 cups of fruit, 2.5 cups vegetables, 6 oz of grains,
5.5 oz of protein, and 3 cups of dairy products

Oxygenation
● Types of O2 Masks
○ Nasal Cannula
■ Preferred method → less intrusive
■ Deliver oxygen through prongs inserted into nares → oxygen inspired when
client inhales
■ Lower oxygen requirements in stable patients
■ Tubing goes over ears and under chin
■ Allows for eating/drinking, avoids rebreathing of CO2
■ Can cause skin breakdown → prevented by humidified oxygen
■ Flow Rate: 1-6 L/min
○ Simple Face Mask
■ For short term, moderate oxygen requirements → medium concentration
■ Inexpensive and can be used on mouth breathers
■ Flowmeter can keep flow at a constant rate → oxygen delivered based on
depth/rate of client’s breathing
■ Can retain CO2 during exhalation
■ May cause claustrophobia
■ Monitor patients → especially those with nausea/vomiting
■ Provide skin care to avoid breakdown
■ Flow Rate: 6-10 L/min
○ Partial Rebreather Mask
■ For short-term use with acute illness and trauma
■ Similar to simple face mask, but has a reservoir bag → bag must remain inflated
to prevent retention
■ Good seal around the face → not to be used with humidification
■ Risk of atelectasis and oxygen toxicity
■ Flow Rate: 10-15 L//min
○ Venturi Mask
■ For more precise O2 delivery for low-moderate O2 needs → fixed-performance
device that delivers at high concentrations
■ Reduces rebreathing of exhaled air → works independently of client breathing
factors and oxygen flow
■ Can be noisy and feel claustrophobic; interferes with eating/drinking
■ Flow Rate: 4-12 L/min
○ Non-rebreather mask
■ High flow oxygen requirements for emergencies
■ Flow Rate: 10-15 L/min
 ○ High-flow Nasal Cannula
■ For patients with high O2 needs for longer period of time
■ Provides humidification to reduce dryness
■ Flow Rate: up to 60 L/min
○ Aerosol Mask
■ Used to administer nebulized solutions → medications changed from liquid form
into a mist, which the client inhales
■ Used at home or in medical facilities
■ Comes with either a mouthpiece or a mask
■ Breathing treatments → corticosteroids (decrease lung inflammation) and
bronchodilators (open the airways)
○ Positive Airway Pressure Treatment
■ Patients in need of pressure support to maintain open airway
■ Can provide rate control
■ Last step before intubation
■ CPAP (continuous positive airway pressure) → machine with a hose and either
a mask or nose piece that delivers flow of constant/steady air → keeps upper
airway open
● Keeps alveoli open and improves amount of oxygen in the client’s blood
● Treatment for OSA (obstructive sleep apnea), premature infants, clients with
cardiopulmonary disease (stroke, hypertension, CAD)
● Utilized with or without supplemental oxygen
■ BPAP (bilevel positive airway pressure) → air moves through a tube into a mask
that fits over the client’s nose
● Pressures are higher when inhaling and lower when exhaling → CPAP
delivers a single pressure
● Recommended for clients whose airway collapses while they are sleeping →
difficulty breathing and decreased air exchange in the lung
● Required for clients who have disorders that cause muscle weakness that
inhibits breathing → COPD, heart failure, sleep apnea
○ Ventilator
■ Patients in respiratory failure and unable to support own airway
■ Flow rate per life support needs
● Nursing Interventions
○ Sputum Specimen Collection
■ Sputum examined by lab
■ Must be collected with correct equipment/technique → preferably before
eating/drinking in the morning
○ ​Chest physiotherapy (CPT): percussion of the chest, vibration, and postural
drainage.
■ Enhances the clearance of secretions from the lungs through the use of external
mechanical maneuvers.
■ Beneficial for COPD, cystic fibrosis, pneumonia or other clients who are unable
to expectorate thick, copious secretions
 ■ Expansion of alveoli, decreased infection risk, strengthening of respiratory
muscles
■ Clearing from airway toward the bronchi and trachea → postural drainage
■ Lasts between 20-30 minutes and performed up to 4 times a day
■ Cupping hand and using a clapping motion to the back → hollow sound is heard
● Avoid ribs, sides of chest, lower back, breast bone, spine
■ Document vital signs, characteristics/color/amount of sputum, and any
complications
○ Incentive Spirometer
■ Used by clients to promote deep breathing
■ Breathing in → 10 repetitions per hour with each breath held for 3-4 sounds
■ Improves pulmonary function and clears breath sounds
■ Decreases risk of atelectasis
○ Pursed lip breathing
■ Can release air trapped in the lungs by keeping the airway open for easier
breathing, slows breathing, encourages relaxation
■ Helps with breathlessness
■ Similar to blowing in a straw through a glass of water
○ Cough and deep breathing
■ Postsurgical clients → prevent pneumonia → aid in expansion of the lungs and
clearing secretions
● Use a pillow for splinting abdomen and chest for support
■ Take a deep breath, hold it for several seconds, exhale slowly → repeat 5 times
→ brace incision and try to cough deeply → repeat every 1-2 hours
○ Huff breathing
■ Clears music from the lungs
■ Inhaling air and holding it → forcefully exhaling to permit mucus to be coughed
out of the lung (not as forceful as a regular cough) → similar to exhaling onto a
mirror or streaming up a mirror
● Cycle of 4-5 huffs
○ Suctioning
■ Clears airway and prevent respiratory infections
■ Performed through mouth, nose, tracheostomy, or endotracheal tube →
improvement in client’s oxygenation and decreased respiratory effort
■ Closed → catheter in a sheath so suctioning can be done quickly without
interrupting ventilation
● Aseptic (clean) technique
■ Open → single-use unsheathed suction
● Sterile technique
○ Tracheostomy
■ Long-term airway management device inserted into the trachea through a
surgical opening in the front of the neck below the vocal cords
■ Hyperoxygenate client before placing catheter → withdraw while intermittent
suction is applied → hyperoxygenate again and allow to rest
 ■ Perform care to → maintain patency, prevent secretion buildup in the cannula,
avoid skin breakdown at stoma site, and avert accumulation of bacteria on the
inner surface of the cannula
■ Stoma site care, cleaning, replacing tracheostomy tube’s inner cannula →
perform every 4-8 hours
○ Closed chest drainage
■ Chest tube → inserted into the pleural or mediastinal space of the thorax of the
client → allows for drainage of blood, fluid, or air
● Facilitates lung expansion and restoration of normal intrapleural pressure
■ Used in emergency situations or for postoperative drainage
■ Three-chamber drainage system
● Collection chamber → drainage from chest tube collected
● Water seal chamber → allows air to exit chest during exhalation and
prevents air from entering hen client inhales
○ Inject sterile water to assess for tidaling → absence indicates normal
intrapleural pressure
■ Bubbling may signal air leak
● Suction chamber → wet or dry
○ Wet suction → filled with sterile water; attach to wall suction and gentle
bubbling
○ Dry suction → nothing inserted; regulator of suction
■ Drainage system should always be below the client’s chest and tubing should
not be kinked or occluded
■ Assess/document amount/color/consistency of drainage in the chamber
frequently
● Assess insertion site for redness, swelling, pain, signs of subcutaneous
emphysema
● Assess vital signs, breath sounds, oxygenation, and respiratory effort
frequently
● Health Promotion
○ Vaccinations
○ Healthy lifestyle
○ Environmental pollutants
● Cardiac Output → the volume of blood pumped by the left ventricle in 1 minute
○ CO = HR x SV
○ Ranges from 4-6 L/min
● Electrical Conduction of the Heart
○ SA node → atrioventricular (AV) node → Bundle of His → right and left bundle
branches → Purkinje fibers
○ Responsible for normal sinus rhythm → expected heart rhythm for adults
● Normal Breath Sounds
○ Bronchial → heard over the trachea and bronchi
○ Vesicular sounds → heard over lung tissue
● Adventitious Lung Sounds
 ○ Crackles → fluid filling the air sacs → popping and crackling
■ Ex. clients with pneumonia or an infection
○ Wheezing → whistling or musical noise heard on exhalation → caused by constricted
airways
■ Ex. clients with asthma and COPD
○ Rhonchi → rattling; caused by obstruction of the airway
■ Ex. clients with asthma and COPD
○ Stridor → sound like wheezing; caused by constriction in the upper airways heard on
inhalation
■ Medical emergency
■ Ex. inflammation of the epiglottis (epiglottitis) or by croup (a viral infection)
● Gas Exchange Terms
○ Diffusion → Large airways and bronchioles → deliver gas to the alveoli and the
pulmonary capillaries (blood vessels in the alveoli walls)
○ Ventilation → flow of air inside/outside the alveoli
■ Oxygen transported in, carbon dioxide taken out
○ Perfusion → flow of blood, driven by the cardiopulmonary system, into the alveolar
capillaries → deoxygenated blood exchanged for oxygenated blood there → travels
to the heart, which pumps it to the rest of the body
■ Oxygenated blood directed into the capillaries and deoxygenated blood is
returned to the lungs

Elimination
● Anatomy
○ Urinary Tract
■ Primary function → convert and remove excess waste and fluids from the body
in the form of urine
■ Healthy urinary tract also → regulates electrolyte levels and production of red
blood cells, produces hormones important for BP regulation, and keeps bones
strong
■ Kidneys → two bean-shaped organs located below the ribcage → each adjacent
to the spine
● Can filter 120-150 quarts of blood daily → also convert waste products and
excess fluid into urine to be removed from the body
● 1-2 quarts of urine produced each day
■ Urine transported from kidney to bladder by ureters → thin tubes of muscle
● One ureter from each kidney
■ Bladder → hollow, balloon-shaped muscle
● Fills and stretches to accommodate urine → holds up to two cups
● Muscles remain relaxed during urine filling
● At capacity → receptors send signal to the brain to tell patient it is time to
empty reservoir
● Amount of urine produced is determined by kidney function
 ■ Urination → body releasing urine through the urethra and out of the body once
the bladder has filled
● Muscles that prevent accidental urination
○ Urethra → connects to bladder at the bladder neck
○ Internal sphincter → within the bladder neck; holds urine inside the
bladder
○ Pelvic floor muscles → work with external sphincter to help support the
urethra
○ GI Tract
■ GI tract → mouth, esophagus, stomach, small and large intestines, anus
● Works with liver, pancreas, gallbladder → digest food/beverages so body
can utilize them and properly function
■ Mouth → food enters and chewing begins
● Food broken down and pushed into the throat → swallowed
○ Epiglottis → small flap of cartilage that prevents food/liquid from entering
the airway, but allows them to continue into the esophagus
■ Esophagus → peristalsis (muscle contractions) → moves food along pathway to
be digested
■ Stomach → food and liquid mixed with digestive secretions before being
emptied into small intestine
■ Small intestine → food and liquid continue to mix with digestive secretions from
the pancreas/liver/small intestine
● Peristalsis aids in transport to large intestine
● Nutrients absorbed by intestinal walls and enter into the bloodstream →
transported to other tissues for use by the body
■ Large intestine → liquid is absorbed from the waste by-product and stool begins
to form
● Peristalsis continues to move the stool until it reaches the rectum → pushed
out of the body through the anus during a bowel movement
● Types of catheters and ostomies
○ Straight/intermittent catheters → used as needed to empty the bladder, removed
when bladder emptying is complete
■ Done when placement of indwelling is not necessary or client does not wish to
wear a urine collection bag
■ Used with clients with paraplegia in conjunction with bladder training
○ External Catheters
■ Condom catheters → condom-like device placed on the penis with a collection
system attached to a urine bag
● Ensure no leakage of urine occurs around the device, client remains
clean/dry and catheter is changed daily
■ Female external urinary catheter → soft, flexible wick connected to wall suction
to pull urine into a drainage canister
● Alternative to indwelling catheters
 ● Do not predispose the urethra to infection and skin damage due to urine
pooling (unlike male condom catheters)
○ Indwelling catheters → resemble intermittent but have a small inflatable balloon at
the end of the catheter to hold the catheter in place inside the bladder for continuous
drainage
■ Sterile technique for insertion
■ Attached to urine collection bag that is attached to leg
○ Urostomy
■ Ileal conduit → surgically created diversion that uses part of the small intestine
● Repositioned with one end attached to the ureters and the other attached to
the abdomen wall
● Stoma is created to allow urine to pass into a pouch attached to the
abdominal wall
■ Cutaneous ureterostomy → ureters are attached directly to the stoma
○ Nephrostomy
■ Drains urine directly from the kidney into an external pouch
■ Tube surgically inserted through the skin on the back and into the kidney →
usually performed following the removal of kidney stones
■ Usually temporary and removed once the kidney has healed
○ Cystostomy (Suprapubic Catheter)
■ Similar to urinary catheterization but more invasive
■ Catheter inserted directly into the bladder and attached to a drainage bag
outside the client’s abdomen
○ Ileostomy
■ Temporary or permanent fecal diversion that uses terminal end of small intestine
(ileum)
■ Permanent ileostomies → entire colon (including rectum/anus) must be removed
or bypassed
■ Redirects ileum through surgically created opening (stoma or ostomy) in
abdominal wall to allow for stoll drainage
■ Temporary → stoma can be reversed by removing ileum from abdominal wall
and reattaching it to colon → so bowel contents can continue to pass through
○ Colostomy
■ Fecal diversion in which the part of the colon is used to form a stoma through
the abdominal wall, allowing for the passage of body waste
■ Can be temporary or permanent
■ Colostomy irrigation
● Especially beneficial for clients with permanent colostomies who had
expected bowel function prior to the procedure
● Sterile water inserted into colon via stoma site → acts as a type of bowel
training → prevents passage of stool at other times and reducing client’s
need to wear a colostomy pouch
● Also prevents constipation
● Urinary retention → bladder does not completely empty with urination
 ○ Can be due to prostate enlargement or a cystocele (prolapsed bladder)
■ Males more likely to develop due to an enlarged prostate
● Common in males older than age 40 and with a family history of BPH
○ Can cause UTIs, bladder damage, kidney damage, urinary incontinence
○ Difficulty urinating, pain, abdominal distention, urinary frequency, urinary hesitancy,
weak/slow urine stream, urinary leakage
○ Can lead to stones or UTI
○ Interventions → find source of the problem, once the bladder is drained of urine
■ Cause and treatment of enlarged prostate
■ Cystoscopy → look inside urethra and bladder → determine whether cause
related to stone or another lesion
■ Vaginal pessary → females with bladder prolapse → strop urine from leaking
■ Surgery
■ Physical therapy
● Factors that can cause constipation
○ Low-fiber diet
○ Drinking too little water
○ Most common after pregnancy and in older adults
○ Certain medications → antacids, anticholinergics, antispasmodics, anti-seizure
meds, CCBs, diuretics, iron supplements, narcotics, antidepressants
○ GI disorders → IBS-C
○ Immobility
● Nursing interventions (Urinary Elimination)
○ Urinal and Bedpan Use
○ Bladder Irrigation
■ Prescribed solution is connected to a urinary catheter → prevents blood clots
from forming in the bladder or to remove any clots that may be present
■ Explain to client what to expect and what to alert the provider to
■ Bladder irrigation is usually uncomfortable → filling of the bladder and urinary
catheter
● Not pain → report immediately to the provider
○ Lifestyle Changes → reducing caffeine intake, avoiding bladder irritants (alcohol,
acidic fruits, chocolate, solid, spicy food), balancing amount of fluids, smoking
cessation and weight loss
○ Bladder Training → retraining bladder by gradually increasing the time between
bathroom visits and setting a schedule
○ Bladder Scanning
■ Determines need for catheterization; calculates volume of urine in bladder
■ Reduces need for unnecessary catheters and CAUTIs
○ Catheterization
○ Medications → antidiuretics
● Nursing Interventions (Bowel Elimination)
○ Lifestyle changes → dietary modifications (high in fiber, fruits, vegetables), stress
reduction techniques, adequate hydration, staying active, regular exercise
 ○ Enema → instillation of liquid solution through the anus to relieve constipation or
cleanse bowel in preparation for diagnostic testing, procedure, or surgery
■ Tap water, 0.9% saline, sodium phosphate
■ Cleansing enema
■ Retention enema
○ Medications → laxatives and stool softeners
○ Rectal Tube → used in intensive care units to assist with protecting skin from
breakdown and infection when there is no bowel control
○ Bowel Training
● *Diversions and Ostomies are performed when nursing interventions are no longer an
option
● Types of incontinence
○ *Incontinence is most commonly related to UTIs
○ *Incontinence can be very irritating to skin → use pads, incontinence briefs, and
waterproof undergarments to absorb leaking urine
○ Stress incontinence → coughing, sneezing, laughing, or physical activity that
increases pressure on the bladder
■ Occurs in pregnant females or later in life due to loss of pelvic floor muscle tone
○ Urge incontinence → strong urge to urinate, but leaking occurs before getting to the
toilet
■ Results from nerve damage, weak pelvic muscles, ore decreased physical
mobility
○ Reflex incontinence → urinary leakage as a result of nerve damage
○ Overflow incontinence → incomplete bladder emptying which results in the bladder
overfilling when full, leading to urine leakage
○ Functional incontinence → physical inability to reach the toilet in time
■ Due to physical impairment such as being wheelchair bound or having arthritis
of the hands (can hinder fine motor skills needed to unbutton clothing)
○ Bedwetting (Nocturnal enuresis) → common in children but may occur in adults who
have consumed too much alcohol, who consume caffeine at night, or who take
certain medications
● Alterations in elimination
○ Alterations in urinary elimination → usually treatable or manageable
■ Lifestyle changes, provide bladder training, instruct clients how to perform pelvic
floor muscle exercises
■ Risk factors → urinary anatomy, privacy, medication
■ Urinary catheterization
● Intermittent (straight cath)→ short-term; taken in and out
■ Types: Urinary Incontinence, Urinary Retention
○ Alterations in bowel elimination → usually treatable or manageable
■ Lifestyle changes, provide bowel training, provide client with agents to stimulate
a bowel movement
■ Types: Bowel Incontinence, Diarrhea, Constipation
*Other Med Stuff (Not in her original study list):
● Dispensing Medications
○ Process: Provider (writes prescription) → Pharmacist or pharmacy technician
(prepares meds and distributes to storage areas) → Nurse (administers/distributes
medication)
○ Storage Areas
■ Medication carts → unit-dose packaging → each client’s meds in individual
drawer labeled with their name (some have barcodes)
■ Individual medication cabinets → all meds except controlled substances
■ Medication rooms → stock medications, multi-dose medications, emergency
medications, intravenous solutions, and medication supplies
○ Automated Dispensing Devices
■ Access to all medications including controlled substances
■ Electronic checks built in → if all criteria met, drawer opens with the med
■ Advantages → adherence to controlled substance regulations, reduced
medication errors and cost, improved accuracy in documentation
■ Disadvantages → limited number of systems on each unit so nurses have to
wait to obtain access to meds; never retrieve more than one client’s medications
at one time
● Injectable Medications:
○ Routes of Administration
■ Intradermal → less than 0.1 mL fluid → into dermis
● Site: forearm or upper back → easily accessible for monitoring → hairless,
free of wounds/lesions/tattoos
● Ex. tuberculosis and allergy testing
● Syringe: Tuberculin
○ 25- or 27-gauge, 6.35-16mm needle
● Process:
○ Clean injection site
○ Pull skin taut with nondominant hand → decrease discomfort and
increase ease with insertion
○ Insert needle at 5-15 degree angle with bevel up → advance approx.
3mm
○ Inject slowly → small bleb should appear
○ Withdraw needle at same angle it was introduced
■ Subcutaneous → 0.5 -1mL fluid → into tissue just below dermis
● Site: outer posterior aspects of upper arm, abdomen, upper back, upper
area of hip below waist, and anterior/interior aspects of thighs → convenient
and good blood supply → no skin lesions and no areas over bony
prominences
● Ex. Anticoagulants (heparin & enoxaparin) and insulin
○ Anticoags → must be at least 2 inches away from umbilicus
 ● Syringe → depends on site, client body weight, and amount of tissue present
○ Typically 25- to 31- gauge, 12-16mm needle
■ Length is ½ width of injection site skinfold
○ Shorter needle → insert at 45 degree angle
■ Skinfold is 1 inch or less
○ Larger needle → insert at 90 degree angle
■ Skinfold is greater than 1 inch
● *Note: slower absorption rate than intramuscular
■ Intramuscular → large volumes of medications
● Sites → identify landmarks
○ Larger Muscles → large medication amounts
■ 1 mL for older infants and young children; 2 mL for older children,
older adults, and individuals who are thin (some adults have muscles
developed enough to tolerate up to 3 mL of medication)
■ Ventrogluteal muscle
● Preferred for children/adults
● Not close to any major nerves or blood vessels
● How to locate site: Place palm on client’s greater trochanter with
thumb pointed towards client’s groin, index finger lies across
anterior superior iliac spine and middle finger under iliac crest
○ Inject at middle of triangular area formed by index/middle
finger and iliac crest

■ Vastus Lateralis Muscle

● Anterolateral aspect of thigh; well-developed muscle in
children/adults
● Preferred site for infants
● How to locate site: Select area in the middle third of the thigh
between the greater trochanter and just above the knee

○ Deltoid Muscle → upper arm; small and not well-developed in adults

■ Used for immunizations for adults/children older than 18 months
■ Not the best choice → located near many nerves/arteries
■ No more than 1 mL of solution
 ■ How to locate site: Find the center of upper arm that is 3-5 cm below
the acromion process

● Ex. Medication injections (Morphine, Cyanocobalamin) and some

vaccinations (Hepatitis B, Tetanus)
● Syringe → size depends on client size, muscle used for injection, and
medication viscosity
○ Thicker medication → larger-gauge needle
■ Intravenous → used for administering meds and providing
fluids/electrolytes/nutrition
● Short Peripheral IV Catheter
○ Less than 3 inches long
○ Tip rests in superficial vein in one of the extremities
● Central Lines
○ Terminate in superior vena cava
○ Peripherally inserted central catheters (PICC)
■ Done by nurses with advanced education/training
■ How to insert: goes peripherally into a vein in the upper arm and is
threaded so the tip lies in superior vena cava
■ Use → clients needing administration of long-term IV medications,
vesicant medications, and parenteral nutrition
■ No blood draw
○ Nontunneled central venous catheters
■ Done by physician or advanced practice nurse
■ Tip lies in the superior vena cava
■ How to insert: goes into subclavian vein in upper chest or through
internal jugular vein
■ Use → cases of trauma and critical care; blood draw and meds
○ Insulin
■ Insulin injections are used with absolute or relative deficiency of insulin → they
promote entry of glucose, potassium, and amino acids in to the cells, while also
promoting the conversion of glucose into glycogen in the liver
■ Administration
● Subcutaneous
● Individual injections or continuous infusion via insulin pump
● IV infusion → when client needs rapid reduction of blood glucose
○ Regular insulin, insulin lispro, insulin aspart, insulin glulisine
■ Types:
● Rapid-acting insulin → most rapid onset; shortest duration
○ Works 10-15 minutes after administration
○ Administered immediately before meal to prevent hypoglycemia
○ Clear
○ subQ or IV
○ Ex. insulin lispro, insulin aspart, insulin glulisine
● Regular Insulin → short-acting
○ Works 30 minutes after administration
○ Clear
○ subQ or IV
■ IV → situations like diabetic ketoacidosis
● Intermediate-acting insulin
○ Works 1-2 hours after administration
○ NPH insulin → cloudy suspension with protein → delays onset/duration
■ Only insulin preparation that is a suspension and requires agitation
before drawn into a syringe
■ Often mixed with regular insulin
■ subQ
● Long-acting insulin
○ 18-24 hour duration
○ Glargine
■ U-100 → 18-24 hrs
 ■ U-300 → ultra long-acting insulin supplied in prefilled injection pens →
duration longer than 24 hours
○ Detemir → ultra long-acting → longer than 24 hours
○ Administered in morning, afternoon, or evening → but has to be same
time every day
○ Degludec
● Premixed insulin combinations
○ Useful for clients who have difficulty mixing (poor eyesight or dexterity
issues)
○ Contains one intermediate- acting insulin and one rapid- or short-acting
insulin
■ Ex. 70% NPH insulin and 30% regular insulin OR 70% insulin aspart
protamine and 30% insulin aspart
■ Source of insulin can affect onset, peak, and duration times
■ Insulin is measured in units
● Most common concentration → U-100 → 100 units of insulin in 1 mL
● U-500 → 500 units in 1 mL of solution → used for clients with severe insulin
resistance and require large doses; not frequently prescribed; administered
only subQ
■ Most insulin is dispensed in vials containing 10mL of medication
■ *Client education is critical because of routine at-home insulin administration →
discuss purchase/storage of insulin, syringes, monitoring supplies;
prep/administration; identify/treat complications; onset, peak,duration
● Self-monitoring of glucose & periodic lab measurement of glycosylated
hemoglobin (hemoglobin A1c) assists provider in prescribing therapeutic
dose
■ Insulin pens → disposable needle, insulin-filled cartridge, dial to measure dose
■ External infusion pumps → regular or rapid-acting insulin subQ over 24 hours →
infuses at set basal rate that mimics pancreatic secretion of insulin → can be
worn in pocket or on belt → contains syringe with insulin connected to needle
placed subQ
■ Insulin syringes
● U-100 syringe → orange cap; U-100 insulin
● U-500 syringe → green cap; U-500 insulin (concentrated
● Lower dose syringes → more accurate for smaller doses (<30 units); 1 unit
increments
■ Mixing Two Insulin Types
● Only short- or rapid-acting insulin can be mixed with another insulin
● Administer in same syringe if can be mixed
● Process
○ Roll vial → cleanse tops of the vials → draw 20 units of air into the
syringe → inject air into bottle → draw 5 units of air into the syringe and
inject air into the regular insulin vial → invert the vial and draw up 5 units
of insulin → re-insert the needle into the vial
● Oral Medications
○ Solid Medications
■ Forms:
● Tablet → disk-like; must be scored to divide in half
● Enteric-Coated Tablet → coated with compound that will not dissolve until
the tablet passes through the stomach and is exposed to the fluids in the
small intestine → prevents irritation of the stomach lining
● Troche → flat, round tablet (a.k.a lozenge)
○ Dissolved in mouth, not swallowed!
● Capsule → encased in a container made of gelatin
○ Sustained-release capsule → medication contained in small beads with a
coating that allows release over a period of time → usually 12-24 hours
(once or twice a day dose)
● Caplet → cross between a capsule and tablet
■ Routes of administration
● Swallowing → primary route
● Liquid preparations → if patient cannot swallow or they have
enteral/small-bore feeding tube
○ Some medications can be crushed and mixed into small amount of fluid or
soft food
○ Do not crush → delayed-release, long-acting, enteric-coated,
capsule-dispensed, unpleasant-tasting or irritating to mucous membranes
medications
● Troche → dissolves in mouth → *nothing to eat/drink 5 minutes before/after
● Sublingual/buccal → local/systemic effects
○ Do not chew/swallow and do not eat/drink anything until fully dissolved
○ Sublingual → under tongue → absorbed directly into bloodstream (faster
than swallowed meds)
○ Buccal → between client’s cheek and gum → dissolve
■ *Note: alternating sides with each administration prevents mucosal
irritation
○ Liquid Medications
■ Prescribed using mcg, mg, g, and mEq → dispensed using mL and oz
■ Use calibrated measuring devices → dosing spoons, medication cups, oral
syringes, calibrated medication droppers
■ Forms:
● Elixir → water, alcohol, sweetener, medication
○ Ex. Hydrocodone, Acetaminophen
● Syrup → water, concentrated sugar, medication
○ Ex. Valproic acid
● Suspension → small/fine particles of med that don’t dissolve completely in
water → must shake or stir immediately prior to administration
○ Ex. Ampicillin
● Solution → medication dissolved in water or 0.9% sodium chloride
 ○ Ex. Furosemide
■ Calibrated Measuring Devices:
● Medicine cup → 5-30 mL
● Medicine spoons → 1-10 mL
● Calibrated oral syringe, dropper, or medicine spoon → doses less than 5 mL
● *Educate patient → household spoons do not provide accurate doses
● Powdered Medications
○ Reconstitution → from powder to liquid right before administration
■ Some meds are unstable in liquid form for an extended period of time →
reconstituting makes sure it is stable when it goes into the body
■ Add appropriate fluid (diluent) directly to bottle/vial
○ Diluents
■ Common additives → 0.9% NaCl, D5W, sterile water, and bacteriostatic water
■ For oral medication → can use tap water or bottled water
○ Syringe Usage
■ Understand oral vs. parenteral syringe
● Oral syringe does not have Luer-Lok hub

■ Administration can be Oral, IV, IM, or subQ

○ Process
■ Gather your supplies → two aseptic wipes and two syringes with needles that
are appropriate for amount of diluent, vial of powdered medication, vial of
diluent, sharps container
■ Perform hand hygiene
■ Read vial of medication to verify type and amount of diluent to add; Read diluent
■ Clean access diaphragm on top of medication vial with an aseptic wipe; with
new aseptic wipe, cleanse access diaphragm of diluent vial to prevent
contamination
■ Attach one of the safety needles to one of the syringes
■ Pull back on syringe plunger to recommended amount of diluent to inject into
vial → prevents buildup of negative pressure in the vial
■ Remove cap from the needle → keep vial on table and insert needle into diluent
vial
■ Inject air by pushing plunger down
■ Leaving needle and syringe in place, invert vial → withdraw amount of diluent
from vial, ensuring syringe is free from air bubbles
■ Turn vial right-side up with the needle still in it, then withdraw needle → insert
needle into top of medication and inject diluent into vial
 ■ Withdraw needle and close safety cap → discard into sharps container
■ Mix medication vial → roll vial gently between palms of hands or gently upend
and rotate it → do not shake it unless directed by manufacturer (air bubbles)
■ Read vial carefully to determine dose after reconstitution and withdraw desired
amount using new syringe and needle
○ *Always label vial after reconstitution → dosage strength, date/time of prep,
date/time of expiration, storage method, and initials