Nadia R. Singh

NursiNgThe ulTimaTe sTudy guide

NURSINGThe Ultimate Study Guide

Nadia R. Singh, BSN, RN, graduated in 2008 with her Bachelor of Science in Nursing from Simmons College School of Nursing, Boston. Her clinical rotation experience included Boston Medical Center, Mas-sachusetts General Hospital, and Brigham and Women’s Hospital, all in Boston. From October 2008 to October 2009, Ms. Singh worked as a Medical Surgical Nurse at the Jupiter Medical Center, Jupiter, Florida, where she gained experience on a medical surgical/orthopedic unit as a member of an interdisciplinary team. Since February 2010, Ms. Singh has worked on a Medical Surgical/Telemetry unit with patients of varying acuities, gaining experience in all aspects of delivering nurs-ing care. She is certified in IV Infusion, Telemetry, Pressure Ulcer Care (ANA), and in BLS/ACLS by the American Red Cross. She is licensed to practice in three states (Massachusetts, New York, and Florida).

NURSINGThe Ultimate Study Guide

Nadia R. Singh, BSN, RN

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Library of Congress Cataloging-in-Publication Data

Singh, Nadia R. Nursing : the ultimate study guide / Nadia R. Singh. p. ; cm. ISBN 978-0-8261-9336-0 — ISBN 978-0-8261-9337-7 (e-book) I. Title. [DNLM: 1. Nursing Care. 2. Nursing. WY 100.1] LC classification not assigned 610.73—dc23 2011042453

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I dedicate this book to Mom, Dad, and Riaz.Thank you for everything.

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Contents

Reviewers xiPreface xiiiAcknowledgments xv

1. Fundamentals of Nursing 1History of Nursing 1Therapeutic Communication 2Vital Signs 3The Nursing Process 7Functional Health Patterns 9Immobility 10Oxygenation 11Fluids and Electrolytes 12Urinary and Bowel Function 16Medication Administration 17The Surgical Experience 18Bye Bye, Fundamentals; Hello, Health Assessment 19

2. Health Assessment 21Skin, Hair, and Nails 21Head, Eyes, Ears, and Nose 23Mouth and Lips 25Neck and Nodes Assessment 25Neurological System 25Thorax and Lungs 27Musculoskeletal Assessment 28Breast Assessment 30Abdominal Assessment 30

3. Medical-Surgical Nursing 33Cardiovascular Disorders 34Respiratory Disorders 42Neurological Disorders 49Endocrine Disorders 57Gastrointestinal Disorders 64Genitourinary Disorders 70

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Musculoskeletal Disorders 76Integumentary Disorders 81Immunological Disorders 84Oncological Disorders 86

4. Pharmacology 93Introduction to Pharmacology 94Cardiovascular Medications 96Respiratory Medications 104Neurologic Medications 110Endocrine Medications 113Gastrointestinal Medications 118Genitourinary Medications 121Musculoskeletal Medications 123Integumentary Medications 125Immunological Medications 126Chemotherapy Medications 128Antibiotics 131Pain Management 132

5. Pediatric Nursing 135Pediatric Physical Assessment 136Growth & Development 140Cardiovascular Disorders 142Respiratory Disorders 148Neurological Disorders 152Endocrine Disorders 156Gastrointestinal Disorders 159Genitourinary Disorders 166Musculoskeletal Disorders 169Hematologic Disorders 173Pediatric Cancers 176Ear, Eye, and Throat Disorders 178Infectious Disorders 179

6. Maternity Nursing 185Fetal Development 186The Prenatal Experience 187Labor and Delivery 192The Postpartum Experience 198The Newborn Assessment 202Newborn Complications 205Maternity Pharmacology 209

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7. Psychiatric Mental Health Nursing 213Psychiatric Disorders in the Adult Population 214Psychiatric Disorders in the Elderly Population 218Psychiatric Medications 220

Conclusion 227

AppendicesAbbreviations 229NCLEX Tips 231NCLEX Question Formats 233Basic EKG Rhythm Examples 245

Bibliography 251

Index 253

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Reviewers

Faculty Reviewers

Donna J. Bowles, MSN, EdD, RN, CNEAssociate ProfessorIndiana University SoutheastNew Albany, Indiana

Amy M. Karch, MSN, RNClinical ProfessorUniversity of RochesterRochester, New York

Kathleen R. Tusaie, PhD, APRN-BCAssociate ProfessorCollege of NursingUniversity of AkronAkron, Ohio

Ruth Wittmann-Price, DNSc, RN, CNS, CNEProfessor and ChairpersonDepartment of NursingFrancis Marion UniversityFlorence, South Carolina

Student Reviewers

Annie N. BoehmStudent, School of NursingUniversity of RochesterRochester, New York

John CleghornStudent, School of NursingUniversity of RochesterRochester, New York

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Gretchen CorleStudent, School of NursingIndiana University SoutheastNew Albany, Indiana

Brittany FranceStudent, School of NursingUniversity of RochesterRochester, New York

Jessica HennemanStudent, School of NursingUniversity of RochesterRochester, New York

Kate TannerStudent, Department of NursingFrancis Marion UniversityFlorence, South Carolina

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Preface

I was running a little late, so the class was nearly full. It’s easy to be late when a class begins at eight in the morning! On my desk was the syllabus for “Fundamentals of Nursing.” Looking through the syllabus, I saw the awful words “Medication Calculation Quiz on Friday.” My first thought was, “Excuse me—a quiz on what?” I didn’t even know what medication calculation was. In that moment, I realized that this class was going to be a challenge. You may have heard rumors about the difficulty of the nursing program. At times, yes, I felt over-whelmed and unenthusiastic, but after completing the program, I wouldn’t have changed it for the world. As you go through the program, you will find the enthusiasm, confidence, and cour-age to complete each course. Remember, too, that you cleared the first obstacle just by being accepted into the program!

During the course of my four years, I kept all my notes, quizzes, exams, case studies, and research papers. By gradu-ation, there were about fifteen binders sitting on my desk. I realized that sitting in front of me was my entire nursing stu-dent experience. I thought to myself, “Wouldn’t it be helpful to future students to condense this material to make one all-encompassing study aid?” That is when I developed the idea for this book. I found no support or relief in the study guides available at the time. Most of them were hard to understand or just plain boring. I wanted to produce a study guide that would provide the important information while also empathizing with the harried nursing student.

My intent with this study guide was to be precise and resourceful, providing you, the nursing student, with the vital information in conjunction with related test questions. The for-mat of this book is divided into chapters, with each chapter representing a nursing course. For example, chapter one is “Fundamentals of Nursing.” I have also highlighted material in bold and also flagged in the margin with a checkbox anytime I mention something that most likely will appear on a test.

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This book should be helpful as a supplement to your text readings and exam preparation. You should first use your own class notes—most professors base their tests on lecture notes. You’ll also need to read the textbook—you pay a lot of money for it, so read it! By the time I was finished with nursing school, my textbook expenses could have paid for several pairs of Gucci shoes!

Although it has its sacrifices and challenges, nursing is a major filled with both compassion and intellectual challenge. Enjoy this book, and I hope that it will make your nursing student experience a little easier. By the way, I passed that first med-calc quiz.

Welcome to the world of nursing. Let’s get started.

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Acknowledgments

Thank you, God, for the guidance and blessings.Mom, Dad, and Riaz, thank you for all the support and ideas

you have shared.Family and friends, thank you for the helping hand. Your

kindness will not be forgotten.Simmons College, thank you for the education and founda-

tion that helped me create this book and become the nurse I am today.

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Welcome to the beginning of your nursing education! Fundamentals of Nursing is the first nursing class you

will take. The skills taught in this course will provide the foundation for the many nursing responsibilities you will assume throughout your career. Use this book to help you with the various procedures you will learn, and take time to go to the nursing lab and practice these procedures on the medical manikins. Ask your professor the times that the laboratories are available for student use. Practice is the key to success.

Fundamentals of Nursing introduces you to nursing assess-ment skills, the nursing processes, and the overall framework of nursing practice. You will learn how to use communication skills, identify functional health patterns, and more. As I looked through my notes, I realized that an overview of the fundamen-tals of nursing starts in depth with the history of nursing. After reviewing some of my examinations from my own Fundamen-tals of Nursing course, I could see that I was struggling during the beginning of the course: Let’s just say my first test scores were not my best. I seemed to get the hang of the material fur-ther on in the semester; however, I wasn’t one of those students who grasped concepts quickly. I had to work hard, and the old saying “Hard work does pay off” is true. If you begin to see that you are not receiving the grades you expected, remember that by working hard and putting extra time into studying, you will begin to see improved test results.

Let’s get started on the history of nursing.

HiStoRy oF NuRSiNg

Nursing history content is dense. The history of nursing is important to learn, but to be honest, it is not tested frequently. I am going to highlight just a few facts that you may need to know. Do not concentrate on remembering the dates and the exact times of the events. You will be required to know the importance of Florence Nightingale’s work and her influence on

Fundamentals of Nursing

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ing the nurse’s role. Pay attention to the information the professor

highlights; although this is a brief section in this study guide, the professor may want you to remember more facts. Refer to your textbook or class notes for more in-depth information.

• Florence Nightingale—where would nurses be without her influence? Nightingale was able to change the face of nursing by establishing her own nursing school in 1860.

• Between 1890 and 1900, Nightingale established 400 training schools, a huge growth in hospital care.

• In 1956, the first Health Amendment Act, which gave nurses the financial aid needed during nursing training and educa-tion, was established.

I told you it was quick! If you do feel the need to go through this information in more depth, refer to your textbook.

tHeRapeutic commuNicatioN

Everyone knows what communication is; we take part in it every day. Sending an e-mail, talking on the phone, or tex-ting a friend are all types of communication. When working with a patient, think about how you would communicate with a friend or family member. Make sure that the patient feels comfortable. Some important key points about communication techniques include listening, giving feedback, restating, and clarifying information. There may be cultural differences to consider. Also, remember you are going to communicate with both patients and family members. So find that inner confi-dence and engage in the interaction.

there are two types of communication: (a) verbal, which involves speaking to the patient, (b) nonverbal, which involves the use of facial expressions, eye contact, and therapeutic touch to the patient. Silence may be uncomfortable for you but can be very beneficial in a patient–nurse relationship.

phases of communication

There are three basic phases of communication: (a) introduc-tory, (b) working, and (c) termination. Try to keep them in mind when you communicate. The first phase, the introductory phase, is when you introduce yourself and your role to the patient, clarify the problem, and establish a mutual relationship. The second is the working phase, during which you explore the problem and begin to encourage collaborative thinking about possible solutions to resolve the problem. Third and last is the

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appropriate referrals are made.Compare these phases with a discussion you would have

with a friend who has shared a problem with you. You first lis-ten to his or her problem and then, while maintaining a neutral position, explore answers and possible resolutions.

tips on What Not to Do

When you are communicating with a patient, there are three pitfalls you should avoid. First, do not be judgmental, abrupt, use clichés, ask leading questions, interrupt the person when speaking, avoid eye contact, state false information, or simply ignore the patient because of language barriers. Second, when speaking to a patient who does not speak English, the best choice is to find a certified interpreter or an interpreter phone. Do not rely on the patient’s family to give you the correct infor-mation. Last, make sure that both the subjective matter and objective matter are accurate.

tips on What to Do to Develop therapeutic communication Skills

There are several things you can do to improve your commu-nication skills. Above all, listen carefully and make sure you understand the information being conveyed. Restate the infor-mation to help with clarification.

using open-ended questions—avoiding questions with yes/no answers—is key. the goal is to encourage the patient to give you a more elaborate response to your questions.

The most important communication tool may be giving the patient privacy during periods of communication, such as clos-ing the bedside curtain when speaking with him or her. Believe me, the patient and family will appreciate it. Be compassionate; medical care often is a difficult time for both patient and family. Emotional support is often needed. A change in the patient’s mental status may inhibit or even prevent communication; in such cases, you can use a health care proxy to gather informa-tion about the patient.

Vital SigNS

Vital signs, by definition, are a person’s temperature, pulse, res-piration rate, and blood pressure (BP). These signs reflect the status of a person’s circulatory, respiratory, neurological, and

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ing endocrine functions. You will need to become familiar with

these signs and practice obtaining accurate results. In this course, you will have plenty of time to practice on other stu-dents and those attractive-looking manikins. At the end of the semester, you will go to a health care facility where you will be able to practice these skills on real patients.

Time for a funny story that I know some of you will relate to. I was almost done with my Fundamentals course and was at a local hospital where I had to practice on my very first patient. I was assessing the man’s vital signs and obtaining the cor-rect results. I felt comfortable and confident because I thought I was doing so well. When I exited the room, one of the nurses walked up to me and asked, “Did you take his temperature with the red thermometer?” My response was yes. She went on to tell me: “Though the thermometer was clean, all red ther-mometers are for rectal temperatures.” Well, that just turned my confidence into pure embarrassment. It’s so true what they say about learning from your mistakes, because believe me, I never made that mistake again. So always remember, when you see a red thermometer, red stands for “rectal.” With that said, let’s move on.

Body temperature

Definition: Body temperature is the balance between the produc-tions of heat in the body, which is measured in degrees. the body’s temperature is controlled by the hypothalamus. this is in the preoptic part of the brain. The hypothalamus is able to detect when the body’s temperature is too high, indicating a fever, or too low, indicating hypothermia. A normal tem-perature is 98.6 °F (36 °C).

Assessing Body Temperature: The four main ways to assess body temperature are (a) orally, (b) rectally (this is the most reli-able method), (c) axillary (i.e., under the arm; this is used mostly with newborns), and (d) tympanically (which indi-cates core body temperature). Many hospitals use electronic thermometers or infrared tympanic thermometers. Rectal temperatures are not used on patients who are immunocom-promised. When taking oral temperatures, make sure that the patient has not had anything to eat or drink 15 minutes before the assessment. cold or hot liquids or food content can alter the temperature.

Factors That Affect Temperature: Age, exercise, stress, illness, and infection are all factors that can affect temperature.

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ingTemperature Gone Wrong: In your training, you will come across

words such as pyrexia, hyperpyrexia, and hypothermia. Pyrexia means that the temperature is above the normal level. Hyper-pyrexia is a very high fever, with an elevation in temperature greater than 105.8 °F. Hypothermia is the opposite of both of these terms; the patients usually present as having a tem-perature lower than average.

pulse

Definition: A pulse is caused by the amount of blood being pumped by the left ventricle of the heart. the heart expels about 5 l of blood per minute. This would be a great time to look over your A&P textbook. Remember the term cardiac output? You can apply this process to the pulse. The nor-mal adult pulse ranges from 60 to 100 beats per minute (bpm).

Assessing the Pulse: There are many sites on the human body where you can auscultate, or palpate, a pulse. the apical pulse, located between fourth and fifth left intercostal space, is the most accurate site at which to measure a rhythm. Other sites include temporal (over the temporal bone of the head), brachial (at the antecubital fossa), radial (below the thumb, at the wrist), carotid (at the sides of neck), popliteal (behind the knee), femoral (in the inguinal area), poste-rior tibial (at the inner ankle), and pedal (along the top of the foot).

Factors That Affect Pulse: Age, gender, exercise, medications, stress, anxiety, position changes, illness, and loss of blood can cause alterations in a pulse rate and rhythm. Infants have a higher pulse rate; a rate of 110 to 160 bpm is common. School-age children may have a pulse rate of approximately 75 to 120 bpm.

Pulse Gone Wrong: Become familiar with the terms that describe alteration in pulse. They will be used frequently not only when describing a pulse but also when reading electrocar-diogram (EKG) strips depicting a patient’s heart rhythm. Tachycardia means an increase or higher than normal pulse rate. Bradycardia is a pulse rate less than normal or less than 60 bpm. Dysrhythmia is an irregular pulse pattern that is usu-ally shown on an EKG. Patients with dysrhythmia are usu-ally placed on telemetry—a continuous cardiac monitor—to monitor these irregular heartbeats.

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ing Respiration

Definition: Gas exchange is the changing of carbon dioxide into oxygen in the lungs. It is the body’s way of regulating the necessary amount of oxygen in the circulating blood to maintain healthy cells. Here is a little exercise: Take a deep breath (called inspiration), and now exhale (a more techni-cal term is exhalation). A normal respiratory rate is 16 to 20 breaths per minute. This can vary on the basis of the patient’s condition.

Assessing Respiration: The first step in evaluating a patient’s res-piration is to assess him or her visually; note if the patient is having any problems breathing, such as using his or her accessory muscles (chest muscles used to draw in breath/inhale). Ask if the patient has a history of any respiratory problems. After visual assessment, auscultate or listen to the patient’s breathing pattern by placing the stethoscope over the diaphragm or by simply looking at the movement of the chest. an easy way to determine the respiration rate is by count-ing the number of breaths for 30 seconds then multiplying by 2 to get a full-minute rate.

Factors That Affect Respiration: Smoking, stress, anxiety, exer-cise, temperature, infection, pneumonia, and medications all affect respiration, and the list goes on. It is important to document and report these variables. Here is one of the biggest secrets that I am going to tell you: For any respira-tion-related multiple-choice question that you have on an exam, always choose the answer in which the breathing is disrupted! choose answers that coincide with “aBc” (airway, breathing, and circulation).

Respiration Gone Wrong: An increase in respiration rate is defined as tachypnea (more than 20 breaths per minute). A decrease in respiration rate is defined as bradypnea (fewer than 12 breaths per minute). Remember that the ending -pnea represents an alteration in breathing. I don’t know about you, but with all this information, my respirations are changing!

Blood pressure

Definition: Blood pressure (Bp) is the force of blood against the wall of the left ventricle of the heart. For all you visual learners, pic-ture a waterslide of blood pushing against the arterial walls. You probably are familiar with the terms systolic and diastolic.

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ingThe systolic BP is the first number obtained when assessing

the BP; the measurement determines the heart’s ability to contract. The diastolic BP is the second number, which signi-fies the relaxation of the heart. Normal BP is anything less than 120/80 mmHg.

Assessing the Blood Pressure: BP is measured using a BP cuff, a sphygmomanometer (that’s a funny word), and a stethoscope. One of your textbooks likely will have a picture of this equip-ment or, even better, go to the lab and practice. the cuff should be placed in two-thirds length of the upper arm and cover three-fourths circumference of the arm. The sounds that you hear are called Korotkoff sounds, which represent the diastolic and sys-tolic BP. When measuring someone’s BP, don’t leave the cuff inflated on the patient too long; this can be very uncomfort-able. Also, if you do not get an accurate reading the first time, try again. Ask the patient his or her normal BP range; that way, you will be aware of any significant changes.

Blood Pressure Gone Wrong: I discuss hypertension in further detail in Chapter 3, but I offer a quick definition here: any BP that is greater than 120/80 mmHg. Hypotension is any-thing less than 120/80 mmHg. It can be caused by medica-tions, hemorrhage, or hypovolemia (decreased body fluid volume). A decrease in BP can also be caused by a change in position (e.g., moving quickly from a sitting to a standing position); this is called orthostatic hypotension. This is a safety issue, because hypotension can cause a person to become very dizzy. if your patient has orthostatic hypotension, make sure you help him or her stand and have him or her change posi-tions slowly.

That pretty much wraps up vital signs and their measure-ment. I cannot stress enough the importance of practicing these skills. It may be difficult at first, but with a little practice, you will become an expert.

tHe NuRSiNg pRoceSS

The nursing process is a five-step systematic approach to prob-lem solving in a nurse–patient situation. It allows the nurse to obtain the proper information to determine the health care problem and apply the skills to solve it. The five steps are (a) assessment, (b) diagnosing, (c) planning, (d) implement-ing, and (e) evaluating (“ADPIE”). Remember the section on communication? You will apply those skills during the ADPIE process.

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ing assessment

Collecting accurate data is very important; it allows the patient to verbally communicate the manifestations (signs and symptoms) that he or she is experiencing. It also allows you to assess the patient and determine the causes of these mani-festations. In assessment, two types of data or information are collected. The first type is subjective; this is what the patient tells you (e.g., “My arm feels itchy and has little red bumps all over it”). The second type is objective and includes signs that are observed only by the nurse (e.g., “The patient has quarter-size rash located on her right arm”). objective data are signs and symptoms that can be assessed by the nurse. Vital signs are a kind of objective data.

Assessment is needed to help you formulate nursing diag-noses. There are many methods you can use to obtain the data needed to complete your assessment and then make a diagno-sis. Nurses use observation, interview, consultation with other health care professionals or with the patient’s medical record, and physical examination.

Diagnosing

Diagnoses are organized data obtained from the patient assessment. A nursing diagnosis is the statement of a problem based on the actual symptoms the patient is experiencing. An example of a nursing diagnosis is “ineffective airway clear-ance related to accumulation of secretions.” In simpler terms, nursing diagnoses are statements of problems that the patient is experiencing related to an overall health care situation. I have some bad news for you: This would be a good time to buy a nursing diagnoses book if you haven’t bought one already. Each clinical instructor will ask you to conduct dif-ferent nursing diagnoses, so you would do well to get familiar with a few.

planning

Because the nursing process is a step-by-step one, the planning phase involves making a prioritized list of the nursing diagno-ses. After you have made the list, the next step is to formulate goals and desired outcomes for these diagnoses. When you have established these goals, it is your responsibility to make sure that the nursing care plan is carried out through nursing interventions: the care given to a patient, family, or population.

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ingTwo examples of interventions are (a) the nurse will monitor

vital signs every 2 hours and (b) the nurse will turn the patient every 2 hours. The list of diagnoses, goals, and interventions make up a nursing care plan.

implementing

When all the other steps have been completed, you can then move on to the next step and implement the care plan in the appropriate manner. When implementing the goals, you must establish a realistic time frame within which the interventions can be completed. The most important part of this step is backing up your interventions with scientific data. You should have a reason for each intervention you do. In regard to the previous example of a nursing diagnosis, airway clearance related to accumulation of secretions, the scientific rationale would be found in resources such as your textbook.

evaluation

So, we have finally reached the last step of ADPIE: evaluation. In this step, you review and reassess the patient. You will need to make sure that the goals you set have been met by the inter-ventions you have provided and that the nursing care plan has been completed.

The nursing process is important to understand, but there is no need to memorize every part of it. You will use this process throughout your nursing education and after graduating. It is an essential component of caring for a patient, family, or popu-lation. A nursing care plan ensures that the patient is receiving the care he or she deserves. The test questions will be based on your recognition of the appropriate nursing interventions for a health care situation and your ability to produce a nurs-ing care plan. So pay particular attention to this in class—no sleeping.

FuNctioNal HealtH patteRNS

Functional health patterns are the basic activities that people perform on a daily basis. An evaluation of a patient’s func-tional health patterns comprises a series of questions that help you assess the patient’s health care behavior. A packet of health care patterns will be given to you at the beginning of the course. As you go through the questions, you might note

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ing some that make you feel uncomfortable—for example, discuss-

ing a patient’s sexual and elimination patterns. Try to find a way that you can ask the question in a comfortable manner before entering the patient’s room. Remember, as I discussed earlier in this chapter, your goal is to make the patient comfort-able while also keeping a serious face. There were times when I wanted to laugh, especially one time when I was discussing sexual patterns with an 80-year-old man. I am not going to describe each health pattern in depth; neither is there a need to memorize them. An overall functional health pattern includes health management, activity/exercise, nutrition, elimination, sleep, cognitive–perceptual patterns, self-concepts, relation-ship roles, sexuality, coping skills, and values. You will not get tested on memorizing each health pattern, but you should become familiar with the questions, because they are usually asked when a patient is being admitted to a hospital or other health care facility.

immoBility

Immobility is an impairment in which one is unable to move one’s upper and/or lower extremities. When a patient is con-fined in one spot for a long time, skin breakdown, ulcers, and blood clots are all possible complications. Repositioning every 2 hours, skin care, and hydration can help maintain skin integ-rity. If a patient is unable to move either the upper or lower extremities, perform full range of motion exercises to increase mobility and decrease contraction of the muscles.

complications

UlcersIt is important to memorize the stages of a skin ulcer (both pressure and diabetic ulcers) and be able to identify them by sight. You’ve got it—turn to your textbook and learn your ulcers. Patients who are immobile are at risk for ulcers because of the constant friction and tension on the skin; ulcers are commonly seen in older adults. Skin breakdown and skin tissue necrosis can occur from the shearing, tension, and friction caused by the constant contact with bed linens due to immobility. as a nurse, your main goal is to prevent pres-sure ulcers by repositioning the patient every 2 hours, keeping the skin dry, using barrier creams, dressing changes, and maintaining adequate hydration. You can request assistance from a wound care nurse to help assess the patient and perform dressing

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ingchanges. Skin ulcers can be characterized into the following

four stages:Stage I: Reddening of the skin on the epidermal layer. Skin

remains intact.Stage II: Reddening and edema of the epidermis and dermis

layer. Looks similar to a blister. Skin breakdown is present.Stage III: Destruction of the subcutaneous layer, excluding

the muscle and bone.Stage IV: Severe damage to all the layers of skin, including

muscles and bone. In most cases, the bone is visible.

Deep Vein ThrombosisBecause of poor circulation and decrease in blood flow, immo-bile patients are more at risk for thrombus (clot) formations. The symptoms include warmth at the site, swelling, redness, and pain. It is important to assess the patient’s circulation to prevent related complications. the main nursing intervention to prevent a deep vein thrombosis (DVt) is repositioning the patient frequently, along with leg elevation.

oxygeNatioN

One of the first steps of patient care is to monitor a patient’s respiratory status and level of blood oxygen saturation. You must identify whether the patient is experiencing shortness of breath, labored breathing, and/or is using the accessory mus-cles to inhale/exhale.

alterations in Breathing patterns

There are several types of alterations in breathing patterns:

• Tachypnea: a rapid increase in respiration, usually seen with pain, fever, asthma, and hyperventilation, anxiety, or decrease in oxygen

• Bradypnea: a slow respiration rate usually caused by pain medication

• Kussmaul’s breathing: deep, rapid breathing usually seen in patients who suffer from acidosis or change in blood gases

• Cheyne–Stokes respiration: very deep, shallow respirations

Diagnostic tests

Some diagnostic tests you might use include a patient’s com-plete blood count, chest x-ray, arterial blood gases, pulse oxim-etry (which may be continuous), and sputum specimens.

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ing Nursing interventions

Placing the patient in a semi-Fowlers position (in which the head of the bed is angled at 30–45 degrees) can increase drain-age of secretions and lung expansion. The use of an incentive spirometer keeps alveoli intact. Chest physiotherapy also can be used to facilitate drainage. Instructing the patient to cough and deep breathe can help him or her expel secretions and facilitate breathing; this should be done every 2 hours. A nasal cannula set at 2 L is used for patients. When applying o2, remember to set the amount to 2 l before increasing it or adjust it according to the orders of the primary care provider. In an emergency setting, a face mask is used to deliver adequate amounts of oxygen. an early sign of a lack of oxygen is change in mental status, and a late sign is clubbing of the fingers.

FluiDS aND electRolyteS

I am not going to lie: Fluids and electrolytes were difficult con-cepts for me to understand, although they may not be difficult for you. I am going to do my best to describe it to you. Hydration is the key to keeping the body balanced. The way that I was able to understand the changes in electrolytes was by memo-rization. I discuss fluid changes in more detail in Chapter 3, but these concepts will come up time and time again. I know by this time you’re probably thinking, “How much more can I memorize?!” Nursing has many concepts that each student must understand to move on to other concepts. So, if you need help understanding fluids and electrolytes, make sure you seek the help you need. To make it a little easier, let’s work through this step by step.

First, get familiar with the normal values of the main electro-lytes, acid, and bases you need to know:

Electrolytes:

• Sodium (Na): 135–145 mEq/L (milliequivalents per liter)• Potassium (K): 3.5–5.0 mEq/L• Magnesium (Mg): 1.5–2.6 mg/dl• Calcium (Ca): 8.6–10.4 mg/dl• Phosphorus: 2.7–4.5 mg/dl

I would take time to understand these concepts you will use them throughout your nursing career. This information will be used more frequently in Med-Surg classes and when studying for the NCLEX-RN®. Now, i do have two little secrets. First, your professors are going to make sure you know all of the electrolytes,

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ingbut the main two that are tested are potassium and sodium. Second,

become familiar with the various changes in fluids and electro-lytes patients can exhibit.

Fluid and electrolyte imbalances

DehydrationDehydration can be caused by a decrease in daily fluids due to lack of fluid intake, illness, or surgery. Signs and symptoms include increase in pulse rate, decreased BP, flat neck veins, weakness, poor skin turgor, and weight loss. Oral hydration (drinking) is the first form of treatment. Intravenous (IV) fluid administration should be used if oral hydration is not successful or possible. Monitor and document intake and output accordingly.

Overhydration (Hypervolemia)Overhydration, also known as hypervolemia, is a problem of too much fluid. Causes can be congestive heart failure or edema. Manifestations include increased pulse rate, normal BP, dis-tended neck veins, edema, and weight gain. Care includes decreasing fluids or administering a diuretic such as furo-semide (Lasix), which excretes fluid through the urine. A fluid restriction may be ordered.

Potassium

• Hypokalemia (K level below 3.5 mEq/L). Causes are vomiting, gastric suctioning, and diuretics. Manifestations are irregular pulse, irregular BP, muscle weakness, and cramping. Treat-ment includes administering potassium. Oral potassium is usually given with a cup of juice to mask the taste. IV potas-sium can also be administered. patients with hypokalemia usu-ally have an eKg pattern with depressed u waves.

• Hyperkalemia (K level above 5.0 mEq/L). Can be caused by vomiting, kidney failure, and medications. Manifestations include abnormal pulse, abnormal BP, abdominal cramping, and twitching. increased K can lead to cardiac arrest, and an eKg with elevated t waves. Interventions include decreasing potassium by giving sodium polystyrene (Kayexalate) and restriction of K in the diet.

Sodium

• Hyponatremia (Na level below 135 mEq/L). Caused by vomiting, diarrhea, diuretics, burns/wounds, congestive heart failure, and renal failure. Manifestations include headache, muscle cramps/weakness, nausea and vomiting, and dry mucous

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ing membranes. Treatment includes giving the patient sodium

and replacing fluids.• Hypernatremia (Na level above 145 mEq/L). Most commonly

caused by dehydration or too much sodium in the diet. Manifestations include restlessness, thirst weakness, oligu-ria (small amount of urine), muscle weakness, and twitch-ing. Treatment is IV normal saline, diuretics, and a decrease in salt in the diet.

Magnesium

• Hypomagnesemia (Mg level below 1.5 mg/dl). Usually caused by chronic alcoholism, vomiting, suctioning, medications, and malnutrition. Manifestations include increase in BP, positive Chvostek’s and Trousseau’s signs, mental status changes, and tremors. A positive Chvostek’s sign is an abnormal facial muscle contraction. Trousseau’s sign is identified by using a BP cuff, which causes an abnormal spasm in the arm. Treat-ment involves increasing magnesium and calcium in the patient’s diet. administer magnesium sulfate as ordered; it is usually given intravenously.

• Hypermagnesemia (Mg level above 2.6 mg/dl). Can be caused by renal failure, increased magnesium intake, and adrenal insufficiency. Symptoms are muscle weakness, decrease in heart rate and BP, respiratory depression, decreased reflexes, and gastrointestinal disturbances. interventions include moni-toring the patient’s level of consciousness and administering ca gluconate to decrease mg.

Phosphorus

• Hypophosphatemia (phosphorus level less than 2.7 mg/dl). A lack of phosphorus due to increased calcium levels and hyper-parathyroidism. Manifestations are a decrease in respira-tions, confusion, weakness, and positive Chvostek’s and Trousseau’s signs. Treatment is oral phosphorus with vita-min D and an increased level of phosphorous in the diet.

• Hyperphosphatemia (phosphorus level above 4.5 mg/dl). Caused by a decrease in calcium levels which increases phosphorus. Manifestations include a decrease in calcium levels. Treat-ment is administration of sevelamar (Renagel), a calcium-containing phosphate binder.

Calcium

• Hypocalcemia (calcium level below 8.6 mg/dl). Often due to para-thyroid damage, chronic renal failure, vitamin D deficiency,

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ingand chemotherapy. Manifestations are positive Chvostek’s

and Trousseau’s signs and muscle twitching. Treatment is administration of calcium and vitamin D.

• Hypercalcemia (calcium level above 10.4 mg/dl). Can be caused by an overactive thyroid. Manifestations are muscle weak-ness, nausea, confusion, and abdominal pain. Treatment is calcitonin (Calcimar).

In all cases of fluid and electrolyte imbalances, continue to monitor the patient’s labs throughout treatment until they return to normal levels.

types of intravenous Fluids

Several types of solutions can be administered intravenously to correct electrolyte imbalances. Isotonic solutions (which is equal to osmotic pressure) are used to treat metabolic acidosis and dehydration. Some types are 0.9% sodium chloride, lac-tated Ringer’s solution, and 5% dextrose in water.

Hypotonic solutions (which have low osmotic pressure) are used to treat edema. Some types are 5% dextrose and half- normal saline and 0.45% normal saline.

Hypertonic solutions (which have high osmotic pressure) are used to treat blood loss, hypovolemia, and hyponatremia. Some types are 5% dextrose in normal saline and 10% dextrose in water. While using these fluids, it is important to monitor the patient for fluid overload.

acid–Base imbalances

Along with fluid and electrolytes, it is important to understand acid–base balances. Many students, including myself, needed a little extra help with this concept. When this concept is first presented it can be very confusing; mastery takes practice and patience. Again, you need to know the normal values of acids and bases so you can accurately interpret patients’ laboratory reports. Not only were these concepts seen on nursing exams, but I also had many questions about acid–base imbalances on the NCLEX-RN. If there are students in your class who under-stand these concepts, ask them to sit down and explain them to you. Most of the time, students figure out a way to understand the concepts than is easier than the one presented in class.

The following are normal ranges for arterial blood gas values:

• Ph: 7.35–7.45• Pco2: 35–45 mmHg

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ing • Hco3: 22–26 mEq/L

• Po2: 80–100 mmHg

Arterial Blood GasesArterial blood gas values are used to determine acid–base imbalances. The laboratory samples are obtained through an Allen’s test, which is done by the physician.

• Respiratory acidosis. Blood pH decreases and Pco2 increases. Most of the time, the causes are respiratory complications such as chronic obstructive pulmonary disorder, pneumo-nia, and asthma. Manifestations are increased pulse and res-pirations, mental status changes, and fatigue. interventions include monitoring the patient’s airway and treating the underly-ing cause through antibiotics or other methods.

• Respiratory alkalosis. Blood pH increases and Pco2 decreases. Causes are hyperventilation and hyperthermia. Manifes-tations include muscle twitching, tingling of the fingers, dizziness, and difficulty breathing. Interventions include instructing the patient to breathe slowly and deeply. Another trick is to have the patient breathe into a paper bag. assess respiratory status.

• Metabolic acidosis. Decrease in blood pH and Hco3. Causes are renal failure, diarrhea, and diabetes mellitus. Symptoms are Kussmaul’s breathing, fruity breath, anorexia, nausea/vomiting/diarrhea, headache, and confusion. treatment is to administer iV sodium bicarbonate. Monitor the patient’s respi-ratory status and ensure proper nutrition and fluid intake.

• Metabolic alkalosis. Increase in blood pH and Hco3. Causes are vomiting, excessive intake of antacids, and gastric suc-tioning. Symptoms are tingling of the fingers, decreased res-pirations, tetany, and confusion. treatment is to administer iV fluids, monitor electrolytes, and treat the underlying problem.

uRiNaRy aND BoWel FuNctioN

urinary elimination

The key point to remember in urinary elimination is to under-stand the kidney process and the importance of recording a patient’s intake and output. an adult patient’s urinary output should total at least 30 ml every hour. Also, it may not be that fun, but you should look at a patient’s urine to determine the color; for example, blood in the urine can signify a serious complication. In this portion of the class, you will learn how to insert a Foley catheter. If an opportunity arises during your

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ingclinical training to perform this procedure, be sure to volun-

teer, because this procedure is done frequently in the clinical setting. Attached to the Foley catheter is a bag that is used to collect and measure urinary output.

Complications can occur within the urinary system, and the most common is urinary tract infections. The longer a patient has a Foley catheter in place, the more at risk he or she is for infection. It is your job to prevent infection by using an aseptic technique, assessing the patency of the tubing, Foley care, and assessing the urine. Symptoms of a urinary tract infection are dys-uria (burning with urination); fever; abdominal pain; foul-smelling urine; nausea/vomiting; and, in older adults, mental status changes. Interventions are focused on administering proper antibiotics as ordered.

Bowel elimination

Now, I don’t know about you, but assessing stools does not float my boat. It is important, though, and with a mask and a quick look at the stool, your assessment is complete before you know it. The most common complications with regard to bowel elimination are constipation and diarrhea. Treatment for constipation is to give a stool softener, if ordered, such as docu-sate sodium (Colace), and to increase the patient’s fiber intake. Treatment for diarrhea is to assess the patient’s electrolytes and encourage a low-fiber diet. Remember: Bowel and urinary changes often can occur because of the medication regimen, and patient education regarding medication management is important. So, know your meds along with the million other facts I have already told you to remember!

meDicatioN aDmiNiStRatioN

After graduating, I came to the conclusion that the two tasks that demand most of the nurses’ time include documentation and administering lots of meds! During clinical experiences, you will spend a lot of time looking up meds and giving them to the patients. I cannot stress enough the importance of knowing the medications, performing accurate calculations, and reinforcing steps to ensure patient safety. If there is one part of nursing to pay attention to, it is medications. Pharmacology is one of the most difficult courses. You would think that it would be impossible to remember all these medications, routes, and side effects, but it’s a miracle that by the end of nursing school, you will become familiar with most of the medications. You won’t

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they are used for.Now, for a little heart to heart: I was a nervous wreck when

it came to medication administration that involves needs. Even giving a simple blood glucose test would turn my stomach into knots. Because I myself don’t like injections, I also don’t like giving them to patients. So I am telling you that it is OK to feel nervous, and your hand may shake, but just remember: The more you practice, the more you will feel comfortable administering injectable medications. Remember that you may have to administer such medications in front of your peers. If the thought of other students looking at you makes you ner-vous, talk to your instructor and tell him or her your struggles with administering medications. Ask for a little one-on-one time. Also, go to your nursing laboratory and practice giving injections to the mannequins. Pretend they are big dartboards and practice, practice, practice.

tHe SuRgical expeRieNce

There are three main phases of the surgical experience: (a) p reoperative, (b) intraoperative, and (c) postoperative. In the following sections I describe each in detail. Hang in there; this is the last section of this chapter. So let’s wrap this up so we can move on to more facts to remember. An aseptic technique is used throughout each phase of the surgical experience. Hand washing is the most important technique used on the unit and all phases of the surgical experience.

preoperative

The preoperative stage begins with the decision to have the sur-gery and ends when the patient is transferred to the operating table. Before each operation, it is important that the patient has signed a consent form, after the surgery has been explained by the surgeon. The nurse’s role in the preparation of surgery is checking vital signs, removing valuables (e.g., jewelry), prepar-ing the bowel and bladder, giving all preoperative medications, and educating the patient about the what to expect during sur-gery so as to prevent complications that could arise after sur-gery. it is important to teach the patient to reposition his or her body after the surgery to maintain circulation, to cough and breathe deeply to prevent pneumonia, and to perform leg exercises to pre-vent thrombus formation.˛

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ingintraoperative

The intraoperative stage begins when the patient is being trans-ferred from the operating table and ends in the postanesthesia care unit. Nurses have multiple roles in the operating room, including scrub nurse and circulating nurse. They assist sur-geons with instruments and monitor the patient.

postoperative/postanesthesia care unit

The postoperative stage begins with the admission of the patient to the postanesthesia care unit and ends when the patient is admitted to a regular hospital unit. This is an important phase for the nurse; it is crucial to monitor the patient for complica-tions that could occur after surgery. You will be responsible for maintaining the patient’s airway, promoting tissue heal-ing, administering ordered pain medications, assessing uri-nary elimination, preventing constipation, and assessing for complications.

the most common postsurgery complications are shock, hemor-rhage, pneumonia, wound infections, and a pulmonary embolus.

In my own education, I was not tested frequently on the sur-gical process. The most important facts to focus on would be the postop phase and possible complications. I would not con-centrate too much on these phases because not too many test questions were based on these concepts.

Bye Bye, FuNDameNtalS; Hello, HealtH aSSeSSmeNt

I know what you’re thinking: Why is the textbook so large? Why do I have so many notes? Why does this book cover the whole subject in only 20 pages? Well, I have answers for you. This book is used to highlight the most important and most frequently tested content in nursing education. Now, I am not telling you to disregard chapters not touched on in this book. As a student, the information highlighted in this chapter was the used on the exams and NCLEX-RN that I took. However, review the other chapters and pay attention to what the professors recommend as important content to study and learn. Every nursing program is a bit different, and professors do tend to surprise you.

Congrats! You have finished your first nursing class. Can you see the light at the end of the tunnel yet? If you don’t, believe me—you will soon. By this time, you should have received your scrubs and been to your first clinical site. Try to journal

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ing your experience because it will be interesting to read, espe-

cially at the end of nursing school. Write down your fears and the various patients you have encountered. Also, this would be a great time to find out what struggles you seem to have and, if needed, take some extra time to work with the instruc-tor. So let’s move onto Chapter 2, which is one of my favorite courses, “Health Assessment.”