Nursing Fundamentals Study Guide

Health History: Obtain subjective information using therapeutic communication. Include chief complaint, history of present illness, past medical history, medications, allergies, family history, and social history. Use open-ended questions to encourage detailed responses.

Physical Examination: Systematic assessment using inspection, palpation, percussion, and auscultation. Follow a head-to-toe or body systems approach for consistency and completeness.

Mental Status Assessment: Evaluate orientation (person, place, time), mood, affect, cognition, and behavior. Note any changes from baseline.

Functional Assessment: Assess activities of daily living (ADL), mobility, self-care ability, and independence level. Critical for discharge planning and care needs.

Nursing Diagnosis: Analyze findings to identify problems requiring nursing intervention. Distinguish between actual problems and risk problems.

Normal Range: 98.6°F (37°C) orally; 99.5°F (37.5°C) rectally; 97.6°F (36.4°C) axillary; 100.4°F (38°C) tympanic.

Fever (Pyrexia): Body temperature >38°C (100.4°F). Sign of infection or inflammatory response. Causes: infection, malignancy, medications, heat exposure, CNS disorders.

Hypothermia: Body temperature <35°C (95°F). Causes: cold exposure, sepsis, hypothyroidism, medications. Can impair mental function and cause cardiac arrhythmias.

Nursing Considerations: Measure temperature consistently using same site. Oral route most common but avoid if patient recently drank hot/cold beverages. Rectal most accurate. Monitor for fever patterns (continuous, intermittent, remittent). Treat fever if >38.3°C or if causing discomfort. Monitor fluid status during fever.

Pulse: Normal adult heart rate 60-100 bpm. Palpate radial artery for 15-60 seconds. Note rate, rhythm (regular or irregular), and quality (strong, weak, bounding).

Tachycardia: HR >100 bpm. Causes: fever, pain, anxiety, hyperthyroidism, heart failure, shock, exercise. Assess patient and treat underlying cause.

Bradycardia: HR <60 bpm. Causes: athletic conditioning, hypothyroidism, heart block, increased intracranial pressure, beta-blockers. Can be normal or pathologic depending on context.

Respirations: Normal adult respiratory rate 12-20 breaths per minute. Count for 15-60 seconds. Assess depth (shallow, normal, deep), rhythm (regular, irregular), effort (labored, easy).

Abnormal Respirations: Tachypnea (>20), bradypnea (<12), dyspnea (difficulty breathing), orthopnea (shortness of breath when lying flat), Cheyne-Stokes (increasing then decreasing respiratory depth).

Normal Blood Pressure: Less than 120/80 mmHg. Systolic (top) measures pressure during heart contraction; diastolic (bottom) during relaxation.

Hypertension Stages: Elevated 120-129/<80; Stage 1 130-139/80-89; Stage 2 ≥140/≥90. Associated with increased cardiovascular risk.

Hypotension: BP <90/60 mmHg. Can indicate shock, dehydration, medication side effects, or bleeding. Assess patient for dizziness and weakness.

Orthostatic Hypotension: BP drop of >20 mmHg systolic or >10 mmHg diastolic when changing position from lying to sitting or standing. Causes: dehydration, prolonged bed rest, medications.

Nursing Considerations: Measure BP in both arms on first assessment. Use appropriate cuff size. Position patient seated with feet flat. Average multiple readings. Take on both upper extremities if first reading abnormal. Monitor for signs of hypotension: dizziness, weakness, confusion.

Risk Factors for Falls: Advanced age, weakness, confusion, medications (sedatives, orthostatic agents), vision impairment, environmental hazards, balance disorders.

Fall Prevention Strategies: Keep call light within reach. Assist with ambulation. Use side rails and bed alarm. Provide non-slip footwear. Remove environmental hazards (clutter, wet floors). Encourage use of assistive devices. Monitor high-risk patients frequently. Ensure adequate lighting.

Post-Fall Assessment: Check for injuries. Assess neuro status. Verify vital signs. Report fall to provider. Document incident thoroughly. Reassess fall risk and modify plan as needed.

Nursing Considerations: Implement fall precautions for all patients. Reinforce safety measures with patient and family. Educate patients about fall prevention. Use bedrails and bed alarms appropriately—restraints can increase fall risk.

Standard Precautions (All Patients): Hand hygiene (most important!). Use PPE (gloves, gown, mask, eye protection) when contact with blood/body fluids likely. Handle sharps safely—use safety needles and never recap. Properly dispose of contaminated items. Clean and disinfect equipment. Ensure adequate ventilation.

Contact Precautions: For infections spread by direct contact (MRSA, C. difficile, scabies). Don gown and gloves before entering room. Dedicated equipment (thermometer, BP cuff) stays in room. Single or cohorting with same organism.

Droplet Precautions: For infections spread by respiratory droplets (influenza, measles, meningitis). Wear surgical mask within 3-6 feet of patient. Patient may wear mask if coughing. Avoid droplet production (minimize suctioning, nebulizers).

Airborne Precautions: For airborne pathogens (TB, measles, varicella). Use N95 respirator, not surgical mask. Negative pressure room required. Minimize patient transport. Patient wears surgical mask if leaving room.

Nursing Considerations: Perform hand hygiene before and after patient contact, before clean/aseptic procedures, after body fluid exposure, and after touching patient surroundings. Know your facility's isolation protocols. Educate patients and visitors about precautions. Monitor compliance with isolation measures.

Hand Washing Technique: Use soap and water when visibly soiled. Lather for at least 20 seconds, covering all surfaces (palms, backs, between fingers, under nails, wrists). Alcohol-based hand sanitizer acceptable when hands not visibly dirty.

Surgical Asepsis (Sterile Technique): Used for procedures entering sterile body cavities or bloodstream (catheterization, surgery, wound care). Maintain sterile field. Only sterile items contact field. Keep field dry. Never reach over sterile field.

Clean Technique (Medical Asepsis): Reduces microorganism transmission in general patient care. Proper hand hygiene, clean environment, proper disposal of soiled items.

Nursing Considerations: Hand hygiene is the #1 infection control measure. Perform before and after every patient contact. Don't touch face, hair, or other body areas while hands are contaminated. Avoid artificial nails when working with high-risk patients. Use proper technique for all procedures.

Active Listening: Give full attention. Don't interrupt. Focus on patient's words and non-verbal cues. Reflect back what you hear to confirm understanding. Validates patient feelings.

Empathy vs. Sympathy: Empathy means understanding patient's feelings without sharing them emotionally. Maintains professional boundaries. Sympathy (feeling sorry for patient) can cloud judgment and therapeutic relationship.

Open-Ended Questions: Encourage detailed responses ("Tell me about your pain" vs. "Does your pain hurt?"). Gather comprehensive information and show genuine interest in patient.

Barriers to Communication: Giving advice, false reassurance, judgmental responses, changing subject, using medical jargon with patient, interrupting. Avoid these to maintain therapeutic relationship.

Nursing Considerations: Maintain professional demeanor. Respect cultural and language differences. Make eye contact and appropriate touch. Provide private space for sensitive discussions. Document communication accurately.

Principles of Documentation: Accurate, legible, timely, objective, complete. Use only approved abbreviations. Chart in black or blue ink. Never use white-out—use single line through error with date/time and initials. Chart chronologically. Never chart for another nurse.

What to Document: Objective observations (vital signs, appearance, behavior), assessment findings, interventions provided, patient responses, patient education, medications given, time and initials on all entries.

Legal Considerations: Documentation is legal record and can be used in court. Chart only what you personally observed. Don't chart anticipatory actions. Be specific (not "patient comfortable" but "patient states pain decreased from 7 to 4 after pain medication").

Electronic Health Records (EHR): Secure, password-protected access only. Never share login credentials. Log out after charting. EHR systems audit all entries and changes. Meets legal and privacy requirements better than paper charts.

Nursing Considerations: Chart immediately after intervention or assessment. Include patient quotes in quotation marks. Use objective descriptors (size measured in cm, not "large"). Avoid charting errors in documentation. Keep confidential information private.

SBAR Technique (Situation-Background-Assessment-Recommendation): Structured approach for communicating patient information between nurses or with providers.

Situation: Identify patient and current problem ("I'm calling about John Smith in room 402 who is experiencing increased shortness of breath").

Background: Relevant history ("He was admitted 2 days ago with pneumonia and was improving until this morning").

Assessment: Current status and vital signs ("Respiratory rate increased from 18 to 28, O2 saturation dropped from 95% to 88%").

Recommendation: Suggest action ("I recommend the provider assess him for possible complications and consider increasing oxygen therapy").

Nursing Considerations: Use SBAR to improve clarity and reduce miscommunication. Handoff at shift change should be private and organized. Allow receiving nurse to ask questions. Keep handoff focused on essential information. Ensure continuity of care.

Bathing and Hygiene: Promote independence when possible. Assist as needed with bathing, grooming, oral hygiene. Respect cultural practices and preferences. Ensure privacy. Adapt techniques for mobility limitations. Assess skin during hygiene for pressure areas, skin breakdown, or abnormalities.

Toileting: Promote continent toileting through regular schedules. Ensure bedpan/urinal/commode easily accessible. Provide privacy. Maintain dignity. Assess for incontinence or urinary retention. Document elimination patterns.

Grooming and Appearance: Help with hair care, shaving, makeup per patient preference. Many patients feel better when appearance improved. Show sensitivity to cultural practices (headwear, beard grooming).

Dressing: Choose loose, easily removable clothing. Respect cultural and personal preferences. Assist with adaptive techniques for mobility limitations. Allow patient maximum independence.

Nursing Considerations: Balance assistance with promoting independence. Use proper body mechanics when assisting. Involve family in care when appropriate. Respect patient preferences and dignity throughout ADL assistance.

Occupied vs. Unoccupied Bed: Unoccupied: patient not in bed, use standard technique. Occupied: patient in bed, work one side, use smooth motions to avoid discomfort or contamination.

Proper Sheet Placement: Bottom sheets mitered corners for security. Fitted sheets or draw sheets prevent wrinkles. Top sheets and blankets loose at foot for movement. Avoid bunching or tightness.

Environmental Comfort: Appropriate temperature (68-74°F comfortable for most). Minimize noise. Provide adequate lighting. Ensure clean, dry environment. Remove clutter. Organize frequently used items within reach. Respect patient preferences.

Pressure Relief: Change position every 2 hours. Use pressure-relieving mattresses or cushions. Keep skin clean and dry. Assess bony prominences for skin breakdown. Proper positioning prevents pressure injuries.

Nursing Considerations: Maintain clean linen on all surfaces. Change soiled linens promptly. Prevent cross-contamination. Use proper technique to avoid self-injury. Work efficiently to minimize patient disturbance.

Macronutrients: Carbohydrates (primary energy source), proteins (tissue building and repair), fats (energy and cellular function). Balance all three for optimal nutrition.

Micronutrients: Vitamins and minerals essential for metabolism, immunity, and cellular function. Deficiencies cause specific syndromes (scurvy from vitamin C lack, anemia from iron deficiency).

Nutritional Assessment: Dietary history, weight change, laboratory values (albumin, prealbumin, total protein). Assess for signs of malnutrition: weakness, poor wound healing, dry skin, hair loss, edema.

Factors Affecting Nutrition: Age, activity level, illness, medications, cultural preferences, dentition, ability to swallow, appetite changes, nausea, difficulty accessing food.

Nursing Considerations: Promote adequate nutrition to support healing. Respect dietary preferences and restrictions. Monitor weight and intake. Report significant changes to provider. Consider nutritional supplements if intake inadequate. Involve dietitian for complex nutrition needs.

Total Body Water: Comprises 50-60% of adult body weight. Located in intracellular space (2/3) and extracellular space (1/3: blood plasma and interstitial fluid).

Fluid Intake and Output: Normal daily requirement about 2000-2500 mL. Sources: beverages, food, metabolic production. Losses: urine, feces, insensible loss (respiratory, skin).

Dehydration (Hypovolemia): Loss of water and electrolytes. Causes: inadequate intake, excessive losses (diarrhea, vomiting, diuretics). Signs: dry mucous membranes, poor skin turgor, weakness, orthostatic hypotension, decreased urine output.

Overhydration (Hypervolemia): Excess water relative to solutes. Causes: excessive intake, heart/kidney/liver disease, SIADH. Signs: weight gain, edema, shortness of breath, increased BP, jugular venous distention.

Key Electrolytes: Sodium (fluid balance), potassium (heart rhythm), calcium (bones, muscle), magnesium (enzyme function). Imbalances cause serious cardiac and neurological effects.

Nursing Considerations: Accurately measure intake and output. Monitor weight daily (1 kg = ~1 liter fluid). Check laboratory electrolyte values. Maintain IV therapy appropriately. Monitor for signs of fluid imbalance. Report significant changes.

Pain is Subjective: "Pain is whatever the person says it is, existing whenever they say it does." Accept patient's report. Don't judge or minimize pain experience.

Pain Assessment Components: Location (where is pain?), intensity (0-10 scale), quality (sharp, dull, burning, aching), onset (when did it start?), aggravating factors (what makes it worse?), alleviating factors (what helps?), effect on function (interference with ADLs).

Pain Scales: Numeric (0-10), visual analog (line with extremes marked), faces scale (especially for children/non-verbal), descriptive (mild, moderate, severe, unbearable).

Acute vs. Chronic Pain: Acute pain is recent onset with identifiable cause, usually severe, associated with anxiety. Chronic pain persists beyond expected healing time, may have multiple causes, reduces anxiety over time but increases depression.

Nursing Considerations: Assess pain regularly per facility protocol. Use same scale consistently. Document findings accurately. Don't assume patient in pain will look/act suffering. Consider cultural differences in pain expression. Reassess after interventions.

Pharmacological Approaches: NSAIDs (ibuprofen, naproxen) for mild-moderate pain. Opioids (morphine, oxycodone) for moderate-severe pain. Adjuvant medications (muscle relaxants, antidepressants) enhance pain control. Multimodal approach combines different medication classes for better effect.

Non-Pharmacological Interventions: Heat/cold therapy reduces inflammation and muscle spasms. Relaxation and breathing techniques reduce muscle tension. Distraction (music, TV, conversation) diverts attention from pain. Guided imagery and meditation promote relaxation. Massage and gentle touch provide comfort.

Positioning and Rest: Proper body alignment reduces strain. Support painful areas with pillows. Frequent position changes prevent stiffness. Allow rest between activities.

Nursing Considerations: Combine pharmacological and non-pharmacological approaches for best results. Assess pain regularly and adjust interventions. Consider potential side effects of medications. Teach patients self-care pain management strategies. Report inadequate pain control to provider.

Assessment Before Teaching: Learning readiness (is patient alert, focused, motivated?), previous knowledge, barriers to learning (language, hearing, pain, anxiety), preferred learning style (visual, auditory, kinesthetic), cultural beliefs affecting learning.

Adult Learning Principles: Adults learn best when information relevant to their situation. Involve them in planning. Use problem-centered approach. Respect experience. Allow self-direction. Provide immediate application.

Teaching Methods: Demonstration with return demonstration (psychomotor skills). Discussion and small group teaching (social learners). Written materials and videos (visual learners). One-on-one teaching (low literacy or complex topics). Involve family/caregivers when appropriate.

Teaching Documentation: What was taught, how long session lasted, patient's understanding (return demonstration, teach-back method), any barriers encountered, plan for reinforcement.

Nursing Considerations: Assess learning at time of hospital admission. Teach throughout hospital stay, not just at discharge. Provide written materials at appropriate literacy level. Confirm understanding using teach-back method. Adapt teaching for individual learning needs and preferences.

Comprehensive Discharge Planning: Start at admission. Identify discharge needs early. Coordinate with interdisciplinary team. Arrange follow-up appointments and referrals. Arrange equipment/supplies needed at home.

Key Components: Medication instructions (names, doses, times, side effects). Activity restrictions and resumption of ADLs. Dietary restrictions or modifications. Wound/catheter care instructions. When to call provider. Signs/symptoms to report. Follow-up appointment information.

Discharge Environment Assessment: Home safety (stairs, bathroom, lighting). Ability to obtain medications and food. Support system available. Financial resources for equipment/supplies. Access to transportation for follow-up care.

Vulnerable Populations: Elderly, homeless, substance-abusing, or non-English speaking patients need extra planning. Involve social work, case management, community resources. Ensure adequate time for teaching and questions.

Nursing Considerations: Provide written discharge instructions signed by patient/caregiver. Confirm understanding of instructions. Suggest community resources (support groups, adult day care, home health). Follow up after discharge to ensure safe transition. Document all discharge teaching thoroughly.

Beneficence (Do Good): Act in patient's best interest. Provide competent care. Pursue health and prevent harm.

Non-Maleficence (Do No Harm): Avoid actions that could injure patient. Minimize risk. Practice safely within scope.

Autonomy (Respect Independence): Respect patient's right to make decisions about their care. Provide informed consent. Support patient choices even if you disagree.

Justice (Fair Treatment): Allocate resources fairly. Don't discriminate based on race, gender, religion, or socioeconomic status. Treat all patients with equal respect.

Fidelity (Loyalty and Accountability): Keep promises. Maintain confidentiality. Report unsafe practice. Advocate for patient needs.

Veracity (Truthfulness): Communicate honestly with patients, families, and colleagues. Don't mislead or deceive.

Scope of Practice: RNs perform assessments, develop care plans, teach, administer medications/treatments, coordinate care. Work within state nursing practice acts. Know limitations and delegate appropriately.

Standard of Care: What a reasonably competent nurse would do in similar situation. Measured against peer practice. Failing to meet standard can result in malpractice liability.

Informed Consent: Patient must understand procedure, risks, benefits, alternatives before treatment. Provider obtains consent. Nurse verifies consent and witnesses signature. Can't force treatment on competent adult.

Confidentiality and HIPAA: Keep patient information private. Don't discuss details outside care team. Only share what patient authorizes. Electronic records password-protected. Violations result in legal penalties.

Reporting Obligations: Report suspected abuse (child, elder, domestic). Report unsafe practice of colleagues. Report medication errors. Failure to report can result in criminal charges or loss of license.

Nursing Considerations: Practice within scope. Document thoroughly and accurately. Know facility policies. Ask for help when unsure. Maintain professional boundaries. Report incidents/accidents. Carry liability insurance. Continue education to maintain competence.

Advance Directives: Legal document stating patient's wishes regarding life-sustaining treatment. Includes living will and healthcare power of attorney. Allows patient voice in care decisions even if unable to communicate.

Do Not Resuscitate (DNR): Patient/family request that CPR not performed if cardiac/respiratory arrest. Must be documented in chart per facility policy. Respected legally and ethically.

Palliative Care: Focus on comfort and dignity rather than cure when cure impossible. Addresses pain, symptoms, psychosocial needs. Can occur alongside curative treatment or alone in end-stage disease.

Hospice Care: Specialized palliative care for terminally ill patients. Focus on quality of life, not prolonging death. Family-centered, addresses spiritual needs, pain management, emotional support.

Nursing Considerations: Ask about advance directives on admission. Respect patient wishes regarding code status. Provide compassionate end-of-life care. Support family grieving. Advocate for patient preferences even if conflicting with family wishes. Practice self-care to prevent burnout from emotional demands.