Nursing 100 Final Study Guide Latest Update 2024 Guaranteed Success, Exams of Nursing

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Chapter 10: Medical and Surgical Asepsis

• Hand Hygiene: Use antimicrobial soap and water when your hands are visibly soiled, before you eat, after using the bathroom, and after contact of bodily fluid. Scrub your hands for 15 seconds
• Alcohol based product use 3-5ml of the product
• Stand 3 feet away from those coughing
• Keep nails short
• No gel polishes because it increases risk of microbes
• Remove jewelry from hands and wrist
• Never shake linens
• Clean the least soiled area first and the worst last How to set up a sterile field:
• Position it so the top flap is facing away from you and open it away from you
• Open the right flap with your right hand and the left flap with the left hand and the last flap open towards you
• If you need to use a sterile solution, remove the bottle cap and place it face it up on a clean surface not the sterile surface, hold the bottle so that the label is against your palm, and you want to pour 1-2 ml out, and then pour the solution on the sit

• Do not cough, sneeze, or talk over sterile field
• The 1 inch outer edge of the sterile field is not sterile
• Any object help below the waste or above the chest is considered contaminated
• Any objects that need to be added to the sterile field should be added 6 inches above and dropped into
• Never turn your back or reach across a sterile field
• Any sterile field item that comes in contact with moisture is not considered sterile Chapter 11: Immunity Nonspecific innate immunity vs. Specific Adaptive Immunity Nonspecific innate immunity: our bodies defense mechanisms or barriers that respond immediately to all antigens ex: skin, mucous membranes, stomach acid Specific adaptive immunity: your body produces antibodies in response to a specific antigen to through the actions of B and T lymphocytes. It requires more time, but in the future the immune response will be more specific and effective through this specific adaptive immunity

Active Natural immunity: the body produces antibodies in response to exposure to a life pathogen. Ex: when you get exposed to a cold virus and get sick, your body produces antibodies that when you exposed to that same cold virus again, your body can really defend it off more quickly. Active Artificial Immunity: when your body produces antibodies in response to a vaccine Passive natural immunity: when the antibodies are passed from the mom to the baby through the breast milk or through the placenta. Passive artificial immunity: patient would get immunoglobulins administered to them after they have been exposed to a pathogen. Ex: someone who has a compromised immunity and can’t mount to a proper immune response, so they get ready made immunoglobulin’s in them. Infections (6 components)

1. Causative agent like a bacteria and a toxin
2. A reservoir- where the causative agent lives (human or environment)
3. Portal of exit- how that pathogen leaves the host
4. Mode of transmission- it is transmitted through airborne, droplet, or contact
5. Portal of entry-how the pathogen enters the host
6. Susceptible host- how a pathogen goes from the reservoir to the host

RISK FACTORS for Infection -compromised immunity

• Chronic or acute disease -poor personal and hand hygiene -crowded living environment -IV drug use -unprotected sex -poor sanitation Virulence: ability of a pathogen to produce a disease Different stages of infection

1. Incubation- time from when the pathogen enters the body until the first symptom appears
2. Prodromal stage- time from the onset of general symptoms such as fatigue and fever until the patient exhibits specific symptoms to that particular infection
3. Illness stage- time from when specific symptoms occur that is specific to that particular illness
4. Convalescence- time from when the symptoms disappear to complete recovery occurs, this can take several months Systemic Infection: symptoms such as fever, chills, fatigue, increased respiratory rate, increased pulse, and large lymph nodes

Local infection- edema, pain at a specific place in your body, warmth Inflammation- the body’s local response to an injury or infection (3 stages)

1. When the patient exhibits erythema, warmth, edema, and pain at the site of injury
2. When white blood cells kill the microorganisms and exudate containing those WBC’s as well as the dead tissue cells that accumulate at the site of the injury. This exudate can take Many forms. Serous exudate or drainage which is clear, sanguineous drainage is bloody, serous sanguineous, may be pink tint, it is in-between, purulent drainage contains leukocytes and bacteria
3. This is when damaged tissue is replaced by scar tissue Lab tests that indicate an infection
4. WBC count should be between 5,000 and 10,000… it is over 10,000 there is an infection
5. Left shit in the WBC count means when you are fighting off a bad infection and your immune system is working really hard, when it gets overwhelmed it starts releasing immature WBC’s… releasing immature WBC’s because we are overwhelmed by an infection

3. ESR- Erythrocyte sedimentation rate is a good indicator that there is inflammation in the body
4. CRP- C- reactive protein is a good indicator that there is inflammation in the body
5. Positive culture result- indicate infection, you want to collect all the culture before the patient starts any antibiotics Precautions:
6. Standard precautions are used for ALL patients, hand hygiene, use alcohol based antiseptic rather than soap and water unless your hands are visibly soiled, always use face masks whenever there is splashing of bodily fluids, clean cloves whenever you touch anything in the room, and use a moisture resistance bag for soaked items and proper sharps disposal
7. Air borne precautions: Measles, Varicella (chicken pox) TB (MTV is airborne) the room must have negative airflow. Any visitors must wear a N95 mask
8. Droplet precautions: Influenza, Pneumonia, Putrescence, Sepsis, Mumps, Bacterial meningitis, rubella….. Patient will get a private room and caregivers and visitors will need to wear masks
9. Contact precautions- impetigo, scabies, mesa, Cliff, other enteric infection, RSV, wound infections … usually given a private room, visitors and caregivers need to wear gowns and gloves

Herpes Zoster: This is shingles, it is caused by the reactivation of chicken pox, and if you had chicken pox as a kid you are at risk

• Risk factors: compromised immune system, stress, fatigue, and poor nutrition Chapter 12: Patient Safety How to prevent falls?
• Patients with orthostatic hypotension advise them to get up slowly
• Provide our patients with regular toileting for those that require assistance
• Round on patients hourly
• Put frequently used items in reach
• Always position the bed in the lowest position and lock the breaks
• Don not put up all 4 side rails; leave at least 1 side down Seizures
• During seizures make sure you lower the patient to the floor or the bed and turn the patient on to their side
• Loosen any restrictive clothing
• Do not restrain patient or put anything in their mouth
• Note the onset and duration of the seizure

• After the seizure take patient’s vital signs, do neurological check, implement seizure precautions Restraints
• Physical restraints like a vest, belt, or mittens
• Chemical restraints like sedatives or psychotics
• If you can’t calm the patient down, in an emergency the RN can place the patient in restraints but you must get a prescription from the doctor in the next hour
• Orders can be written for up to 4 hours for adults
• Remove restraints one at a time and check every 2 hours
• Always use the least restrictive restraint like mittens
• Apply restraints so that 2 fingers can fit between the restraint and the patient
• Always use a quick release knot Fire Safety
• Use acronym RACE (rescue: do a horizontal then a lateral evacuation) (A: alarm) (C- contain, close doors and windows and turn off O2 sources) (E- Extinguish)
• PASS (use of a fire extinguisher) P: pull the pin, a: aim at the base of the fire, S: squeeze the handle, S: sweep side to side

Chapter 14: Safe Patient Movement

• When lifting an object, you should hold it as close to your body as close as possible
• Avoid twisting and bending at the waist
• Always gen help when repositioning the patient Moving patient from the gurney to the bed:
• Position the bed slightly lower than the gurney, lower the head of the bed so it’s flat, have them tuck their chin in to their chest and cross their arms over their chest and you slide them across
• Foot drop happens when patient gets older, and patient’s toes are pointed down so you put in a board to hold the foot in the flex position Bed positions:
• Semi-Fowler’s: this is when the patient is when their head of the bed is elevated 15-30 degrees. It helps prevent aspiration and ventilation
• Fowlers position is between 45-60 degrees, this is good for procedures like suctioning and better ventilation

• High Fowlers is between 60 -90 degrees this is good during meals and are having a really hard time breathing
• Prone position is good for someone who has had a lower extremity amputation it will help prevent hip flexure contractors
• Orthopedic position is when the patient is sitting on the side of the bed and are leaning over a bed table or pillow for patients with COPD it helps lung expansion
• Sims position- the patient lays on their left side with their left hip and lower extremity straight and their right hip and knee bent, it is used for enemas and rectal examinations
• Trendelenburg: when the whole bed is tilted where the head of the bed is lower than the foot of the bed, it helps venous return of blood from the extremities to the heart
• Reverse Trendelenburg: opposite of Trendelenburg, where the foot of the bed is lower than the head of the bed, this is for gastric emptying like GERD
• Modified Trendelenburg: where the patient lies flat where their legs are elevated above their heart, this is good for hypovolemic shock Chapter 15: Security and Disaster Plans

Triage: Class 1: gets a red tag, patients who have an immediate threat to life, breathing issues, hemorrhaging wound, major burns Class 2: Yellow tag: patients who have a major injury that requires prompt attention like a bone fracture Class 3: patients who have a minor injury who do not require immediate attention, like a sprain or a cut Class 4: Black tag, is for patients who are expected to die During tornadoes: close shades on the windows and move patient away from windows, place blankets over patients who are bed bound Chemical exposure: undress the patient and irrigate them profusely with water, if they have dry chemicals on them brush the chemicals off clothing and skin Hazardous material: locate the safety data sheet, water is the universal antidote for most hazardous materials Bomb threat: keep the caller on the phone as long as possible, listen for background noise

Chapter 26: Data Collection and General Survey -Assess and data collection for an older adult: should be gathered during multiple shorter sessions instead of one long session

• Allow for more time for response to question and position changes
• Make sure patient has sensory aids in place
• Reduce environmental noise Physical assessment: Inspection, palpation, percussion, auscultation (normal order for everything except abdomen) Abdomen is inspect, auscultate, percuss, palpate Inspection is where we use our eyes to assess for size, shape, color or symmetry Palpation: using touch to assess for temperature, size, texture, tenderness… always assess the most tender areas last, use the dorsal surface of the hand that is the best for assessing temp Percussion: tapping different body parts

Auscultation: Listening for sounds like bowl, lung, and heart sounds what is included in a general survey?

• Physical appearance (age, race, gender, LOC, signs of substance abuse, signs of distress)
• Body structure (height, weight, nutritional status, posture)
• Mobility (gait, range of motion)
• Behavior (mood, speech, grooming)
• Vital signs (temp, pulse, Respiration rate, Bop, O2) Chapter 27: Vital signs TEMP
• Normal range orally for an adult is between 36-38 degrees C or 96.8-100. degrees F)
• Rectal temp is usually o.5 degrees C higher or 0.9 degrees F higher than oral and tympanic temp
• Axillary temp are 0.5 degrees C or 0.9 degrees F lower than oral and tympanic temp
• Temporal temps are close to rectal, but they are 0.5 degrees C and 1 degree F higher than oral, and 1 degree C and 2 degrees F higher than axillary temps What impacts body temp?
• Age: A newborn will have a lower temp, 36.5 and 37.5 degrees C or 97. and 99.5 degrees F
• Older adults have lower temps, 36 degrees C, or 96.8 degrees F

• Wait 20-30 minutes to take oral temp if the patient has eaten or drunken hot or cold foods Rectal temp: place patient in Sims position, use lube, insert thermometer 1- 2. inches for adults
• Do not take rectal temp for anyone under 3 months or anyone who is at risk for bleeding Tympanic temp (Ear): adults pull up and back and children under 3 years old pull back and down Temporal temp: slide thermometer across forehead to the hairline and then touching behind the ear Nursing Intervention for hypo and hyperthermia Hyperthermia: temps is over 39 degrees C, obtain blood cultures and other specimens to check for infection, administer antibiotics but make sure to get cultures first, administer Tylenol to bring their temp down and administer fluids, prevent shivering Hypothermia: temps below 35 degrees C, provide warm blankets, warm IV fluids, increase room temp, and keeping patients head covered

PULSE

Assess for the

• Rate: adult 60-100 beats per minute
• Rhythm: pulse regular or irregular
• Quality: how is the pulse on the left side compared to the right side of the body?
• Strength: 0 means no pulse, its absent, 1+ means pulse is diminished, 2+ is normal, 3+ is stronger than normal, and 4+ means it is bounding Radial Pulse
• Take on the thumb side of the wrist, if they have a regular pulse you can count for 20 seconds and multiply by 2, and if you have irregular pulse you need to count for the full minute Apical pulse
• Take it at the 5th intercostal space at the left mid- clavicle line
• If it’s regular you can count for 30 seconds and multiply for 2
• Pulse is irregular or if they are taking meds, you need to count for the full minute Calculating pulse deficit
• Pulse deficit is the difference between the apical pulse and the radial pulse
• It is most likely zero differences

• If they are different there is a heart problem Tachycardia
• Heart rate over 100 BPM
• Due to: fever, exercise, meds, pain. Hyperthyroidism, stress, hypovolemic Bradycardia
• Heart rate under 60 BPM
• Due to meds, could be an athlete, hypothyroidism, hypothermia RESPIRATIONS
• Normal range is between 12 and 20 breaths per minute for adults
• Assess for the rate and the depth (shallow or deep), rhythm (regular or irregular respirations)
• Chemoreceptors in your body detect when C02 levels rise in the blood, this can respiratory control center in your brain to increase your respiratory rate
• When taking respiratory rate: place patient in semi-fowlers position, place your hand on their abdomen, if its rig count for 30 and multiply by 2, irregular count for 1 minute Ventilation: exchange of 02 and Co2 between the environment and lungs Diffusion: is the exchange of 02 and C02 between the alveoli and the red blood cells in the blood stream

Perfusion: is the exchange of 02 and C02 between the red blood cells in the blood stream and your body tissues What increases respiratory rate? -anxiety -smoking -anemia -high altitude -illnesses What decreases respiratory rate?

• Opioid and sedative meds
• Older age When taking a patient’s SpO2 saturation a normal range is between 95-100%
• COPD is normal to have ranges in the low 90’s BLOOD PRESSURE
• Normal ranges: Systolic is under 120 AND diastolic is under 80
• Prehypertension:

Systolic is 120-139 OR Diastolic is 80-

• Stage 1: Systolic are 140 to 159 OR Diastolic 90 to 99
• Stage 2: Systolic is greater than 160 OR diastolic is greater than 100 Hypotension is their systolic is under 90 You want to take BP reading over 3 separate occasions on different days over a couple weeks is how to assess for hypertension When taking someone’s BP if they have Orthostatic hypotension, you want to take it when they are supine, lying flat, have them sit up and wait a couple minutes then take their BP again, then have them stand wait a couple minutes and take it again
• If there systolic BP decreased 20 mm hg or more, when changing position or if there diastolic BP decreases 10 mm hg or more with a 10-20 % increase in Heart rate this means they could have orthostatic hypotension BLOOD PRESSURE -Pulse pressure is systolic BP minus Diastolic BP

-If the pulse pressure is elevated it can lead to increased risk for cardiovascular disease -The cuff width should be 40% or the arm circumference and the bladder should surround 80% of the arm circumference -If the cuff is too large your reading will be low, and if the cuff is too small you’ll get a high reading -Do not take BP in the arm where there is an IV, don’t take it on the side of they have had a mastectomy, or a shunt, or fistula To estimate BP, palpate the radial pulse, and inflate the cuff until the pulse disappears, and then inflate the cuff another 30 mph, release pressure, and note when the pulse is palpable again Chapter 28: Head and Neck Assessment Cranial Nerves: On Occasion our trusty truck acts funny very good vehicle any how (pneumonic for all 12) some say marry money but my brother says big brains matter more (Sensory function)

• Words that starts with (S) is for sensory, (M) is for motor, and (B) is for both

1. : Olfactory: controls smell

2. Optic: controls vision
3. Ocular Motor: responsible for eye movements and pupil restriction
4. Trochlear: eye movement in, down, and laterally 5) Trigeminal: controls chewing (motor and sensation) 6) Abdu cense: allows the eye to move laterally
5. Facial: facial muscles and taste (anterior 2/3 of tongue) and salivary glands 8) Vestibular cochlear: controls hearing and balance
6. Glossopharyngeal: controls gag reflex, and taste (posterior 1/3 of tongue)
7. Valgus: controls pharyngeal and laryngeal muscles used for swallowing, speech, voice, gag reflex, and thoracic and abdominal viscera
8. Accessory nerve: allows shoulder and head movement
9. Hypoglossal: tongue movement When assessing a patient’s thyroid gland, it shouldn’t be visible, you can have them sip a glass of water and you can feel their thyroid gland move up and feel that it is not enlarged or any bumps Assessment of the eyes: the Snelling chart, (letter chart), have the patient stand 20 feet away from chart, this can let you know if your patient has impaired far vision (Myopia). The Rosenbaum eye chart checks for presiopia, impaired near vision and you hold the chart 14 inches away from the patient Ichihara test: color vision Extra- Ocular movement of the eyes:

• Corneal light reflex test
• Cover, uncover test
• Six cardinal gaze by having patient follow your finger
• PERRLA When patients get older they will have decreased vision, yellowing of lenses, issues of glare and darkness, hearing loss is common, thickening of tympanic membrane, decreased sense of taste, gum disease, tooth loss, decreased salivation and pallor gums, increase vocal pitch, decreased sense of smell Chapter 29: Thorax, Heart, and Abdomen Encourage female patients to do monthly breast exams, it is best to do them after your period Lung assessment: Percussion, you are expected to hear resonant, if you hear dullness (abnormal) this can indicate a tumor or pneumonia, if you hear Hyper resonant, this can indicate a pneumothorax or emphysema. Auscultation of the lungs:

• When listening over the tracheal area, you should hear bronchial sounds
• When listening over the large airways, you should hear bronchovesicular sounds
• When listening over the peripheral areas of the lungs, you should hear vesicular sounds Abnormal findings:
• If you hear crackles, this means there is fluid around the lungs
• Wheezes sounds like whistling musical sounds
• Rhonchi are like rumbling sounds
• Pleural friction rub is a grating, rubbing sound Heart Assessment:
• S1 sound is the sound of the mitral and tricuspid valves closing (LUB)
• S2 sounds is the sound of the aortic and pulmonic closing (DUB)
• Thrills are vibrations associated with murmurs and other cardiac abnormalities (someone who has a fistula)
• Bruitt (brewee) is swishing sounds associated with obstructive blood flow like a narrowed artery
• The point of maximal impulse (PMI) is the apical pulse; it is located at the left mid- clavicular line at the 5th intercostal space Auscultation sites for the heart:

-Aortic: listen to the right of the sternum at the second intercostal space

• Pulmonic: listen to the left of the sternum at the second intercostal space
• Ernes point: listen to the left of the sternum at the third intercostal space
• Tricuspid: listen to the left of the sternum at the fourth intercostal space
• Mitral (apical): listen to the left mid-clavicular line at the fifth intercostal Abdominal assessment:
• Should hear high pitch clicking and gurgling
• What is not expected is loud growling sounds or no bowel sounds after listening for 5 minutes
• Percussion of the abdomen: should expect tympani sounds (drum like sounds), dullness over liver area is expected (right upper quadrant)
• Palpation: if they have a tender area you always want to palpate the tender area last Chapter30: Integumentary and Peripheral Vascular Systems Skin assessment:
• When you see discoloration like Pallor that means there is a circulation issue or they are suffering from anemia
• If they are turning blue, cyanosis, this is due to hypoxia and is an emergency situation

• If they are jaundice looking (yellow), this means hepatic or liver dysfunction or this happens when there is a lot of red blood cell destruction
• Erythema (red color) can be due to inflammation, sunburn, or rash
• Brown discoloration on the lower extremities, this means poor blood circulation back to the heart (venous insufficiency) Capillary Refill:
• It should refill within 2 seconds or less (3 or 4 seconds is unexpected finding) Skin turgor
• If you see tenting this means they are dehydrated or they are older Check for Edema: -Compress the skin for 5 seconds over a bony prominence in the lower extremities
• 1+ is trace edema, rapid skin response (2mm)
• 2+ is mild edema, 10-15 second response (4mm)
• 3+ is moderate edema, prolonged skin response (6mm)
• 4+ severe edema, prolonged skin response (8mm) Primary Lesions:
• Macule: flat area of discoloration, less than 1 cm wide (ex: freckle)

• Patch: flat area of discoloration, more than 1cm wide (ex: birthmark)
• Papule: elevated solid lesion that is under 1 cm (ex: mole)
• Plaque: elevated solid lesion that is over 1 cm wide (ex: psoriasis)
• Vesicle: elevated serous (clear) filed lesion that is under 1 cm wide (ex: herpes or varicella) or (ex: blister)
• Nodule: firm deep lesion that is 1-2 cm wide (ex: wart)
• Pustule: puss filled vesicle that is under 1cm (acne)
• Wheal: transient elevated irregular border, itchy, red (insect bite) Secondary Lesions:
• Crust: slightly elevated lesion that is either dry blood, wound exudate, or puss (scab)
• Erosion: moist, loss of the epidermis, like a ruptured vesicle (blister that popped)
• Scale: dry skin that flakes (dandruff and eczema)
• Fissure: linear break in the skin surface, due to skin being too dry or too moist (between the but crack like a crack in the skin)
• Ulcer: loss of the epidermis and dermis with possible bleeding and scarring (round lesion over bony prominence) Chapter 31: Musculoskeletal and Neurosensory Systems