❤️ Unit 4

Physiological Integrity · 21 topics

My own notes. Rewritten from scratch — nothing here is copied from a review module.

Ch 37Hygiene

Hygiene care covers skin, oral, hair, nail, foot, eye, and perineal care, plus the environment the client rests in. Exams treat hygiene as a head-to-toe assessment opportunity rather than a chore, so most questions ask what you observed, what you delegated, and which client cannot safely receive a routine intervention (diabetes, anticoagulants, unconscious).

Bathing is assessmentEvery bath is a chance to inspect skin folds, bony prominences, IV sites, and mobility. Document new redness, breakdown, drainage, or bruising rather than simply charting that the bath was completed.

Water temperatureUse warm water around 43-46 C (110-115 F) for an adult bath, and test it before use. Lower the temperature and test with a thermometer for clients with neuropathy, spinal cord injury, or infants, who cannot reliably sense scalding.

Clean to dirty orderWork from cleanest to most contaminated: eyes and face, arms, chest, abdomen, legs, back, then perineum last. Change water and gloves before perineal care, and wash from front to back or from the urinary meatus outward.

Eye and ear careWipe the eye from the inner canthus outward using a separate clean section of cloth for each eye. Never insert anything smaller than a washcloth-covered finger into the ear canal, and hold irrigations for a suspected perforated eardrum.

Unconscious oral careTurn the client to a side-lying position with the head turned toward you and the head of bed elevated if permitted, keep suction available, and use minimal fluid. This prevents aspiration in a client with no gag or swallow protection.

Diabetic foot rulesInspect feet daily including between the toes, wash with lukewarm water without soaking, pat dry thoroughly between toes, and apply lotion everywhere except between the toes. Trim nails straight across only if permitted by policy, and refer thick, ingrown, or fungal nails to podiatry.

Bleeding risk shavingUse an electric razor for anyone on anticoagulants, antiplatelets, thrombolytics, or with a low platelet count. A single nick from a blade razor can become prolonged bleeding.

Denture handlingLine the sink with a washcloth and partially fill it with water so a dropped denture does not fracture. Clean with cool or tepid water since hot water warps the acrylic, and store in labeled water or denture solution when out of the mouth.

Perineal and catheter careProvide perineal care with soap and water at least daily and after each episode of incontinence; retract and then replace the foreskin in an uncircumcised male. Antiseptic scrubs and powders at the catheter insertion site are not recommended.

Delegation limitsBathing, oral care, and nail filing can generally be delegated to assistive personnel, but the assessment of the skin remains the nurse's responsibility. Nail cutting for clients with diabetes or peripheral vascular disease is typically not delegated.

Hygiene is a skin assessment: if you provided the bath, you are accountable for identifying and documenting every new area of breakdown, redness, or injury you could have seen.

Never soak the feet of a client with diabetes or peripheral neuropathy, and never use a blade razor on a client who is anticoagulated or thrombocytopenic.

Ch 38Rest and Sleep

Sleep is an active, cyclic process divided into NREM stages N1-N3 and REM, each with a different restorative job. Exam questions center on stage characteristics, normal sleep requirements by age, sleep hygiene teaching, and recognizing disorders such as obstructive sleep apnea, insomnia, and narcolepsy.

Cycle architectureOne full sleep cycle lasts roughly 90-110 minutes, and a typical adult completes 4-6 cycles per night. The first REM period arrives about 90 minutes after sleep onset, and REM periods lengthen while N3 shortens toward morning.

Stage percentagesIn a healthy adult, N1 is about 5 percent of sleep, N2 about 45-55 percent, N3 about 13-23 percent, and REM about 20-25 percent. N1 is the light transitional stage from which a person is easily aroused and may deny having slept.

N3 restores the bodyN3 is slow-wave, deepest sleep with the greatest growth hormone release, tissue repair, and protein synthesis, and it is the hardest stage from which to wake someone. Sleepwalking, night terrors, and bedwetting arise out of N3.

REM restores the mindREM brings vivid dreaming, memory consolidation, skeletal muscle atonia, and irregular pulse, blood pressure, and respirations. Loss of REM produces irritability, poor concentration, and REM rebound once normal sleep resumes.

Requirements by ageNewborns need roughly 14-17 hours, infants 12-16, toddlers 11-14, preschoolers 10-13, school-age children 9-12, adolescents 8-10, and adults 7-9 hours. Older adults need about the same total as younger adults but get less N3 and wake more often.

Sleep hygiene teachingKeep a consistent wake time, reserve the bed for sleep and sex, and get up after about 20 minutes of lying awake rather than staying in bed frustrated. Avoid caffeine and nicotine for at least 4-6 hours before bed and stop heavy meals and vigorous exercise within 2-3 hours of bedtime.

Alcohol and drug effectsAlcohol shortens sleep latency but suppresses REM and fragments the second half of the night, producing rebound awakenings. Benzodiazepines and many sedative hypnotics reduce N3, and beta blockers, corticosteroids, diuretics, and stimulants all disrupt sleep.

Obstructive sleep apneaSuspect OSA with loud snoring, witnessed apneic pauses, gasping arousals, morning headache, and daytime sleepiness, especially with obesity, large neck circumference, and hypertension. CPAP is first-line, and adherence teaching plus mask fit is the usual nursing focus.

Narcolepsy featuresNarcolepsy causes irresistible daytime sleep attacks with abrupt entry into REM, and may include cataplexy, sleep paralysis, and hypnagogic hallucinations. Safety teaching about driving and operating machinery is the priority.

Hospital sleep protectionCluster care, dim lights, silence nonessential alarms, and group blood draws so the client gets uninterrupted blocks. Fragmented sleep in the hospital contributes directly to delirium, especially in older adults.

Match the stage to the function: N3 is deep, physically restorative, and hardest to arouse from; REM is dream sleep with muscle paralysis, unstable vital signs, and mental restoration.

Do not treat chronic insomnia in an older adult with routine sedative hypnotics before trying sleep hygiene measures, since these drugs increase fall, confusion, and daytime sedation risk.

BEARS pediatric sleep screen: Bedtime problems, Excessive daytime sleepiness, Awakenings at night, Regularity and duration, Snoring.

Ch 40Mobility and Immobility

Immobility harms every body system, and the nurse's job is prevention through positioning, range of motion, early ambulation, and skin surveillance. Test questions favor the complication you can prevent, the interval at which you must intervene, and the safe technique for transfers and body mechanics.

Repositioning intervalsReposition a client in bed at least every 2 hours and a client sitting in a chair at least every hour. Clients who can move independently in a chair should shift weight roughly every 15 minutes.

Pressure injury preventionKeep the head of bed at 30 degrees or lower when possible, use the 30-degree lateral tilt instead of side-lying directly on the trochanter, and float the heels off the mattress. Shear increases sharply when the head of bed goes above 30 degrees and the client slides down.

Risk scoringThe Braden Scale scores sensory perception, moisture, activity, mobility, nutrition, and friction/shear; lower total means higher risk, with 18 or below commonly flagged as at risk in adults. Reassess after any change in mobility or condition.

Musculoskeletal lossesMuscle strength drops roughly 1-3 percent per day of bed rest, and disuse osteoporosis begins within days as bone resorption outpaces formation. Contractures and footdrop develop from sustained flexion and plantar flexion, so use range of motion and neutral foot positioning.

Range of motionPerform passive range of motion at least twice daily, moving each joint through its full range about 5 repetitions, stopping at the point of pain or resistance. Support the joint above and below and never force a joint past resistance.

Respiratory consequencesImmobility causes pooled secretions, decreased chest expansion, atelectasis, and hypostatic pneumonia. Counter with turning, deep breathing, incentive spirometry roughly 10 breaths per hour while awake, and early ambulation.

VTE preventionVenous stasis, endothelial injury, and hypercoagulability form the triad behind DVT. Use graduated compression stockings and sequential compression devices, encourage ankle pumps and hydration, and give prescribed prophylactic anticoagulation.

Orthostatic hypotensionDefined as a drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing, often with dizziness and a compensatory rise in pulse. Dangle the client at the bedside first, rise slowly, and check readings before ambulating after prolonged bed rest.

Other system effectsExpect negative nitrogen balance and muscle wasting, hypercalcemia with renal calculi from bone demineralization, urinary stasis and infection, constipation, and increased cardiac workload. Depression and disorientation are real and expected consequences, not incidental.

Safe body mechanicsWiden your stance, bend at hips and knees, keep the load close to your center of gravity, and pivot with your feet instead of twisting your spine. Raise the bed to waist height, lower the rail on your side, and use mechanical lifts and enough personnel rather than lifting manually.

Every 2 hours in bed and every 1 hour in a chair is the repositioning standard, and a client who can shift independently should move about every 15 minutes.

Never massage over a reddened bony prominence or an area suspected of deep tissue injury, and never vigorously rub or massage a calf suspected of DVT.

Ch 41Pain Management

Pain is whatever the client says it is, existing whenever the client says it does, and self-report is the single most reliable indicator. Exams test acute versus chronic and nociceptive versus neuropathic pain, the correct assessment tool when a client cannot self-report, and opioid safety, especially the fact that sedation precedes respiratory depression.

Systematic assessmentCapture location, quality, intensity, timing, aggravating and relieving factors, and the effect on function and sleep. Reassess after intervention within a timeframe matched to the route, commonly around 15-30 minutes after IV and 60 minutes after oral or IM analgesia.

Choosing a scaleUse the 0-10 numeric rating scale for adults who can report, the FACES scale for children roughly 3 years and older and for many adults with limited literacy, and FLACC for children about 2 months to 7 years or nonverbal clients. Once you pick a scale, use the same one consistently for that client.

Nonverbal and cognitively impairedWhen self-report is impossible, use a validated behavioral tool such as PAINAD in advanced dementia or CPOT in intubated critical care clients, and look for grimacing, bracing, guarding, restlessness, moaning, agitation, and refusal to move. Consider pathology likely to cause pain, and use an analgesic trial: if behaviors improve after a scheduled dose, the behavior was pain.

Vital signs are unreliableTachycardia and hypertension may accompany acute pain but normalize with chronic pain because of physiologic adaptation. Normal vital signs never disprove pain, and absence of grimacing does not mean absence of pain.

Pain typesNociceptive somatic pain is sharp and well localized, visceral pain is deep, cramping, and poorly localized with possible referral, and neuropathic pain is burning, shooting, tingling, or electric. Neuropathic pain responds better to adjuvants such as gabapentinoids, SNRIs, and tricyclics than to opioids alone.

Multimodal and around-the-clockCombine nonopioids, adjuvants, and nonpharmacologic strategies so lower opioid doses achieve control. For continuous pain, give analgesia on a schedule rather than waiting for pain to peak, with short-acting doses available for breakthrough.

Nonopioid ceilingsAcetaminophen has a maximum of 4 g per day for healthy adults, with lower limits often used in hepatic disease, chronic alcohol use, or older adults. Check every combination product for hidden acetaminophen. NSAIDs carry GI bleeding, renal, and cardiovascular risk and should be taken with food.

Opioid respiratory safetySedation always precedes respiratory depression, so monitor level of sedation and arousability, not just respiratory rate. Hold the dose and notify the provider for excessive sedation or a respiratory rate below the parameter set, keep naloxone accessible, and titrate naloxone carefully to restore respirations without stripping all analgesia.

Opioid side effectsTolerance develops to sedation, nausea, and respiratory depression but essentially never to constipation, so start a stimulant laxative with or without a stool softener when opioids begin. Also anticipate pruritus, urinary retention, and orthostatic hypotension.

PCA rulesOnly the client presses the PCA button, because a client too sedated to press it is protected by that limitation. Teach the client and family this rule explicitly, verify pump settings with a second nurse, and document sedation level and respiratory status per protocol.

Nonpharmacologic adjunctsHeat, cold, positioning, distraction, guided imagery, relaxation breathing, massage, TENS, and music all reduce pain perception and opioid requirements. These supplement analgesia rather than replacing it in moderate to severe pain.

In an opioid-treated client, rising sedation is the earliest warning of respiratory depression, so assess arousability before the respiratory rate falls.

Never allow anyone except the client to press the PCA button, and do not withhold prescribed analgesia because you doubt the client's report or fear addiction in acute pain.

PQRSTU: Provocation/Palliation, Quality, Region/Radiation, Severity, Timing, Understanding of the client's meaning and goal.

Ch 42Complementary and Alternative Therapies

Complementary therapies are used alongside conventional care; alternative therapies are used in place of it, and integrative care blends evidence-based complementary approaches with standard treatment. Exam emphasis falls on nonjudgmental assessment of what the client is already taking and on herb-drug interactions, especially bleeding risk and St. John's wort.

Ask, do not assumeMany clients do not volunteer supplement or practice use because they consider it natural or fear judgment. Ask directly about herbs, teas, vitamins, homeopathy, and healers at every medication reconciliation and record it on the medication list.

Regulation gapDietary supplements are not held to the premarket efficacy and purity standards required of prescription drugs, so potency, contamination, and mislabeling vary between products and lots. Teach clients to choose products with third-party verification seals.

Bleeding-risk herbsGarlic, ginger, ginkgo, ginseng, feverfew, and high-dose vitamin E and fish oil increase bleeding risk, which compounds with warfarin, antiplatelets, and NSAIDs. Most surgeons ask that herbal products be stopped about 2 weeks before surgery.

St. John's wortIt induces hepatic enzymes and reduces levels of many drugs, including oral contraceptives, warfarin, digoxin, cyclosporine, and some antiretrovirals. Combined with SSRIs or triptans it can precipitate serotonin syndrome, so it is one of the most frequently tested interactions.

Other notable herbsKava and comfrey are associated with hepatotoxicity, valerian and kava add to sedative effects, echinacea is discouraged in autoimmune disease and immunosuppression, and ginseng may alter blood glucose in diabetes. Ephedra-type stimulants raise blood pressure and heart rate.

Mind-body therapiesMeditation, guided imagery, progressive muscle relaxation, biofeedback, yoga, tai chi, and music therapy lower sympathetic arousal and are appropriate nurse-initiated adjuncts for pain, anxiety, insomnia, and nausea. They complement rather than replace prescribed treatment.

Manipulative therapiesMassage, chiropractic manipulation, and acupuncture are body-based approaches with generally low risk in healthy adults. Avoid massage over a suspected DVT, over open or irradiated skin, and in clients with bleeding disorders or bone metastasis.

Energy and biofield modalitiesTherapeutic touch, Reiki, and healing touch are based on manipulating an energy field, and their measurable benefit is largely relaxation and comfort. Support the client's choice while documenting it, and never present them as a substitute for indicated medical therapy.

Nurse's role and boundariesPractice only modalities within your scope, training, and institutional policy, and obtain consent. Document use, monitor for interactions and delayed treatment, and report adverse events.

Cultural respect with safetyApproach traditional practices such as cupping, coining, and folk remedies without judgment and distinguish resulting skin marks from abuse. Intervene only when the practice poses actual harm or delays essential care.

Herbal products are drugs for purposes of interaction: obtain a complete supplement history and flag bleeding-risk herbs and St. John's wort immediately.

Do not tell a client to simply stop a cultural or complementary practice, and never let a complementary therapy substitute for a needed medical intervention without informing the provider.

The G herbs that make you bleed: garlic, ginger, ginkgo, ginseng (plus feverfew).

Ch 43Bowel Elimination

Normal bowel patterns range widely, so the standard is a change from the client's baseline rather than a fixed daily stool. Exams focus on constipation and impaction management, enema administration technique and volumes, ostomy stoma assessment, and recognizing when a bowel finding is an emergency.

Normal rangeA normal pattern falls anywhere from three stools per day to three per week, with soft, formed, brown stool. Assess frequency, consistency, color, odor, effort, and any change from the client's usual pattern.

Abnormal stool colorsBlack tarry stool suggests upper GI bleeding, bright red blood suggests lower GI bleeding or hemorrhoids, and clay or white stool suggests bile obstruction. Iron and bismuth also darken stool, so ask about medications before assuming a bleed.

Constipation preventionTeach roughly 25-38 g of fiber daily, fluid intake around 2-3 L per day unless restricted, regular activity, and responding promptly to the urge. Recommend a consistent toileting time, often after breakfast when the gastrocolic reflex is strongest.

Impaction pictureSuspect fecal impaction when a client has no formed stool for days and then passes liquid seepage around the mass, often with abdominal distention, anorexia, and restlessness in older adults. Confirm with digital examination per policy and treat with an oil retention enema before manual removal.

Vagal cautionDigital removal of stool and straining both stimulate the vagus nerve and can cause bradycardia and syncope, which is dangerous in cardiac clients. Monitor heart rate during the procedure, stop for any drop, and avoid these interventions in clients who are neutropenic or thrombocytopenic.

Enema techniquePosition the client left lateral Sims to follow the sigmoid curve, lubricate the tube, and insert about 7.5-10 cm (3-4 in) in an adult, less in children. Hang the solution roughly 30-45 cm (12-18 in) above the anus, use fluid around 40-43 C (105-110 F), and slow or stop for cramping.

Enema volumes and typesA typical adult cleansing enema uses roughly 750-1000 mL, an adolescent 500-750 mL, a school-age child 300-500 mL, and an infant under 250 mL. Hypertonic small-volume enemas pull water into the bowel, soapsuds irritate the mucosa, and tap water carries fluid overload risk if repeated.

Ostomy output differencesAn ileostomy produces continuous liquid to pasty output high in enzymes that quickly excoriate skin, while a descending or sigmoid colostomy produces more formed, predictable stool. Empty the pouch when it is about one-third to one-half full so the weight does not break the seal.

Stoma assessmentA healthy stoma is pink to beefy red, moist, and slightly raised, and mild bleeding when cleaned is expected. Pale, dusky, purple, or black color signals ischemia and must be reported immediately, as does retraction or prolapse.

Peristomal skinCut the barrier opening about 3 mm (1/8 in) larger than the stoma so effluent cannot contact skin while the barrier does not constrict it. Avoid soaps with oils or lotions on the peristomal skin because residue prevents adhesion.

Infection controlFor suspected or confirmed C. difficile use contact precautions and wash hands with soap and water, because alcohol-based rub does not kill spores. Dedicate equipment and clean the room with a sporicidal agent.

Liquid stool leaking around an otherwise constipated client is impaction with overflow, not diarrhea, and antidiarrheals would worsen it.

Never give an enema or perform digital stool removal in a client with neutropenia, thrombocytopenia, or recent rectal or prostate surgery without a specific provider order, and never report a dusky or black stoma as a routine finding.

Ch 44Urinary Elimination

Urinary questions center on recognizing inadequate output, distinguishing retention from incontinence, safe catheter technique, and preventing catheter-associated urinary tract infection. Output numbers and catheter maintenance rules are the most reliably tested facts.

Output thresholdsNormal adult output is roughly 1500 mL per day, and the minimum acceptable is about 30 mL per hour or 0.5 mL/kg per hour. Output below 30 mL/hr for two consecutive hours requires provider notification because it signals hypoperfusion or obstruction.

Bladder capacity and urgeAn adult bladder holds about 300-500 mL, and the urge to void typically begins around 150-300 mL. Ignoring the urge chronically stretches the bladder and contributes to retention and incontinence.

Urine characteristicsNormal urine is clear, pale yellow to amber, with specific gravity roughly 1.005-1.030. Cloudiness, foul odor, and sediment suggest infection, dark concentrated urine suggests dehydration, and tea-colored urine may indicate liver disease or myoglobin.

Retention assessmentSuspect retention with frequent small voids, distention above the symphysis, and restlessness. Verify with a bladder scan rather than catheterizing to check, and a post-void residual above about 100 mL is generally considered abnormal and reported per policy.

Incontinence typesStress incontinence leaks with cough, laugh, or lift; urge incontinence is a sudden compelling need with loss before reaching the toilet; overflow is dribbling from an overfull bladder; and functional incontinence occurs when mobility or cognition prevents reaching the toilet in time. The type dictates the intervention, from pelvic floor exercises to timed voiding to environmental changes.

Pelvic floor trainingTeach the client to contract the muscles used to stop urine flow, hold several seconds, and relax equally long, repeating in sets several times daily. Benefit typically requires several weeks to a few months of consistent practice.

Catheter insertion depthUsing sterile technique, advance the catheter about 5-7.5 cm (2-3 in) in a female and about 17-22.5 cm (6-8 in) in a male until urine returns, then advance another 2.5-5 cm before inflating the balloon with sterile water. Never inflate the balloon before urine flow confirms bladder placement.

CAUTI preventionKeep the drainage bag below bladder level and off the floor, maintain an unobstructed dependent loop-free closed system, secure the tubing to prevent traction, and perform routine perineal care with soap and water. The most effective measure is removing the catheter as early as possible.

Specimen collectionCollect a sterile specimen from the sampling port after disinfecting it, never from the drainage bag. For a clean-catch midstream, clean front to back or from the meatus outward, start the stream, then collect midstream.

Older adult red flagNew confusion, falls, or functional decline may be the only presentation of urinary tract infection in an older adult, often without fever or dysuria. Investigate rather than attributing acute mental status change to age or dementia.

Less than 30 mL of urine per hour in an adult is a reportable finding, and the single best CAUTI prevention measure is early catheter removal.

Never raise the urinary drainage bag above the level of the bladder or rest it on the floor, and never open the closed drainage system to collect a specimen.

Ch 45Sensory Perception

Sensory alterations include deficits, deprivation, and overload, and each produces distinct behavior that can be mistaken for confusion or noncompliance. Exams focus on communication adaptations for hearing and vision loss, safety modifications, and distinguishing delirium from dementia.

Deprivation versus overloadSensory deprivation from isolation, immobility, or a monotonous environment produces boredom, restlessness, hallucinations, and confusion. Sensory overload from alarms, pain, lights, and constant interruptions produces irritability, scattered attention, and refusal of care, and the fix is opposite in each case.

Age-related changesPresbyopia impairs near vision, presbycusis causes high-frequency hearing loss making consonants hard to distinguish, and taste, smell, and tactile sensitivity decline. Reduced sensation raises risk for burns, falls, medication errors, and poor nutrition.

Talking with hearing lossFace the client at eye level in good light, get their attention first, speak at a normal or slightly slower pace in a lower pitch, and reduce background noise. Shouting distorts speech and raises pitch, making comprehension worse; rephrase rather than simply repeating louder.

Hearing aid careTurn the aid off and open the battery door when it is not in use to preserve battery life, clean the earmold gently, and check for cerumen blockage when sound is weak. Whistling feedback usually means poor fit or excess volume.

Talking with vision lossAnnounce yourself on entering and state when you are leaving, address the client by name, and describe what you are doing before touching. Do not raise your voice, since vision loss does not affect hearing.

Orienting to environmentWalk the client around the room once and keep furniture, call light, and personal items in fixed positions. Describe food using clock positions on the plate, and when guiding, let the client hold your arm just above the elbow while you walk a half step ahead.

Cerumen and reversible causesBefore labeling hearing loss permanent, check for impacted cerumen, a foreign body, or an ototoxic medication such as aminoglycosides, high-dose loop diuretics, or high-dose salicylates. Removing a reversible cause restores function faster than any adaptation.

Aphasia distinctionsExpressive aphasia means the client knows what they want to say but cannot produce it, so allow extra time, use yes/no questions, and offer a communication board. Receptive aphasia impairs comprehension, so use short sentences, gestures, and demonstration.

Delirium versus dementiaDelirium is acute in onset, fluctuating, and often reversible, with impaired attention and altered consciousness caused by infection, hypoxia, medications, pain, or metabolic disturbance. Dementia is gradual and progressive with preserved consciousness early, so a sudden change in an established dementia client is delirium until proven otherwise.

Safety adaptationsProvide good non-glare lighting, contrasting colors at edges and thresholds, secured rugs, grab bars, and clear walkways. Ensure the client has glasses and working hearing aids on before teaching, procedures, or ambulation.

Confirm that glasses and hearing aids are in place and functioning before you judge a client confused, uncooperative, or unable to learn.

Never shout at a client with hearing loss or rearrange the room of a client with visual impairment without telling them and re-orienting them.

Ch 46Pharmacokinetics and Routes of Administration

Pharmacokinetics is what the body does to a drug through absorption, distribution, metabolism, and excretion, while pharmacodynamics is what the drug does to the body. Exams test first-pass effect, half-life and steady state, peak and trough timing, and the correct technique, angle, and volume for each route.

ADME frameworkAbsorption moves drug from the site of administration into the blood, distribution carries it to tissues, metabolism chiefly in the liver converts it to more water-soluble forms, and excretion removes it mainly through the kidneys. Liver disease slows metabolism and kidney disease slows excretion, and both prolong drug effect.

First-pass effectOral drugs travel through portal circulation and are partially metabolized by the liver before reaching systemic circulation, which is why oral doses often exceed IV doses of the same drug. Sublingual, buccal, IV, IM, transdermal, and inhaled routes largely bypass first-pass metabolism.

Bioavailability and route speedIV delivers 100 percent bioavailability with immediate onset and no absorption step, which is also why it is the least forgiving route. Rough onset order from fastest to slowest is IV, inhalation, sublingual, IM, subcutaneous, oral, and topical.

Half-life and steady stateHalf-life is the time to eliminate half the drug from plasma; with regular dosing, steady state is reached after about 4-5 half-lives, and after stopping, roughly 4-5 half-lives are needed for near-complete elimination. A loading dose is used when therapeutic levels are needed sooner than steady state would allow.

Peak and troughDraw the trough level immediately before the next scheduled dose, generally within 30 minutes of it, and draw the peak at the time specified for that drug and route. Trough monitoring protects against toxicity and is central for drugs such as vancomycin and aminoglycosides.

Protein bindingOnly unbound drug is pharmacologically active, so low albumin leaves more free drug and increases effect and toxicity risk. Two highly protein-bound drugs given together compete for binding sites and can raise free levels of both.

Narrow therapeutic indexDrugs whose toxic level sits close to the therapeutic level require serum monitoring, including digoxin, lithium, warfarin, phenytoin, and theophylline. Small dose changes, dehydration, or renal decline can push these into toxicity.

Oral form integrityEnteric-coated and extended-release tablets must be swallowed whole, since crushing destroys the release mechanism and can deliver a full day's dose at once. Sublingual tablets go under the tongue and are not swallowed or followed with water.

Injection specificsIntradermal uses about 0.1 mL at a 5-15 degree angle bevel up to raise a wheal; subcutaneous uses roughly 0.5-1 mL at 45-90 degrees depending on tissue; intramuscular uses a 90-degree angle, with the ventrogluteal site preferred in adults, the vastus lateralis in infants, and the deltoid limited to about 1 mL. Use Z-track technique for irritating or staining IM medications to seal the drug in muscle.

Topical and instilled routesRemove the previous transdermal patch and document it, rotate sites, and wear gloves so you do not absorb the drug. Instill eye drops into the lower conjunctival sac rather than on the cornea and apply punctal pressure for systemic drugs; pull the pinna up and back for adults and down and back for children under about 3 years.

Older adult pharmacokineticsReduced hepatic blood flow, decreased renal clearance, lower lean body mass, and lower albumin all extend drug action and increase sensitivity. Expect lower starting doses and slower titration, and reassess for polypharmacy at every visit.

It takes about 4-5 half-lives to reach steady state on a fixed dose and about 4-5 half-lives to clear a drug after it is stopped.

Never crush or split an enteric-coated or extended-release tablet, and never inject an IM medication into the dorsogluteal site given sciatic nerve and vascular risk.

ADME: Absorption, Distribution, Metabolism, Excretion.

Ch 47Safe Medication Administration and Error Reduction

Safe administration rests on the rights of medication administration, the three label checks, two client identifiers, and independent double checks for high-alert drugs. Error questions almost always reward assessing the client first, then reporting through the correct channel, rather than concealing or self-correcting quietly.

The core rightsVerify the right client, right medication, right dose, right route, right time, and right documentation, and extend this to right reason, right response, right client education, and the client's right to refuse. Documentation happens after administration, never before.

Three checksCompare the label to the order when you take the medication from storage, when you prepare or pour it, and again at the bedside before administering. Returning an unused dose is a fourth opportunity to catch a mismatch.

Two identifiersUse two client-specific identifiers such as full name and date of birth, verified against the armband and the medication record. The room or bed number is never an acceptable identifier.

Timing windowsTime-critical medications such as insulin, anticoagulants, and antibiotics are generally given within 30 minutes before or after the scheduled time. Non-time-critical scheduled medications commonly allow a wider window per facility policy, but the policy governs, not convenience.

High-alert medicationsInsulin, heparin and other anticoagulants, opioids, concentrated electrolytes, chemotherapy, and neuromuscular blockers cause disproportionate harm when given in error. These require an independent double check by a second nurse, meaning each nurse calculates and verifies separately without being told the first answer.

Potassium rulePotassium chloride is diluted and infused, never given IV push and never as a bolus, and infusion rates are limited by policy with cardiac monitoring for higher rates. Concentrated potassium vials are not stored on general units.

Dangerous abbreviationsAvoid U and IU for units, QD and QOD, MS, MSO4, and MgSO4, and write out the terms instead. Never use a trailing zero (write 1 mg, not 1.0 mg) and always use a leading zero (write 0.5 mg, not .5 mg), because misread decimal points cause tenfold overdoses.

Look-alike sound-alike drugsConfusable name pairs are a leading error source, which is why tall man lettering and separated storage are used. When a name looks similar to another, confirm the indication against the client's diagnosis before giving it.

Verbal and telephone ordersAccept these only in urgent situations, write the order down and read it back to the prescriber for confirmation, spelling drug names and stating numbers digit by digit. Document who gave the order and the read-back, and have it authenticated within the required timeframe.

Question the orderYou are accountable for medications you administer, so clarify any order that is illegible, incomplete, outside the safe range, or inconsistent with the client's condition, allergies, or current labs. Administering a known unsafe order is not defensible because a provider wrote it.

After an error occursAssess and stabilize the client first, then notify the provider and charge nurse, monitor per orders, and complete an incident or occurrence report. Chart the objective facts of the client's condition and the interventions in the medical record, but do not chart that an incident report was filed.

System safeguardsBarcode scanning, computerized order entry, automated dispensing cabinets, and medication reconciliation at every transition of care reduce errors, but only when used as designed. Never scan a barcode from anything other than the medication being given to that client.

When a medication error happens, assess the client first; notification, documentation, and the incident report follow, and the report itself is never referenced in the chart.

Never administer a medication you did not prepare yourself, never leave medications unattended at the bedside, and never give potassium chloride by IV push.

Ch 48Dosage Calculation

Dosage calculation questions reduce to a few reliable formulas plus disciplined unit conversion, and most errors come from mismatched units or misplaced decimals rather than arithmetic. Know the basic dose formula, IV flow rate formulas, weight-based safe dose checking, and the standard rounding and equivalency rules.

Basic dose formulaDesired dose divided by dose on hand, multiplied by the quantity that contains the on-hand dose, gives the amount to administer: (D / H) x Q = amount. Convert so that D and H are in the same unit before dividing, or the answer will be off by a factor of a thousand.

Worked exampleOrder reads 0.25 g of a drug; the supply is 125 mg per 5 mL tablet suspension. Convert 0.25 g to 250 mg, then (250 / 125) x 5 mL = 10 mL. The conversion step, not the division, is where the error would have occurred.

Dimensional analysisStart with the unit you want on the left, then multiply by conversion fractions arranged so every unwanted unit cancels diagonally. It is slower to set up but self-checking, because if the leftover unit is not mL or tablets you know the setup is wrong.

Metric equivalencies1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL. Moving from a larger to a smaller unit multiplies by 1000 and moves the decimal three places to the right.

Household and weight conversions1 tsp = 5 mL, 1 tbsp = 15 mL, 1 oz = 30 mL, 1 cup = 8 oz = 240 mL, and 1 kg = 2.2 lb. To convert pounds to kilograms, divide by 2.2; converting the wrong direction more than doubles the dose.

Continuous IV ratemL per hour equals total volume in mL divided by total time in hours. For a 1000 mL bag ordered over 8 hours, the pump is set at 125 mL/hr.

Gravity drip rateDrops per minute equals volume in mL multiplied by the drop factor in gtt/mL, divided by time in minutes: gtt/min = (mL x gtt/mL) / min. Common macrodrip factors are 10, 15, and 20 gtt/mL, and microdrip is always 60 gtt/mL, which means with microdrip tubing the gtt/min equals the mL/hr.

Weight-based safe doseMultiply the ordered mg/kg by the client's weight in kilograms to get the safe dose or safe range per day, then divide by the number of doses per day to compare against a single ordered dose. If the order exceeds the safe range, hold it and contact the prescriber rather than adjusting it yourself.

Rounding conventionsRound most volumes to the nearest tenth of a mL, round doses under 1 mL for infants and critical drugs to the hundredth per policy, and round drops per minute and mL per hour to whole numbers because pumps and drips are not fractional. Only scored tablets may be split, so a calculation yielding one third of a tablet signals an error.

Reasonableness checkBefore administering, ask whether the answer is plausible: more than 2-3 tablets, more than about 3 mL in a single IM injection for an adult, or more than 1 mL subcutaneously should prompt recalculation. An answer that is off by exactly ten or a thousand is almost always a decimal or unit conversion error.

Insulin and unitsMeasure insulin only in an insulin syringe matched to the concentration, and never convert units to mL by formula. Insulin doses require an independent double check by a second nurse.

Convert to a common unit first, then apply (Desired / Have) x Quantity, and confirm the resulting volume or tablet count is physically reasonable before giving it.

Never administer a dose you calculated as exceeding the safe range, and never measure insulin or heparin doses in a standard syringe by converting units to milliliters.

Desired over Have times Quantity: (D / H) x Q.

Ch 49Intravenous Therapy

IV therapy delivers fluids, electrolytes, medications, and blood directly into the vascular space, so effects are immediate and errors are not retrievable. Exams focus on matching tonicity to the patient's problem and on recognizing the difference between complications you fix at the bedside and those that are life-threatening. Know the emergency responses cold: air embolism, extravasation, and circulatory overload.

Isotonic solutions0.9% sodium chloride, lactated Ringer's, and D5W (isotonic in the bag only) stay in the extracellular space and expand circulating volume without shifting water into or out of cells. Use for hypovolemia, hemorrhage, and vomiting or diarrhea losses; watch for overload in heart failure and renal disease.

Hypotonic solutions0.45% sodium chloride and similar dilute fluids move water out of vessels into cells, so they treat cellular dehydration and hypernatremia. Never give them to a patient with a head injury, stroke, or rising intracranial pressure, and avoid in burns or major trauma because they worsen cerebral edema and hypotension.

Hypertonic solutions3% sodium chloride, D10W, D5 in 0.9% saline, and D5 in lactated Ringer's pull water out of cells into the vessels. They are used for symptomatic hyponatremia and cerebral edema, run slowly on a pump with frequent sodium checks, and 3% saline is typically a central-line, monitored-setting infusion.

Air embolism is an emergencySudden dyspnea, chest pain, hypotension, tachycardia, and altered consciousness after a line is opened or disconnected suggest air in the circulation. Clamp the line immediately, place the patient in Trendelenburg on the LEFT side to trap air in the right atrium, deliver high-flow oxygen, and call for help.

Infiltration versus extravasationInfiltration is a non-vesicant fluid leaking into tissue: swelling, coolness, pallor, and a sluggish or stopped drip. Extravasation is the same leak with a vesicant such as a vasopressor or many chemotherapy agents, and it causes blistering, severe pain, and tissue necrosis, so it is the true emergency of the two.

Managing a leaking siteFor both, stop the infusion at once. For infiltration, discontinue the catheter, elevate the limb, and apply the compress the drug requires. For extravasation, do not pull the catheter first: disconnect the tubing, attempt to aspirate residual drug through the catheter, give the prescribed antidote, and notify the provider.

Phlebitis and infectionPhlebitis presents as redness, warmth, tenderness, and a palpable cord along the vein; remove the catheter, restart in the opposite extremity, and apply warmth. Purulent drainage, fever, chills, and hypotension suggest catheter-related bloodstream infection, which requires line removal and cultures.

Circulatory overloadCrackles, dyspnea, bounding pulse, distended neck veins, rising blood pressure, and sudden weight gain mean too much fluid too fast. Slow the infusion to a keep-open rate, raise the head of the bed to high Fowler's, give oxygen, notify the provider, and anticipate a diuretic.

Site and tubing maintenanceAssess the site at least every shift and with every medication, and change peripheral catheters based on clinical indication or facility policy rather than habit. Continuous administration sets are generally changed every 4 to 7 days per policy, intermittent sets every 24 hours, blood tubing after 2 units or 4 hours, and lipid-containing solutions every 12 to 24 hours.

Rate mathDrops per minute equal total volume in milliliters times the drop factor of the tubing, divided by total infusion time in minutes. Milliliters per hour equal total volume divided by total hours; always label the bag with start time and verify with an infusion pump for high-alert drugs.

Match tonicity to the deficit: isotonic replaces lost volume, hypotonic rehydrates cells, hypertonic pulls water back into the vessels, and hypotonic fluid is never given to a patient with increased intracranial pressure.

Never leave an air-filled or disconnected IV line open to the patient, and never delay clamping and left-side Trendelenburg positioning if air embolism is suspected.

Ch 50Adverse Effects, Interactions, and Contraindications

Every medication has predictable unwanted effects, some tolerable and some fatal, and nursing responsibility is to anticipate them rather than merely report them. Exam items test whether you can separate an expected side effect from an adverse effect that requires stopping the drug, and whether you know which drug and food combinations are dangerous. Anaphylaxis is the emergency you must be able to recognize in one sentence of stem.

Side effect versus adverse effectA side effect is an expected, usually tolerable secondary response such as dry mouth from an anticholinergic. An adverse effect is a harmful, unintended response such as hepatotoxicity or agranulocytosis and generally requires holding the drug and notifying the provider.

Toxicity and drug levelsToxicity occurs when the drug exceeds the therapeutic range because of excess dose, accumulation, or impaired clearance. Narrow-therapeutic-index drugs including digoxin, lithium, warfarin, phenytoin, theophylline, and aminoglycosides require scheduled levels, with troughs drawn just before the next dose and peaks timed after administration.

Anaphylaxis is an emergencyHives, flushing, lip or tongue swelling, wheezing, stridor, hypotension, and a sense of impending doom within minutes of a dose signal anaphylaxis. Stop the medication, maintain the airway, call for rapid response, and anticipate intramuscular epinephrine into the vastus lateralis, followed by oxygen, IV fluids, antihistamines, and corticosteroids.

Idiosyncratic and paradoxical responsesAn idiosyncratic effect is an unpredictable, individual reaction unrelated to dose, such as agitation from a sedative in an older adult. Report it, document it, and expect the drug to be discontinued rather than titrated.

Interaction categoriesAdditive effects sum two similar drugs, synergistic effects exceed the sum, antagonistic effects cancel one another, and potentiation occurs when one drug amplifies another. Alcohol plus opioids or benzodiazepines is the classic lethal additive-to-synergistic CNS and respiratory depression combination.

Metabolism-based interactionsEnzyme inhibitors such as grapefruit juice and many azole antifungals raise serum levels of drugs cleared by the same pathway, increasing toxicity risk. Enzyme inducers such as St. John's wort, rifampin, phenytoin, and carbamazepine lower levels and can cause oral contraceptive or anticoagulant failure.

Food and supplement interactionsMonoamine oxidase inhibitors plus tyramine-rich aged cheese, cured meats, and fermented foods can trigger hypertensive crisis. Tetracyclines and fluoroquinolones bind to calcium, iron, magnesium, and antacids, so separate them from dairy and mineral supplements; vitamin K-rich greens should be kept consistent, not eliminated, on warfarin.

Electrolyte-linked toxicityHypokalemia sharply increases digoxin toxicity, so check potassium and apical pulse before dosing. Combining ACE inhibitors, angiotensin receptor blockers, potassium-sparing diuretics, or potassium supplements risks dangerous hyperkalemia.

Contraindications and warningsAn absolute contraindication means the drug must not be used at all, such as a live vaccine in severe immunosuppression or an NSAID in active GI bleeding. A relative contraindication means use only when the benefit outweighs harm; a boxed warning is the strongest safety alert placed on a drug label.

Nursing responsibilityTake a full allergy, herbal, and over-the-counter history before the first dose, because patients often omit supplements and PRN products. Teach patients not to add any new product, including herbals, without checking, and to report new rash, bleeding, jaundice, dark urine, fever, or sore throat immediately.

If a reaction is expected and tolerable it is a side effect to manage, but if it is harmful, unexpected, or involves airway, bleeding, blood counts, liver, or kidneys, hold the drug and notify the provider.

Never give another dose of a medication after signs of an allergic or anaphylactic reaction, even if the symptoms appear mild.

Ch 51Individual Considerations of Medication Administration

The same dose is not equally safe in every patient because age, organ function, pregnancy, genetics, weight, and beliefs all change how a drug is handled. Exams test whether you adjust assessment and teaching for older adults, children, and patients with renal or hepatic impairment. The pharmacologic principle underneath most questions is that reduced clearance means more free active drug and greater toxicity risk.

Older adult pharmacokineticsAging brings decreased gastric motility, reduced lean body mass and total body water, lower serum albumin, and declining hepatic and renal clearance. The result is more free drug and longer half-life, so the guiding rule is to start low and go slow and to reassess renal function regularly.

Polypharmacy and high-risk classesMultiple prescribers and over-the-counter products create duplication and interaction risk, so perform medication reconciliation at every transition. Benzodiazepines, anticholinergics, sedating antihistamines, muscle relaxants, and long-acting sulfonylureas are especially likely to cause confusion, falls, urinary retention, and hypoglycemia in older adults.

Pediatric dosingDoses are calculated by weight in kilograms or body surface area, and a second nurse independently verifies calculations for high-alert drugs. Always confirm the child's current weight in kilograms and question any dose that exceeds the safe range rather than administering and reporting afterward.

Pediatric-specific cautionsAspirin is avoided in children and adolescents with viral illness because of the risk of Reye syndrome. Infants and young children have immature hepatic enzymes, higher body water, and thinner skin, so topical and systemic absorption is greater than expected.

Pregnancy and lactationAssess pregnancy status before radiologic contrast, teratogens, and category-restricted drugs, and use the lowest effective dose for the shortest time. Teach breastfeeding patients to time doses immediately after a feeding when possible and to verify each medication's compatibility with lactation.

Renal and hepatic impairmentImpaired kidneys reduce excretion of drugs such as aminoglycosides, vancomycin, metformin, and digoxin, requiring dose reduction and level monitoring. Impaired liver reduces first-pass metabolism and albumin production, raising free drug levels and bleeding risk with anticoagulants.

Genetics and ethnicityPharmacogenetic variation changes enzyme activity, so identical doses produce different responses in rapid and poor metabolizers. This underlies variable response to codeine, clopidogrel, warfarin, and some antidepressants, and it is a reason to assess effect rather than assume it.

Route-specific techniqueVentrogluteal is the preferred intramuscular site for adults because it avoids major nerves and vessels, while vastus lateralis is used for infants. Use Z-track technique for irritating agents, rotate subcutaneous insulin sites within one anatomic region, and never massage after heparin or insulin injection.

Oral and enteral formulationsDo not crush enteric-coated, sustained-release, extended-release, or controlled-release tablets, and do not open capsules whose coating controls the release rate. For enteral tubes, use liquid forms when available, give medications one at a time, and flush with water before, between, and after doses.

Culture, literacy, and adherenceAssess beliefs about medication, use of traditional or herbal remedies, cost barriers, vision, dexterity, and swallowing ability before assuming nonadherence is willful. Use a trained interpreter rather than a family member, provide written material at an accessible reading level, and confirm understanding with teach-back.

Reduced renal or hepatic function means the drug stays in the body longer, so anticipate lower doses, longer intervals, and closer monitoring in older adults and in anyone with organ impairment.

Do not crush or open extended-release, sustained-release, or enteric-coated preparations, because the entire dose is released at once and can cause overdose.

Ch 52Specimen Collection for Glucose Monitoring

Capillary blood glucose testing is one of the most frequently performed nursing skills, and results drive immediate insulin, food, and emergency decisions. Exam questions target correct puncture technique, interpretation of the numbers, and what to do at the two extremes. Treat any value under 70 mg/dL as hypoglycemia requiring action, not just documentation.

Reference valuesA normal fasting plasma glucose is roughly 70 to 99 mg/dL, with fasting values of 126 mg/dL or higher on repeat testing diagnostic of diabetes and 100 to 125 mg/dL indicating impaired fasting glucose. A random value of 200 mg/dL or higher with classic symptoms is also diagnostic.

Hemoglobin A1CA1C reflects average glycemic control over roughly the previous 3 months and does not require fasting. Under 5.7 percent is normal, 5.7 to 6.4 percent indicates prediabetes, and 6.5 percent or higher indicates diabetes; a common individualized treatment target for nonpregnant adults is below 7 percent.

Puncture techniqueUse the lateral aspect of the fingertip rather than the center pad, which is more richly innervated and more painful. Let the hand hang dependent or warm it first, allow alcohol to dry completely, wipe away the first drop, and use a gentle proximal-to-distal milking motion without hard squeezing, which dilutes the sample with tissue fluid.

Equipment accuracyCheck the expiration date on the strip vial, keep the vial closed and out of heat and moisture, and run control solution per policy or when results do not fit the clinical picture. Code or calibrate the meter to the strip lot when the device requires it.

Timing mattersFasting samples require roughly 8 hours without caloric intake, and postprandial values are timed from the first bite of the meal, not the end. Rapid-acting insulin is generally given within about 15 minutes of eating, so verify that food is actually available before dosing.

Hypoglycemia responseFor a conscious patient with a glucose under 70 mg/dL, give 15 grams of fast-acting carbohydrate such as 4 ounces of juice or regular soda, glucose tablets, or gel, then recheck in 15 minutes and repeat until above 70 mg/dL. Follow with a protein and carbohydrate snack if the next meal is more than an hour away.

Unconscious hypoglycemiaNever place food or fluid in the mouth of a patient who cannot protect the airway. Give intramuscular or subcutaneous glucagon, or intravenous dextrose 50 percent if IV access exists, then reposition to the side, monitor for vomiting, and recheck glucose.

Hyperglycemia cluesPolyuria, polydipsia, polyphagia, blurred vision, fatigue, and dry mucous membranes suggest hyperglycemia. Kussmaul respirations with fruity acetone breath point to diabetic ketoacidosis, while extreme glucose elevation with profound dehydration and neurologic change without ketosis suggests hyperosmolar hyperglycemic state.

Morning hyperglycemia patternsDawn phenomenon is a normal predawn surge in counterregulatory hormones producing high morning glucose without preceding hypoglycemia. Somogyi effect is rebound morning hyperglycemia following unrecognized nighttime hypoglycemia; a 2 to 3 a.m. glucose check distinguishes them, and treatment differs because one needs more evening insulin and the other needs less.

Safety and site selectionWear gloves, use a single-use retractable lancet, and dispose of it in a sharps container immediately, never recapping. Avoid alternate sites such as the forearm when glucose is changing rapidly or hypoglycemia is suspected, because those readings lag behind fingertip values.

Any glucose below 70 mg/dL is treated first and charted second, using the 15 grams of carbohydrate then recheck in 15 minutes rule for a conscious patient and glucagon or IV dextrose for one who cannot swallow.

Never give oral carbohydrate to an unconscious or seizing patient with hypoglycemia.

Rule of 15: 15 grams of carbohydrate, wait 15 minutes, recheck.

Ch 53Airway Management

Airway is always the first priority, and nursing management ranges from positioning and oral airways to suctioning and tracheostomy care. Exams focus on suction pressures and durations, the sequence of hyperoxygenation, and recognizing complications such as hypoxemia and vagal bradycardia. A dislodged fresh tracheostomy tube is a true emergency.

Oropharyngeal airwayUsed only in an unconscious patient without a gag reflex to hold the tongue off the posterior pharynx. Size it from the corner of the mouth to the angle of the jaw or earlobe; inserting one in a responsive patient provokes gagging, vomiting, and aspiration.

Nasopharyngeal airwayA soft nasal trumpet is better tolerated by a semiconscious patient with an intact gag reflex and provides a route for frequent nasotracheal suctioning. Measure from the nare to the earlobe, lubricate with water-soluble gel, and avoid it with facial or basilar skull trauma or coagulopathy.

Suction pressure limitsFor wall suction, typical settings are about 100 to 150 mmHg for adults, 50 to 100 mmHg for children, and 40 to 60 mmHg for infants. Use the lowest effective pressure, because excessive negative pressure causes mucosal trauma, bleeding, and atelectasis.

Suction duration and passesApply suction only while withdrawing the catheter, rotating it, and limit each pass to 10 to 15 seconds. Allow at least 30 seconds to 1 minute of recovery between passes, limit the episode to about 2 or 3 passes, and keep total suctioning time short.

Oxygenation around suctioningHyperoxygenate with 100 percent oxygen for roughly 30 to 60 seconds before and after each suctioning episode in an intubated patient. Suction only when clinically indicated by audible or auscultated secretions, rising airway pressures, or falling oxygen saturation, not on a fixed schedule.

Catheter selection and depthThe suction catheter outer diameter should be no more than half the inner diameter of the artificial airway so airflow is not fully occluded. Use sterile technique and a sterile catheter for tracheal suctioning and clean technique with a Yankauer for oral secretions, and never reuse an oral device for the trachea.

Recognizing complicationsStop suctioning immediately for oxygen desaturation, new dysrhythmias, or bradycardia, which reflects vagal stimulation, and reoxygenate the patient. Other risks include hypoxemia, mucosal bleeding, bronchospasm, infection, and increased intracranial pressure.

Tracheostomy care basicsPerform care using sterile technique, clean the inner cannula or replace a disposable one, and use precut or manufactured tracheostomy dressings because cut gauze sheds fibers into the stoma. Secure ties snugly enough to admit one or two fingers, and have a second nurse hold the tube while ties are changed.

Tracheostomy emergenciesKeep the obturator, a same-size spare tube, and a smaller spare tube at the bedside at all times. If the tube dislodges within about the first week before the tract matures, it is an emergency: call for help, keep the stoma open with a tracheal spreader or hemostat if trained, and ventilate with a bag-valve mask over the mouth and nose while occluding the stoma.

Cuff and aspiration preventionCuff pressure is kept at the minimum that seals the airway, generally around 20 to 25 cm H2O, because higher pressures cause tracheal ischemia and lower ones permit aspiration. Keep the head of the bed elevated, provide frequent oral care, and assess swallowing before oral intake in a patient with an artificial airway.

Secretion mobilizationAdequate systemic hydration, humidified oxygen, turning, early mobility, coughing and deep breathing, and incentive spirometry thin and move secretions so that suctioning is needed less often. Teach the patient to inhale slowly and fully, hold for several seconds, and repeat about 10 times each hour while awake.

Suction only on withdrawal, for 10 to 15 seconds per pass, with hyperoxygenation before and after, and stop immediately if the patient desaturates or becomes bradycardic.

Never apply suction while advancing the catheter, and never suction a patient longer than 15 seconds per pass.

Ch 54Nasogastric Intubation and Enteral Feedings

Nasogastric tubes decompress the stomach, deliver nutrition and medication, and remove gastric contents, and every one of those uses carries aspiration risk. Exams concentrate on measuring and verifying placement, aspiration precautions, and how to handle residual volumes and clogged tubes. Radiographic confirmation before the first use of a newly placed tube is the non-negotiable rule.

Tube types and purposesLarge-bore tubes such as the Salem sump and Levin are used for decompression, lavage, and suction, while small-bore flexible tubes are used for feeding. The Salem sump has a blue air vent lumen that must be kept above the level of the stomach and never clamped or used for irrigation.

Measuring insertion lengthMeasure from the tip of the nose to the earlobe and then to the xiphoid process, and mark the tube at that point. Position the patient in high Fowler's, insert with the head slightly flexed forward once past the nasopharynx, and have the alert patient sip water to trigger swallowing.

Signs to stop insertionWithdraw the tube immediately if the patient coughs persistently, chokes, becomes cyanotic, or cannot speak, because these suggest tracheal placement. Gagging alone may resolve with pausing and having the patient breathe and swallow.

Initial placement verificationAbdominal radiograph is the definitive standard and is required before the first feeding or medication through a newly inserted tube. Do not rely on the auscultated air bolus whoosh method, which cannot distinguish gastric from respiratory placement.

Ongoing verificationBefore every feeding, medication, and at least every 4 to 8 hours during continuous feeding, check aspirate pH and compare the external tube marking with the documented insertion length. Gastric aspirate is typically acidic at about 5.0 or less, while respiratory and intestinal secretions are usually 6.0 or higher; acid-suppressing drugs raise gastric pH and make this less reliable.

Gastric residual volumeAspirate residual per facility policy, commonly every 4 to 6 hours during continuous feeding and before each intermittent feeding. Return the aspirate to the stomach when policy permits to avoid loss of fluid, electrolytes, and acid, and hold the feeding and notify the provider for a persistently elevated residual, generally in the range of about 500 mL or the facility-defined threshold, or for distention, nausea, or vomiting.

Aspiration precautionsKeep the head of the bed elevated 30 to 45 degrees during feeding and for at least 30 to 60 minutes after an intermittent feeding. Stop the feeding before laying the patient flat for care, and stop immediately and suction if coughing, choking, or a sudden drop in oxygen saturation occurs.

Flushing and patencyFlush with 30 mL of water before and after each intermittent feeding, before and after each medication, between medications, and every 4 to 6 hours during continuous feeding, unless fluid is restricted. Use warm water and gentle push-pull pressure for a sluggish tube, and never force a clog or introduce carbonated beverage or cranberry juice, which worsen clotting of the formula.

Medication administrationUse liquid formulations when available, and if a tablet must be crushed, crush only immediate-release forms to a fine powder and dissolve fully in water. Give each medication separately with a flush between, and hold enteral feeding around drugs that require an empty stomach, such as phenytoin.

Formula handling and toleranceHang formula at room temperature, limit open-system hang time to about 4 to 8 hours per policy, label with date and time, and refrigerate opened cans no longer than 24 hours. Monitor for diarrhea, cramping, and dumping-type symptoms by slowing the rate, and monitor weight, intake and output, glucose, and electrolytes, watching for refeeding syndrome in the malnourished.

Nasogastric suction cautionsContinuous or intermittent suction removes hydrogen, chloride, potassium, and sodium, so watch for metabolic alkalosis, hypokalemia, and hypochloremia. Provide frequent oral and nasal care, assess for skin breakdown at the nare, and irrigate with normal saline rather than plain water to limit electrolyte washout.

Confirm a newly placed tube by X-ray before anything is instilled, then verify at every use with pH and the external marking, and never accept auscultation alone as proof of placement.

Never instill feeding, medication, or fluid into a newly placed tube before radiographic confirmation of placement.

NEX for measurement: Nose to Earlobe to Xiphoid.

Ch 55Pressure Injury, Wounds, and Wound Management

Pressure injuries result from unrelieved pressure, shear, friction, and moisture over bony prominences, and most are preventable with repositioning, nutrition, and skin care. Exams require exact staging language and the ability to distinguish an unstageable injury from a deep tissue injury. Dehiscence and evisceration are surgical emergencies with a specific immediate nursing response.

Stage 1Intact skin with localized nonblanchable erythema, meaning the redness does not fade with fingertip pressure. In darker skin tones look for changes in color compared with surrounding skin, plus warmth, edema, firmness, or pain rather than visible redness.

Stage 2Partial-thickness skin loss exposing a viable pink or red moist dermis, or an intact or ruptured serum-filled blister. There is no slough, eschar, granulation tissue, or visible fat; deeper tissue is not exposed.

Stage 3Full-thickness skin loss in which subcutaneous fat is visible, and granulation tissue, rolled wound edges, slough, or eschar may be present. Undermining and tunneling can occur, but bone, tendon, muscle, cartilage, and fascia are not exposed.

Stage 4Full-thickness skin and tissue loss with directly visible or palpable fascia, muscle, tendon, ligament, cartilage, or bone. Undermining, tunneling, slough, eschar, and osteomyelitis risk are common.

Unstageable and deep tissueAn unstageable injury has full-thickness loss whose base is obscured by slough or eschar, so depth cannot be determined until the base is exposed; stable dry adherent eschar on an ischemic heel is generally not removed. A deep tissue pressure injury shows intact or nonintact skin with persistent nonblanchable deep red, maroon, or purple discoloration or a blood-filled blister from injury at the bone-muscle interface.

Risk assessment and preventionUse a validated risk scale on admission and at regular intervals, in which lower scores indicate greater risk across sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Reposition dependent patients about every 2 hours in bed and every hour in a chair, use pressure-redistributing surfaces, and keep the head of the bed at or below 30 degrees when tolerated to limit shear.

Skin and moisture careCleanse promptly after incontinence, pat rather than rub dry, apply a moisture barrier, and use lift sheets instead of dragging to avoid friction. Never massage over a reddened bony prominence, and do not use donut-shaped devices, which concentrate pressure and reduce circulation.

Nutrition and healingHealing requires adequate calories, protein, fluid, vitamin C, vitamin A, and zinc, and albumin or prealbumin trends help identify risk. Uncontrolled hyperglycemia, smoking, steroids, immunosuppression, poor perfusion, and advanced age all delay healing.

Healing phases and intentionWounds progress through hemostasis, inflammation with redness and warmth for roughly the first 3 to 4 days, proliferation with granulation and epithelialization over about 3 weeks, and remodeling that can continue for a year or more with the scar reaching only about 80 percent of original strength. Primary intention closes clean approximated edges, secondary intention allows an open wound to granulate, and tertiary intention delays closure until contamination or edema resolves.

Dressing selectionKeep the wound bed moist and the surrounding skin dry: transparent films for minimal drainage and autolytic debridement, hydrocolloids for light to moderate exudate, hydrogels for dry wounds, foams and alginates for moderate to heavy exudate. Wet-to-damp gauze provides mechanical debridement, and negative pressure wound therapy removes exudate and promotes granulation.

Infection versus normal healingExpect mild erythema, warmth, and serosanguineous drainage early on; suspect infection with increasing pain, purulent or malodorous drainage, spreading erythema, induration, fever, and rising white blood cell count. Culture from viable tissue after cleansing rather than swabbing surface exudate or eschar.

Dehiscence and eviscerationA sudden gush of serosanguineous drainage or a report that something gave way suggests dehiscence; protruding viscera is evisceration. Cover the site immediately with sterile gauze moistened in sterile normal saline, place the patient in low Fowler's with knees slightly flexed, keep them NPO and calm, stay with them, and notify the surgeon for emergency repair.

Stage by the deepest visible viable tissue: intact nonblanchable redness is stage 1, exposed dermis is stage 2, visible fat is stage 3, visible bone, muscle, or tendon is stage 4, and a base covered by slough or eschar is unstageable.

Never massage or rub a reddened area over a bony prominence, and never reverse-stage a healing pressure injury back to a lower stage.

Ch 56Bacterial, Viral, Fungal, and Parasitic Infections

Infection control questions test the chain of infection, which precautions match which organism, and how treatment differs by pathogen class. Antibiotics do not treat viruses, and the most effective single intervention against transmission remains hand hygiene. Recognizing sepsis early and knowing the alcohol-resistant organisms are consistently high-yield.

Chain of infectionTransmission requires an infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Nursing interventions break specific links, and hand hygiene interrupts the mode of transmission, the link most easily and most often broken.

Precaution categoriesStandard precautions apply to all patients and all body fluids except sweat. Contact precautions add gown and gloves, droplet precautions add a surgical mask for organisms spread by large droplets within about 6 feet, and airborne precautions require an N95 or higher respirator plus a negative-pressure room.

Airborne and droplet examplesAirborne organisms include tuberculosis, measles, varicella, and disseminated herpes zoster, with the latter two also requiring contact precautions. Droplet examples include influenza, pertussis, mumps, rubella, and meningococcal disease; a patient on airborne precautions who must leave the room wears a surgical mask while staff wear the respirator.

Clostridioides difficileWatery, foul-smelling diarrhea after antibiotic exposure suggests C. difficile, which forms alcohol-resistant spores. Use contact precautions, wash with soap and water rather than alcohol-based rub, disinfect the room with a sporicidal bleach product, and expect oral vancomycin or fidaxomicin rather than antidiarrheals.

Resistant bacteria and stewardshipMRSA and VRE require contact precautions and dedicated equipment. Obtain cultures before starting antibiotics, give broad-spectrum coverage only until sensitivities return, and teach patients to complete the entire prescribed course, since incomplete therapy drives resistance.

Viral principlesAntibiotics are ineffective against viruses; antivirals such as oseltamivir and acyclovir shorten illness only when started early, generally within about 48 hours of symptom onset for influenza. Care is largely supportive with hydration, rest, and fever control, and prevention centers on vaccination.

Fungal infectionsCandidiasis of the mouth is treated with nystatin swish and swallow or a systemic azole, and dentures and inhaler use after corticosteroids are common contributing factors. Azole antifungals require monitoring of liver enzymes and have many CYP-mediated interactions, and amphotericin B causes infusion reactions, hypokalemia, hypomagnesemia, and nephrotoxicity, so premedication and hydration are used.

Parasitic infectionsPinworm is diagnosed with a transparent tape test applied to the perianal area first thing in the morning before bathing or a bowel movement, and the whole household is usually treated. Scabies and lice require contact precautions with permethrin or similar therapy and laundering of linens in hot water, and giardiasis follows contaminated water exposure.

Immunocompromised protectionNeutropenia is generally an absolute neutrophil count below 1,000 per cubic millimeter and is severe below 500. Institute protective measures: strict hand hygiene, no fresh flowers or standing water, no live vaccines, avoidance of ill visitors, cooked foods per policy, no rectal temperatures, suppositories, or enemas, and immediate reporting of any fever.

Localized versus systemic responseA localized infection produces redness, warmth, swelling, pain, and purulent drainage. Systemic infection adds fever, chills, malaise, tachycardia, and leukocytosis above the normal white blood cell range of roughly 5,000 to 10,000 per cubic millimeter, with a left shift toward immature bands.

Atypical presentation and sepsisOlder adults often present with confusion, falls, anorexia, or hypothermia rather than fever, and immunosuppressed patients may not mount a fever at all. Suspect sepsis with new confusion, fever or hypothermia, tachycardia, tachypnea, hypotension, and rising lactate, and act urgently on cultures, antibiotics, and fluid resuscitation.

PPE sequenceDon in the order gown, mask or respirator, goggles or face shield, gloves. Remove gloves and gown first inside the room, then eye protection, and remove the mask or respirator last after leaving the room, performing hand hygiene between steps and after the final removal.

Hand hygiene is the single most effective infection control measure, and for C. difficile and other spore-forming organisms it must be soap and water, because alcohol-based rub does not kill spores.

Never rely on alcohol-based hand rub after caring for a patient with C. difficile, and never take a rectal temperature or give a suppository or enema to a neutropenic patient.

Ch 57Fluid Imbalances

Fluid volume deficit and excess are assessed through weight, vital signs, urine output, and neck veins, and the same findings appear repeatedly on exams. Daily weight is the most sensitive indicator of fluid change, with 1 kilogram of change equaling roughly 1 liter of fluid. Knowing which lab values rise from hemoconcentration and which fall from hemodilution answers most items.

Fluid compartmentsAbout two-thirds of body water is intracellular and one-third extracellular, with the extracellular space divided into interstitial and intravascular fluid. Osmosis moves water toward the higher solute concentration, which is why tonicity of an IV solution determines whether cells swell or shrink.

Key reference valuesSerum osmolality is roughly 275 to 295 mOsm/kg and urine specific gravity roughly 1.005 to 1.030. Minimum acceptable adult urine output is about 30 mL per hour, or 0.5 mL per kilogram per hour, and output below that requires evaluation.

Causes of fluid volume deficitVomiting, diarrhea, nasogastric suction, hemorrhage, burns, excessive diuresis, fever, diaphoresis, and inadequate intake all deplete extracellular volume. Third spacing shifts fluid into the peritoneum or interstitium, so the patient can be intravascularly depleted while total body water appears normal or high.

Signs of fluid volume deficitExpect weight loss, thirst, dry mucous membranes, poor skin turgor, flat neck veins when supine, tachycardia with a weak thready pulse, orthostatic hypotension, cool clammy skin, decreased capillary refill, and concentrated scant urine. Late findings include restlessness progressing to confusion and hypovolemic shock.

Labs in deficitHemoconcentration raises hematocrit, hemoglobin, BUN, serum osmolality, and urine specific gravity above 1.030. A BUN-to-creatinine ratio elevated out of proportion to creatinine suggests dehydration rather than intrinsic renal injury.

Managing deficitReplace with oral fluids when tolerated and with isotonic IV solutions such as 0.9% sodium chloride or lactated Ringer's for significant intravascular depletion. Monitor hourly urine output, vital signs, mental status, and daily weight, restore volume gradually in older adults and those with cardiac or renal disease, and institute fall precautions for orthostatic hypotension.

Causes of fluid volume excessHeart failure, kidney injury, cirrhosis, syndrome of inappropriate antidiuretic hormone, corticosteroid therapy, excessive sodium intake, and overly rapid IV infusion all expand volume. Older adults, infants, and patients with impaired cardiac or renal function are at greatest risk.

Signs of fluid volume excessExpect rapid weight gain, dependent or generalized edema, distended neck veins, bounding pulse, hypertension with a widened pulse pressure, dyspnea, orthopnea, crackles, cough with frothy sputum, and altered mental status. Sudden extreme dyspnea with pink frothy sputum indicates acute pulmonary edema and is an emergency.

Labs in excessHemodilution lowers hematocrit, hemoglobin, BUN, and serum osmolality, and urine specific gravity falls below normal unless renal failure limits excretion. Compare against the patient's own baseline rather than a single value.

Managing excessRestrict sodium and often fluid, administer loop diuretics as prescribed while monitoring potassium, position in semi to high Fowler's for dyspnea, and apply oxygen. Track strict intake and output, weigh daily, assess lung sounds and edema each shift, and protect edematous skin from breakdown.

Weight is the best monitorWeigh at the same time each day, on the same scale, in similar clothing, after voiding. A gain or loss of 1 kilogram, about 2.2 pounds, corresponds to roughly 1 liter of fluid, and a change of about 2 pounds in a day or 5 pounds in a week warrants provider notification.

Daily weight measured the same way at the same time is the most reliable indicator of fluid status, because 1 kilogram of weight change equals about 1 liter of fluid gained or lost.

Do not infuse IV fluids rapidly in a patient with heart failure or kidney disease without close monitoring, because circulatory overload and pulmonary edema can develop quickly.

Ch 58Electrolyte Imbalances

Electrolyte questions are pattern questions: know the normal range, the mechanism, and whether the imbalance makes the patient hyperexcitable or depressed. Potassium, calcium, and magnesium disturbances kill through cardiac and respiratory effects, so they carry the highest priority. Learn the normal values precisely and the classic signs that pair with each direction.

Sodium 135 to 145 mEq/LSodium is the primary determinant of extracellular osmolality and therefore of water movement into and out of brain cells, which is why symptoms are neurologic. Hyponatremia below 135 causes headache, confusion, lethargy, muscle cramps and weakness, nausea, and at severe levels seizures and coma.

Sodium excess and correction speedHypernatremia above 145 produces intense thirst, dry sticky mucous membranes, flushed skin, restlessness and agitation, hyperreflexia, and seizures. Correct either imbalance slowly, because rapid correction of hyponatremia causes osmotic demyelination and rapid correction of hypernatremia causes cerebral edema; hypertonic 3% saline is reserved for severely symptomatic hyponatremia given slowly with frequent level checks.

Potassium 3.5 to 5.0 mEq/LHypokalemia below 3.5 causes generalized muscle weakness, leg cramps, decreased deep tendon reflexes, constipation and ileus, shallow respirations, and heightened digoxin toxicity risk. The ECG shows flattened T waves, ST depression, and prominent U waves, and life-threatening ventricular dysrhythmias can occur.

Hyperkalemia is an emergencyPotassium above 5.0, especially above 6.0, causes muscle weakness that ascends, paresthesias, diarrhea, and cardiac arrest. The ECG progresses from tall peaked T waves to a widened QRS, prolonged PR, and loss of the P wave, and treatment includes IV calcium gluconate to stabilize the myocardium, insulin with dextrose and beta agonists to shift potassium into cells, plus potassium binders or dialysis to remove it.

Potassium administration safetyPotassium chloride is always diluted and infused on a pump, generally not faster than about 10 mEq per hour on a general unit, with cardiac monitoring for faster rates. Verify adequate urine output before administration, never give it as an IV bolus or push, and never add it to a hanging bag.

Calcium 9.0 to 10.5 mg/dL totalHypocalcemia causes neuromuscular hyperexcitability: perioral and fingertip numbness and tingling, muscle twitching and cramps, tetany, hyperactive reflexes, laryngospasm, and seizures. Positive Chvostek sign is facial twitching when the facial nerve is tapped, and positive Trousseau sign is carpal spasm when a blood pressure cuff is inflated above systolic for a few minutes.

Hypercalcemia is dangerousCalcium above the normal range, commonly from malignancy or hyperparathyroidism, causes lethargy, confusion, profound muscle weakness, decreased deep tendon reflexes, constipation, nausea, polyuria, kidney stones, and bone pain, with dysrhythmias at severe levels. Treatment includes IV isotonic saline with a loop diuretic, calcitonin, and bisphosphonates, plus fall precautions and safe mobilization to prevent pathologic fracture.

Magnesium 1.3 to 2.1 mEq/LHypomagnesemia mirrors hypocalcemia with hyperreflexia, tremors, tetany, positive Chvostek and Trousseau signs, nystagmus, and torsades de pointes; it commonly accompanies alcohol use disorder and malabsorption. It frequently coexists with hypokalemia and hypocalcemia that will not correct until magnesium is replaced.

HypermagnesemiaMagnesium excess, typically from renal failure or magnesium-containing antacids and laxatives or obstetric magnesium therapy, causes flushing, hypotension, bradycardia, lethargy, and respiratory depression. The earliest reliable warning is loss of deep tendon reflexes, and IV calcium gluconate is the antagonist.

Phosphate 3.0 to 4.5 mg/dLPhosphate moves inversely to calcium, so hyperphosphatemia presents with hypocalcemia-like tetany and is treated with dietary restriction and phosphate binders taken with meals. Hypophosphatemia causes muscle weakness including respiratory muscle weakness, bone pain, confusion, and is a hallmark of refeeding syndrome in the malnourished.

Chloride 98 to 106 mEq/LChloride follows sodium and shifts inversely with bicarbonate. Hypochloremia typically arises from vomiting, gastric suction, or diuretics and accompanies metabolic alkalosis with hyperexcitability and tetany-like signs, while hyperchloremia accompanies metabolic acidosis, dehydration, and large-volume saline resuscitation with weakness and Kussmaul respirations.

Assessment prioritiesFor any electrolyte abnormality, prioritize airway, cardiac rhythm, and level of consciousness, and place the patient on a monitor for potassium, calcium, and magnesium derangements. Check renal function, review medications such as diuretics, digoxin, ACE inhibitors, and supplements, and always ask what recent losses occurred through vomiting, diarrhea, suction, or diuresis.

Potassium outside 3.5 to 5.0 mEq/L is the most immediately lethal common electrolyte abnormality, and any patient with it needs cardiac monitoring, with peaked T waves signaling high and flat T waves with U waves signaling low.

Never administer potassium by IV push or bolus, and never give undiluted concentrated potassium chloride, because it causes fatal cardiac arrest.

Chvostek is Cheek twitching, Trousseau is the Tourniquet or cuff causing carpal spasm, both signaling low calcium or low magnesium.