NR 302 Final Exam 3 Study Guide / NR302 Final Exam 3 Study Guide: Health Assessment I:, Study notes of Nursing

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NR I 302 IExam I 3 IFinal IExam

Exam I 3 I– IFinal

IExamIReview Iof

IKnowledge

Exam I3: I 200 Ipoints, I 50 Iquestions

This Iis Ia Ireview Iof Imajor Iconcepts Ifrom Ithe Isession. IThis Istudy Iguide Iis Inot Iexclusive. IAlso Ireview Ithe IPowerPointsIand Iread Iassigned Ichapters Iin IPerry I& IPotter. IReview Iall Iunfamiliar Iterminology Iboth Iin Ippt Iand Ibook. IReview Iall Iquestions Iat Ithe Iend Iof Ichapters. IReview Imath Imed Icalc Iproblems Ireviewed Iin Iclass. IReview Iall Iskills Iperformed Iin Ilab—rationale Ifor Iall Isteps Iwhen Icompleting Iskills. IReview Iany Imaterial Iin Ithe IATI ISkills IModules.

Comprehensive Ifinal Iblueprint:

54% IComprehensive I(Weeks I1-5)

20% IMedication IAdministration/patient

IsafetyI20% IBowel IElimination

6% IMedication

ICalculationI Tissue

IIntegrity I Pressure

IUlcers:

• Braden Iscale I& Irisk Ibased Ion Iscore o Sensory IPerception, IMoisture, IActivity, IMobility, INutrition, Iand IFriction I& IShear. IModerateIrisk Iis Ia Iscore Iof I 13 Ior I 14 Iand Ia Ihigh Irisk Iis Ia Iscore Iof I 12 Ior Iless.
• Prevention o Relieve Ipressure, Ikeep Iskin Iclean, Idry, Iand Imoisturized, Iprovide Iproper Inutrition, IpreventIdehydration, Iand Iminimize Ishearing Iand Ifriction.
• Staging Iand Iassessment o Stage II IPressure IUlcer ▪ Pressure Irelated Ialteration Iof Iintact Iskin Iusually Iover Ibony Iprominenc ▪ ~Presentation: ▪ -Non-blanchable Ierythema Iin Ilighter Iskin Itones ▪ -Difficult Ito Iassess Iin Idarker Iskinned Ipatients ▪ -Discoloration ▪ -Warmth/coolness ▪ -Edema ▪ -Induration ▪ -Itching Isensation o Stage III IPressure IUlcer ▪ -Partial Ithickness Iloss Iof Idermis ▪ -Presentation: ▪ -Shallow, Iopen Iulcer Iwith Ia Ired-pink Iwound Ibed ▪ -Wounds Iare Iclean Iand Ivascular ▪ -Intact Ior Iopen Iblister ▪ -Without Islough, Ieschar, Iecchymosis Ior Iundermining ▪ -It Iis INOT: ▪ Skin Itears, Itape Iburns, Iincontinence Idermatitis, Imaceration, Iexcoriation o Stage IIII IPressure IUlcer

▪ -Pressure Irelated Ifull-thickness Itissue Iloss

Hygiene

▪ Presentation: ▪ -Subcutaneous Ifat Imay Ibe Ivisible ▪ -Bone, Itendon Iand Imuscle Iare Inot Iexposed ▪ -Slough Imay Ibe Ipresent, Ibut Idoes Inot Iobscure Ithe Idepth Iof Itissue Iloss ▪ -Undermining Imay Ior Imay Inot Ibe Ipresent o Stage IIV IPressure IUlcer ▪ -Pressure Irelated Ifull Ithickness Iloss Iof Itissue Iwith Iexposed Ibone, Itendon Ior Imuscle ▪ Presentation: ▪ -Subcutaneous Ifat Imay Ibe Ivisible ▪ -Slough Ior Ieschar Imay Ibe Ipresent ▪ -Often Iincludes Iundermining Iand Itunneling o Unstageable ▪ -Pressure Irelated Ifull Ithickness Itissue Iloss Iin Iwhich Ithe Iactual Idepth Iof Ithe Iulcer IisIobscured Iby Islough Ior Ieschar

Bathing Iguidelines

• Safety Iand Iinfection Iprevention Iconcepts Iduring Ibathing
• • IMaintain Isafety: Iside Irails Iup Iwhen Iaway Ifrom Ithe Ipatient’s Ibedside, Iutilize Ichairs, Ishower IchairsIappropriately, Iprevent Islipping
• • IPromote Iindependence: Iencourage Ithe Ipatient Ito Iparticipate Iin Ias Imuch Ias Ipossible
• • IAnticipate Ineeds: Ibring Iin Ithe Iequipment, Ilinens, Igown, Isocks Iand Iother Iitems Iyou Iwill Ineed
• Perineal Icare Ifor Imales Iand Ifemales
• ~Males I–
• Retract Iforeskin, Imove Iin Ia Icircular Imotion Istarting Iat Ithe Itip Iof Ithe Ipenis Iand Imove Itoward Ithe Ibase. Replace Iforeskin. ILift Iand Iwash Iscrotum Iand Iskinfolds. IDry Ithoroughly.
• ~Females I–
• Wash Ilabia Imajora Ifirst, Iwiping Iform Iperineum Ito Irectum I(front Ito Iback). IRepeat Iwith Idifferent Ipart Iof Iwash Icloth. ISeparate Ilabia Iwith Inon-dominant Ihand Ito Iexpose Iurinary Imeatus Iand Ivaignal Iorifice. IWashIdownward Ifrom Ipubic Iarea Ito Iward Irectum I(middle Iand Iboth Isides) Iwith Ia Iseparate Isection Iof Ithe Iwash Icloth Ieach Itime. IRinse Iand Idry Ithoroughly.
• ~Incontinence Icare Iincludes Iperineal Icare Iand Iuse Iof Ibarrier Icreams. IBarrier Icreams Ican Ialso Ihave antifungal Iproperties. IThere Iare Ialso Icloths Ithat Ihave Ia Ibarrier Icream Iinfused Iinto Ithe Icloth Ithat IcanIsimultaneously Iclean Iand Iprovide Ia Ibarrier.

Oral Icare

▪ -Conscious Ipatient: IEncourage Iindependence, Iset Iup Iwith Ibasin, Iwater, Itoothbrush, Itoothpaste. IDetermineIwhich Imethod Iis Ibest Ibased Ion Ipatient’s Ineeds Iand Iability. ▪ -Unconscious Ipatient: IExplain Iprocedure, Iturn Ipatient’s Ihead Ito Ithe Iside, Iswab Imouth Iout Iwith Iwater Iand mouth Iswabs. IApply Ilip Imoisturizer Iif Ineeded. IDo Inot Iuse Itoothpaste Iand Ia Itooth Ibrush.

Oxygenation

Assessment Ifor Ichronic Iversus Iacute Ihypoxia

▪ Look Ifor Isigns Iof Iacute Idistress I(breathing Ipatterns, Iwork Iof Ibreathing) Iversus Ilong Iterm Isigns Iof IhypoxiaI(clubbing/barrel Ichest)

Oxygen Itherapy:

• Devices I^

• Liter Iflow I^

• Indications I^

• Oxygen Isafety

• Always Iensure Ithat Ithe Ipatient Iis Ion Ithe Iappropriate Ilevel Iof Ioxygen Iper Iphysician Iorder. IThe Iflow Imeters Iare Isensitive Iand Iare Ieasily Ibumped Iand Imoved. ICheck Ithat Ioxygen Itubing Ihas Inot IbecomeIdisconnected.

• When Ireading Ia Iflow Imeter Iensure Ithe Inumber Iline Iis Ibisecting Ithe Imetal Iball.

• Ensure Ithe Ipatient Ihas Isufficient Iamounts Iof Ioxygen Itubing Ito Imove Ifreely Iwithin Itheir Iroom. I Use IaIportable Ioxygen Itank Iwhen Iambulating.

• • IDo Inot Itake Ia Ipatient Ioff Iof Itheir Ioxygen Isource Ito Ihelp Ithem Ito Ithe Ibathroom.

• Oxygen Iis Ia Ihighly Icombustible Igas. IIt Idoes Inot Iburn Ispontaneously Ior Icause Ian Iexplosion, Iit Ican IeasyIcause Ia Ifire Iwhen Iexposed Ito Ispark Ior Iopen Iflame.

• Place Ian I“oxygen Iin Iuse” Isign Ion Ithe Ipatients Idoor.

• Keep Ioxygen-delivery Isystems I 10 Ifeet Ifrom Iany Iopen Iflames.

• Assess Ielectrical Iequipment Iand Iensure Iit Iis Iworking Iproperly.

• During Itransport, Ipatients Imay Ineed Ian Ioxygen Itank Ifor Itransport.

• Always Istore Ioxygen Itanks Iupright Iin Itheir Iapproved Icarrier.

• There Iwill Ibe Ia Idesignated Ilocation Ifor Ifull Itanks Iand Ia Idesignated Ilocation Ifor Iempty Itanks. IAfter Ia Itank Ihas Ibeen Iremoved Ifrom Ithe Ifull Itank Ilocation Iand Iused, Iit Iis Iconsidered Iempty. I“Empty” Itanks ImayIstill Ibe Iused, Ibut Ishould Ionly Ibe Iused Ifor Ishort Itransports Ior Ineeds. IThe Igauge Ion Ithe Itank Iwill Ishow Iyou Iapproximately Ihow Imuch Ioxygen Iis Ileft Iwithin Ithe Itank.

• Teach Ipatients Iabout Ihome Ioxygen Isafety.

• Comfort Imeasures

• Humidity I– Ioxygen Iwith Ihigh Irelative Ihumidity Ikeeps Ithe Iairways Imoist Iand Iloosens Iand ImobilizesIpulmonary Isecretions

• Necessary Ifor Ipatients Ireceiving Ioxygen Iat I> I4L/min

• Skin Iprotection I– IThe Itubing Iof Ithe Ioxygen Idevices Imay Icause Ipressure Iulcers Iif Ito Itight.

• Assess Ithe Iskin Iunder Ioxygen Itherapy Idevices Iat Ileast Ionce Ia Ishift, Iand Iutilize Ipressure IreducingIdevices Ias Iappropriate Iand Iper Ifacility Ipolicy.

• Moisten Imucus Imembranes Iusing Iwater Isoluble Imoisturizer Ito Iprevent Idrying Iand Icracking Iof ImucousImembranes.

• Perform Ioral Icare Ifrequently Ifor Ipatients Ion Ioxygen I(especially Imasks) Ito Iprevent Idrying Iof Ithe IoralImucosa. IMoisten Ithe Ilips Iwith Ian Iapproved I(non-petroleum) Ilip Imoisturizer.

Artificial Iairways:

Nasal Iairway I– Iprevents Iairway Iobstruction Iof Ia Iconscious Ipatient I(also Icalled Ia Inasal Itrumpet)

Oral Iairway I- Iprevents Iobstruction Iof Ithe Itrachea Iby Idisplacement Iof Ithe Itongue Iinto Ithe Ioropharynx Ifor IunconsciousIpatients

The Ioral Iairway Iextends Ifrom Ithe Iteeth Ito Ithe Ioropharynx, Imaintaining Ithe Itongue Iin Ithe Inormal

Iposition.IUse Ithe Icorrect-size Iairway.

Determine Ithe Iproper Ioral Iairway Isize Iby Imeasuring Ithe Idistance Ifrom Ithe Icorner Iof Ithe Imouth Ito Ithe Iangle Iof Ithe IjawIjust Ibelow Ithe Iear.

If Ithe Iairway Iis Itoo Ismall, Ithe Itongue Idoes Inot Istay Iin Ithe Ianterior Iportion Iof Ithe Imouth

If Ithe Iairway Iis Itoo Ilarge, Iit Iforces Ithe Itongue Itoward Ithe Iepiglottis Iand Iobstructs Ithe Iairway.

Insert Ithe Iairway Iby Iturning Ithe Icurve Iof Ithe Iairway Itoward Ithe Icheek Iand Iplacing Iit Iover Ithe Itongue. IWhen Ithe Iairway Iis Iin Ithe Ioropharynx, Iturn Iit Iso Ithe Iopening Ipoints Idownward. ICorrectly Iplaced, Ithe Iairway Imoves Ithe ItongueIforward Iaway Ifrom Ithe Ioropharynx, Iand Ithe Iflange I(e.g., Ithe Iflat Iportion Iof Ithe Iairway) Irests Iagainst Ithe Ipatient’s Iteeth.

Incorrect Iinsertion Imerely Iforces Ithe Itongue Iback Iinto Ithe Ioropharynx.

IWhen Ia Ipatient Iis I“intubated” Itypically Ian Iendotracheal I(ET) Itube Iis

Iused.

The Itube Iis Ipassed Ithrough Ithe Ipatient’s Imouth, Ipast Ithe Ipharynx, Iand Iinto Ithe Itrachea.

It Iis Igenerally Iremoved Iwithin I 14 Idays; Ihowever, Iit Iis Isometimes Iused Ifor Ia Ilonger Iperiod Iof Itime Iif Ithe Ipatient Iis IstillIshowing Iprogress Itoward Iweaning Ifrom Iinvasive Imechanical Iventilation Iand Iextubation.

If Ia Ipatient Irequires Ilong-term Iassistance Ifrom Ian Iartificial Iairway, Ia Itracheostomy Iis Iconsidered.

A Isurgical Iincision Iis Imade Iinto Ithe Itrachea, Iand Ia Ishort Iartificial Iairway I(a Itracheostomy Itube) Iis

Iinserted.IMost Itracheostomies Ihave Ia Ismall Iplastic Iinner Itube Ithat Ifits Iinside Ia Ilarger Ione I(the Iinner

Icannula).

The Imost Icommon Icomplication Iof Ia Itracheostomy Itube Iis Ipartial Ior Itotal Iairway Iobstruction Icaused Iby Ibuildup Iof Irespiratory Isecretions. IIf Ithis Ioccurs, Ithe Iinner Itube Ican Ibe Iremoved Iand Icleaned Ior Ireplaced Iwith Ia Itemporary IspareIinner Itube Ithat Ishould Ibe Ikept Iat Ithe Ipatient’s Ibedside.

Keep Itracheal Idilators Iat Ithe Ibedside Ito Ihave Iavailable Ifor Iemergency Itube Ireplacement Ior Ireinsertion.

Humidification Ifrom Iair Ihumidifiers Ior Ihumidified Ioxygen Itracheostomy Icollars Ican Ihelp Iprevent Idrying IofIsecretions Ithat Icause Iocclusion.

Tracheostomy Isuctioning Ishould Ibe Idone Ias Ioften Ias Inecessary Ito Iclear Isecretions.

• Types I^
• Indications I^

• Insertion I(who Ican Iinsert, Ihow)

I^ISuctioning:

Suctioning Iis Inecessary Iwhen Ipatients Iare Iunable Ito Iclear Irespiratory Isecretions Ifrom Iairways Iby Icoughing. IWhatIassessment Ifindings Iindicate Ithe Ineed Ifor Isuctioning?

Use Isterile Itechnique

Suction Iat I100-150mmHg Ifor Iadults

Utilize Iintermittent Isuction Ion Iwithdrawal Iof Ithe Icatheter, Inever Ion

IinsertionISuctioning Itechniques Iinclude:

Oro/Nasopharyngeal I– Iused Iwhen Ithe Ipatient Iis Iunable Ito Icough Ieffectively Ibut Iable Ito Iclear Isecretions IbyIexpectorating

Perform Ioral Ihygiene Iprior Ito Isuctioning

Apply Isuction Iafter Ithe Ipatient Ihas Icoughed Ito Iremove Isecretions

Oro/Nasotracheal I– Iused Iwhen Ia Ipatient Iis Iunable Ito Imanage Isecretions Iby Icoughing Iand Idoes Inot Ihave Ian IartificialIairway Ipresent

The Inose Iis Ithe Ipreferred Iroute Ibecause Igag Ireflex Iis Iminimal

The Iprocess Iis Isimilar Ito Ithe Ipharyngeal Isuctioning, Ibut Ithe Icatheter Iis Ipassed Ifarther Iinto Ithe

ItracheaITracheal

Open Iand Iclosed Imethods:

Open Isuctioning Iinvolves Iusing Ia Inew Isterile Icatheter Ifor Ieach Isuction Isession I(AARC, I2010a). IWear Isterile IglovesIand Ifollow IStandard IPrecautions Iduring Ithe Isuction Iprocedure. IClosed Isuctioning Iinvolves Iusing Ia Ireusable Isterile Isuction Icatheter Ithat Iis Iencased Iin Ia Iplastic Isheath Ito Iprotect Iit Ibetween Isuction Isessions.

Closed Isuctioning Iis Imost Ioften Iused Ion Ipatients Iwho Irequire Iinvasive Imechanical Iventilation Ito Isupport Itheir Irespiratory Iefforts Ibecause Iit Ipermits Icontinuous Idelivery Iof Ioxygen Iwhile Isuction Iis Iperformed Iand Ireduces Ithe IriskIof Ioxygen Idesaturation.

Although Isterile Igloves Iare Inot Iused Iin Ithis Iprocedure, Inonsterile Igloves Iare Irecommended Ito Iprevent Icontact IwithIsplashes Ifrom Ibody Ifluids.

• Indications Ifor Idifferent Itypes Iof Isuctioning I^
• Tracheal Isuctioning Iprocedure I^
• Hyperoxygenation Iwith Itracheal Isuctioning- Iwith Iclosed

IsuctioningILung Iexpansion:

• Different Ipatient Ipositions Iand Iwhen Ithey Iare Iindicated Ito Iincrease Ilung Iexpansion

The I45-degree Isemi-Fowler’s Iis Ithe Imost Ieffective Iposition Ifor Ipromoting Ilung Iexpansion Iand IreducingIpressure Ifrom Ithe Iabdomen Ion Ithe Idiaphragm. In Ithe Ipresence Iof Ipulmonary Iabscess Ior Ihemorrhage, Iposition Ithe Ipatient Iwith Ithe Iaffected Ilung Idown Why? Iprevent Idrainage Ito Ihealthy Ilung, Iand Ipromote Ifull Iexpansion Iof Ithat Ilung IFor Ibilateral Ilung Idisease, Ithe Ibest Iposition Idepends Ion Ithe Iseverity Iof Ithe Idisease.

• Chest Itube Iindications I(hemothorax Iversus Ipneumothorax Ipresentations)
• The Ipleural Ispace Iis Ia Ipotential Ifor Ispace Iin Ibetween Ithe Ivisceral Iand Iparietal Ipleura. IWhen Ithis IspaceIfills Iwith Iair Ior Ifluid/blood, Iit Icollapses Ithe Ilung.
• A Ichest Itube Ipulls Ithe Ifluid Ior Iair Iout Iof Ithe Ipleural Ispace Iand Iallows Ifor Ilung Ire-expansion.
• Placement Iof Ithe Ichest Itube:
• Bases I– IFluid
• Apices I– IAir I(remember Iair Irises Ito Ithe Itop)
• A Ipneumothorax Iis Ithe Icollection Iof Iair Iin Ithe Ipleural Ispace.
• Spontaneous Ipneumothorax I– Igenetic Icondition Ithat Ioccurs Iunexpectedly Iin Ihealthy Iindividuals I(usually Ithin Imales) Iwho Idevelop Iblisterlike Iformations I(blebs) Ion Ithe Ivisceral Ipleura, Ithen Ithey IruptureIduring Isleep Ior Iexercise, Icausing Iair Ito Ienter Ithe Ipleural Ispace
• Secondary Ipneumothorax
• Chest Itrauma
• Emphysema
• Invasive Iprocedures
• Hemothorax Iis Ithe Iaccumulation Iof Iblood Iand Ifluid Iin Ithe Ipleural Ispace.

Urinary IElimination

Urinary Ipathophysiology I& Iterminology:

• Urinary Iretention I(signs Iand Isymptoms) o Inability Ito Ipartially Ior Icompletely Iempty Ithe Ibladder. o Symptoms: Ibladder Idistension, Ipain, Irestlessness, Idiaphoresis
• UTI I(signs Iand Isymptoms) o Infection Iof Ithe Ibladder, Iurethra, Ior Ikidney o Symptoms: Idysuria, Iurgency, Ifrequency, Iincontinence, Isuprapubic Itenderness, Ifoul Ismelling IorIcloudy Iurine, Ifever, Iconfusion Iin Iolder Iadults, Iand Ihematuria
• Urinary Iincontinence I(signs Iand Isymptoms) o Involuntary Iloss Iof Iurine o Symptoms: Ileakage Iwith Iurgency, Ileakage Iwith Istress

Assessment:

• Urine I(color, Iclarity, Iodor Iand Iwhat Ithese Imean) o Color: Iindicates Ihydration Iand Ibleeding; Imay Ibe Ifrom Imedications ▪ Straw Icolor: Inormal ▪ Dark Iyellow: Iconcentrated Iurine I(AM Ivoid) ▪ Amber: Idehydrated ▪ Hematuria: Ibleeding o Clarity: Ithere Iis Icloudy Iand Iclear. I Cloudy Icould Iindicate Iinfection o Odor: Ithere Iis Iammonia Iand Ifoul Iodor. I Foul Iodor Icould Iindicate Iinfection
• Laboratory Icollection o CBC I– Iassessing Ifor Ibleeding I(low IH&H) Iand Ileukocytosis I(high Iwhite Iblood Icells) o BMP I– IKidney Ifunction I(Creatinine/BUN) IElectrolyte Istatus I(K, INa, ICl, IGlucose) o Urinalysis I– Iindicators Iof IUTI, Idehydration o Urine Iculture Ilooking Ifor Ispecific Ibacteria

• Output I(normal Iversus Iabnormal Ivalues; Iwhat Ito Ido Iif Iabnormal) o Normal Ioutput Iis I30mL/hr Iand I1200-1500/day o Abnormal Iis Iless Ithan I30mL/hr Iand Ino Ivoid Iin I3-6 Ihours. I If Iabnormal Ithen Icall IphysicianIimmediately
• Bladder Iscan I(indications, Iprocedure) o Noninvasive Imonitoring Iof Iurine Iin Ithe Ibladder o Place Ithe Ipatient Iin Ithe Isupine Iposition, Ichoose Ithe Imale Ioption Ifor Ia Ifemale Iwho Ihas Ihad IaIhysterectomy, Iuse Iultrasound Igel, Iand Iplace Ithe Iprobe I 2 Iinches Iabout Ithe Isymphysis Ipubis

Catheters:

• Types Iand Iindications Ifor Ieach o Intermittent(straight Icath Ior Iin Iand Iout Icath): I single Ilumen Icatheter Iused Ito Imeasure IPVRIand Ias Ia Iway Ito Imanage Ichronic Iurinary Iretention o Indwelling Ior Ifoley Icath: I double(foley) Ior Itriple Ilumen Icatheter(continuous Ibladder irrigation) Iused Ifor Iclose Ioutput Imonitoring, Iperioperative, Iinadequate Ibladder Iemptying o External Ior Icondom Icath : Inon-invasive Iway Ito Icollect Iurine Ifor Imale Ipatients Iwho IareIincontinent o Suprapubic: I surgically Iinserted Icath Iinto Ithe Ibladder Ithrough Ithe Iabdominal Iwall Iabove Ithe symphysis Ipubis Iplaced Iwhen Ithere Iis Ia Iblockage Iof Ithe Iurethra o Coude : Ia Icurved Itip Isingle Ior Idouble Ilumen Icatheter Imade Ifor Imaneuvering Ithrough ItheIprostatic Iurethra Iin Ithe Ipresence Iof Ia Ilarge Iprostate
• Insertion, Imaintenance Iand Iremoval Iof Ian Iindwelling Icatheter o For Imales Iyou Ineed Ito Iinsert Iit Iall Ithe Iway Iup Ito Ithe Ibifurcation. I For Ifemales Iyou Ineed Ito Iinsert Iit Iuntil Iyou Isee Iurine Iand Ithen Itwo Imore Iinches. I (with Ilube) IOnce Iin, Iyou Ineed Ito IinflateIballoon Iand Ipull Iout Iuntil Iyou Ifeel Iresistance o To Iremove, Ideflate Iballoon Iand Ipull Iout o Before Iinserting, Icheck Ifor Ialternatives Iand Iindications o Review Ithe Ineed Ifor Icath Iand Iengage Ifamily Iin Idecision Iabout Icath o Maintenance Ifor Iinsertion, Imake Isure Iit’s Iinserted Icorrectly, Imake Isure Iit Iis Isecured, IcheckIdrainage Ibag, Iand Ihygiene.
• Prevention Iof ICAUTI o N-need Ifor Icatheter Iassessed o O- Ioffer Ipatient Ieducation o C-complete Icath Icare Ionce Idaily Iand Ias Ineeded Iwith Iperineal Icare o A-maintain IAsepsis Iduring Iinsertion Iand Iwhile Icath Iis Iin Iplace o U-check Ito Imake Isure Iit Iis IUnobstructed, Ialso Ibag Imust Ibe Ibelow Ibladder Ibut Inot Ion Ifloor o T-timely Icath Iremoval o I-infection Ireduction, Imaintain Ia Iclosed Idrainage Isystem

Nutrition

Enteral Ifeedings:

• Types Iof Itubes Iand Iwhen Ieach Iis Iindicated o Small Ibore ING Itube-when Ithe Ipatient Ijust Ineeds Ifeeding, Ishort Iterm o Small Ibore Inasoenteric- Iwhen Ithe Ipatient Ineeds Ifeeding Istraight Iinto Ithe Ipylorus/ IsmallIintestines, Ishort Iterm o Large Ibore ING- Iwhen Ithe Ipatient Ineeds Ifeeding Iand/or Isuctioning, Ialso Imedicine administration, Ishort Iterm

o JEG, IPEG- Iwhen Ithe Ipatient Ineeds Ithe Itube Istraight Iinto Istomach Ior Iintestines Ibut Ican’t IgoIthrough Ithe Imouth, Ilong Iterm

• All Icomplications Iof Ienteral Ifeeding Itherapy o Assessing Ifor Imalposition I(initial Iversus Iongoing) - Initial- Itaking Ian Ix-ray - Ongoing- Igastric Iresidual Icontents Iassessment(color, Iamount, IpH) ▪ pH Ilevels Ifor Ivarious Ifluids I(gastric/enteric/pleural)
• gastric-1-
• nasoenteric- Igreater Ithan Ior Iequal Ito I 6
• pleural- Igreater Ithan Ior Iequal Ito I 6
• continuous- Igreater Ithan Ior Iequal Ito I 5 o Patient Isafety Iconcepts Iwith Itube Ifeedings ▪ Aspiration I(assessing Iresidual) - Raise IHOB Ito Iat Ileast I 30 Idegrees ▪ Prevention Iof Itubing Imisconnections - Tape Ithe Itube, Ido Inot Iput Iit Ion Isame Iside Iof IIV ▪ Infection - Change Ithe Ibag Ievery I 24 Ihours, Iflush Itube
• Types Iof Ienteral Iformulas Iand Iwhen Ieach Iis Iindicated o Polymeric I(1-2kcal/mL) ▪ Milk Ibased Iblenderized Ifoods, Iwhole Inutrient Iformulas o Modular I(3.8-4kcal/mL) ▪ Single Imacronutrient(protein, Iglucose, Ipolymers, Ior Ilipids) ▪ Supplements I)added Ito Ipatient’s Iintake) o Elemental I(1-3kcal/mL) ▪ Predigested Inutrients Ieasier Ifor Idysfunctional IGI Itracts Ito Iabsorb o Specialty I(1-2kcal/mL) ▪ Designed Ito Imeet Ispecific Inutritional Ineeds Iin Icertain Iillness(renal Ifailure, IpulmonaryIdisease, IHIV)
• Intermittent Iversus Icontinuous Ifeedings I(changes Iin Inursing Icare) o Intermittent ▪ HOB I> I 45 Idegrees Iduring Itube Ifeeding Iand I30-60 Iminutes Iafter Ithe Ifeeding ▪ Assess Ithe Igastric Iresidual Iamount Ibefore Ieach Ifeeding o Continuous ▪ HOB I>30 Idegrees Ifor Ithe Iduration Iof Ithe Ifeeding ▪ Assess Igastric Iresidual Iaccording Ito Iphysician Iorder I(4 Ihours Ifor Icritically IillIpatients; I4-6 Ihours Ifor Inon-critically Iill Ipatients)

Parenteral Inutrition:

• Indications Iand Iadministration o Use Iit Iwith Isomeone Iwho Ihas Ia Igastrointestinal Ior Idigestive Idisorder Iand Iwith Isomeone IwhoIneeds Iextra Isupplements Ito Itheir Idiet
• TPN Iversus IPN o PN Iis Iused Iwith Ianother Isource Iof Inutrition, Iusually Iused Ito Igive Iextra Isupplements o TPN Iis Ithe Ionly Isource Iof Inutrition
• Prevention Iof Icomplications o Infection ▪ Change ITPN Itubing Ievery I 24 Ihours. IComplete Isterile ICVC Idressing Ievery I 7 Idays Ior Iif Iit Ibecomes Iwet/non-occlusive. IUse Ialcohol Ito Iscrub Ithe Iaccess Ipoint Ifor I 15 IsecondsIprior Ito Iaccessing Ithe Iline o Occlusion

▪ Flush Ithe Iline Iwith I20mL Iof Inormal Isaline Iafter ITPN Iadministration o Pneumothorax ▪ Might Inot Ibe Iable Ito Iprevent Iit Ibecause Iit Ioccurs Ion Iinsertion. I Monitor Ifor IsymptomsIof Ipulmonary Idistress o Air Iembolus ▪ Maintain Iintegrity Iof Ithe Iclosed ICVC Isystem, Iespecially Iduring Icap Ichanges IandIblood Idraws

Diet:

• Types Iof Idiets Iand Iwhen Ieach Iis Iindicated o Clear Iliquids: Ibroths, Icoffee, Itea, Icarbonated Ibeverages, Iclear Ifruit Ijuices, Ijello, Ipopsicles o Full Iliquids: I(cloudy) Imilk, Icream Isoups, Icustards, Irefined Icooked Icereals, Ivegetable Ijuice,Isherbets, Ipuddings, Ifrozen Iyogurts o Dysphagia Istages IPureed: IScrambled Ieggs, Ipureed Imeats, Ivegetables Iand Ifruits, Imashed potatoes Iand Igravy; I(Mechanically Ialtered, Iadvanced Iand Iregular) o Mechanical Isoft: IFinely Idiced Imeats, Iflaked Ifish, Icottage Icheese, Icheese, Irice Ipotatoes,Ipancakes, Ilight Ibreads, Icooked Ivegetables/fruits, Ibananas, Ipeanut Ibutter o Regular: INo Irestrictions Iunless Ispecified
• Advancing Ia Idiet o Start Ithe Ipatient Ioff Iat Ia Iclear Iliquid Ithen Islowly Iadvance Ithem Iuntil Ithey Ireach Iregular Ifoods.IIf Iyou Ithink Ithat Ithey Ican’t Ihandle Ia Icertain Idiet Itype Ithen Ilower Ithem Ito Ithe Idiet Ibelow Ithat
• Thickened Iliquids o Nectar Ilike Iliquids ▪ Easily Ipourable, Icomparable Ito Ithick Isyrup, Iforms Ia Ithin Iweb Iover Ithe Iprongs Iof IaIfork o Honey Ilike Iliquids ▪ Slightly Ithicker, Idrizzles Iwhen Ipoured ▪ Comparable Ito Ihoney ▪ Forms Ia Ithick Iweb Iover Ithe Iprongs Iof Ithe Ifork o Spoon Ithick/ Ipudding Ilike Iliquids ▪ Not Ipourable, Iholds Ishape ▪ Comparable Ito Iyogurt ▪ Sits Ion Ithe Iprongs Iof Ifork

HIPAA

Protecting Ipatient Iconfidentiality

• Do Inot Idisplay Ipatients’ Iidentifying Iinformation I(name, Isocial Isecurity Inumber, Iaddress, Itelephone Inumber)Iin Ipublic Iplaces. IThis Iincludes Icharts Ileft Ioutside Iof Ithe Inurses’ Istation, Iwhere Ipeople Ican Isee Ipatients’ Inames Ior Igain Iaccess Ito Ithe Icharts. IIf Iyou Imust Itake Ipatients’ Icharts Ito Iother Iareas, Imake Isure Ithat Iyou Ikeep Ithem Iin Iview Iand Ithat Iothers Icannot Isee Ithe Ipatients’ Inames.
• Computer Iworkstations Ishould Ibe Ipassword Iprotected Iso Ithat Ithe Iagency Ican Itrack Iwho Iis Iaccessing Ipatients’ Irecords. IDo Inot Ishare Iyour Ipassword Iwith Ianyone, Iso Ithat Iyour Itracking Iinformation Iwill Inot Ibe Ilinked Ito Imedical Irecords Iof Ipatients Iwho Iare Inot Iunder Iyour Icare. IBe Isure Ito Isign Ioff Ifrom Iyour IworkstationIeach Itime Iyou Ileave Ithe Iconsole Iso Ithat Iother Iindividuals Ido Inot Iuse Iyour Ipassword Ito Igain Iaccess Ito Ipatient Irecords Iand Iunauthorized Iindividuals Icannot Igain Iaccess Ito Imedical Irecords.
• Make Isure Ithat Iany Ipaper Idocuments Ithat Iare Inot Ipart Iof Ithe Imedical Irecord Iare Ishredded Iafter Iuse Iso IthatIprivacy Iof IPHI Iis Imaintained. IThis Iincludes Ithe Inotes Iof Iindividuals Iproviding Icare.
• Communicate Iorally Iin Ia Iway Ithat Iothers Inot Iinvolved Iin Ithe Ipatient’s Icare Icannot Ihear Iyou.
• Communicate Iby Itelephone Iusing Ia Iprivate Iline, Iand Iverify Ithe Iidentity Iof Ithe Iperson Ior Iagency IreceivingIthe Iinformation.

• Nurses Imust Ibe Imindful Iof Ithe Iprohibition Iagainst Iposting IPHI, Iincluding Inon-identifying Iimages IofIpatients Ion Isocial Imedia Isites.
• Patient Imust Igive Iconsent Ibefore Inurse Ior Iphysician Igives Iout Itheir

IinformationIExamples Iof Iviolations Iof Ipatient Iconfidentiality

• Not Ifollowing Iany Iof Ithe Iabove^

I Types Iof ICommunication

I Documentation Iin Ithe Imedical Ihealth

Irecord

• Written Icommunication o I Must Ibe Itimely Iand Iaccurate Iand Isupport Ithe Iaction Iof Inurse/physician

Infection IControl-

Nursing Iprocess Irelated Ito Iinfections—nursing Iinterventions Ito Icontrol/eliminate Iinfections

▪ properly Iadministering Iantibiotics, Imonitoring Iresponse Ito Itherapy, Ihand Ihygiene, Ifollowing Istandard IandIisolation Iprecautions, Icleaning/disinfecting Ienvironment, Imedical Iasepsis Iand Isterile Itechniques Ifor Iprocedures

Surgical I(sterile) Iversus Imedical I(clean) Iasepsis I—when Ieach Iis Iused Iand Ihow Ito Imaintain Ieach

▪ Medical Iasepsis Ior Iclean Itechnique, Iincludes Iprocedures Ifor Ireducing Ithe Inumber Iof Iorganisms Ipresent IandIpreventing Ithe Itransfer Iof Iorganisms ▪ Surgical Iasepsis Ior Isterile Itechnique Iprevents Icontamination Iof Ian Iopen Iwound, Iisolate Ithe Ioperative Iarea from Ithe Iunsterile Ienvironment, Iand Imaintains Ia Isterile Ifield Ifor Iinvasive Ior Isurgical Iprocedures.

Standard Iprecautions- Iwhat Ithis Iis Iand Iwhen Iit Iis Iused, Idifference Ibetween Istandard Iprecautions Iand Iother IisolationItypes

▪ Standard Iprecautions Iapply Ito Icontact Iwith Iblood, Ibodily Ifluids, Inonintact Iskin, Iand Imucous Imembranes.

Isolation—when Ithis Iis Iused, Ireasons Ifor Iisolation, Itypes Iof Iisolation—differences Iin Ithe Itypes Iof Iisolation, InursingIconsiderations, Ipatient Iresponse, Ipatient Itransport, Ilinen Iremoval, Ispecimen,

▪ Isolation Iis Iused Iwhen Iyou Ihave Ia Ipatient Iwith Ian Iinfection Ithat Iis Ivery Icontagious Ior Iwhen Iyou Iaren’t IsureIwhat Ikind Iof Iinfection Ithe Ipatient Ihas Iand Iyou Idon’t Iwant Ito Irisk Ispreading Iit Ito Iothers. ▪ Three Itypes Iof Iisolation: o Contact Iisolation: Iused Ifor Idirect Ior Iindirect Icontact. IIt Ican Ibe Itouching Ithe Ipatient’s Ithings Ior ItheirIbodily Ifluids. I Nurse Ishould Iwear Igloves Iand Igown Ito Iprotect Ifrom Iinfection. IIf Ithe Ipatient Ineeds ItoIbe Itransported Ithen Ithey Ishould Iwear Ia Igown. o Droplet: Iwithin I 3 Ifeet Iof Ithe Ipatient Ia Isurgical Imask Iand Igloves Iwhen Inecessary. IPatient Ishould wear Ia Isurgical Imask Iif Ithey Ineed Ito Ibe Itransported. o Airborne: Ipatients Ishould Ibe Iin Ia Ispecial Iroom Iwith Ia Inegative Iair Iflow. IA IN95 Irespirator Ishould Ibe Iworn Iwhen Ientering Ithe Iroom. IIf Ia Ipatient Ineeds Ito Ibe Itransported Ithen Ithey Ishould Iwear Ia IsurgicalImask ▪ A Ipatient Imay Ifeel Ilonely, Ihave Ialtered Ibody Iimages, Iand Idisrupted Isocial Irelationships. I A Inurse Ishould take Ithis Iinto Iconsideration Iand Ipossibly Ihelp Iby Ieducating Ithe Ifamily Ion Iisolation Imeasures, Ilisten Ito Ithe Ipatients, Iopen Ithe Iblinds Ifor Ithem, Iprovide Icomfort Imeasures, Iand Iencourage Ithe Ipatient Ito Imove Iif Ieligible.

• Sterile Iprocedures—skill Iof Idoing Isterile Idressing, Iprinciples Iof Isurgical Iasepsis, Iwhen Ito Iuse IsurgicalIasepsis, Iproper Iskill Iof Iplacing Ion Isterile Igloves
• Isolation Iis Iused Iwhen Iyou Ihave Ia Ipatient Iwith Ian Iinfection Ithat Iis Ivery Icontagious Ior Iwhen Iyou Iaren’t Isure what Ikind Iof Iinfection Ithe Ipatient Ihas Iand Iyou Idon’t Iwant Ito Irisk Ispreading Iit Ito Iothers.
• Three Itypes Iof Iisolation: o Contact Iisolation: Iused Ifor Idirect Ior Iindirect Icontact. IIt Ican Ibe Itouching Ithe Ipatient’s Ithings Ior ItheirIbodily Ifluids. I Nurse Ishould Iwear Igloves Iand Igown Ito Iprotect Ifrom Iinfection. IIf Ithe Ipatient Ineeds ItoIbe Itransported Ithen Ithey Ishould Iwear Ia Igown. o Droplet: Iwithin I 3 Ifeet Iof Ithe Ipatient Ia Isurgical Imask Iand Igloves Iwhen Inecessary. IPatient Ishould wear Ia Isurgical Imask Iif Ithey Ineed Ito Ibe Itransported. o Airborne: Ipatients Ishould Ibe Iin Ia Ispecial Iroom Iwith Ia Inegative Iair Iflow. IA IN95 Irespirator Ishould Ibe Iworn Iwhen Ientering Ithe Iroom. IIf Ia Ipatient Ineeds Ito Ibe Itransported Ithen Ithey Ishould Iwear Ia IsurgicalImask
• A Ipatient Imay Ifeel Ilonely, Ihave Ialtered Ibody Iimages, Iand Idisrupted Isocial Irelationships. I A Inurse Ishould take Ithis Iinto Iconsideration Iand Ipossibly Ihelp Iby Ieducating Ithe Ifamily Ion Iisolation Imeasures, Ilisten Ito Ithe Ipatients, Iopen Ithe Iblinds Ifor Ithem, Iprovide Icomfort Imeasures, Iand Iencourage Ithe Ipatient Ito Imove Iif Ieligible.

PPE- Iplacing Ion Iand Itaking Ioff, Iproper Iorder Ito Iremove

▪ Put Ion Igown, Imask, Igoogles, Iand Igloves Ilast, Ialways Ioutside Ithe Iroom Ior Iin Iante-room ▪ Taking Ioff Iwith Ia Itie Igown: Itake Ioff Igloves Ifirst, Ithen Igoggles, Ithen Igown, Ithen Imask. IWithout Ia Itie: IgownIand Igloves Ifirst, Igoggles, Iand Ithen Imask. IAlways Iwash Ihands Iafterwards.

Mobility Iand IImmobility

Safe Ipatient Ihandling Iguidelines

▪ -determine Ithe Iamount Iand Itype Iof Iassistance Irequired Ifor Isafe Ipositioning, Iincluding Iany Itransfer Iequipment Iand Ithe Inumber Iof Ipersonnel Ito Isafely Itransfer Iand Iprevent Iharm Ito Ipatient Iand Ihealth IcareIproviders ▪ -raise Ithe Iside Irail Ion Ithe Iside Iof Ithe Ibed Iopposite Iof Iwhere Iyou Iare Istanding Ito Iprevent Ithe Ipatient Ifrom falling Iout Iof Ibed Ion Ithat Iside ▪ -arrange Iequipment Iso Iit Idoes Inot Iinterfere Iwith Ithe Ipositioning Iprocess ▪ -evaluate Ithe Ipatient Ifor Icorrect Ibody Ialignment Iand Ipressure Irisks Iafter Irepositioning

Systemic Ieffects Iof Iimmobility-review Iall Ibody Iaffects Ifrom Iimmobility, Ihow Ithis Iaffects Ipatient Iand Inursing IactionsIto Iprevent Iand Itreat Ithese Ieffects

▪ Endocrine Isystem o -immobility Idisrupts Inormal Imetabolic Ifunctioning: Idecreasing Ithe Imetabolic Irate; Ialtering ItheImetabolism Iof Icarbohydrates, Ifats, Iand Iproteins; Icausing Ifluid, Ielectrolyte, Iand Icalcium Iimbalances; Iand Icausing Igastrointestinal Idisturbances Isuch Ias Idecreased Iappetite Iand Iclowing Iperistalsis o -immobility Icauses Ithe Irelease Iof Icalcium Iinto Ithe Icirculation; Inormally Ikidneys Ifilter Ithis Ibut Ithey are Iunable Ito Irespond Icorrectly Iresulting Iin Ihypercalcemia o -GI Ifunction Iis Iimpaired Iby Idecreased Imobility ▪ Respiratory o -atelectasis: Icollapse Iof Ialveoli o -hypostatic Ipneumonia: Icaused Iby Ithe Ipooling Iof Isecretion Iin Ithe Ilungs Iduring Iimmobility o -decreased Idiffusion Iand Iperfusion ▪ Cardiovascular ISystem

o -orthostatic Ihypotension: Idrop Iof Ibp Igreater Ithan I 20 Imm IHg Iin Isystolic Ior I 10 Imm IHg Iin IdiastolicIw/ Isymptoms Iof Idizziness, Ilight-headedness, Inausea, Itachycardia, Ipallor Ior Ifainting Iwhen Ithe Ipatient Ichanges Ifrom Ithe Isupine Ito Istanding Iposition o -immobilized Ipt Idecreased Icirculating Ifluid Ivolume, Ipooling Iof Iblood Iin Ilower Iextremities, Iand decreased Iautonomic Iresponse Ioccur o -thrombus Iformation: Iaccumulation Iof Iplatelets, Ifibrin, Iclotting Ifactors, Iand Ithe Icellular IelementsIof Ithe Iblood Iattached Ito Ithe Iinterior Iwall Iof Ia Ivein Ior Iartery o -3 Ifactors Icontribute Ito Ithrombus: I(1) Idamage Ito Ivessel Iwall, I(2) Ialternation Iof Iblood Iflow, Iand I(3) alternation Iin Iblood Iconstituents I(these Iare Ireferred Ito Ias IVirchow’s Itriad) ▪ Musculoskeletal o -muscle Iatrophy/weakness Ifrom Idisuse o -disuse Iosteoporosis o -joint Icontracture: Ifixation Iof Ijoint; Iflexor Imuscles Istronger Ithan Iextensor Imuscles o -footdrop: Ipermanently Ifixed Iin Iplantar Iflexion ▪ Urinary ISystem o -Stasis Iof Iurine Iwith Ireflux Iinto Ithe Iureters Ias Ia Iresult Iof Ilaying Iflat I(gravitational Iforces Ipulling ItheI“wrong” Idirection. o -Diminished Ifluid Iintake Ileads Ito Idehydration. IAs Ia Iresult, Iurinary Ioutput Ideclines Ion Ior Iabout Ithe fifth Ior Isixth Iday Iafter Iimmobilization, Iand Ithe Iurine Ibecomes Iconcentrated. IThis IconcentratedIurine Iincreases Ithe Irisk Ifor Icalculi Iformation Iand Iinfection. o -Renal Icalculi Iare Icalcium Istones Ithat Ilodge Iin Ithe Irenal Ipelvis Ior Ipass Ithrough Ithe Iureters. Immobilized Ipatients Iare Iat Irisk Ifor Icalculi Ibecause Ithey Ifrequently Ihave Ihypercalcemia. o -Inappropriate Iperineal Icare Iafter Ibowel Imovements, Iparticularly Iin Iwomen, Iincreases Ithe Irisk Iof Iurinary Itract Icontamination Iby I Escherichia Icoli I bacteria. IAnother Icause Iof Iurinary Itract IinfectionsIin Iimmobilized Ipatients Iis Ithe Iuse Iof Ian Iindwelling Iurinary Icatheter. ▪ Integumentary ISystem o -A Ipressure Iulcer Iis Ian Iimpairment Iof Ithe Iskin Ithat Iresults Ifrom Iprolonged Iischemia I(decreasedIblood Isupply) Iin Itissues. o -Characterized Iinitially Iby Iinflammation Iand Iusually Iforms Iover Ia Ibony Iprominence. o -Ischemia Idevelops Iwhen Ipressure Ion Ithe Iskin Iis Igreater Ithan Ipressure Iinside Ithe Ismall IperipheralIblood Ivessels Isupplying Iblood Ito Ithe Iskin. o -When Ia Ipatient Ilies Iin Ibed Ior Isits Iin Ia Ichair, Ithe Iweight Iof Ithe Ibody Iis Ion Ibony Iprominences. IThe longer Ithe Ipressure Iis Iapplied, Ithe Ilonger Ithe Iperiod Iof Iischemia Iand Itherefore Ithe Igreater Ithe IriskIof Iskin Ibreakdown. o -Tissue Imetabolism Idepends Ion Ithe Isupply Iof Ioxygen Iand Inutrients Ito Iand Ithe Ielimination Iof metabolic Iwastes Ifrom Ithe Iblood. IPressure Iaffects Icellular Imetabolism Iby Idecreasing Ior ItotallyIeliminating Itissue Icirculation. o -The Iprevalence Iof Ipressure Iulcers Iis Ihighest Iin Ilong-term Icare Ifacilities Iwith Ifacility-acquired being Ithe Ihighest Iin Iadult Iintensive Icare Iunits.

SCDs Iand Ited Ihose-what Ithey Ido, Ihow Ito Icorrectly Iapply, Inursing Iactions Iassociated Iwith

▪ -used Ito Iprevent Iblood Iclots Iin Ithe Ilower Iextremities ▪ -pick Ithe Icorrect Isize Ifor Ithe Ipatient’s Ileg Iand Iwrap Iaround Ithe Icalf

Positioning Itechniques Iin Ibed, Iassisting Ipatient Iup Ito Ichair Iusing Imechanical Ilifts Iand Imanually, Itransferring IpatientsIfrom Ibed Ito Istretcher

▪ -Semi IFowler’s: Isitting Iin Ibed Iwith Ia I45-60 Iangle Ihead Iof Ibed ▪ -High IFowler’s: Isitting Iwith Ihead Iof Ibed Iat I90-degree Iangle ▪ -Supine: Ilaying Ion Iback

▪ -Prone: Ilaying Ion Istomach ▪ -Side ILying I(lateral): Ipt Ilaying Ion Iside ▪ - Sim’s: Ilaying Ion Iside Iwith Ileg Ipropped Iup Iwith Ipillow Iin-between

IlegsISafety Iguidelines Ifor Imovement Iof Ipatients

• Mentally Ireview Ithe Itransfer Isteps Ibefore Ibeginning Ithe Iprocedure; Ithis Iensures Iboth Iyour Isafety Iand Ithat Iof the Ipatient.
• Assess Ithe Ipatient's Imobility Iand Istrength Ito Idetermine Ithe Iassistance Ithat Ihe Ior Ishe Iis Iable Ito Ioffer IduringItransfer. IStand Ion Ipatient's Iweak Iside Iwhen Iassisting
• Determine Ithe Iamount Iand Itype Iof Iassistance Irequired Ifor Itransfer, Iincluding Ithe Itype Iof Itransfer Iequipment and Ithe Inumber Iof Ipersonnel Ito Isafely Itransfer Iand Iprevent Iharm Ito Ithe Ipatient Iand Ihealth Icare Iproviders.
• Raise Ithe Iside Irail Ion Ithe Iside Iof Ithe Ibed Iopposite Iof Iwhere Iyou Iare Istanding Ito Iprevent Ithe Ipatient IfromIfalling Iout Iof Ibed Ion Ithat Iside.
• Arrange Iequipment I(e.g., Iintravenous Ilines, Ifeeding Itube, Iindwelling Icatheter) Iso Iit Idoes Inot Iinterfere Iwith the Ipositioning Ior Itransfer Iprocess.
• Evaluate Ithe Ipatient Ifor Icorrect Ibody Ialignment Iand Ipressure Irisks Iafter Ithe Itransfer.
• Make Isure Ithat Iall Ipersonnel Iunderstand Ihow Ithe Iequipment Ifunctions Ibefore Iit Iis Iused.
• Educate Ipatients Iabout Ihow Iequipment Ifunctions Ito Ireduce Itheir Ianxiety Iand Ienlist Itheir Icooperation.

Activity Iand IExercise

Assessment Iof Istanding, Isitting Iand Ilying

IdownIStanding:

• -head Iis Ierect Iand Imidline Ibody Iparts Iare Isymmetrical
• -spine Iis Istraight Iwith Inormal Icurvatures
• -abdomen Iis Icomfortably Itucked
• -the Iknees Iare Iin Istraight Iline Ibetween Ithe Ihips Iand Iankles Iand Islightly Iflexed
• -the Ifeet Iare Iflat Ion Ithe Ifloor Iand Ipointed Idirectly Iforward Iand Islightly Iapart Ito Imaintain Ia Iwide Ibase IofIsupport
• -arms Ihand Icomfortably Iat Ithe Isides
• -center Iof Igravity Iis Iin Ithe

ImidlineISitting

• -head Iis Ierect Iand Ineck Iand Ivertebral Icolumn Iare Iin Istraight Ialignment
• -body Iweight Iis Idistributed Ion Ithe Ibuttocks Iand Ithighs
• -thighs Iare Iparallel Iand Iin Ihorizontal Iplane
• -feet Iare Isupported Ion Ithe Ifloor
• -forearms Iare Isupported Ion Ithe Iarmrest, Iin Ithe Ilap, Ior Ion Ia Itable Iin Ifront Iof Ithe

IchairILaying

• -place Ihim Ior Iher Iin Ilateral Iposition, Iremoving Iall Ipositioning Isupports Iand Iall Ibut Ione Ipillow
• -vertebrae Iare Iin Istraight Ialignment Iw/out Iobservable Icurves

Principles Iof Itransferring Iand Ipositioning Itechniques/safe Ihandling Iand Imovement

• -An Iergonomics Iassessment Iprotocol Ifor Ihealth Icare Ienvironments
• -Patient Iassessment Icriteria Iand Ialgorithms Ifor Ipatient Ihandling Iand Imovement
• -Special Iequipment Ikept Iin Iconvenient Ilocations Ito Ihelp Itransfer Ipatients

• -Back-injury Iresource Inurses
• -An I“after-action Ireview” Ithat Iallows Ithe Ihealth Icare Iteam Ito Iapply Iknowledge Iabout Imoving Ipatients IsafelyIin Idifferent Isettings
• -A Ino-lift Ipolicy

Assistive Idevices Icorrect Isize, Imeasurement Iand Iusage Ifor Ipatient, Iteaching Iassociated Iwith Ithese

IdevicesICane

• -Two Icommon Itypes Iof Icanes Iare Ithe Isingle Istraight-legged Icane Iand Ithe Iquad Icane.
• -The Isingle Istraight-legged Icane Iis Imore Icommon Iand Iis Iused Ito Isupport Iand Ibalance Ia Ipatient IwithIdecreased Ileg Istrength.
• -The Iquad Icane Iprovides Ithe Imost Isupport Iand Iis Iused Iwhen Ithere Iis Ipartial Ior Icomplete Ileg Iparalysis Ior some Ihemiplegia.
• -Have Ithe Ipatient Ikeep Ithe Icane Ion Ithe Istronger Iside Iof Ithe Ibody.
• -For Imaximum Isupport Iwhen Iwalking, Ithe Ipatient Iplaces Ithe Icane Iforward I 15 Ito I 25 Icm I(6 Ito I 10 Iinches), Ikeeping Ibody Iweight Ion Iboth Ilegs. IThe Iweaker Ileg Iis Imoved Iforward Ito Ithe Icane Iso Ibody Iweight Iis IdividedIbetween Ithe Icane Iand Ithe Istronger Ileg. IThe Istronger Ileg Iis Ithen Iadvanced Ipast Ithe Icane Iso Ithe Iweaker Ileg Iand Ithe Ibody Iweight Iare Isupported Iby Ithe Icane Iand Iweaker Ileg. IDuring Iwalking Ithe Ipatient Icontinually Irepeats Ithese Ithree Isteps.
• -The Ipatient Ineeds Ito Ilearn Ithat Itwo Ipoints Iof Isupport Isuch Ias Iboth Ifeet Ior Ione Ifoot Iand Ithe Icane Iare Ion Ithe floor Iat Iall Itimes.

Crutches

• -Position Ithe Ihandgrips Iso Ithe Iaxillae Iare Inot Isupporting Ithe Ipatient’s Ibody Iweight.
• -Pressure Ion Ithe Iaxillae Iincreases Irisk Ito Iunderlying Inerves, Iwhich Isometimes Iresults Iin Ipartial Iparalysis IofIthe Iarm.
• -Determine Icorrect Iposition Iof Ithe Ihandgrips Iwith Ithe Ipatient Iupright, Isupporting Iweight Iby Ithe Ihandgrips with Ithe Ielbows Islightly Iflexed Iat I 20 Ito I 25 Idegrees.
• -Elbow Iflexion Imay Ibe Iverified Iwith Ia Igoniometer.
• -When Iyou Idetermine Ithe Iheight Iand Iplacement Iof Ithe Ihandgrips, Iverify Ithat Ithe Idistance Ibetween Ithe IcrutchIpad Iand Ithe Ipatient’s Iaxilla Iis Iapproximately I 2 Iinches I(two Ito Ithree Ifinger Iwidths).

Review Iuses Iof Irestraints-types, Iuses, Ilegal Iissues, Ipreventing Ipatients Ifrom Ihaving Ito Ibe Iin Irestraints

• -soft Ilimb Irestraints
• -leather Irestraints
• -chemical Irestraints
• • IReduce Ithe Irisk Iof Ipatient Iinjury Ifrom Ifalls
• • IPrevent Iinterruption Iof Itherapy Isuch Ias Itraction, IIV Iinfusions, Inasogastric I(NG) Itube Ifeeding, Ior IFoleyIcatheterization
• • IPrevent Ipatients Iwho Iare Iconfused Ior Icombative Ifrom Iremoving Ilife-support Iequipment
• • IReduce Ithe Irisk Iof Iinjury Ito Iothers Iby Ithe

IpatientIRestoring Iactivity Iwith Ichronic Iillnesses

Increase Iactivity Iand Iexercise Ito Ihelp Iliving Ioutcomes Iwith Ichronic Iillnesses

Vital ISigns

Reason IVS Iare Icompleted Ion Ipatients

To Itell Ius Ithe Istatus Iof Ithe Ipatient. IBaseline: Idone Iat Ithe Ibeginning Iof Ithe Ishift Ito Itell Ithe Ipatient’s Inormal

IrangesIWhat Iare Ithe I 6 IVS Ithat Iare Itaken Ion Ipatients?

1. Temperature
2. Pulse
3. Oxygen ISaturation
4. Blood IPressure
5. Respiratory IRate
6. Pain Ilevel

IGuidelines Ifor Itaking

IVS

It Iis Ithe Inurse’s Iresponsibility Ito Iensure Iaccurate Idata Iis Icollected. IThis Imeans Imaking Isure Ithe Iequipment Iis ItheIcorrect Isize Ifor Ithe Ipatient Iand Ithat Iit Iis Iworking Iproperly, Iand Ithat Ithe Icorrect Itechnique Iis Ibeing Iused.

Frequency Iof IVS

• Baseline I(beginning Iof Ithe Ishift)- Iso Iyou Ihave Ia Istarting Ipoint Ito Icompare Ito Iin Icase Iof Ipatient IstatusIchanges
• When Iyou Iobserve Ichanges Iin Ipatient Istatus I(to Isee Iif Ivitals Iindicate Iany Ifurther Iinformation)
• Before Icertain Imedication Iadministration I(based Ion Icontraindications Iand Iindications Ifor Imedications)
• When Imight Iyou Iobtain Ivital Isigns Imore Ifrequently? I– I post Ioperatively, Iduring Iblood Iadministration, IforIcertain Imedications/drips, Iand Icertain Ipatient Iconditions.

Temperature-

• Normal Iranges Axillary I(36.5C/ I97.7F), IOral Iand ITympanic I(37C/ I98.6F), IRectal Iand ITemporal I(37.5C/ I99.5F)
• Temperature Isites I– Inursing Iconsiderations o Axillary- Ilong Imeasurement Itimes Iand Inot Ias Iaccurate o Oral- IHot/cold Ibeverages Iand Ifood Imay Ialter Iresults o Tympanic- INot Ias Iaccurate, Iposition Icorrectly Iin Ichildren Iunder Ithree o Rectal- IContraindicated Iin Ipatients Iwith Idiarrhea, IGI Ibleed, Irectal Isurgery/disorders o Temporal- IInaccurate Iif Ithe Ipatient Iis Idiaphoretic
• Factors Ithat Iinfluence Itemperature Age, Iexercise, Ihormone Ilevels, Icircadian Irhythms, Istress, Iand Ithe Ienvironment

Pulse-

• Correct Iassessment Iof Ipulse Find Ithe Irate, Irhythm, Istrength, Iand Iequality
• Normal Irange Iof Iadult IpulseI60-100 Ibeats Iper Iminute
• Locations Iof Ipulse, Ifactors Ithat Iinfluence Ia Ipulse Irate Temporal I(children), Icarotid I(emergency), Ibrachial I(getting Ia Iblood Ipressure), Iradial I(routine Ivital Isigns Iand Icirculation Istatus), Ifemoral I(emergencies I– Ishock), Ipopliteal I(used Ifor Ilower Iextremity Iblood Ipressure IwhenInecessary), Iposterior Itibial I(circulation Istatus Ito Ifoot) Iand Idorsalis Ipedis I(circulation Istatus Ito Ifoot). Different Ipulses Imay Ibe Iused Iat Idifferent Itimes Ito Iassess Icirculatory Istatus Iand Iobtain Ivital Isigns. IApicalIpulse Iis Iused Iwhen Ithe Iradial Iis Iirregular, Idifficult Ito Iobtain, Ior Ipatient Itakes Icertain Icardiac Imedications.IFactors Ithat Iinfluence Ia Ipulse Iincludes Iexercise, Itemperature, Ipain I& Ianxiety, Imedications, Ihemorrhage,Ipostural Ichanges, Iand Ipulmonary Iconditions
• Difference Iin Iapical Iand Iperipheral Ipulses

When Ipalpating Iperipheral Ipulses, Ilocate Ithe Ipulse Isite Iand Iusing Ifirm Ipressure Iwith Ithe Ifirst Itwo Ifingers,Ipalpate Ifor Ia Ipulse. IDo Inot Iuse Ithe Ithumb, Ias Iit Ihas Iits Iown Ipulse. IYou Imust Iauscultate Ithe Iapical Ipulse Ilocated Iat Ithe IPMI. IYou Ishould Iuse Ithe Idiaphragm Iof Ithe Istethoscope Iand Iyou Ishould Ilisten Ifor Ia Ifull Iminute.

• Correct Iuse Iof Istethoscope Ito Iauscultate Ian Iapical Ipulse Use Idiaphragm Iand Ilisten Ifor Ione Ifull Iminute o What Isounds Iare Iheard Iusing Ibell Iand Idiaphragm Iof Istethoscope, Icharacter Iof Ipulses, Ipulse Ideficit,Inursing Iprocess Irelated Ito Ipulse Diaphragm Iis Iused Ito Ilisten Ito Ithe Ihigh Ipitched Isounds, Iwhich Iwould Ibe Ithe Iregular Iheart Ibeat sound I(lub-dub). IBell Iis Iused Ito Ihear Iheart Imurmurs. ICharacter Iof Ipulses Iis Ithe Irate, Irhythm, Istrength, Iand Iequality. IPulse Ideficit Iis Ithe Idifference Iin Ia Iminute's Itime Ibetween Ithe Inumber Iof Ibeats Iof Ithe Iheart Iand Ithe Inumber Iof Ibeats Iof Ithe Ipulse Iobserved Iin Idiseases Iof Ithe Iheart. ISome Inursing Idiagnoses Iare Iactivity Iintolerance, Ianxiety, Idecreased Icardiac Ioutput, Ideficient/excess IfluidIvolume, Iimpaired Igas Iexchange, Iacute Ipain, Iand Iineffective Iperipheral Itissue Iperfusion. IOutcome Iplanning Iis Ifocused Ion Itreating Ithe Iunderlying Icause Ifor Ithe Ipulse Iabnormality. IThe Igoal Iis Ithe IgetIthe Ipulse Iback Ito Inormal.

Respirations-

• Ventilation/perfusion/diffusion Ventilation Iis Ithe Imovement Iof Igas Iinto Iand Iout Iof Ithe Ilungs. IPerfusion Iis Ioxygenation Iof Itissues Ithrough Idistribution Iof Ired Iblood Icells Ito Iand Ifrom Ithe Ipulmonary Icapillaries. I Diffusion Icould Ibe Ithe Imovement IofIoxygen Ito Ithe Iblood Ivessel Ior Icarbon Idioxide Iback Ito Ithe Ilungs.
• Correct Iassessment Iof Irespirations ~Assess Iventilation Iby Idetermining Irespiratory Irate, Idepth, Irhythm Iand Iend-tidal Icarbon Idioxide I(ETCO2)Ivalue. IAssess Idiffusion Iand Iperfusion Iby Idetermining Ioxygen Isaturation. ~Accurate Iassessment Iof Irespirations Idepends Ion Ithe Irecognition Iof Inormal Ithoracic Iand Iabdominal movements. IDuring Iquiet Ibreathing, Ithe Ichest Iwall Igently Irises Iand Ifalls. IContraction Iof Ithe Iintercostal Imuscles Ibetween Ithe Iribs Ior Icontraction Iof Ithe Imuscles Iin Ithe Ineck Iand Ishoulders I(the Iaccessory Imuscles IofIbreathing) Iis Inot Ivisible. IDuring Inormal Iquiet Ibreathing, Idiaphragmatic Imovement Icauses Ithe Iabdominal Icavity Ito Irise Iand Ifall Islowly ~To Iassess Irespirations: IDo Inot Ilet Ia Ipatient Iknow Ithat Iyou Iare Iassessing Irespirations. IA Ipatient Iaware Iof Ithe assessment Ican Ialter Ithe Irate Iand Idepth Iof Ibreathing. IAssess Irespirations Iimmediately Iafter Imeasuring IpulseIrate, Iwith Iour Ihand Istill Ion Ithe Ipatient’s Iwrist Ias Iit Irests Iover Ithe Ichest Ior Iabdomen. IIf Ithe Irhythm Iis Iregular Icount Irespirations Ifor I 30 Iseconds Iand Imultiply Iby I2. ~Always Iassess Ithe Iquality Ito Iget Ian Iaccurate Ipicture Iof Ipatient Istatus. IWhat Idoes Ithe Iquality Itell Ius? IDepth
  • Ishallow/labored Ibreathing Idoes Inot Iallow Ifor Ifull Iventilation Iof Ithe Ilungs, IRate/Rhythm I– Iif Ithe IpatientIhas Itachypnea I(over I20) Ior Ibradypnea I(under I12) Iventilation Iis Ialtered, IEffort I– Iif Ipatient Iis Ireporting Idyspnea Ior Idifficulty Ibreathing Ithere Imay Ibe Ia Iventilation Ior Ioxygenation Iproblem. IHow Ido Iyou Iknow IifIyour Ipatient Iis Idyspneic? ISubjective Ipatient Ireport, Ianxiety, Idiaphoresis, Itripod Ipositioning, Iuse Iof Irefractory Imuscles
• Normal Irespiratory Irate Ipulse Ioximeter Ireading Iand Iend Itidal ICO2 Imonitoring Normal Ipulse Iox Ireading Iis I95-100%. I Normal IETCO2 Iis I35-45mmHg
• Factors Ithat Iinfluence Ia Irespiratory Irate, Ialterations Iin Ibreathing Ipattern, Inursing Iprocess Irelated ItoIrespirations ~Exercise I– Iincreased Irate Iand Idepth Ito Imeet Ioxygen Idemands ~Pain/anxiety I– Ipain Imakes Ibreathing Ibecomes Ishallow Iand Ianxiety Iincreases Ithe Irate ~Lung IDiseases I– ICertain Ilung Itissue Idamage Imay Icause Iissues Iwith Ioxygenation I(diffusion I& Iperfusion)Iand Iso Ithe Irespiratory Irate Iand Idepth Imay Ibe Iincreased Ito Icompensate ~Smoking I– IChronic Ismoking Ileads Ito Imany Ilung Idiseases Ias Iit Icauses Itissue Idamage Iand Ithe Irespiratory rate Iwill Iincrease

~Body Iposition I– IA Istraight, Ierect Iposture Ipromotes Ifull Ilung Iexpansion, Iif Ithe Ipatient Iis Ilaying Iflat Ior IwithIthe IHOB Idown Iand Iin Ia Islumped Iposition Iventilation Iis Iimpaired ~Medications I– IOpioid Ianalgesics, Igeneral Ianesthetics Icause Idecreased Iin Irate Iand Idepth Iof Irespirations, amphetamines Icause Ian Iincrease Iin Irate Iand Idepth ~Neurological Iinjury I– IInjury Ito Ithe Ibrainstem Iimpairs Ithe Irespiratory Icenter Iand Iinhibits Irespiratory IrateIand Irhythm ~Hemoglobin Ifunction I– Ianemia Ireduces Ioxygen Iperfusion Ito Ithe Irest Iof Ithe Ibody Iand Iso Ithe Ipatient Imay have Ian Iincreased Irespiratory Irate Ito Icompensate; ~Some Inursing Idiagnoses Iinclude Iactivity Iintolerance, Ianxiety, Iineffective Iairway Iclearance, IineffectiveIbreathing Ipattern, Iimpaired Igas Iexchange, Iacute Ipain, Iineffective Iperipheral Itissue Iperfusion, Iand Idysfunctional Iventilator Iweaning Iresponse. IPlanning Iincludes Iinterventions Ibased Ion Ithe Idiagnosis IandIrelated Ifactors.

BP-

• Normal Irange Iof Iadult IBPI120mmHg Iand I<80mmHg
• Factors Iinfluencing IBP ~Age I– IBP Iincreases Iduring Ichildhood ~Stress I– Ianxiety, Ipain Iand Ifear Iresult Iin Isympathetic Istimulation Iwhich Iincreases Iblood Ipressure ~Ethnicity I– Ihigher Iinstances Iin Ihypertension Iin IAfrican IAmericans ~Gender I– IMales Ihave Ihigher Iblood Ipressure Ithan Ifemales, Iuntil Imenopause, Ithen Ifemales Ihave Ihigher IBPIlevels Ithan Imen ~Daily IVariation I– IBP Iis Ilower Iduring Isleep Iand Ibetween I3am I– I6am Ithere Iis Ia Isteady Irise Iand Iis Ihighest during Ithe Iday Ibetween I10am Iand I6pm ~Medications I– IWhat Ikinds Iof Imedications Idirectly Iimpact Iblood Ipressure? IAntihypertensives, Idiuretics,Icardiac Imedications ~Some Imedications Imay Ihave Ian Iindirect Ieffect Ion Iblood Ipressure Ilike Iopioid Ianalgesics. ~Activity Iand Iweight I– Iexercise Ican Ireduce IBP Ifor Iseveral Ihours Iafterward, Iinactivity Ileads Ito Iweight IgainIwhich Iis Ia Irisk Ifactor Ifor Ihypertension ~Smoking I– Icauses Ivasoconstriction, Iwhich Ileads Ito Ihypertension
• Correct Isizing Iof IBP Icuff ~Cuff Isize Iis Iimportant Iwhen Iselecting Iequipment. IAt Imost Ifacilities Ieach Ipatient Ireceives Itheir Iown IcuffIthat Ifollows Ithem Ithroughout Itheir Iadmission. ~The Iwidth Iof Ithe Icuff Ishould Icover I40% Ithe Icircumference Iof Ithe Imidpoint Iof Ithe Ilimb. IOn Imost Icuffs there Iis Iline Ithat Imarks I40% I- Igo Iby Ithis Iindicator. ~If Icuff Iis Itoo Ibig Iit Icould Ilead Ito Ia Ifalse Ilow Ibp Iand Iif Iit Iis Itoo Ismall Iit Icould Ilead Ito Ia Ifalse Ihigh Ibp
• Hypertension Ivs Ihypotension Hypertension Iis Iabnormally Ihigh Ibp Iand Ihypotension Iis Iabnormally Ilow Ibp. IHypotension Iis Iassociated IwithIpallor, Iskin Imottling, Iclamminess, Iconfusion, Iincreased IHR, Ior Idecreased Iurine Ioutput Iis Ilife Ithreatening Iand Iis Ireported Ito Ia Ihealth Icare Iprovider Iimmediately. INo Isymptoms Iwith Ihypertension Iand Ino Idirect Icause.

Pulse Ioximetry I–

• Normal Irange 90%-100% Iin Ihospitals, Ibook Isays I95%-100%
• Factors Ithat Iinfluence Iaccuracy IAnemia I(low Ihemoglobin/hematocrit)INail Ipolish Inadequate Iperfusion
• Sites Ithat Ican Ibe Iused, Inormal Irange, Iwhat Ito Ido Iif Ireading Iis Itoo Ilow Fingers, Iforehead, Iear Ilobe Iprobe, Ior Iheal Iprobe Ion Iinfants. IIf Ipulse Iox Iis Itoo Ilow, Iput Ipatient Ion Ioxygen.

Patient ISafety

Various Isafety Iprecautions/codes Iand Inursing

IinterventionsIFocus Ion:

• Fall o Armband, Isocks, Isign, Icannot Iget Iup Ion Itheir Iown, Ibed Ialarm, Ipatient Inear Ithe Inurses’ Istation, IlowIbed. I Entrapment: I Getting Ilimbs, Ineck, Ichest Icaught Iin Ithe Ibed.
• Seizure o What Ipatients? IHistory Iof Iseizures, Ibrain Itumors/metastasis, IepilepsyIPad Ithe Iside Irails o What Ido Iyou Ido Iif Ithe Ipatient Iexperiences Ia Iseizure? ▪ Note Ithe Itime/call Ifor Ihelp ▪ Keep Ithe Ipatient Isafe I(use Ipillows Ietc) ▪ Turn Ithe Ipatient Ion Itheir Iside Iif Ipossible ▪ Do Inot Iput Ianything Iin Itheir Imouth Ior Itry Ito Ihold Ithem Istill
• Bleeding o Patients Ion Ianticoagulants, Iwith Ibleeding Idisorders Ior Iactively Ibleeding o What Iinterventions Iwould Ibe Inecessary Ifor Ithese Ipatients? I Prevent Iinjury, Iminimize Iinvasive Itherapies, Ihold Ipressure Iafter Iinvasive Ivenipuncture Ifor Iat Ileast I 5 Iminutes, Iuse Isoft Itoothbrush IorItoothettes Ifor Ioral Icare, Ielectric Irazors Ionly
• Suicide o Do Iall Iat Irisk Ipatients Iget Iplaced Ion Isuicide Iprecautions? I No I How Iare Isuicide Iprecautions Iinitiated? I Nurse Ican Iinitiate, Ibut Iphysician I(psychiatrist) Imust Ibe Iconsulted Ior Isee Ithe Ipatient o What Iinterventions Iwould Ibe Inecessary Ifor Ithese Ipatients? I One Ito Ione Iobservation, Iremove unsafe Iarticles Ifrom Ithe Iroom Iand Ifrom Ithe Ipatient’s Ibelongings, Ispecial Iutensils Ifor Ifood o Elopement Iprecautions Iare Ivery Isimilar Ito Isuicide Iprecautions, Iwithout Ias Imany Irestrictions

Medication IAdministration

Patients’ Irights: Iright Ito Ibe Iinformed/right Ito Irefuse; Iknow Ihow Ithese Irelated Ito Imedication Iadministration IandIdocumentation

o To Ibe Iinformed Iabout Ithe Imedication Ithey Iare Ireceiving Iand Iwhat Iit Iis Ibeing Iadministered Ifor o To Irefuse Ithe Imedication. I Document Ithe Irefusal Iand Itime Iin Ithe Ichart o To Ibe Iadvised Iabout Iexperimentation/research Istudies o To Ireceive Ilabeled Imedications o To Ireceive Iappropriate Isupportive Itherapy Iin Irelation Ito Imedication Itherapy

Medication Ireconciliation I– Iwhen Iit Iis Idone, Iwhy Iit Iis Idone, Inursing Iresponsibilities Iin Ithe Iprocess

o Medication Ireconciliation Iis Ithe Iprocess Iwhere Inurses, Ipharmacists Iand Iphysicians/NPs Icompare Ithe Imedication Ithat Ia Ipatient Iis Itaking Icurrently Iwith Iwhat Ithe Ipatient Ishould Ibe Itaking Iand Iany Inewly IorderedImedications. o Medication Ihistory/reconciliation: o Obtain Ia Ithorough Imedication Ihistory I(name Iof Idrug, Idosage, Iroute, Ifrequency, Ireason Ifor Iprescription).IDon’t Iforget Iabout Iherbals Iand Iover-the-counters! IMany Itimes Ipatients Iwill Iforget Ito Ireport Ithese. o Obtain Iinformation Ion Ithe Iadherence Ito Imedication Itherapy. o A Ipatient’s Iattitude Iabout Imedications Imay Ireveal Imedication Idependence Ior Iavoidance. o Many Ifactors Iaffect Ipatient’s Iability Ito Iadhere Ito Iprescribed Imedications. o Examples: Iknowledge/understanding, Ifunding, Imotivation

o Obtain Iinformation Ion Iwhen Ithe Ipatient Itook Ithe Imedication Ilast. o Obtain Iinformation Ion Ithe Ipatient’s Ilearning Ineeds Irelated Ito Iprescribed Imedications.

Order Ireview I– Iensuring Iall Iorder Icontents Iare Ipresent, Iwhat Ito Ido Iif Isomething Iis Iincorrect Ior Iorder Icomponents IareImissing

o When Ireviewing Iorders Ithe Inurse Iassesses Ithe Iorder Ifor Iaccuracy Iand Ipreparation Iconsiderations. o Orders Ishould Iuse Iapproved Iabbreviations Ionly I– Isee Itable I32-7 Ifor Ia Ilist Iof Iinappropriate Iabbreviations IthatImight Ibe Iused. o Dosages Ishould Ibe Iclear I– Ino Iuse Iof Itrailing Izeros Ior Inaked Idecimal Ipoints. IExample: I.50 Ior I.5 I– Ithese Iare error Iprone o Orders Ishould Icontain Idrug Iname, Idose, Iroute, Ifrequency, Irationale Iand Iany Ispecial Iinstructions. o Consider Inursing Iimplications Iof Iorders Iwhen Ireviewing. o 6 IRights: IRight Imedication, Iright Idose, Iright Ipatient, Iright Iroute, Iright Itime, Iright Idocumentation IHow IdoIyou Ifind Iout Ithat Iinformation? ILook Iup Iyour Imedications Iuntil Iyou Iare Iused Ito Istandard Idoses Iand Idrug Iinformation Iassociated Iwith Ithe Idrug) o Nurses Ishould Iknow Ithe Iconsiderations Iassociated Iwith Ieach Idrug. IThese Iinclude: Iassessments Ito Imake prior Ito/during Iadministration, Ihow Ito Ievaluate Ithe Ieffectiveness Iof Ithe Idrug, Icontraindications Iand IsafetyIparameters Iwhen Igiving Ithe Idrugs, Iside Ieffects Ito Ibe Iexpected, Iside Ieffects Ithat Iare Iconsidered Inormal Iversus Idangerous o If Ithe Iorder Iis Iwrong, Icontact Ithe Iphysician Ito Iverify Iand Ithen Ithe Ipharmacy Ito Ichange

3 IChecks I– Iwhat Ithey Iare Iwhen Ito Ido Ithem

1. Dispense
2. Preparation
3. Bedside o When Iyou Iare Icomparing Ithe IMAR Ito Ithe Idrugs Iwhen Idispensing o When Iyou Iare Ipreparing Ithe Imedications o At Ithe Iimmediate Ibedside Iprior Ito Igiving Ito Ithe

IpatientI 6 Irights I– Iwhat Ithey Iare Iand Ihow Ito Iassess Ieach

Proper Iadministration Itechnique:

• IV Ipush I(ampules Iversus Ivials) Injection Iof Ia Ibolus Ior Ismall Ivolume Iof Imedication Ithrough Ian Iexisting IIV IsiteIAmpules: o Contain Isingle Idoses Iof Imedication Iin Ia Iliquid. o They Iare Iavailable Iin Iseveral Isizes, Ifrom I 1 ImL Ito I 10 ImL Ior Imore. o An Iampule Iis Imade Iof Iglass Iwith Ia Iconstricted Ineck Ithat Imust Ibe Isnapped Ioff Ito Iallow Iaccess Ito ItheImedication. IA Icolored Iring Iaround Ithe Ineck Iindicates Iwhere Ithe Iampule Iis Iprescored Iso Iyou Ican Ibreak Iit Ieasily. o Carefully Iaspirate Ithe Imedication Iinto Ia Isyringe Iwith Ia Ifilter Ineedle. IThe Iuse Iof Ia Ifilter Ineedle prevents Iparticulate Imatter Isuch Ias Ismall Iglass Ifragments Ifrom Ientering Ithe Isyringe.
  • Vials o Single-dose Ior Imultidose Icontainer Iwith Ia Irubber Iseal Iat Ithe Itop. IA Imetal Icap Iprotects Ithe Iseal IuntilIit Iis Iready Ifor Iuse. o Vials Icontain Iliquid Ior Idry Iforms Iof Imedications. IMedications Ithat Iare Iunstable Iin Isolution Iare packaged Idry. IThe Ivial Ilabel Ispecifies Ithe Isolvent Ior Idiluent Iused Ito Idissolve Ithe Imedication IandIthe Iamount Iof Idiluent Ineeded Ito Iprepare Ia Idesired Imedication Iconcentration. o Normal Isaline Iand Isterile Idistilled Iwater Iare Icommonly Iused Ito Idissolve Imedications.

o Unlike Ithe Iampule, Ithe Ivial Iis Ia Iclosed Isystem, Iand Iair Ineeds Ito Ibe Iinjected Iinto Iit Ito Ipermit Ieasy Iwithdrawal Iof Ithe Isolution. IFailure Ito Iinject Iair Iwhen Iwithdrawing Icreates Ia Ivacuum Iwithin Ithe IvialIthat Imakes Iwithdrawal Idifficult. IIf Iconcerned Iabout Idrawing Iup Iparts Iof Ithe Irubber Istopper Ior IotherIparticles Iinto Ithe Isyringe, Iuse Ia Ifilter Ineedle Iwhen Ipreparing Imedications Ifrom Ivials. ISome Ivials Icontain Ipowder, Iwhich Iis Imixed Iwith Ia Idiluent Iduring Ipreparation Iand Ibefore Iinjection.

• IV Ipiggyback Infusion Iof Ia Isolution Icontaining Ithe Iprescribed Imedication Iand Ia Ismall Ivolume Iof IIV Ifluid Ithrough IanIexisting IIV Iline Piggyback Iadministration:
  • IA Ismall I(25 Ito I 250 ImL) IIV Ibag Ior Ibottle Iconnected Ito Ia Ishort Itubing Iline Ithat Iconnects Ito Ithe Iupper IY- portIof Ia Iprimary Iinfusion Iline Ior Ito Ian Iintermittent Ivenous Iaccess. The Ilabel Ion Ithe Imedication Ifollows Ithe IISMP IIV Ipiggyback Imedication Ilabel Iformat. The Iset Iis Icalled Ia Ipiggyback Ibecause Ithe Ismall Ibag Ior Ibottle Iis Ihigher Ithan Ithe Iprimary Iinfusion Ibag Ior Ibottle. IIn Ithe Ipiggyback Isetup Ithe Imain Iline Idoes Inot Iinfuse Iwhen Ithe Ipiggybacked Imedication Iis Iinfusing.IThe Iport Iof Ithe Iprimary IIV Iline Icontains Ia Iback-check Ivalve Ithat Iautomatically Istops Iflow Iof Ithe Iprimary Iinfusion Ionce Ithe Ipiggyback Iinfusion Iflows. After Ithe Ipiggyback Isolution Iinfuses Iand Ithe Isolution Iwithin Ithe Itubing Ifalls Ibelow Ithe Ilevel Iof Ithe Iprimary infusion Idrip Ichamber, Ithe Iback-check Ivalve Iopens, Iand Ithe Iprimary Iinfusion Iagain Iflows.ICan Ibe Igiven Iintermittently Ior Iwith Ia Icontinuous Iinfusion.

Flush Ibefore Iand Iafter Iadministration Iof IIV Ipiggyback Iand Isyringe Ipump Imedications.

• IM, ISubcutaneous, Iintradermal IinjectionsIIM o Can Ibe Igiven Iin Ithe Ideltoid, Iventrogluteal, Ior Ivastus Ilateralis o Z-track Imethod Ito Iminimize Ilocal Iskin Iirritation Iby Isealing Ithe Imedication Iin Imuscle Itissue o Use Inew Ineedle Ifor Iinjection o Place Ithe Iulnar Iside Iof Ithe Inondominant Ihand Ijust Ibelow Ithe Isite Iand Ipull Ithe IoverlyingIskin Iand Isubcutaneous Itissues Iapproximately I 2 Ito I 3 Icm I(1 Ito I1.2 Iinches) Ilaterally Ior Idownward. IHold Ithe Iskin Iin Ithis Iposition Iuntil Iyou Iadminister Ithe Iinjection. o After Ipreparing Ithe Isite Iwith Ian Iantiseptic Iswab, Iinject Ithe Ineedle Ideep Iinto Ithe Imuscle. o Grasp Ithe Ibarrel Iof Ithe Isyringe Iwith Ithe Ithumb Iand Iindex Ifinger Iof Ithe Inondominant IhandIand Islowly Iinject Ithe Imedication Iif Ithere Iis Ino Iblood Ireturn Ion Iaspiration. o The Ineedle Iremains Iinserted Ifor I 10 Iseconds Ito Iallow Ithe Imedication Ito Idisperse Ievenly rather Ithan Ichanneling Iback Iup Ithe Itrack Iof Ithe Ineedle. o Release Ithe Iskin Iafter Iwithdrawing Ithe Ineedle. o This Ileaves Ia Izigzag Ipath Ithat Iseals Ithe Ineedle Itrack Iwhere Itissue Iplanes Islide Iacross IoneIanother. IThe Imedication Icannot Iescape Ifrom Ithe Imuscle Itissue.

Subcutaneous

o Subcutaneous Itissue Iis Inot Ias Irichly Isupplied Iwith Iblood Ias Ithe Imuscles I- Imedication Iabsorption IisIslower Ithan Iwith IIM Iinjections o The Ibest Isubcutaneous Iinjection Isites Iinclude Ithe Iouter Iposterior Iaspect Iof Ithe Iupper Iarms, Ithe abdomen Ifrom Ibelow Ithe Icostal Imargins Ito Ithe Iiliac Icrests, Iand Ithe Ianterior Iaspects Iof Ithe Ithighs. o The Iinjection Isite Iyou Ichoose Ineeds Ito Ibe Ifree Iof Iskin Ilesions, Ibony Iprominences, Iand IlargeIunderlying Imuscles Ior Inerves. o Insulin Isyringes Iare Idosed Iin I 100 Iunits. IUse Iinsulin Isyringes Ifor Iinsulin Ionly. o Usually Idark Iorange Iin Icolor o Injections Imust Ibe Iverified Iby Ianother IRN o There Iare Idifferent Itypes Iof Iinsulin Ithat Ihave Ivarious Ionset Iand Ipeaks Iof Iaction I– Ithis Iis IimportantIinformation Ito Iknow Iwhen Iyou Iare Iadministering Iinsulin

o Rapid Iacting I- IGiven Ias Ia Isliding Iscale Iwith Imeals I(insulin Ilispro/aspart) o Long Iacting I– Iworks Ifor I12-24 Ihours I(insulin Iglargine) o Also Igiven Iare Ishort I(regular) Iintermediate I(NPH) Iinsulin o Multi-dose Ivials Iare Ionly Igood Ifor I 28 Idays Iafter Iopening I– Ialways Icheck Iexpiration Idates o Insulin Iinjections Iare Itypically Ismall Iamounts Iand Igiven Iin Ithe Iupper Iarms. o Recommended Isites Ifor Iinsulin Iinjections Iinclude Ithe Iupper Iarm Iand Ithe Ianterior Iand Ilateral Iparts Iof Ithe Ithigh, Ibuttocks, Iand Iabdomen. IRotating Iinjections Iwithin Ithe Isame Ibody Ipart I(intrasite Irotation) Iprovides Imore Iconsistency Iin Ithe Iabsorption Iof Ithe Iinsulin. IThe Iinjections Iare Ito Ibe IgivenIat Ileast I2.5 Icm I(1 Iinch) Iaway Ifrom Ithe Iprevious Isite. IInjection Isites Ishould Inot Ibe Iused Iagain Ifor IatIleast I 1 Imonth. o The Irate Iof Iinsulin Iabsorption Ivaries Ibased Ion Ithe Isite; Ithe Iabdomen Ihas Ithe Iquickest Iabsorption, followed Iby Ithe Iarms, Ithighs, Iand Ibuttocks.

Intradermal

o ID Iinjections Itypically Iare Iused Ifor Iskin Itesting I(e.g., Ituberculin Iscreening Iand Iallergy Itests). o Because Ithese Imedications Iare Ipotent, Ithey Iare Iinjected Iinto Ithe Idermis, Iwhere Iblood Isupply IisIreduced Iand Imedication Iabsorption Ioccurs Islowly. ISome Ipatients Ihave Ia Isevere Ianaphylactic Ireaction Iif Imedications Ienter Ithe Icirculation Itoo Irapidly. o You Ineed Ito Ichoose Iskin-testing Isites Ithat Iallow Iyou Ito Ieasily Iassess Ifor Ichanges Iin Icolor Iand Itissue integrity. o ID Isites Ineed Ito Ibe Ilightly Ipigmented, Ifree Iof Ilesions, Iand Irelatively Ihairless. IThe Iinner IforearmIand Iupper Iback Iare Iideal Ilocations. o Use Ia Ituberculin Ior Ismall Ihypodermic Isyringe Ifor Iskin Itesting. o The Iangle Iof Iinsertion Ifor Ian IID Iinjection Iis I 5 Ito I 15 Idegrees, Iand Ithe Ibevel Iof Ithe Ineedle Iis IpointedIup. o As Iyou Iinject Ithe Imedication, Ia Ismall Ibleb Iresembling Ia Imosquito Ibite Iappears Ion Ithe Isurface Iof the Iskin. IIf Ia Ibleb Idoes Inot Iappear Ior Iif Ithe Isite Ibleeds Iafter Ineedle Iwithdrawal, Ithere Iis Ia Igood Ichance Ithat Ithe Imedication Ientered Isubcutaneous Itissues. IIn Ithis Icase Itest Iresults Iwill Inot Ibe Ivalid.

• Oral I– Ipatient Iwith Idysphagia Ior Iconfusion o Identify Iif Iit Iis Ito Ibe Igiven Ion Ian Iempty Istomach Ior Iwith Ifood. o Give Ioral Imedications Ion Ian Iempty Istomach Iif Iabsorption Iis Idecreased o Give Ioral Imedications Iwith Imeals Iif Iabsorption Iis Ienhanced Iby Ifood o Most Itablets Iand Icapsules Ineed Ito Ibe Iswallowed Iand Iadministered Iwith Iapproximately I 60 Ito I 240 ImL Iof IfluidI(as Iallowed) o Aside Ifrom Iswallowing Ioral Ican Ialso Imean Ibuccal I(administration Iinto Ithe Icheek) Ior Isublingual (administration Iunder Ithe Itongue) o Use Iapproved Ipill Icutters Ifor Ipatients Iwho Ineed I½ Itablets. IDo Inot Imanipulate Icapsules. o Patients Iwith Idysphagia Ior Iconfusion: ICrush Ipill Iand Igive Iwith Iapplesauce Ior Ithrough IIV Ior Iask IpharmacyIfor Ia Idifferent Iroute
• Enteral Ithrough IG-tube I(what Iis Iacceptable Ito Icrush) o Special Iconsideration Iis Ineeded Iwhen Iadministering Imedications Ito Ipatients Iwith Ienteral Ior Ismall-Ibore Ifeeding Itubes. o Before Igiving Ia Imedication Iby Ithis Iroute, Iverify Ithat Ithe Ilocation Iof Ithe Itube I(e.g., Istomach Ior jejunum) Iis Icompatible Iwith Imedication Iabsorption. o Use Iliquid Imedications Ifor Ismall Ibore Ifeedings. IIdentify Iwhich Imedications Imay Ibe Icrushed I(noIenteric Icoded Ior Iextended Irelease Ican Ibe Icrushed). o Syringe Imethod I(draw Iup Iliquid Imedications Ior Idissolved Imedications Iin Iwater Ione Iat Ia Itime Iand push Ithrough Itube)

o Flush Iwith I15-30mL Iof Iwater Iin Ibetween Ieach Imedication o Flush Iwith I60mL Iafter Imedication Iadministration o Gravity I– Ipour Imedications Iin Iand Ilet Iit Igo Iin Ivia Igravity o If Ia Imedication Ineeds Ito Ibe Igiven Ion Ian Iempty Istomach Ior Iis Inot Icompatible Iwith Itube Ifeedings,Ihold Ithe Ifeeding Ifor Iat Ileast I 30 Iminutes Ibefore Ior I 30 Iminutes Iafter Imedication Iadministration. ISome Iof Ithese Imedications Imay Ineed Iup Ito I 120 Iminutes Ito Iabsorb. o Monitor Ithe Ipatient Iclosely Ifor Iadverse Ireactions. IThe Irisk Ifor Idrug-drug Iinteractions Iis Ihigh Iwhen two Ior Imore Imedications Iare Igiven Iin Ithis Iroute Ibecause Ithey Ican Iinteract Itogether Ias Isoon Ias ItheyIare Iadministered.

• Other: IOphthalmic/topical/rectal Isuppositories o Skin Iapplication Iprinciples: Iperform Ihand Ihygiene Ibefore Iand Iafter Iadministration, Iwear Igloves,Iuse Iapplicators o Transdermal Ipatches: Iuse Igloves, Irotate Isites, Iplace Itime, Idate, Iinitials Ion Ithe Ipatch o Nasal Iinstillation Iprinciples: o The Imost Icommonly Iadministered Iform Iof Inasal Iinstillation Iis Idecongestant Ispray Ior Idrops, Iused Ito Irelieve Isymptoms Iof Isinus Icongestion Iand Icolds. ICaution Ipatients Ito IavoidIabuse Iof Imedications Ibecause Ioveruse Ileads Ito Ia Irebound Ieffect Iin Iwhich Ithe Inasal Icongestion Iworsens. o It Iis Ieasier Ito Ihave Ipatients Iself-administer Isprays Ibecause Ithey Iare Iable Ito Icontrol Ithe spray Iand Iinhale Ias Ithe Imedication Ienters Ithe Inasal Ipassages. o For Ipatients Iwho Iuse Inasal Isprays Irepeatedly, Icheck Ithe Inares Ifor Iirritation. IWhen Iused ItoItreat Ia Isinus Iinfection, Iposition Ipatients Ito Ipermit Ithe Inasal Imedication Ito Ireach Ithe Iaffected Isinus. o Eye Iinstillation Iprinciples: o Avoid Iinstilling Ieye Idrops Idirectly Ion Ithe Icornea o Avoid Itouching Ithe Ieyelids Ior Iother Ieye Istructures Iwith Ieye Idroppers Ior Iointment Itubes o Use Ieye Imedication Ifor Ithe Iaffected Ieye Ionly o Never Iallow Ia Ipatient Ito Iuse Ianother Ipatient’s Ieye Imedications o Ear Iinstillation Iprinciples: o Instill Iear Idrops Iat Iroom Itemperature o Use Isterile Isolutions o Observe Ifor Iruptured Iear Idrum/occluded Iear Icanal Iprior Ito Iinstilling Imedication o Vaginal Iinstillation Iprinciples: o Available Ias Isuppositories, Ifoam, Ijellies Ior Icreams o Use Iapplicators Ifor Ifoams, Ijellies Iand Icreams o Give Ia Isuppository Iwith Ia Igloved Ihand, Ipatients Imay Iprefer Ito Iadminister Itheir IownImedications o Rectal Iinstillation Iprinciples: o Bullet Ishaped Isuppositories o It Imay Ibe Inecessary Ito Iclear Ithe Ipatient’s Irectum Iwith Ian Ienema Iprior Ito Iadministering IaIsuppository o Position Ithe Ipatient Ion Ileft Iside-lying Iposition Iwith Iknee Iflexed o Use Ilubrication/insert Iwith Ia Igloved Ihand

Prioritization Iof Imedication Iadministration

ICleanest Ito Idirtiest: IIV Ifirst, Itopical…oral

IlastI Bowel IElimination-

Factors Iaffecting Ibowel Ielimination

- Age: o Infants Ihave Ia Ismaller Istomach Icapacity, Iless Isecretions Iof Idigestive Ienzymes Iand Imore Irapid IintestinalIperistalsis. o The Iability Ito Icontrol Idefecation Idoes Inot Ioccur Iuntil I2-3 Iyears. o Older Iadults Ihave Idecreased Ichewing Iability, Iperistalsis Ideclines, Iesophageal Iemptying Islows, IimpairedIabsorption, Idecreased Imuscle Itone Iin Ithe Iperineal Ifloor Iand Ianal Isphincter - Diet: o Regular Iintake, Ifiber I(whole Igrains, Ifresh Ifruits, Ivegetables)

• Fluid IIntake : o 3L/day Ifor Imen; I2.2L/day Ifor Iwomen; Ifluid Iliquefies Iintestinal Icontents Iby Iabsorbing Iinto Ithe Ifiber Ifrom ItheIdiet Ito Icreate Ia Ilarger, Isofter Istool Imass - Physical IActivity: o Promotes Iperistalsis, Iimmobility Idepresses Iit; Iencourage Iearly Iambulation Iafter Iillness - Stress: o The Idigestive Iprocess Iis Iaccelerated, Iand Iperistalsis Iis Iincreased I(diarrhea/gaseous Idistention) - Personal IHabits: o Own Itoilet, Iat Ia Iconvenient Itime o Squatting Iis Ithe Inormal Iposition Ifor Idefecation, Ilean Iforward Ito Iexert Iintraabdominal Ipressure; IsupineIposition Ifor Idefecation Iis Idifficult; Iraise Ithe IHOB Ifor Ipatient Ion Ia Ibedpan - Pain: o hemorrhoids, Irectal Isurgery, Ianal Ifissures, Ipost-partum Ivaginal Idelivery Iwith Itearing - Pregnancy: o As Ithe Isize Iof Ithe Ibaby Iincreases, Ipressure Iis Iplaced Ion Ithe Irectum, Islowing Iof Iperistalsis Iand Iconstipation - Surgery: o General Ianesthesia Icauses Icessation Iof Iperistalsis, Iany Isurgery Ithat Iinvolves Idirect Imanipulation Iof ItheIbowel Itemporarily Istops Iperistalsis I(ileus) - Medications: o Opioids- Idecrease Iperistalsis o Laxatives/stimulants- Iincrease Iperistalsis o How Ido Iantibiotics Iaffect Ibowel Ielimination? I- Idecrease
• Diagnostic IExaminations: o Diagnostic Iexaminations Iinvolving Ivisualization Iof IGI Istructures Ioften Irequire Ia Iprescribed IbowelIpreparation I(what Iis Ithis?) Ito Iensure Ithat Ithe Ibowel Iis Iempty. o Usuallly Ipatients Iare INPO Iprior Ito Iendoscopy/colonoscopy I(tests Ithat Ivisualize Ithe Ibowel) o After Ithe Iprocedure Ithe Ipatient Imay Iexperience Igas Ior Iloose Istools

GI Iassessment I- IBristol Istool Ichart/various Istool Icolors Iand Inursing Iactions Iassociated Iwith Ieach

- Usual Ipattern/routines o Determination Iof Ithe Iusual Ielimination Ipattern: IInclude Ifrequency Iand Itime Iof Iday. IHaving Ithe Ipatient Ior Icaregiver Icomplete Ia Ibowel Ielimination Idiary Iprovides Ian Iaccurate Iassessment Iof Ia Ipatient’s Icurrent IbowelIelimination Ipattern. o Identification Iof Iroutines Ifollowed Ito Ipromote Ibowel Ielimination: IExamples Iare Idrinking Ihot Iliquids, Ieating specific Ifoods, Ior Itaking Itime Ito Idefecate Iduring Ia Icertain Ipart Iof Ithe Iday. IUse Iof Ilaxatives, Ienemas, Ior Ibulk- Iforming Ifiber Iadditives. - Usual Istool Icharacteristics o Patient’s Idescription Iof Iusual Istool Icharacteristics: IDetermine Iif Ithe Istool Iis Inormally Iwatery Ior Iformed, IsoftIor Ihard, Iand Ithe Itypical Icolor. IAsk Ithe Ipatient Ito Idescribe Ia Inormal Istool’s Ishape Iand Ithe Inumber Iof Istools