Nursing Tips: Fundamentals

A patient asked to do a 24-hour urine collection should be taught to discard the first void and then collect all urine voided over the following 24 hours.

A patient on a clear liquid diet may have items that are transparent and liquid at room temperature (e.g., water, clear sodas, pulp-free juices, popsicles, jello, black coffee, clear broth).

Discharge planning for a patient starts at admission. Other important admission tasks include confirming the patient's code status, identifying allergies, assessing fall risk, and assessing for swallowing issues.

A medication reconciliation should be done during admission, upon transfer to another floor/unit/facility, and at discharge.

A living will is an advance directive indicating a patient's desired or prohibited medical interventions (e.g., tube feeding, ventilation).

A home health nurse provides care in the patient's residence. Responsibilities include assessment, treatment, education, and care coordination.

A cultural assessment involves the identification of a patient's cultural and spiritual beliefs, practices, and preferences regarding medical interventions, illness, family, diet, pregnancy, death, and postmortem care.

A High-Fowler's position involves the patient sitting with the head of the bed at 60 - 90°. This is the ideal position to help with difficulty breathing.

A Durable Power of Attorney (DPoA) is a document that identifies another person responsible for medical decision-making. This person does not have to be related to the patient.

A Braden scale score ≤ 18 indicates a patient is at risk for pressure injuries. In this case, take measures to prevent injuries of this type.

Wound irrigation points to remember!

When performing suctioning, apply suction intermittently while withdrawing the catheter and rotating it for 10-15 seconds.

Lead exposure: Pre-1978 housing is at risk for lead-based paint! Check out these patient teaching tips.

Key points when taking a patient's blood glucose: Place hand in dependent position; Pierce outer; Wipe away first drop of blood; Hold test trip NEXT to the blood drop

Incidence vs. Prevalence:

Incidence is the number of NEW cases of disease/injury in a population during a period of time.

Prevalence is the number of ALL cases (new and pre-existing) of disease/injury in a population during a period of time

For abdominal wound dehiscence with evisceration: Place saline-soaked gauze over wound; Don't try to reinsert organs!; Prepare patient for possible surgery.

Airborne precautions require the patient to have a NEGATIVE airflow room. Caregivers and visitors need to wear N95 masks when going in the room.

Know your levels of prevention! Primary, Secondary, Tertiary

When applying restraints, make sure 2 fingers can fit between restraint and patient, se a quick release knot, and don't place restraints on side rail.

REPORT urine output that is less than 30ml/hr! Decreased urine output can be indicative of shock, sepsis, and kidney failure.

Key points about maintaining a sterile field

Enteral feeding: Confirm placement with x-ray; Measure gastric contents; Hold feeding if residual exceeds ~500ml; Flush feeding tubes.

Things can delegate to your CNA/tech partner: Bathing, toileting, dressing, ambulating, positioning, vital signs, bed making, specimen collection...

Windshield Survey: Collect data by literally driving around and look out your windshield.

Smallpox: Symptoms include a RASH that begins on the FACE and spreads down, high fever, headache, vomiting.

Injury prevention in the home: Make sure water heater setting is set to LESS than 120 degrees F to prevent burns.

Community Oriented Nursing is focused on health promotion and disease prevention in the community. No direct care for individuals! Community Based Nursing is focused on illness care for individuals and families.

Best practices for telephone orders

A patient is POSITIVE for orthostatic hypotension if: The SBP decreases more than 20mmHg when changing position AND/OR the DBP decreases more than 10mmHg

For enteral feeding tubes, flush tubing with 15-30ml of water before, after, and in between medications

Triage for a Mass Casualty event: Class I (red tag), Class II (yellow tag), Class III (green tag), Class IV (black tag)

Things can delegate to PN: Medication administration, foley catheter, enteral feeding, NG tube insertion, suctioning, tracheostomy care...

Non-opiod analgesics are use to treat MILD to MODERATE pain. Opioid analgesics are used to treat MODERATE to SEVERE pain.

Key points about Therapeutic Communication: Avoid asking "Why...?" Ask OPEN ended questions. Don't offer opinion, give false reassurance, or change subject.

Who can giveinformed consent? An unimpaired adult (i.e. not under the influence of drugs/alcohol, not experiencing command hallucinations). Emancipated minor. Parent or legal guardian of a minor.

The MOST important side effect to know for BOTH hyperkalemia and hypokalemia is DYSRHYTHMIAS.

Hospice care is focused on palliative care (i.e. symptom management), NOT on curing a disease.

Types of immunity: Active natural: Body produces antibodies in response to exposure to a live pathogen. Active artificial: Body produces antibodies in response to a vaccine.  Passive natural: Antibodies are passed from the mom to her baby through the placenta and breastmilk. Passive artificial: Immunoglobuins are administered to an individual after exposure to a pathogen.

Blood pressure cuffs: If the cuff is too large, you will get a falsely low reading. If the cuff is too small, you will get a falsely high reading.

Oxygen safety: Use COTTON bedding and clothes (vs. synthetic fabrics or wool).

Response to a FIRE: Use the RACE sequence. R = rescue (move patients to safer location). A = alarm (activate alarm system). C = contain (close doors/windows, turn off oxygen sources). E = extinguish (use fire extinguisher).

Apical pulse is taken at the fifth intercostal space at the left midclavicular line.

With the ABCDE principle in Nursing, A is for "airway". Ensure the patient has a patent airway AND the cervical spine is stabilized if neck/head trauma is suspected.

If labwork indicates there is a "Left Shift" in WBCs, this means that the body is fighting an infection and releasing many immature WBCs in response.

Contact precautions require caregivers and visitors to wear a gown and gloves when going into the patient's room.

The  Speech Language Pathologist is a key member of your interprofessional team. In addition to helping patients with speech and language issues, they evaluate and assist with SWALLOWING issues.

DISCHARGE planning for a patient starts at ADMISSION.

An Occupational Therapist (OT) is a key member of the interprofessional team. They help patients regain their ability to perform their ADLs (Activities of Daily Living). Examples of ADLs: brushing teeth, getting dressed, using the bathroom.