F U N DA M E N T A L O NURSING

NAME:

DATE:

Blood Pressure:
PRE-TEST: SCORE:
1. 11. Regulated by:
2. 12.
Normal Systolic:
3. 13.
Normal Diastolic:
4. 14.
5. 15. Cuff Size:
6. 16. Placed:
7. 17.
Too narrow:
8. 18.
9. 19. Obese using standard size:
10. 20. Too tight:
Too loose :
rate is The normal infant respiratory rate is
Too fast:
VITAL SIGNS
Too slow:
Guidelines for measuring vital signs:
Right after meal:
1. Initial measurement of vital signs provides Activities, Alcohol, Smoking:
baseline data on a client’s health status and is
used to help identify changes in the client’s
health status.

2. Vital sign measurements may be

delegated to unlicensed assistive
personnel (UAP), but the nurse is
responsible for interpreting the findings.

3. The nurse collaborates with the health

care provider (HCP) in determining the
frequency of vital sign assessment and also
makes independent decisions regarding
their frequency on the basis of the client’s
status.

Temperature:

Pulse:

Minimum Maximum Approach

Infant:
Toddler:
Preschool:
School Age:
Adolescent:
Adult:

Respiratory Rate:
The normal adult respiratory rate is The normal child respiratory
 F U N DA M E N T A L O NURSING

Pain:
CONVENTIONAL NON-PHARMACOLOGICAL
INTERVENTIONS

1. Cutaneous stimulation
2. Transcutaneous electrical nerve stimulation (TENS)

PHARMACOLOGICAL INTERVENTIONS

Pulse Oximetry:
The normal value is:

FLUIDS AND ELECTROLYTES

 F U N DA M E N T A L O NURSING

FLUID VOLUME FLUID VOLUME

FLUID
DEFICIT EXCESS
IMBALANCE
(HYPOVOLEMIA) (HYPERVOLEMIA)

Vomiting, Excess Congestive heart

Sweating, Diarrhea, failure, liver
CAUSES
burns, diuretic use, failure, kidney
high fever, shock failure, fluid
shifting.
MANIFESTATION
When the concentration of solutes in
the IV fluid is similar to that of plasma Eyeballs

Example: Intracranial
Plain solutions Pressure
Fontanels
D5Water
Cardiac Output LOC
Heart
VOLUME EXPANDER Neck Veins
Lungs
1st line solution to treat shock or Urine Output GIT BUN
any fluid deficit DKA and HHNK. Creatinine
Weight BP
Temperature HR
Are more dilute IV solutions and have
a lower osmolality than plasma RR
Pulse pressure
Example: CVP
Any Solution Less than 0.90 % Hematocrit
D5Water:
Use to treat cellular dehydration Edema
Secondary solution to treat DKA and (UKCBT: oedema)
HHNK

Management:
Are more concentrated solutions and
have a higher osmolality than body Goal: (+) Fluid Balance
fluids 1. HYPOVO
LEMIA
Example: Intravenous Fluids:
5, D10, D50, Solutions (except Increase OFI (If applicable)
D5Water) Monitor I & O
D5LR, D10Water, D50Water
Weight Patient
VOLUME EXPANDER
Use to treat edema accompanied by
diuretics. Maintenance solution to treat
shock. Contraindicated with DKA and Goal: (+) Fluid Balance
HHNK 2.HYPERVOLEMIA
Limit fluids
Limit Sodium Intake
Monitor I & o
Weight patient
Drug:
 F U N DA M E N T A L O NURSING

HYPONATREMIA
HYPOKALEMIA SODIUM
POTASSIUM HYPERNATREMIA
HYPERKALEMIA

MANIFESTATION
MANIFESTATION
SIADH DI
Fluid
Impulses
CNSWeight
ECG
Urine
T Wave
Urine Specific
Wave Gravity GIT
ST Segment PR Interval
Hemo
Muscle

Management:
HYPOCALCEMIA CALCIUM HYPERCALCEMIA
1. HYPONATREMIA
1.Demeclocycline CAUSES Hyperparathyroid ism,
2.Diuretics (for SIADH) Hypoparathyroidi sm, Impulses CNS ECG Cancer
3.Monitor Weight deficiency of Vitamin T Wave
D, Pancreatitis due
4. Monitor I&O
to lipolysis ST Segment GIT
Muscle
2. HYPERNATREMIA
1. Desmopressin MANIFESTATIONS
2.IVF Isotonic
3.Monitor Weight Impulses /
Neuromascular
4. Monitor I&O
ECG excitability ECG
-Prolonged ST Muscle -Shortened ST
-Prolonged QT -Widened T wave

HYPOKALEMIA POTASSIUM HYPERKALEMIA HYPOCALCEMIA CALCIUM HYPERCALCEMIA

Chronic Kidney CAUSES ACE Inhibitors Hypoparathyroid CAUSES Hyperparathyroidism,

Disease, (-Pril), ism, deficiency of Cancer
Diarrhea, Angiotensin II Vitamin D,
Excessive Receptor Pancreatitis due
Sweating, Blocker/ARBs to lipolysis
excessive (-sartan),
laxative. K- excessive K
wasting supplements,
diuretics (F-B- K-sparing diuretic
Ma-D) (S-E-A-T)
F– S – SIGNS: MANIFESTATIONS SIGNS & SYMPTOMS
CHVOSTEK
-Tap the Facial BONES
Nerve STONES
GROANS
TROUSSEAU
 F U N DA M E N T A L O NURSING

B- E –
Ma- A –
D- T–

PUSH PULL EFFECT OF POTASSIUM ON ECG

 F U N DA M E N T A L O NURSING
NAME:

DATE:

HYPOCALCEMIA HYPERCALCEMIA
HYPOPHOSPHAT PHOSPHORUS HYPERPHOSPHA
EMIA 2.5 to 4.5 TEMIA
< 2.5 mg/dl mg/dl > 4.5 mg/dl

An intracellular anion
Inhibits absorption of calcium. Calcium and phosphate
are inversely proportional.
1. Shortened ST
2. Widened T wave
Causes: Causes:
HYPERCALCEMIA HYPOCALCEMIA
HYPOMAGNESE MAGNESIUM
HYPERMAGNESEMIA
MIA 1.5 to 2.5
> 2.5 mEq/L
< 1.5 mEq/L mEq/ L S/Sx
Alcoholism, CAUSES Excessive intake of
burns, chronic magnesium, Impulses /
diarrhea, magnesium sulfate, Neuromasc
excessive toxicity, renal failure ular
urination excitability

S/Sx

Impulses / D - eep tendon Reflex

R - espiratory Rate NUTRITION
Neuromas
O - utput (Urine)
CNS HEART cular P - ressure (BP)
excitability
CARBOHYDRATE (CHO)
Primary Source Of Energy
Muscle
Breakdown:
By Product:
ECG: ECG:
LOW CARBOHYDRATE HIGH CARBOHYDRATE
1. Torsa 1.Prolonged PR
des de 2.Widen QRS
Pointes

2. Tall T
PROTEIN (CHON)
wave
Tissue repair, Albumin production
3. Depressed ST
1. Magnesium MANAGEMENT 1. Calcium Breakdown:
Sulfate Gluconate By Product:
MgS04 2. Diuretics
IV/IM 3. Diaysis 4.02 LOW PROTEIN HIGH PROTEIN
/MechVent
2. Magnesium
Salts PO

3. Antidysrhyth
mics for
Torsades de
Pointes
Notes:
 F U N DA M E N T A L O NURSING
NAME:

DATE:

ACID-ASH DIET ALKALINE-ASH DIET

FATS
Stored form of Energy
FOR:
LOW FAT HIGH FAT FOR:
ALKALINE ASH
ACID ASH is produced by fruits
is produced by meat, (citrus) and Vegetable
poultry, cheese, fish,
eggs, grains and EXCEPT:
fruit (cranberry). CRANBERRIES, PRUNES
AND PLUMS.
“P-C”
LOW RESIDUE HIGH RESIDUE SODIUM RESTRICTED DIET
(Low Roughage/Low Fiber) POTASSIUM RICH FOOD
(High Roughage/High Fiber)
FOR:
FOR: FOR:
FOR:
“BRAT” Diet Low “PABOWS”
B- AVOID:
R- Canned, frozen, instant,
A- smoked, pickled, and boxed
T- foods

Avoid:
OK: HIGH CALCIUM DIET GAS FORMING FOOD
GLUTEN FREE DIET
BLAND DIET FOR: BROCOLLI, CAULIFLOWER,
FOR: CELIAC DISEASE ASPARAGUS, EGG, BEAN
AVOID: CASH MILK, YOGURT, ROOT CROPS, CABBAGE,
C- AVOID: BROW SMALL FISH SEAFFOD, BRUSSEL SPROUD
A- B- NUTS, BROCOLI,
S- R- SPINACH AVOID THESE ON
H- O- PATIENT WITH
W- COLOSTOMY

OKAY: GIVE:

LOW PURINE DIET LOW PURINE DIET

IRON RICH FOOD FOLIC ACID RICH FOOD
FOR: Gouty Arthritis FOR: (VITAMIN B9)
Hyperuricemia FOR: Iron Deficiency
Anemia FOR: Folate - Deficiency
AVOID: 1. Organ Meat Anemia
ALLBOYS A- AVOID: 2.Green Leafy 1. Green Leafy Vegetable
L- Vegetables 2.Banana
L- 3.Dark Dry Fruits 3.Tomato
B-
4. Kiwi
O- OKAY:
Y-
S-
 F U N DA M E N T A L O NURSING

NAM DAT

VITAMIN B12 NGT FEEDING:

(Cyanocobalamin) VITAMIN K RICH FOOD
RICH FOOD
POSITION:
AVOID THESE ON PATIENT
FOR: TAKING WARFARIN 1. Assess
Vit B12 Deficiency Anemia (Coumadin)

1.Fish, Oyster, 1.Green Leafy Vegetable 2.Auscultate

Clam 2.Poultry, 2.Turnip 3.Check Residual Volume:
Egg, Milk 3.Nuts, 3.Tea
CHeese 4. Flush with
5. Feeding:
NASOGASTRIC TUBE:
* BOLUS
TYPE * INFUSION

WOF:

MANAGEMENT:

NGT SUCTION/DRAIN
POSITION:
NGT INSERTION:
POSITION: 1. Assess
2.Irrigate with: :
1. A
ssess
2.Measure Tube:
WOF:
N
E
X
NGT REMOVAL:
3.Lubricate Tube:
4. Insufflation “whoosh test”
4.Nasopharynx:
1. Explain the procedure
5. Oropharynx:
2.Stop the feeding (tube detached from feeding line)
6. Ask the patient to swallow
3.Drain tube contents.
7.Check the tube placement
4.Remove Tape.
8. Anchor the tube on the Nose
5. Remove the tube in one swift motion and dispose in
9. Document Length of the tube.
the waste bag.
6. Wipe the Pt’s Nose.
CHECKING OF TUBE PLACEMENT 7.Remove Gloves, wash hands and dispose waste
1. X-ray
2.Aspiration of Gastric Content properly.
3.Check for gastric PH (< 5.5)
NOTES:
 F U N DA M E N T A L O NURSING

NAM DAT

TPN PPN HIGH FLOW

ACCESS Function/s L/min Fi02

Lipid Emulsions
Most Venturi 4-12 24-60%
Amino Acid-
commonly- Protein
dextrose
used solutions Dextrose
Solution
Face 28-
Tent 8-12
Severe 100%
malnutrition,
malabsorption,
hyperemesis, Supplement or
T-Piece
short bowel when central
Indications
syndrome, venous access is
obstruction, not available.
bowel rest, MECHANICAL VENTILATION
motility
disorder

Glucose
concentration 1. Tidal Volume - Pushes a certain no. of ml on pt’s
respiratory tract
- Should be set right to the pt’s
Priority
OXYGEN THERAPY body weight

NURSING CONSIDERATIONS: -if not too much pressure/volume can

1. Combustible / Flammable burst the lungs (Pneumothorax)
2.COPD
2.RR - respiratory Rate
3.Humidifier
4. Dependent Nursing Function - 16 – 20 breaths per minute
5. Emergency Cases:
3.FiO2 – amount of oxygen that we put on
our ventilator
LOW FLOW
- 35% - 50% (Fraction of inspired O2)
Function/s L/min Fi02
Nasal Cannula - we can push it up to 75% or near 100%
1-6 24-44%
FiO2 if the patient doesn’t breath enough
Simple
Facemask 6-10 35-65%
4.PEEP (positive end expiratory pressure)
Partial Added pressure in the alveoli during
Rebreather 6-15 80-90%

Non-
Rebreather 10-15 60-95%

NOTES:
HIGH PRESSURE LOW PRESSURE ALARM
ALARM
 F U N DA M E N T A L O NURSING

NAM DAT
1. ET is displaced
1. Pt. stops
spontaneous breathing
2.Inc. Secretions
2.Self-extubation
3.Bronchospasm
3.Tube air leak
4. Pt. is anxious or
4. Tube disconnected
fight ventilator
5. Kink in the tube
 F U N DA M E N T A L O NURSING

NAM DAT

CHEST TUBE
(3-way bottle 3.Put on:
system) PLEUR EVAC 4.Lubricate the Cone then insert
5. Irrigate
DRAIN WATERSEAL SUCTION 6. Wait for stool evacuation
CHAMBER 7.CLEANSE!!
COLOR: cm
fluctuation JEJUNOSTOMY ILEOSTOMY COLOSTOMY
Bubbling:
NORMAL cm Bubbling:
AVOID:
STOOL
COLOR: fluctuation (OUTPUT) GIVE:
st
1 24hrs:

ml/hr >24 hrs:

Bubbling:
ABNORMAL
SWIMMING
Bubbling:

WATCH OUT FOR: IRRIGATION

“Dislodged” tube
WHERE:
Management
ENEMA:
“Disconnected” tube Position:
WHERE: Adult:
Infant:
Management: WOF:

OSTOMY CARE: Management:

Bacterial Prophylaxis:
NEOMYCIN, KANAMYCIN
Expected Post-Op Color (STOMA): NON-
RETENTION
RETENTION
Abnormal: ENEMA
ENEMA
STOMA IS STARTING TO FUNCTION:
INDICATOR FOR BODY-IMAGE PURPOSE
ACCEPTANCE: 1.
2. 500-1000mL tap
EXAMPLE Carminative Enema
water, soap suds
COLOSTOMY IRRIGATION PROCEDURE:
1. F HEIGHT OF THE
ill container with SOLUTION
2.Hang it
DURATION
 F U N DA M E N T A L O NURSING

NAM DAT

POST TEST: SCORE:

Indwelling External Short-Term
1. 11.
2. 12.
3.Example/s 13.
4. 14.
5. 15.
6. 16.
7. 17.
8. 18.
9. 19.
10. 20.

MALE FEMALE

POSITION

STEPS OF CBI:
LENTH OF 1. Hand hygiene
INSERTION
2. Connect the irrigation solution to irrigation
tube and prime.

SECURE/ 3. W
ANCHOR AT
ear:
4.Clean the port with antiseptic swab
5.Connect the irrigation bag to the
CONTINUOUS BLADDER IRRIGATION (CBI) 6.Connect the drainage bag to the
Following transurethral resection of the prostate
(TURP) PURPOSE: To Prevent Large Clots 7.Open the clamp of the
8.Open the clamp on the

BALLOON 9.Regulate
INFLOW OUTFLOW
INFLATION
Normal:. or depending on the institutional policy.

mL
Bright Red Drain: Balloon

Clear Drain:

gtts/min

Urine Output:

WOF: