Fundamentals
of
Nursing
rnursingnotes rnursingnotes
The nursing process
''ADPIE''
1. Assessment
Gather information & review
Verify the information collected is clear & accurate
2. Diagnosis
Interpret the information collected
Identify & prioritize the problem through a nursing diagnosis
3. Planning
Set goals to solve the problem
Prioritize the outcomes of care
4. Implementation
Reaching those goals through performing the nursing action
"Implementing" the goals set above in the planning stage
5. Evaluation
Determine the outcome of the goals
Evaluate the patient compliance
Document client's response to pain
Modify & assess for needed changes
Abbreviations
Abd Abdomen
A.B.G Arterial blood gas DX Diagnosis
ADL Activities of daily living ECG Electrocardiogram
a.c Before meals Fx Fracture
A&O Alert & Oriented h.s At bedtime
BP Blood pressure HOB Head of bed
dc Discontinue HOH Hard of hearing
H&H Hemoglobin & Hematocrit H&P History & physical
DNR Do not resuscitate HR Heart rate
ICU Intensive care unit PO By mouth
I&O Intake & output p.r.n As needed
IM Intramuscular ROM Range of motion
IV Intravenous S&S Signs & Symptoms
NGT Nasogastric tube Stat Immediately
NPO Nothing by mouth U/A Urinalysis
CPR Cardiopulmonary VS Vital Signs
PPE Resuscitation PERRLA Pupils equal, round,
Personal Protective
reactive to light &
Equipment
accomodation
Nursing Ethics & Law
Patient Rights HIPAA
Privacy The Health Insurance Portability &
Accountability Act
Considerate & respectful care
Be informed Patient's records are private &
Know the names & roles of the they have the right to ensure
persons who are involved in the medical information is not
care shared without permission
Consent or refuse a treatment All health care professionals must
Have an advance directive inform the patient how their
Obtain their own medical health information is used.
records & results The patient has the right to
obtain a copy of their personal
health information.
Ethical Principles
Autonomy respect for an individual's right to make their own
decisions
Nonmaleficence obligation to do & cause no harm to others
Beneficence duty to do good to others
Justice distribution of benefits & services fairly
Veracity obligation to tell the truth
Fidelity following through with a promise
Types of Consent
Admission Agreement Surgical Consent
Immunization Consent Research Consent
Blood Transfusion Special Consent
Treatment cannot be done without the patient's consent.
In case of emergency when a patient cannot give consent, consent is
implied through emergency laws.
Those under 18 (minors), consent must be obtained from a parent or
legal guardian.
Take note!
Before signing the consent, the pt must be informed of the ff risks & benefits of
surgery, treatments, procedures, & plan of care in layman's terms so the pt
understands clearly what is being done.
Manipulation NCP
Promote 3C's
Cooperation
Compromise
Collaboration
Roles and fuction of a Nurse
Change agent Caregiver
identifies a vision and As a caregiver, a nurse provides
rationale for the change and is hands-on care to patients in a
a role model for nurses and variety of settings. This
other health care personnel. includes physical needs, which
can range from total care
(doing everything for someone)
Leader
to helping a patient with illness
prevention.
A nurse leader oversees a team of
nurses, making decisions and
directing patient care initiatives.
They have advanced clinical
Communicator
knowledge and are focused on
As a communicator, the nurse
improving patient health outcomes
understands that effective
communication techniques can help
improve the healthcare
Manager environment. Barriers to effective
communication can inhibit the
esponsible for managing human and healing proces
financial resources; ensuring patient and
staff satisfaction; maintaining a safe
Teacher
environment for staff, patients, and
visitors; ensuring standards and quality of Nurse educators inspire, teach,
care are maintained; and aligning the and mentor the next generation
unit's goals with the hospital's strategic of nurses, leading the way to the
goals future of patient care
Case Manager Client advocate
A nurse advocate is a nurse who works
A nurse case manager develops, on behalf of patients to maintain
implements, and reviews healthcare quality of care and protect patients'
plans for patients that are geriatric, rights.
recovering from serious injuries, or
dealing with chronic illnesses.
Counselor
Researcher the nurse may represent the client's
needs and wishes to other health
identify research questions, design and professionals, such as relaying the
conduct scientific studies, collect and analyze client's wishes for information to the
data and report their findings physician.
Glasgow coma scale
Behaviour Response
4. Spontaneously
3. To speech
2. To pain
1.No response
Eye opening response
5. Oriented in time, person and place
4. Confused
3. Inappropriate words
Verbal response 2. Incomprehensible sounds
1. No response
6. Obeys command
5. Moves to localised pain
4. Flex to witthdraw from pain
3. Abnormal flexion
Motor response 2. Abnormal extension
1. No response
Maslow's hierarchy of basic needs
the realization of one's best qualities +
Self
drive to reach their full potential actualization
Self-respect and independence Self - esteem
Affection, feeling loved, relationship
Love & Belonging
Physical + emotional safety
Safety & Security
air, food, water, shelter, sleep and
temperature regulation Physiological Needs
Laboratory and Diagnostic Examinations
Urine Specimen
1.Clean-Catch mid-stream urine
-specimen for routine urinalysis, culture and sensitivity test
Best time to collect is in the morning, first voided urine
Provide sterile container
Do perineal care before collection of the urine
Discard the first flow of urine
Label the specimen properly
Send the specimen immediately to the laboratory
Document the time of specimen collection and transport to the lab.
Document the appearance, odor, and usual characteristics of the specimen
2. 24-hour urine specimen
Discard the first voided urine
Collect all specimens thereafter until the following day
Soak the specimen in a container with ice
Add preservative as ordered according to hospital policy
3. Second-Voided urine
Discard the first urine
Give the patient a glass of water to drink
After few minutes, ask the patient to void
4. Catheterized urine specimen
Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the
bladder and adequate specimen can be collected.
Clamping the drainage tube and emptying the urine into a container are
contraindicated after a genitourinary surgery
Collecting a catheter specimen of urine
Stool Specimen
1.Fecalysis
- to assess gross appearance of stool and presence of ova or parasite
Secure a sterile specimen container
Ask the pt. to defecate into a clean, dry bed pan or a portable commode
Instruct client not to contaminate the specimen with urine or toilet
paper (urine inhibits bacterial growth and paper towel contain bismuth
which interfere with the test result.
Laboratory and Diagnostic Examinations
2. Stool culture and sensitivity test
To assess specific etiologic agent causing gastroenteritis and bacterial
sensitivity to various antibiotics.
3. Fecal Occult blood test
Are valuable test for detecting occult blood (hidden) which may be
present in colo-rectal cancer, detecting melena stool
Hematest – (an Orthotolidin reagent tablet)
Hemoccult slide– (filter paper impregnated with guaiac)
Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.
Colocare – a newer test, requires no smear
Instructions
Advise client to avoid ingestion of red meat for 3 days
Patient is advice on a high residue diet
Avoid dark food and bismuth compound
If client is on iron therapy, inform the MD
Make sure the stool in not contaminated with urine, soap solution or toilet paper
Test sample from several portion of the stool.
Venipuncture
Never collect a venous sample from the arm or a leg that is already being
use d for I.V therapy or blood administration because it mat affect the
result.
Never collect venous sample from an infectious site because it may
introduce pathogens into the vascular system
Never collect blood from an edematous area, AV shunt, site of previous
hematoma, or vascular injury.
Don’t wipe off the povidine-iodine with alcohol because alcohol cancels the
effect of povidine iodine.
If the patient has a clotting disorder or is receiving anticoagulant coagulant
therapy, maintain
pressure on the site for at least 5 min after withdrawing the needle.
Arterial puncture for ABG test
Before arterial puncture, perform Allen’s test first.
If the patient is receiving oxygen, make sure that the patient’s therapy has been
underway for at least 15 min before collecting arterial sample
Be sure to indicate on the laboratory request slip the amount and type of oxygen
therapy the patient is having.
If the patient has just received a nebulizer treatment, wait about 20 minutes
before collecting the sample.
Blood Specimen
No fasting for the following tests:
CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes
Fasting is required:
FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride)
Sputum Specimen
1.Gross appearance of the sputum 3. Acid-Fast Bacilli
Collect early in the morning To assess presence of active
Use sterile container pulmonary tuberculosis
Rinse the mount with plain water before Collect sputum in three consecutive
mornings
collection of the specimen
Instruct the patient to hack-up sputum
2. Sputum culture and sensitivity test 4. Cytologic sputum exam
Use sterile container To assess for presence of abnormal
Collect specimen before the first or cancer cells.
dose of antibiotic
Blood Components
Antigen
Plasma Proteins that elicit immune response
55% Identifies the cell
WBC's
1% Plasma Antibodies
Protects body from “invaders” (think
RBC's ANTI) Opposite of the type of antigen
45% that is found on the RBC
Blood Types
Blood type Antigen Antibodies Can donate to Can receive from
Ab AB, A,
AB A, B None
A&AB B&O
A A B
B&AB A&O
B B A
AB, A, B, B&O
O None A&B
&O O
Rh factor
Has Rh on surface Can receive
Does not have Rh on surface Can receive
Lab value memory tricks
Electrolytes
Magnesium: 1.5 - 2.5
Potassium: 3.5-5.0 mEq/L
MAGnifying glass
You buy 3-5 bananas
uou see 15 - 25
at a time.
bigger than normal
Chloride: 98-106 mEq/L Phosphorus: 2.5-4.5
Think of a chlorinated pool that you PHOR: 4
want to go in when its SUPER HOT: 95- US: 2 (me + you = 2)
105°F *dont forget the 5
Calcium: 9-11 mg/dL Sodium 135-145
CALL 911 *commit to memory!
Complete Blood Count (CDC)
Hemoglobin Female
Female: 12-16 g/dL
12 x 3 = 36
Male: 13 - 18 g/dL
16 x 3 = 48
Hematocrit To remember HCT, Male
Female: 36% 0 48% multiply Hgb by 3 12 x 3 = 36
Male: 39% - 54% 16 x 3 = 48
Basal Metabolic Panel (BMP)
BUN: 7- 20 mg/dL Creatinine: 0.6-1.2 mg/dL
Think of hamburger BUNs.. This is the same value as
Hamburgers can cost anywhere LITHIUM's therapeutic range (0.6 - 12 mmol/L)
from $7- $20 dollars
Lithium is excreted almost solely by the kidneys.
And creatinine is a value that tests how well your
kidneys filter
Blood Transfusion
Advantages of blood component therapy
Avoids the risk of sensitizing the patients to other blood components.
Provides optimal therapeutic benefit while reducing risk of volume overload.
Increases availability of needed blood products to larger population.
Principles of blood transfusion therapy
1. Whole blood transfusion
Indicated only for patients who need both increased oxygen- carrying capacity
and restoration of blood volume when there is no time to prepare or obtain
the specific blood components needed.
2. Packed RBCs
Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a
maximum of 4 hours, it may be necessary for the blood bank to divide a unit into
smaller volumes, providing proper refrigeration of remaining blood until needed.
One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit
3%.
3. Platelets
Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes).
Each unit of platelets should raise the recipient’s platelet count by 6000 to
10,000/mm3: however, poor incremental increases occur with alloimmunization
from previous transfusions, bleeding, fever, infection, autoimmune
destruction, and hypertension.
4. Granulocytes
May be beneficial in selected population of infected, severely granulocytopenic
patients (less than 500/mm3) not responding to antibiotic therapy and who are
expected to experienced prolonged suppressed granulocyte production
5. Plasma
Because plasma carries a risk of hepatitis equal to that of whole blood, if only
volume expansion is required, other colloids (e.g., albumin) or electrolyte
solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be
administered as rapidly as tolerated because coagulation factors become unstable
after thawing.
6. Albumin
Indicated to expand to blood volume of patients in hypovolemic shock and to
elevate level of circulating albumin in patients with hypoalbuminemia. The large
protein molecule is a major contributor to plasma oncotic pressure.
7. Cryoprecipitate
Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated
intravascular coagulation (DIC), and uremic bleeding.
8. Factor IX concentrate
Indicated for treatment of hemophilia B; carries a high risk of hepatitis
because it requires pooling from many donors
9. Factor VIII concentrate
Indicated for treatment of hemophilia A; heat-treated product decreases the
risk of hepatitis and HIV transmission.
10. Prothrombin complex
Indicated in congenital or acquired deficiencies of these factors.
Administration of the Transfusion
1. Insert and IV line using an 18-19-gauge IV needle
2. Run it with normal saline (keep vein open rate)
3. Use the largest catheter part available
4. Begin the transfusion slowly
a. The first 15 min "MOST CRITICAL", monitor the patient for S/S of
any transfusion reaction.
b. Vital signs are monitored every 30 mins to 1 hour.
c. After 15 mins, the flow can be increased unless transfusion
reaction occurred.
5. Document the client's tolerance to the administration of blood product.
Transfusion Reaction
Is an adverse reaction that happens as a result of receiving blood
transfusion
Immediate chills, diaphoresis, aches, chest pain, rash, hives, itching,
transfusion reaction swelling rapid, thready pulse, dyspnea, cough or wheezing
Rise in venous pressure, Dyspnea, Crackles or rales,
Circulatory overload
Distended neck vein, Cough, Elevated BP
Rapid onset of chills, Vomiting, Marked Hypotension,
Septicemia
High fever
Iron overload Vomiting, Diarrhea, Hypotension, Altered hematologic
values
Nursing Actions to a
Transfusion Reaction
1. Stop the infusion
2. Change the IV tubing down to the IV site
3. Keep the IV open w/ normal saline
4. Notify the HCP and blood bank
5. Do not leave the client alone (monitor vs & continue
to assess the patient
Facts about blood transfusion
Administered by the RN
Only Normal Saline (NS) can be used in conjunction with blood
Type & screen and a cross match are good for 72 hours
30 minutes - from the time you received it from the blood bank to the
time you infuse
4 hours - All blood must be transfused
STOP the transfusion if you suspect transfusion reaction
Chain of infection
Stages of Infection
interval between the pathogen entering the
Incubation
body & the presentation of the first symptom
onset of the gen. symptoms to more distant
Prodromal Stage
symptoms; the pathogen is multiplying
Illness Stage symptoms specific to the infection appear
acute symptoms disappear and total recovery
Convalescence
could take days to months
Infection Control
PPE PERSONAL PROTECTIVE EQUIPMENT
Donning Doffing
Removing PPE
Putting on PPE
Remove PPE at the client's door way
Put on PPE before entering the client's room or outside the room
Do not touch your face while wearing PPE If hands become soiled while
Avoid touching areas in the client's room removing PPE, stop & perform hang
hygiene. Then, continue with PPE
removal.
Lab Values
Vital Signs Basic Metabolic Panel (BMP)
Blood Pressure: Sodium: 135 - 145 mEq/L
Systolic: 120 mmHg
Diastolic: 80 mmHg Potassium: 3.5 - 5.0 mEq/L
Heart Rate: 60 - 100 BPM Chloride: 95 - 105 mEq/L
Respirations: 12-20 bpm Calcium: 9 - 11 mEq/L
Oxygen: 95% - 100% BUN: 7 - 20 mEq/L
Temperature: 97.8°F - 99°F Creatine: 0.6 - 1.2 mg/dL
Albumin: 3.4 - 5.4 g/dL
Lipid Panel Total protein: 6.2 - 8.2 g/dL
Total cholesterol: <200 mg/dL
Triglyceride: <150 mg/dl
LDL: <100 mg/dL
ABG'S
HDL: >60 mg/dL PH:7. 35 -7.45
PaCO2:35 - 45 mmHg
Renal PaCO2: 80 - 100 mmHg
Calcium: 9 - 11 mg/dL
HCO3: 22 - 26 mEq/L
Magnesium: 1.5 - 2.5 mg/dL
Phosphorus: 2.5 - 4.5 mg/dL Liver Function Test
Specific Gravity: 1.010 - 1.030
GFR: 90 - 120 mL/min/1.73m2 Non-diabetic: 4 - 5.6%
BUN: 7 - 20 mg/dL Pre-diabetic: 5.7 - 6.4%
Creatine: 0.6 - 1.2 mg/dL Diabetic: > 6.5%
(GOAL for diabetic: < 6.5%)
Lab Values
Complete Blood Count (CBC) Pancreas
Amylase: 30 - 110 U/L
• WBC: 4,500 - 11,000
Lipase: 0 - 150 U/L
• RBC’s: 4.5 - 5.5
• PLT: 150,000 - 450,000 HbA1C
Hemoglobin (Hgb) Non-diabetic: 4 - 5.6%
Female: 12 - 16 g/dL
Male: 13 - 18 g/dL Pre-diabetic: 5.7 - 6.4%
Hematocrit (HCT) Diabetic: > 6.5%
Female: 36% - 48%
Male: 39% - 54% (GOAL for diabetic: < 6.5%)
COAGs Other
PT: 10 - 13 sec MAP: 70 - 100 mmHg
PTT: 25 - 35 sec ICP (intracranial
pressure): 5 - 15 mmHg
aPTT: 30 - 40 sec (heparin)
BMI: 18.5 - 24.9
INR
Glascow coma scale:
- NOT ON Warfarin < 1 sec
- ON Warfarin 2 - 3 sec Best = 15
Mild: 13-15
Moderate: 9-12
Severe: 3-8
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References:
Genieieiop (2017). 6 factors that influence the infectious agent in infecting a human body.
WikiMedia Commons. https://commons.wikimedia.org/wiki/File:Chain_of_Infection.png
RN Pedia (2021). Blood Transfusion Therapy. Retrieved from
https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/blood-transfusion-
therapy/
RN Pedia (2021). Laboratory and Diagnostic Examination. Retrieved from
https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/laboratory-
diagnostic-examination/
RN Pedia (2021). Roles and Function of a Nurse. Retrieved from
https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/roles-function-
nurse/
RN Pedia (2021). Theoretical Framework of Nursing Practice. Retrieved from
https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/theoretical-
framework-nursing-practice/
Tuttle, K. (2020). The Complete Nursing School Bundle. NurseInTheMaking LLC.
1.
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