The client should be instructed as follows:

Sit up as straight as possible and hold the incentive spirometer upright.

Set the target pointer to the prescribed level.
Exhale normally and then do the following:
1. Put the mouthpiece in your mouth and close your lips tightly around
it. Do not block the mouthpiece with your tongue.
2. Inhale slowly and deeply through the mouthpiece to raise the
indicator. Try to make the indicator rise to the level of the goal marker.
3. When no more air can be inhaled, remove the mouthpiece and hold
your breath for at least 3 seconds.
4. Exhale normally.
5. Repeat these steps 10–12 times every hour while awake, or as
prescribed.
Note: People with conditions that affect the lungs, like COPD, may also
use an incentive spirometer to keep their lungs fluid-free and active.

 Intravenous pyelogram (IVP) is an x-ray of the urinary system;

 Radiopaque dye is used for visualization. The urinary tract includes the
kidneys, ureters, bladder, and urethra.
 An IVP is performed to assess urinary tract dysfunction or evaluate
progression of kidney diseases such as stones, bleeding, and congenital
anomalies. 
Before the procedure
 The nurse must assess the client for iodine sensitivity to prevent an
allergic reaction.
 The client should have some type of bowel prep and should be NPO for 8
hours before the procedure.
 There are no activity restrictions prior to the procedure.

Supplemental O2
Is required when a client is unable to maintain adequate oxygenation with
room air, which has an O2 concentration of 21%.
A nasal cannula provides oxygen at 1–6 L/min.
Every increase of 1 L/min (LPM) delivers a 4% increase in Fraction of Inspired
Oxygen (FiO2), starting from 24%.
Therefore, FiO2 via nasal cannula is as follows:
1 L/min: 24%.
2 L/min: 28%.
3 L/min: 32%.
4 L/min: 36%.
5 L/min: 40%.

1
6 L/min: 44%.

The NG tubes

 Should be secured to the client’s nose with tape and pinned to the
client's gown to allow easier movement and prevent dislodgement.
 The nostrils need cleansing and lubrication with water-soluble lubricant.
 The tape must be changed when necessary, to minimize irritation from
the NG tube.
 Frequent mouth care (at two-hour intervals) improves comfort and
maintains moisture in the oral mucosa.
 Assessing for bowel sounds or abdominal distention can indicate return
of bowel function.
 Clients can still cough and deep breathe with an NG tube, if there is no
contraindication.

Note: An NG tube is meant to be used only for a short time. Prolonged use
can lead to conditions such as sinusitis, infections, and ulcerations on the
tissues of the sinuses, throat, esophagus, or stomach.

Normal heart sounds include the S1 and S2 sounds ("lub-dub").

S1 is the closing of the mitral valve and is best heard at the apex of the
heart.
The S2 is a high-pitched sound that is dull in quality because of the closing
of the aortic valve. It is best heard over the base of the heart, at the
2nd intercostal space.
The epigastric area is heard at the tip of the sternum.
The tricuspid valve is heard at the 4th intercostal space.

Capnography
Is a monitoring method that measures the concentration of carbon
dioxide in exhaled air and displays a numerical readout and waveform
tracing.

2
Commonly used during anesthesia procedures, it is increasingly used by EMS
and in acute settings to evaluate the success of resuscitative efforts, to confirm
clinical death, and to analyze causes of respiratory distress.

Capnography is increasingly preferred over pulse oximetry for its superior

accuracy while measuring alveolar ventilation and gas exchange.

Arterial blood gas is an invasive method

Pulse oximetry uses this method. - Red and near-infrared spectroscopy is

used to measure hemoglobin O2 saturations;

Treatment for a DVT

 Bed rest to avoid dislodging the clot;

 applying warm heat to reduce leg swelling; and
 elevating the affected leg, or both legs.
 Other nursing interventions include
 application of thigh-high TED hose;
 range-of-motion exercises for the unaffected leg;
 vital signs q 4–6 hours
 administering heparin as ordered; and
 monitoring for complications of pulmonary embolism (PE), such as shortness of
breath, chest pain, apprehension, cough, hemoptysis, tachypnea, crackles, tachycardia,
diaphoresis, and fever.

Wilms' tumor (nephroblastoma)

is a rare kidney cancer that primarily affects children ages 3 to 4
It becomes rare after age 6.
The nurse should notify the HCP of the parent's report of reduced urine output; it could
indicate renal dysfunction requiring immediate attention. Children treated for the tumor are at a
higher risk for kidney failure.
An asymptomatic abdominal mass is often the first sign of Wilms' tumor, and occurs in
about 80% of children with Wilms' tumor; abdominal pain or hematuria in 25%; and
hypertension or gross hematuria in 5–30%. With current multimodality therapy, approximately
80–90% of children with a diagnosis of Wilms' tumor survive.
The abdominal mass will make clothing tight.
Fatigue is common. Food choices aren't related to Wilms' tumor, although loss of appetite is
possible.

FRONTAL LOBE
controls responses from the rest of the central nervous system.

3
 It is responsible for emotion, behavior, intellect, and memory. If the patient is
demonstrating signs of impaired reasoning, frontal lobe function is involved.

OCCIPITAL LOBE
regulates the comprehension of visual images and written words.

HIPPOCAMPUS
is the center for learning and processing information into long-term memory.

There are two amygdalae in the brain

part of the limbic system that controls emotions and the ability to perceive emotions in
others.

ANOREXIA NERVOSA
The key feature of anorexia nervosa is self-imposed starvation, resulting from a
distorted body image and an intense, irrational fear of gaining weight, even when the patient
is emaciated. Anorexia nervosa may include:
@Refusal to eat accompanied by compulsive exercising,
@self-induced vomiting, or
@laxative or diuretic abuse.

BULIMIA NERVOSA
is characterized by binge eating followed by feelings of guilt, humiliation, and self-
deprecation. These feelings cause the patient to engage in self-induced vomiting and the
use of laxatives or diuretics.

MULTIPLE SCLEROSIS
is a demyelinating disease in which the insulating covers of the nerve cells in the brain
and spinal cord are damaged.
This causes inflammation and scar tissue, or lesions. This can make it hard for your
brain to send signals to the rest of your body
Most Common Symptoms:
Fatigue
Difficulty walking

SYSTEMIC SCLEROSIS OR SYSTEMIC SCLERODERMA

is an autoimmune disease of the connective tissues.

PEDIATRICS
By the time toddlers are two years old - they should be able to use a spoon and a cup, albeit
with some spilling.
By Age of 3 or 4 – uses Forks

4
By age 5 - normal development includes using a knife and pouring.

FIRST PERIOD OF REACTIVITY

typically occurs at birth and lasts about 30 minutes. The neonate is alert, active, and
responsive to stimuli. This is the time when parents can begin to bond with their infant.
Following this episode, the neonate falls into a deep sleep for about 4-6 hours.

GLUCOSE SCREENING TEST

is a noninvasive test during pregnancy to check the blood glucose level to determine
if gestational diabetes has developed.

PLACENTA PREVIA
is diagnosed through a routine ultrasound during the second trimester or after an
episode of vaginal bleeding.

HYPEREMESIS GRAVIDARUM
is severe morning sickness (nausea) that begins in the first trimester.

APICAL PULSE
is located in the fourth intercostal space and should be counted for one full minute.
The normal range for a neonate immediately after birth is 120–160 bpm.
The heart rate drops with age: 0–5 months, 90–150 bpm;
6–12 months: 80–140 bpm;
1–3 years: 80–130 bpm;
3–5 years: 80–120 bpm.

APICAL PULSE OF AN ADULT: 60-100 bpm

Located at the apex of the heart
Left side of the chest, 5th INTERCOSTAL SPACE, MIDCLAVICULAR LINE
Point of maximal impulse

PRETERM LABOR
is screened for by direct examination and/or a swab to perform a fetal fibronectin
test (FFN).

FOLIC ACID
Green and leafy vegetables are excellent sources of folic acid.
Examples are spinach, broccoli, Brussels sprouts, avocados, and asparagus.
Other folate-rich foods include lentils, beans, and nuts.
**Neural tube defects** can occur as early as the first month of pregnancy, so
adequate folic acid intake is important before becoming pregnant. Studies show that folic acid
before and in the early phase of pregnancy can prevent 70% of neural tube defects.

5
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
is the inability to move air in or out of the lungs efficiently.
The two main types of COPD
are chronic bronchitis and
emphysema.
**COPD can't be cured, but treatment can improve the condition**. For a client with
COPD, the most important thing is learning how to improve oxygenation and reduce
carbon dioxide retention.

PLACENTA PREVIA
Placenta Previa is a condition in which the placenta lies low in the uterus and
partially or completely covers the cervix.
The risk is that the placenta may separate from the uterine wall as the cervix begins
to dilate during labor.

LECITHIN:SPHINGOMYELIN
The test to measure lung maturity is lecithin-sphingomyelin surfactant ratio. A normal
ratio is more than 2:1 (lecithin: sphingomyelin

HUMAN CHORIONIC GONADOTROPIN

Human Chorionic Gonadotropin is a hormone produced by the placenta after
implantation.

ALPHA-FETOPROTEIN (AFP)
Is a protein produced in the liver of developing fetus. During a baby’s development,
some AFP passes through the placenta and into the mother’s blood.

AFP BLOOD TEST

Is used to check a developing fetus for risk of birth defects and genetic disorder, such as neural
tube defect s or Down Syndrome
done at about 4 months' gestation to detect neural tube defects, Down syndrome, or
other abnormalities
If HIGHER – has neural tube defect such spina bifida or Anencephaly
SPINA BIFIDA - a condition in which the bones of the spine don't close around the spinal
cord
ANENCEPHALY - a condition in which the brain does not develop properly.
If LOWER - it may mean your baby has a genetic disorder such as Down syndrome,
DOWN SYNDROME - a condition that causes intellectual and developmental problems.

TRANSVAGINAL ULTRASOUND
A transvaginal ultrasound is typically performed during the first trimester and does not
measure lung maturity.

CHADWICK’S SIGN
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 Chadwick's sign is the bluish discoloration of the cervix, vagina, and labia resulting from
increased blood flow.
It can be observed as early as 6 to 8 weeks after conception, and its presence is an
early sign of pregnancy.
Other early indications of pregnancy are tender or swollen breasts, nausea (with or
without vomiting), increased urination, and fatigue.
The fundus of the uterus does not reach the navel until about 20 weeks, and it is
palpated, not visualized. The mucus plug is not seen until it dislodges during the birth process.

TIPPED UTERUS
A tilted uterus, also called a tipped uterus, retroverted uterus, or retroflexed uterus, is a normal
anatomical variation unrelated to pregnancy.

The fetal heart rate of 185 bpm for several minutes may indicate a possible complication. The
normal fetal heart rate is typically between 120 and 160 bpm. Although the heart rate will
fluctuate during labor and between contractions, prolonged fetal tachycardia can be an early
sign of hypoxia. Active labor can last about 3 to 5 hours, with cervical dilation from 4 to 7
cm. Normal client B/P values range from 90/60 mmHg to below 140/90 mmHg. Fetal
movements are usually less noticeable because of the intensity of contractions.

HEPATITIS B VACCINE
First dose should be given in the hospital within 12 hours of birth,
Second dose 1–2 months later, and the
Third dose at age 6 months or later.

NOTE: A mother should be tested for the hepatitis B e-antigen (HBeAg) during
pregnancy, preferably in the first trimester. If the mother tests positive, the newborn
should immediately be given two shots in the delivery room: one dose of Hepatitis B
Immune Globulin (HBIG) and the first dose of the hepatitis B vaccine. If these are given
immediately, the newborn will have a greater than 90% chance of being protected against a
lifelong hepatitis B infection.

RESPIRATORY RATE OF A NEWBORN

The nurse should notify the provider if the infant's respiratory rate is 70 breaths per minute.
NORMAL: Respiratory rate for newborn to 6-month-old infants is 30–60 breaths
per minute, with an average of about 40 breaths per minute.

CYSTIC FIBROSIS
Children with cystic fibrosis (CF) require a high-calorie, high-protein diet to avoid failure to
thrive syndrome. Other CF therapies include pancreatic enzyme replacement, fat-soluble
vitamins, and supplemental feedings (gastrostomy or parental) if nutritional needs can't be
met by eating.

7
COLOR DISCRIMINATION IN OLDER ADULTS:
Older adults can develop poor blue-green discrimination. These changes are related to the
yellowing of the lens that occurs with aging. Also, shorter wavelengths (blue and green) are
more difficult to distinguish than the longer wavelengths of orange and red. Red-and-green
color blindness is inherited.

TODDLERS
Toddlers do not play together with other children until they are at least three years old.
Two-year-old may play side by side, called parallel play, watching each other. Providing the
same toy to two toddlers can prevent arguments. Separating children or taking away toys are
not appropriate actions.

EIGHT-YEARS-OLD
Eight-year-olds generally love to be part of social groups, tending to prefer playing with
friends of the same gender. It's a good age for clubs. They enjoy school and are able to follow
directions and solve problems. Their coordination is improving, allowing them to enjoy sports or
learn to play an instrument. At this age, they are aware of their appearance and often decide
how they want to dress or wear their hair.

PURSED-LIP BREATHING (PLB)

Pursed-lip breathing (PLB)is one of the best ways to control shortness of breath. It improves
ventilation by keeping the small airways open and releases air that is trapped in the lungs.
It also extends the expiratory phase, which slows the breathing rate. Because patients with
emphysema have less elastic recoil in their lungs, airways can collapse during expiration, air
gets trapped, and exhalation becomes difficult.
The Cleveland Clinic suggests the following method to teach PLB:
1. Relax the neck and shoulder muscles.
2. Inhale slowly through the nose for two counts, keeping the mouth closed. Don't take a
deep breath; a normal breath will do. It may help to count silently: inhale, one, two.
3. Pucker or "purse" the lips as if whistling.
4. Exhale slowly and gently through the pursed lips for four counts.

A cigarette pack contains 20 cigarettes. Calculate pack-years by multiplying the number of

packs of cigarettes smoked per day by the number of years the person has smoked. For
example, 1 pack-year is equal to smoking 20 cigarettes (1 pack) per day for 1 year.

A drop in hematocrit during the third trimester is normal. To meet the metabolic demands of the
enlarged uterus, placenta, and growing fetus, both plasma volume and red blood cell production
increase. Hemodilution occurs because plasma volume exceeds erythrocyte production,

8
resulting in physiologic anemia of pregnancy. Pregnancy is also associated with the
suppression of some aspects of immune system function to accommodate the "foreign" genetic
material of the fetus, but this does not cause anemia. Nausea is common in pregnancy and can
adversely affect nutritional intake, but this is not the primary reason for the decreased
hematocrit.

Initial signs of puberty include a growth spurt, breast budding, and the development of armpit
and pubic hair. Menarche typically starts approximately 30 months after the first sign.
However, the range is wide: menstruation can start from 9 to 14 years of age. In the United
States, the average age for blacks is 12 years; for whites, 13 years.

The first indication of the primary stage of syphilis is the appearance of a single chancre,
although there may be multiple sores. A chancre is a round, firm, and painless sore found at the
location where syphilis bacteria entered the body. Syphilis is caused by the bacterium
Treponema pallidum. It typically follows a progression of stages, including a latent stage that
can last for weeks, months, or even years. Syphilis is easily cured with antibiotics.

Hemophilia A, also called factor VIII (FVIII) deficiency or classic hemophilia, is a genetic
disorder caused by missing or defective factor VIII, a clotting protein. Hemophilia is inherited in
an X-linked recessive manner. A daughter who inherits an X chromosome that contains the
gene for hemophilia is called a carrier. She can pass the gene on to her children. Hemophilia
can occur in daughters but only rarely.
For a female carrier, there are four possible outcomes for each pregnancy:
1. A girl who is not a carrier.
2. A girl who is a carrier.
3. A boy without hemophilia A. 4.
A boy with hemophilia A.

According to Piaget, during the sensorimotor stage (12–18 months of age), a baby gains
understanding about causality and object permanence. The baby learns that objects continue
to exist even when they are placed out of sight. During the preoperational stage (2–6 years of
age), a child's perception is based on how he or she interprets an event. The concrete
operational stage (6–12 years of age) is the beginning of logical thinking. During the formal
operational stage (13–18 years of age), an adolescent is capable of abstract reasoning.

Under the age of two, an apical pulse is most accurate and easy to locate. A radial pulse
can be difficult to palpate and count in an infant and young child. Typically, apical pulse rate is
taken for a full minute to ensure accuracy; this is particularly important in infants and children
due to the possible presence of sinus arrhythmia.

VITAMIN A

9
Egg yolks, squash, and yellow or orange vegetables such as sweet potatoes and carrots
are good sources of vitamin A. Other excellent sources are fish oil, liver, whole milk, dark
leafy greens, and dried apricots.
However, pregnant clients should avoid excess vitamin A, because it can cause malformations
in the fetus.
Milk and cheese are sources of calcium.
Berries, broccoli, oranges, and tomatoes are rich in vitamin C.
To help you remember which foods have vitamin A, use the mnemonic "Eye Must Feel Very
Lively."
Eye: vitamin A helps with vision. Get it from Eggs.
Must: Milk (whole).
Feel: Fruits.
Very: Vegetables in
"lively" colors of orange, yellow, and green.
Lively: Liver.

Magnesium sulfate
is an anticonvulsant. Blood pressure may drop during its administration,

Ankle clonus
is a series of abnormal movements of the foot, set off by reflex testing.

Scotomas
are areas of blurred vision or blindness, which often precede a seizure.

18-MONTH-OLD
According to Erikson, the child is in the stage of Autonomy vs. Shame and Doubt. The
nurse should encourage increasingly independent activities of daily living, while remaining safe
and secure. Learning to feed himself represents a major accomplishment. Cuddling may be
appropriate at times, but it is not the goal of this stage. He is too young to explore alone or to
play with other toddlers.

GLAUCOMA
Glaucoma is an eye disease that gradually steals vision. There are typically no early
warning signs or painful symptoms of open-angle glaucoma. By the time a patient is aware of
vision loss, the disease is usually quite advanced. Blurred vision should be checked, but it
has several causes. Tiny, painless particles or specks floating inside the eye are called
"floaters." Floaters can be harmless or signal retinal detachment. While dry eyes can occur
with glaucoma, both are age-related issues; some medications can also cause dry eyes.

ACUTE PANCREATITIS
Acute pancreatitis is a sudden inflammation of the pancreas.

10
 Two common causes are alcohol abuse and gallstones. For clients with a history of
alcohol abuse, all alcohol intake should stop, so promising to attend AA meetings is the
appropriate response here. The other responses are unrelated to acute pancreatitis.
The pancreatic acinar cells metabolize alcohol into toxic byproducts that damage
pancreatic ducts. Enzymes that are normally released into the digestive tract build up and begin
to digest the pancreas itself. The damaged pancreatic tissue promotes inflammation, which
leads to further damage of the pancreas. Pancreatitis can present as either acute pancreatitis or
chronic pancreatitis.

PYLORIC STENOSIS
Pyloric stenosis is a birth defect characterized by forceful, projectile vomiting.
It occurs when the pylorus muscles thicken and become abnormally large, blocking food
from reaching the small intestine.
Pyloric stenosis is four times more common in boys than girls.
Besides projectile vomiting, other indications of pyloric stenosis are weight loss,
dehydration, being very hungry despite vomiting, lack of energy, and fewer bowel
movements or frequent stools that contain mucus.
The treatment for pyloric stenosis is surgery (pyloromyotomy

HYPOVOLEMIA FROM INTERNAL HEMORRHAGE

hypovolemia from an internal hemorrhage,
indicated by the increased pulse and drop in blood pressure

INCREASED INTRACRANIAL PRESSURE:

Increased intracranial pressure (ICP) is indicated by a widening pulse pressure and slowing
heart rate.

BRAIN ANEURYSM:
A brain aneurysm is indicated by a sudden, extremely severe headache; double or blurred
vision; seizures; and loss of consciousness

ANXIETY ATTACK
An anxiety attack is indicated by a sense of panic, feeling nervous, and difficulty
concentrating. Blood pressure, pulse, and respiration rates may rise.

GONORRHEA
Gonorrhea is an infection caused by the bacterium Neisseria gonorrhoeae. The symptoms of
gonorrhea generally appear within 7–10 days after exposure.
In males, one of the early symptoms of gonorrhea is a
profuse, purulent discharge from the penis. Other symptoms are a
burning sensation when urinating,
increased urgency and frequency of urination,
swelling or redness at the urinary meatus, and

11
 pain or swelling of the testicles.

NORMAL VALUES FOR A CHILD:

Normal pulse for a child 1–2 years of age : 80–130 bpm.
Normal respiratory rate for a child 1–3 years of age: 24–40 per minute.
Normal systolic B/P for a child 2–6 years of age: 70–106 mmHg,
normal diastolic B/P: 25–65 mmHg.
A child is considered to have a fever when the child's temperature: 100.4 °F (38 °C) or
higher, measured rectally. The nurse should notify the provider about the child's temperature,
whether or not it is related to the fall.

SIGNS OF INFECTED WOUND:

Redness is a sign of wound infection, NOT blanching.
Other signs include loss of movement or function,
fever over 101 degrees Fahrenheit (a low-grade temperature of under 100 degrees is
common),
overall malaise,
purulent drainage,
increasing or constant pain,
swelling at or around the wound, and
warm skin at or around the wound.

SWAN-GANZ CATHETER (PULMONARY ARTERY CATHETER (PAC) OR RIGHT HEART

CATHETER:
The Swan-Ganz catheter (pulmonary artery catheter (PAC) or right heart catheter) can be used
for a variety of clinical purposes.
Interpreting hemodynamic data is important for the diagnosis and management of a range
of conditions including shock and pulmonary artery hypertension. Hemodynamic changes
play a central role in septic shock.
Monitoring the client's circulation is essential for evaluating the severity and course of the
syndrome and its response to treatment. Conventional hemodynamic monitoring in septic shock
pertains to invasive, mostly continuous measurements of arterial blood pressure and pressures
in the lesser circulation (central venous, pulmonary arterial and capillary wedge pressures) and
intermittent measurement of cardiac output.

PICC LINE
A PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications,
and blood draws.

PORT-A-CATH
A port-a-cath is an implanted venous access device for clients who need frequent or
continuous administration of chemotherapy.

12
ARTERIOVENOUS (AV) FISTULA
An arteriovenous (AV) fistula is a blood vessel made wider and stronger by a surgeon to handle
the needles that allow blood to flow out to and return from a dialysis machine.

SEPSIS
Sepsis is a potentially life-threatening condition for children.
One of the first signs is
confusion,
disorientation
dizziness.
Other clinical manifestations include
Tachycardia
shortness of breath
pale or clammy skin
chills
fever or a low temperature
pain
a rash
weakness, and
inability to eat.

PHENYTOIN THERAPY:
 Compliance with long-term phenytoin therapy is essential for clients with seizure
disorders.
 The medication should be taken at the same time every day. If a dose is forgotten, it
can be taken right away, but if it's time for the next dose, do not take a double dose.
 Regular dental care is important, since phenytoin can cause gingival hyperplasia.
 Long-term therapy can lead to osteoporosis, so the client should be evaluated
regularly. Weight-bearing exercise and Vitamin D and calcium supplements will help
prevent bone loss.
 Supplements should not be taken within 2 hours after a dose of phenytoin.

STARTING A VENIPUNCTURE:
 The tourniquet is placed 2-6 inches above the selected site.
 Do not leave the tourniquet in place if venipuncture cannot be successfully completed
with 1-2 minutes. If additional time is needed, release the tourniquet and reapply it a few
minutes later to continue the procedure.
 The selected vein must be palpable and visible before venipuncture is attempted.
 Check the radial pulse to ensure that the arterial circulation is not impaired.
 Grasp the arm with the thumb and gently pull the skin taut distally to the intended
insertion site. This stabilizes the vein and also makes entry into the vein easier.
13
  With the bevel up, insert the needle at a 10 to 30 degree angle.

ROSEOLA
 Roseola is caused by a virus and spread by contact with respiratory secretions or
saliva.
 It typically affects babies 6-24 months old, who suddenly develop a fever of 101-103
degrees. The fever lasts about three days, then the baby develops a non-itchy pink
body rash that can linger for several days.
 The incubation period for roseola is 5-14 days, with the baby becoming
noncontagious when the fever has been absent for 24-48 hours.
 The rash is not contagious.
 Parents should keep the baby comfortable, encourage fluids, and give
acetaminophen as directed by the provider
 About two-thirds of children who are infected show no symptoms.
 After getting roseola, there is lifetime immunity.

PATIENT RECEIVING BRACHYTHERAPY:

When a client receives brachytherapy or radiopharmaceutical therapy,
 staff must wear disposable gloves and shoe covers when in the room.
 Gowns should be worn if significant time will be spent or if there will be
contact with the client or items in the room.
 Urine and stool may be disposed of by the sanitary sewer;
 excess food and liquids may be flushed down the toilet.
 Housekeeping staff are not expected to clean the client's room twice a day, and
should not enter the client's room without a nurse.
 Designated waste containers are placed in the client's room.

BODY MECHANICS TO PREVENT INJURIES

Preventing injury among healthcare givers during client care can often be prevented. With
frequent client lifts and transfers during a shift, nurses must take care to avoid injuring
themselves. Assistive devices, such as gait belts and mechanical lifts should be used.
The 8 steps to performing lifts of heavy objects are:
1. Plan for the lift.
2. Ask for help.
3. Get a firm footing.
4. Bend at the knees.
5. Tighten stomach muscles.
6. Lift with the legs.
7. Keep the load close.
8. Keep the back straight.

AUTOIMMUNE DISEASES:

14
Autoimmune disease occurs when the body's own natural defense system attacks healthy
organs and tissues. There are over 100 known autoimmune diseases. Females are mores
susceptible, accounting for about 80% of diagnoses.
 Alopecia areata is hair loss;
 multiple sclerosis is a nervous system disease;
 Crohn's is an inflammatory bowel disease;
 Guillain-Barre involves the peripheral nervous system.

INSTRUCTIONS INCLUDED TO PATIENT HAVING HEAD AND NECK RADIATION

THERAPY
 The client should be instructed to eat a high-calorie, high-protein diet to promote
healing during radiation therapy.
 Because the radiation can affect saliva glands, saliva can become thick and sticky.
Drinking extra fluids can help thin the secretions.
 Baking soda rinses can help prevent fungal infections, as well as keep the mouth
fresh and clean.
 Ink marks are carefully placed in several sessions before radiation therapy begins;
the client should be instructed to leave them in place for the entire time.
 Skin creams or ointments are applied several times a day throughout the treatment,
but not for 4-5 hours prior to each session.
 Because the radiated skin is fragile, only very mild soap is used.

LEVODOPA (SINEMET)
The medication levodopa (Sinemet) is a protein building block, so it competes for absorption
with other proteins. Clients with Parkinson's disease must be educated about foods that can
interfere with levadopa therapy.
Levadopa (or carbidopa-levodopa) should be taken separately from meats, fish, iron
supplements, and foods high in pyridoxine (Vitamin B6). Protein may otherwise be eaten
in small amounts throughout the day.
Whole grains and foods with fiber (fruits, vegetables, legumes) can prevent
constipation, due to a slower digestive tract.
Bananas provide magnesium, and
dark chocolate (in moderation) provides caffeine and antioxidants.
Two liters of fluids should be consumed every day.
Green tea has antioxidants, so it's a good fluid choice.

END-STAGE RENAL DISEASE

 Decreased creatinine clearance:

15
  As the glomerular filtration rate (GFR) decreases,
 serum creatinine increases
 blood urea nitrogen (BUN) increase.
 Metabolic acidosis: kidneys are not able to excrete ammonia and reabsorb sodium
bicarbonate.
 Because the kidneys are not able to filter phosphorus, hyperphosphatemia develops,
with a corresponding hypocalcemia, because of their reciprocal relationship.
 Suppressed erythropoiesis

****In ESRF, the kidneys are functioning at less than 10% of normal. With decreased ability
to produce erythropoietin and maintain water balance, findings will show edema and anemia. As
kidneys fail, urine output is decreased, and hypertension develops. As fluids build up,
tachycardia attempts to elevate O2 levels.

CUSHING SYNDROME:
Cushing’s syndrome is a disorder that occurs when the adrenal glands produce too much of
the cortisol hormone over a long period of time. 
Signs and symptoms include:
weight gain, as well as fatty tissue deposits, especially around the mid-torso,
upper back, between the shoulders (buffalo hump), and
face (moon face).
Pink or purple stretch marks can appear on the abdomen, thighs, breasts, and arms.
Skin becomes thin and easily bruised.
Body and facial hair become thick and more visible (hirsutism).
Libido decreases, as well as fertility in females and
ability to maintain an erection in males.
New or worsening hypertension is another sign.
*****Treatment is by an endocrinologist. ***

HIGHEST RISK FOR DEATH BY SUICIDE:

Although suicide occurs across all ages, genders, ethnicities, and medical/social diagnoses, the
main risk factors are:
1. Age over 60;
2. A prior attempt;
3. Depression and other mental health disorders;
4. Substance abuse disorder;
5. Family history of mental health or substance abuse disorder;
6. Family history of suicide;
7. Medical illness;
8. Age over 60.
The highest ethnicity group is Native American/Alaska Native, followed by Caucasian.
16
 While females make more attempts, males are more likely to complete suicide.

CARBAMAZEPINE (TEGRETOL)
Tegretol, generic name carbamazepine, is an anticonvulsant that is sometimes prescribed
as a mood stabilizer in bipolar disorder. 
The nurse should assess a client on long-term therapy for:
1. Signs of bone marrow depression, indicated by bruising or unusual
bleeding;
2. Infection;
3. Hepatic impairment, indicated by jaundice, dark-colored urine, or light-
colored stools;
4. Heart problems, especially heart block;
5. Visual disturbances, such as blurred or double vision, and nystagmus.
6. Depression or feelings of sadness, discouragement.

TYPE 1 DIABETES
The nurse will always provide the same education for male or female type 1 diabetes,
regarding
 foot and skin care,
 glucose monitoring,
 carbohydrate counting and
 nutrition requirements, and the need to be checked for osteoporosis.
 Females may experience different blood glucose levels before and during their
periods, related to hormone levels. They may also have longer/heavier periods and
food cravings.

ACUTE COMPARTMENT SYNDROME

About three-quarters of the time, Acute Compartment Syndrome (ACS) is caused by a broken
leg or arm.
ACS develops rapidly over hours or days.
"The 5 Ps" can help the nurse quickly assess the client.
1. Pain: The most important indicator of impending ACS, it is diffuse and
progressive.
2. Pulse: When weak or absent, blood is not reaching tissues.
3. Paralysis: Client can't move toes or fingers distal to the extremity.
4. Paresthesia: Partial or full loss of sensation, or a "pins and needles" feeling.
5. Pallor: Dusky or ashy appearance distal to the injury or cast. Cool to the
touch.
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VENTILATORS ALARMS:
First, when a ventilator alarms, the nurse should always evaluate the client before checking the
ventilator.
If the high airway pressure reaches the set limit, the alarm may sound because of:
1. kinks in the patient circuit;
2. water in the ventilator circuit;
3. increased/thicker mucus or secretions blocking the airway, caused by not enough
humidity;
4. bronchospasm;
5. coughing, gagging, or "fighting" the ventilator;
6. biting the ETT.
The low-pressure alarm sounds if:
1. the client becomes disconnected from the ventilator circuit;
2. there is a tracheostomy cuff leak;
3. loose circuit or tubing connections;
4. the client needs higher levels of air than the ventilator is providing.

IMPLANTABLE CARDIOVERTER DEFRIBILLATOR

An implantable cardioverter-defibrillator (ICD) is a small battery-powered device placed in
the chest to monitor heart rhythm and detect irregular heartbeats.
An ICD can deliver electric shocks via one or more wires connected to the heart that detect
and fix arrythmias, such as ventricular tachycardia or ventricular fibrillation.
It is recommended that the client
AVOID driving,
AVOID operating heavy equipment,
AVOID Swimming for 6 months after an ICD is implanted or if the device
fires.
The life-threatening heart rhythms these devices treat can cause loss of
consciousness, which would be very dangerous.
**The client should always carry an ID card or wear a medic-alert bracelet.
Clients should keep their cell phone AWAY from their ICD, including not
carrying it in a shirt pocket, even if it is turned off.
AVOID leaning over the hood of a running car. A running car engine creates
an electrical field.
Microwaves are perfectly safe.
***All health care providers, including dentists, should be informed about the
ICD**

VENTILATOR-ASSOCIATED PNEUMONIA
Ventilator-associated pneumonia (VAP) is a nosocomial infection that can develop after 48
hours on a ventilator.
 Proper hand hygiene is essential.
 Oral hygiene q 2-4 hrs can reduce VAP by up to 60%.
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  Elevate the head of the bed 30-45 degrees.
 Coordinating with the respiratory therapist to perform subglottic suctioning can
reduce VAP by about 45%.
 Endotracheal tubes (ETT) are not changed routinely.

SPINAL SHOCK
Spinal shock is a combination of areflexia/hyporeflexia and autonomic dysfunction
that accompanies spinal cord injury.
The initial hyporeflexia presents as a loss of both cutaneous and deep tendon
reflexes below the level of injury accompanied by loss of sympathetic outflow,
Resulting in hypotension and bradycardia.
It may last 1-6 weeks.
Indications that spinal shock is resolving include:
Return of the "Osinski" or bulbocavernosus reflex;
Ability to feel pain or tingling;
Muscle spasticity;
Positive Babinski's reflex; and
Hyperreflexia, a pattern of unusually strong reflexes.

WHEN CLIENT EXPERIENCES NAUSEA DURING CHEMOTHERAPY AND DO NOT FEEL

TO EAT:
When a client experiences nausea during chemotherapy, it can be difficult to maintain proper
nutrition.
The nurse can suggest:
1. Avoid warm foods. Cold or room temperature foods are often better tolerated.
2. Eating every 2-3 hours prevents the stomach from emptying, which can cause
nausea.
3. Surprisingly, the client should not eat favorite foods when nauseated, because it can
lead to negative associations.
4. Ginger and peppermint have been used since ancient times to relieve nausea. Tea
or candies may be helpful.
5. The client should be encouraged to drink between meals, so that more food can be
taken during the actual meal, while promoting hydration.
6. The nurse can encourage the client to eat what sounds good, no matter the time of
day.
***** The nurse may also contact the provider to prescribe an anti-emetic. ****

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of connective tissue. It
can affect the skin, joints, kidneys, brain, and other organs.
Signs and symptoms include:
 Butterfly rash on the face;
 Musculoskeletal aches and pains;
 Fever;
19
  Glomerulonephritis;
 Pleurisy;
 Generalized lymphadenopathy;
 Hair thinning and loss; and
 Severe fatigue.
*** It is more common in women than men, occurring most often between the ages of
15 and 44. It affect African Americans and Asians more than other races. ****

STANDARD POST-MORTEM CARE INCLUDES:

1. Closing the eyelids and jaw. If either is open, manually close and support, as
necessary.
2. If the client will be a coroner or medical examiner case, do NOT remove lines or
tubes unless specific permission has been granted. Otherwise, removing them is
appropriate.
3. Give a complete bed bath. Dress in a hospital gown, per policy.
4. Remove jewelry and personal effects. Place them with other personal belongings to
give to the family. Document, per policy.
5. Place the body in a supine position, with legs straight and arms at the side.
6. Put absorbent pads underneath the perineal area.
7. Cover the client in a clean sheet, folded back at the chin.
8. Remove equipment and supplies from the room.
9. Per policy, tagging the body and using a post-mortem kit may be indicated
before family viewing. (NOTE: in some cultures, or situations, the family may wish to participate
in bathing or preparing the body.)

AUTISM SPECTRUM DISORDER (ASD)

is an umbrella term that accounts for a number of neurodevelopmental conditions.
EARLY SIGNS include
 Not babbling or cooing as an infant;
 Not responding to their name;
 Difficulty understanding feelings and expressing their own.
 As they get older, they can become consumed with a topic or with a
certain object.
 They often engage in repetitive motions, such as rocking.
 They require structure and routine, becoming upset if it is not
maintained.
 They may adopt an unusual speech pattern, such as talking like a
robot.

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BRONCHOSCOPY 
is an invasive procedure that permits the direct examination of the larynx, trachea,
and bronchi using either a flexible fiberoptic bronchoscope or a rigid metal
bronchoscope.
THE NURSE PREPARES THE CLIENT FOR THE PROCEDURE by
 Explaining the procedure;
 Reassuring the client;
 Ensuring the signed consent is completed;
 Maintaining NPO status for 8-12 hours as ordered;
 Providing proper oral hygiene, including removing dentures;
 Administering pre-op medications, such as sedatives;
 Monitoring vital signs during the procedure;
 Assisting with obtaining tissue samples, including labeling and delivering to the
lab; and
 Placing emergency equipment at the bedside prior to starting the procedure.

WITH LEFT-SIDED HEART FAILURE,

the left ventricle is unable to pump oxygenated blood into the body.
Pulmonary congestion occurs, as the pulmonary venous blood volume and pressure
increase, causing pulmonary interstitial edema and impaired gas exchange.
The mnemonic for left-sided heart failure is "DO CHAP."
D = Dyspnea;
O = Orthopnea;
C = Cough;
H = Hemoptysis;
A = Adventitious Breath Sounds;
P = Pulmonary Congestion. Peripheral edema and distended neck veins are
signs of right-sided heart failure.

CEREBRAL PALSY (CP)

is a group of disorders that affect a person’s ability to move and maintain balance
and posture.
It is the most common motor disability in childhood.
Brain damage can occur before, during, or after birth;
85-90% is congenital, occurring before or during birth. It is not the result of an
infectious disease process.
Risk factors include
Premature birth,
Low birthweight,
Multiple births, and
Birth complications.
**CP does not get worse over time, though symptoms may change over the lifetime. **

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SIGNS AND SYMPTOMS OF PREGNANCY INCLUDE:
 Tender, swollen breasts;
 Fatigue;
 Slight bleeding or cramping;
 Nausea with or without vomiting;
 Headaches;
 Constipation;
 Mood swings.

ANEMIA
is a decrease in the number of red blood cells (RBCs—as measured by the hematocrit
or red cell hemoglobin content).
In men, anemia is defined as hemoglobin < 14 g/dL, hematocrit < 42%, or RBC < 4.5
million/mcL.
In women, hemoglobin < 12 g/dL, hematocrit< 37% , or RBC < 4 million/mcL is
considered anemia.
Anemia is not a diagnosis; it is a manifestation of an underlying disorder.
COMMON CAUSES ARE:
 pregnancy;
 chronic kidney disease,
 autoimmune diseases,
 cancer,
 poor nutrition, and
 blood loss from surgery or trauma.
SIGNS AND SYMPTOMS INCLUDE:
fatigue,
weakness,
pallor,
dyspnea,
tachycardia,
headaches,
insomnia,
leg cramps, and
difficulty concentrating

THE FIVE RIGHTS OF DELEGATION ARE:

1. Right Task: Identify what tasks are appropriate to delegate for each client,
matched with the appropriate team member.
2. Right Circumstance: Match the client's acuity with skill level and workload of
each team member.

22
 3. Right Person: Task is within competency and scope of practice for the team
member.
4. Right Communication: Directions are clear, client-specific, and time-specific.
5. Right Supervision: Provide direct or indirect supervision, with clear directions
and expectations. Monitor performance and provide feedback. Right Diagnosis is incorrect.

FAT-SOLUBLE VITAMINS
Use the mnemonic "All Dogs Eat Kibble" to remember which vitamins are fat-soluble:
Vitamins A, D, E, and K. Fat-soluble vitamins are not lost during cooking, and are
stored in the liver and adipose tissue when not needed.

*** Vitamin B-complex and Vitamin C are water-soluble vitamins that need to replaced
regularly. **

DISULFIRAM (ANTABUSE)
an alcohol antagonist drug used to treat chronic alcoholism. Clients must be extremely
careful to
 avoid alcohol, or products with alcohol, while taking this medication.
o Cough syrup, mouthwash, and aftershave are examples.
DISULFIRAM INTERACTS WITH:
 Isoniazid, monoamine oxidase inhibitors (MAOIs),
 benzodiazepines,
 tricyclic antidepressants,
 warfarin,
 metronidazole,
 theophylline,
 phenytoin, or
 lithium.

SIDE EFFECTS INCLUDE:

 garlic or metallic taste in the mouth,
 headaches,
 fatigue,
 rash,
 swollen or sore tongue, and
 impotence.
Even a small amount of alcohol can produce unpleasant effects.
With large amounts of alcohol, there is a risk of death.
Disulfiram can increase the side effects of caffeine.

23
  Avoid drinking large amounts of beverages containing caffeine (coffee, tea,
colas) or eating large amounts of chocolate. It is prescribed as a "supportive"
therapy, to be used with counseling and other measures.

SIGNS OF STROKES:
The F.A.S.T. test is an easy way to recognize the signs of a stroke (also called a brain attack
or cerebrovascular accident).
F = Face: Ask the person to smile. Drooping on one side of the mouth or face is a sign of
a stroke.
A = Arms: Ask the person to raise both arms. One arm that slowly comes back down or
cannot be raised is a sign of a stroke.
S = Speech: Ask the person to repeat a simple sentence that you say first, such as "The
sky is blue." Speech that is slurred or sounds strange is a sign of a stroke.
T = Time: Call 911 if you see ANY of these signs. This is an emergency! The person
should be taken to the hospital immediately!

DE-ESCALATION TECHNIQUE:
De-escalation refers to behavior that is intended to escape escalations of conflicts. It may also
refer to approaches in conflict resolution.
De-Escalation techniques include:
1. Be empathetic and nonjudgmental;
2. Respect personal space;
3. Use a calm and clear tone of voice;
4. Avoid overreacting;
5. Focus on feelings and needs;
6. Ignore challenging questions;
7. Set limits;
8. Choose non-negotiables carefully;
9. Allow silence for refection;
10. Allow time for decisions.

HEMOLYTIC TRANSFUSION REACTION:

A hemolytic transfusion reaction occurs when the red blood cells that were given during
the transfusion are destroyed by the client's immune system in a process called
hemolysis.
Common signs and symptoms of a reaction include:
Fever,
chills,
pruritis (itching),
urticaria (hives),
dyspnea,
24
 hemoglobinuria (red urine),
fever,
chills,
back or flank pain

CVA ON THE RIGHT HEMISPHERE OF THE BRAIN

The right hemisphere of the brain controls movement in the left side of the body, as well as
analytical and perceptual tasks.
Depending on where the CVA lesion occurs, the right hemisphere controls:
 Facial recognition;
 tone of voice,
 spatial orientation and understanding where objects are in relation to the body;
 visual memory, such as pathfinding; musical and art ability;
 general creativity;
 insight;
 emotions; and
 the ability to understand humor and metaphors.
 Lack of insights
 Poor decision-making skills
 Trouble recognizing the faces
 Impulsive behavior
 Left-sided neglect

CIRRHOSIS is a late stage of scarring (fibrosis) of the liver caused by many forms of liver
diseases and conditions, such as hepatitis and chronic alcoholism.
Complications include:
 Ascites and edema of the lower extremities;
 bleeding from varices;
 portal hypertension;
 hepatic encephalopathy;
 hepatorenal syndrome;
 hepatopulmonary syndrome;
 splenomegaly;
 spontaneous bacterial peritonitis; jaundice and liver cancer.
**To help remember the common cirrhosis complications, use the mnemonic
"Please Bring Happy Energy," where the first letters stand for
PLEASE - Portal hypertension,
BRING - Bleeding risks,
HAPPY - Hepatic encephalopathy, and
ENERGY - Esophageal varices.

APHASIA
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Aphasia is the most common language disorder post-stroke, with one third of all clients
diagnosed with stroke experiencing it.
Receptive aphasia (also known as Wernicke’s aphasia, fluent aphasia and
sensory aphasia), is caused by damage to the posterior left portion of brain in the medial
temporal/parietal lobes.
Clients may not be able to understand what is being said or have difficulty
following long or complex sentences.
Appropriate actions for communicating include:
1. Reduce background noise and distraction;
2. Tell the client the topic of conversation before starting;
3. Assess their comprehension by starting with simple yes/no questions: "Are the
lights on in this room?”
4. Use short and simple sentences;
5. Allow plenty of time for the client to respond;
6. Talk about one topic at a time.
***Reading and writing are often severely impaired in receptive aphasia.
Also, speak to the client in a normal voice; do not "talk down" to the client.

INDICATIONS FOR DIALYSIS

Although dialysis effectively treats the signs and symptoms of uremia and fluid overload (some
of which may be life threatening), it is a lifelong therapy that is associated with discomfort,
inconvenience, and some risk for the patient. Dialysis is started when the benefit from relieving
uremic signs and symptoms is thought to outweigh its risk and associated effect on quality of
life, but not before this time.
Use the mnemonic "A-E-I-O-U" to help remember the indications for dialysis:
A - Acid-Base imbalances (intractable acidosis);
E - Electrolyte problems (K+, Na+, Ca++);
I - Intoxicants (methanol ethylene glycol);
O - Overload of fluids (refractory to diuretics); and
U - Uremic symptoms (nausea, pericarditis, bleeding, encephalopathy, seizures). Other
indications include: Lethargy, malaise, stupor, coma, gastritis with hemorrhage, Bleeding
problems are related to cirrhosis.

PERCUSSION
Percussion is a method of tapping body parts with fingers, hands, or small instruments as
part of a physical examination.
 It is performed to assess:
1. Size, consistency, and borders of organs; and
2. Presence or absence of fluid within the body.
3. Pain or tenderness.

PALPATION
Palpation is used to determine

26
 Resistance,
Resilience,
Texture,
Roughness, and
Mobility

COMMON EMERGENCY DRUGS:

Remember the mnemonic "LEAN" for these common emergency drugs.
L - Lidocaine is used for ventricular arrhythmias.
E - Epinephrine is used for ACLS protocols and severe allergic reactions.
A - Atropine sulfate is used for symptomatic bradycardia.
N - Narcan is used to reverse opiate overdose.

**Methylphenidate (Concerta) is a medication for attention deficit hyperactivity disorder

(ADHD).
**Bisacodyl (Dulcolax) is a stool softener.

COMMON CAUSES OF HYPERVOLEMIA (fluid overload or fluid excess volume) include:

Hypernatremia,
Right-sided heart failure,
Cirrhosis,
Kidney failure,
Premenstrual edema, and
Pregnancy

SIGNS AND SYMPTOMS OF HYPERVOLEMIA INCLUDE:

Visible edema of the feet, ankles, wrists, and face;
Hypertension;
Shortness of breath;
Complaints of cramping,
Headache, and
Abdominal swelling; and
Unexplained or rapid weight gain.

GUILLAIN-BARRÉ SYNDROME
is a rare but serious autoimmune disorder in which the immune system attacks healthy
nerve cells in the peripheral nervous system (PNS).
This leads to
Weakness,
Numbness, and
tingling, and can eventually cause paralysis.
SIGNS AND SYMPTOMS include:
Pricking or pins-and-needles sensations in hands and feet;

27
 Muscle weakness in the legs that progresses to the upper body
Coordination problems and unsteadiness
Difficulty with eye muscles and vision;
Difficulty talking,
Chewing, or swallowing;
Severe lower back pain or pain that gets worse at night;
Loss of bladder control;
Digestion problems;
Tachycardia;
Dyspnea;
Paralysis

HYPOGLYCEMIA
Hypoglycemia occurs when serum glucose drops below 70 mg/dl and requires action to
return the glucose level to a normal or target range.
SIGNS AND SYMPTOMS ARE unpleasant and include:
 Shakiness and dizziness;
 feeling nervous or anxious;
 sweating,
 chills, and
 clamminess;
 irritability and impatience;
 restlessness;
 confusion;
 tachycardia;
 hunger and weakness;
 fatigue;
 nausea;
 pallor;
 blurred or impaired vision;
 headaches;
 coordination problems;
 slurred speech; and
 seizures.
****Use the mnemonic "TIRED" to recall some major indications of
hypoglycemia:
T - Tachycardia,
I - Irritability,
R - Restlessness;
E - Excessive hunger, and
D - Diaphoresis/Drowsiness.

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BECLOMETHASONE
is used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused
by asthma in adults and children 5 years of age and older. It belongs to a class of medications
called corticosteroids.
It works by decreasing swelling and irritation in the airways to allow for easier
breathing.
Instructions include:
1. Keep cover tightly in place between use.
2. Exhale as much as possible through the mouth.
3. Hold the inhaler in an upright position. Place the mouthpiece firmly between the lips
and tilt the head back. Inhale slowly and deeply.
4. Breathe in slowly and deeply through the mouthpiece while spraying the medication
into the mouth.
5. Remove the inhaler and close the mouth.
6. Try to hold the breath for 5-10 seconds, then breathe out gently.
7. Replace the cap.
8. Rinse the mouth with water and spit.
***DO NOT wash or put any part of the inhaler in water. Keep it clean and dry.

DEHYDRATION
is a serious condition in infants, and can happen quickly.
Clinical manifestations of dehydration include
 thirst,
 listlessness,
 sleepiness,
 irritability,
 sunken fontanelles and eyes,
 poor skin turgor,
 lack of or decreased tears,
 weight loss,
 rapid pulse,
 dry mucous membranes,
 less than 6 wet diapers in 24 hours, and
 dark, concentrated urine.
 A capillary refill time of >2 seconds indicates dehydration.

HYPOTHYROIDISM, OR AN UNDERACTIVE THYROID,

occurs when the thyroid gland produces too few hormones, triiodothyronine (T3) and thyroxine
(T4).
Signs and symptoms include:
 fatigue,

29
  weight gain,
 sore muscles and joints,
 mood and memory changes,
 feeling cold, constipation,
 high cholesterol,
 slow heart rate,
 hair loss,
 dry skin,
 weak hair and nails, and
 Presence of a goiter.

CORRECT STEPS IN INSERTING NASOGASTRIC TUBE:

The nurse may insert a nasogastric (NG) tube in an adult client to administer tube feedings
and medications, remove and suction stomach contents, or lavage the client's stomach.
From the Journal of Nursing, appropriate steps include:
1. Checking the client's history for past nasal surgery/deviated septum.
2. Assess LOC and ability to cooperate.
3. Position in High-Fowler's.
4. Measure the distance from tip of client's nose to the earlobe to the xiphoid process.
(NEX length) Mark the length with a piece of tape.
5. Tightly curve the end of the tube, release it, and lubricate the first 4 in/10 cm with
water-soluble lubricant.
6. Give the client a glass of water with a straw and ask them to extend their neck
backward.
7. With the curved end pointing down, insert the tube and gently advance to the
nasopharynx.
8. When the end just passes the nasopharynx, ask the client to flex their head forward
and swallow sips of water. If the client gags or the tube doesn't advance, withdraw it slightly and
inspect the back of the pharynx to see if it's coiled.
9. Verify correct tube placement by aspirating stomach contents, observing the color,
and measuring the pH, which should be acidic.
10. Confirm placement by X-ray.
11. Measure and document visible tube length.

The Joint Commission has issued an Official "Do Not Use" List that applies to all orders
and all medication-related documentation that is handwritten, including free-text
computer entry, as well as on pre-printed forms.
INCLUDED ARE:
1. Write "daily" instead of QD, Q.D., or qd.
2. Write "units" instead of U or u, as when prescribing insulin.
3. Write "morphine sulfate" or "magnesium sulfate" instead of MS.

30
 4. Whole numbers do not have a "trailing zero" to avoid accidental administration of a
ten-fold dose. (Example: Coumadin 1.0 could be interpreted as Coumadin 10.)
5. Write out "right eye, left eye, or both eyes" instead of OD, OS, or OU.
6. Write out medication names, do not use abbreviations. (NOTE: Abbreviations in this
question that are not on the "Do Not Use" list: PRN, PO, q, HS, QID.

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

is a rare but serious condition that causes abnormal blood clotting throughout the
body’s blood vessels.
It is caused by another disease or condition, such as an infection or injury that
makes the body’s normal blood clotting process become overactive. 
Signs and symptoms include:
 Bleeding,
 bruising,
 low blood pressure,
 shortness of breath, or confusion
 Findings such as unusual bruising at IV insertion sites or where blood
pressure cuff was placed;
o tachycardia;
o diaphoresis;
o low platelet count (Normal range is from 150,000 to 450,000 platelets per
microliter of blood.) should be immediately reported.
o Urine output of >30 mL/hr is normal.
** Temperature is not a factor in DIC.

VIRCHOW’S TRIAD consists of three factors which may predispose a person to the
development of venous thrombosis.
These factors include:
 Hypercoagulability,
 venous stasis, and
 Endothelial injury.

SEPTIC SHOCK
"Red flag" findings include:
1. Presence of fever (core temperature >38.3°C [101°F] for patients 3 months of age and
older or >38°C [100.4°F] for infants <3 months of age)
2. Hypothermia (core temperature <36°C [96.8°F])
3. Tachycardia

31
 4. Tachypnea
5. Abnormal pulse (diminished, weak, bounding)
6. Hypotensive
7. Abnormal mental status (Irritability, excessive drowsiness, lethargy, confused)
8. Purpura anywhere on the body or petechia below the nipple line
9. Strawberry tongue.
****Septic shock in children is an extreme medical emergency; treatment should be
started within 1 hour.

COMPARING RESPIRATORY SYSTEM OF CHILDREN AND ADULT:

 Children have shorter and softer tracheas.
 A child's chest is rounded, while the adult chest is more oval-shaped.
 Because children have smaller chest capacity, their respiratory rate is
faster.
 Rib cartilage is springier in children making the chest wall less rigid.
 The internal diameter of the airways in a child is smaller. Any inflammation
or obstruction may cause more severe distress

ONDANSETRON (ZOFRAN)
Works in the stomach to block the signals to the brain that cause nausea and
vomiting.
The standard tablets that are swallowed will start to work within half an hour to 2
hours.
The client should be instructed to be aware of possible adverse effects, including
 Headache,
 fatigue,
 constipation,
 hypoxia,
 drowsiness,
 diarrhea,
 fever,
 anxiety,
 urinary retention
 pruritis
Blood pressure is not affected by this medication.

IRON-DEFICIENCY ANEMIA
develops when there is not enough iron available for the formation of RBCs.
Insufficient iron stores lead to smaller RBCs than normal and a low hemoglobin
concentration, decreasing the blood's ability to carry oxygen to the tissues and organs.
Clinical manifestations include the following:

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 1. Glossitis, a condition in which the tongue is swollen and inflamed. This often makes
the surface of the tongue appear smooth.
2. Craving ice, called pagophagia, a form of pica. About 50% of people with iron-
deficiency anemia develop pagophagia.
3. Angular stomatitis (also called angular cheilitis) is dry, reddened, swollen fissures
at the corners of the mouth.
4. Difficulty concentrating or altered behavior.
5. Leg cramps on exertion or when climbing stairs.
6. Inability to tolerate cold.
7. Tachycardia or palpitations.
8. Brittle, ridged nails.
9. Dizziness or lightheadedness.
10. Pallor.
*****Iron-deficiency anemia affects up to 30% of adults in the United States.

HIV  (HUMAN IMMUNODEFICIENCY  VIRUS)

is a virus that attacks cells that help the body fight infection, making a person more
vulnerable to other infections and diseases.
If HIV is not treated, it can develop into AIDS (acquired immunodeficiency syndrome). A
CD4+ lymphocyte count is normally 500–1,600 cells/mm³.
The Centers for Disease Control defines AIDS as someone who has a positive HIV blood
test, one or more opportunistic infections (such as candidiasis or Kaposi sarcoma) and a
CD4+ lymphocyte count of less than 200 cells/mm³.

The ELISA test is the basic HIV screening test, used to detect HIV antibodies in the blood.

The Western blot test is used to confirm a positive ELISA test.

A viral load (HIV RNA) test measures the amount of virus in the blood; individuals with
higher viral loads are at the greatest risk of progressing from HIV infection to AIDS.

Hepatitis A is transmitted through contaminated food, water, or the feces of someone who
is infected.

MYOCARDIAL INFARCTION (DIFFERENT SYMPTOMS REPORTED BY WOMEN)

According to the American Heart Association, even though heart disease is the number one
killer of women in the United States, women often chalk up the symptoms to less life-
threatening conditions, such as Acid Reflux, The Flu, Or Normal Aging. The symptoms
most frequently reported by women don't include chest pain. Instead, women report unusual

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levels of fatigue, sleep disturbances, and anxiety. For both men and women, chest pain is
the most common sign of a heart attack. Most often, it starts slowly, with mild pain or discomfort
in the left or center of the chest.

PALLIATIVE CARE 
 is specialized medical care for clients living with a serious diagnosis.
 Care is focused on providing relief from the symptoms and stress of the illness.
 The goal is to improve quality of life for both the client and their family.
Goals can include:
1. enhancing the quality of life;
2. offering a support system to help the client live as fully as possible;
3. relief from pain and distressing symptoms;
4. helping families cope; viewing death as a normal process;
5. neither hastening or postponing death; and
6. including spiritual and psychological care for client and family.
***Palliative care differs from hospice in that it doesn't only serve the dying.***

STAPHYLOCOCCUS AUREUS

MRSA is
 transmitted by contact, and
 MRSA bacteria remain alive for up to 3 days after the host dies.
 Therefore, contact precautions must still be used after the client dies, including
the use of a gown and gloves.
 The body and bag should also be labeled as MRSA contaminated so other hospital,
transportation, and funeral home employees can protect themselves as well.

ZOLPIDEM (AMBIEN)
is used to treat a certain sleep problem (insomnia) in adults. If you have trouble falling
asleep, it helps you fall asleep faster, so you can get a better night's rest. Zolpidem belongs to a
class of drugs called sedative-hypnotics. It acts on your brain to produce a calming
effect.This medication is usually limited to short treatment periods of 1 to 2 weeks or less.
Take this medication by mouth on an empty stomach as directed by your doctor, usually
once a night. Since zolpidem works quickly, take it right before you get into bed. Do not take it
with or after a meal because it will not work as quickly.

ISONIAZID

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 Peripheral neuropathy is a common side effect of isoniazid and other
antitubercular medications.
Extremity tingling and numbness should be reported to the primary health care
provider (HCP).
Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral
neuropathy caused by the use of isoniazid.
Other side effects include
 liver involvement,
 fever,
 rash, and
 weakness.

INTRAVENOUS SOLUTIONS:
isotonic solution; Sodium Chloride (Normal Saline),
D5W, and
Lactated Ringer's

Hypertonic solutions include; 5% Dextrose in Normal Saline (D5/NS, D5/NaCl, or

D5/0.9% NaCl); D5 in Lactated Ringer's (D5/LR);
5% Dextrose in 0.45% Normal Saline (D5/0.45NS,
D5/0.45NaCl, or D5/0.45% NaCl).

Hypotonic solutions include; 2.5% Dextrose in Normal Saline (D2.5/NS,

0.25/NaCl, or D2.5/NaCl);
0.45NS (0.45% NaCl); and
2.5W (2.5% Dextrose in Water).

BEFORE ADMINISTRATION OF ANTI-COAGULANT SUCH AS HEPARIN:

Most important assessment findings are their WEIGHT
The dosage of anticoagulant therapy in children is calculated on the basis of weight
(weight-based calculation) of units/kg.
Other medications in children are dosed according to body weight (mg/kg) or body surface
area (BSA) (mg/m²). Care must be taken to properly convert body weight from pounds to
kilograms (1 kg = 2.2 lb.) before calculating doses based on body weight. Doses are often
expressed as mg/kg/day or mg/kg/dose. Therefore, an order written as "mg/kg/d" is ambiguous
and will require further clarification from the prescriber.

ASPIRIN
Aspirin inhibits the enzyme COX-1, which produces thromboxane A2, which is necessary
for platelet aggregation.
Aspirin is one of the oldest drugs in the world, going back to ancient times.

WARFARIN (COUMADIN)
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Warfarin (Coumadin) blocks Vitamin K-dependent clotting factors.

HEPARIN increases the effect of antithrombin to inhibit thrombin activation.

NEOMYCIN is an antibiotic.

GASTRO-ESOPHAGEAL REFLUX DISEASE:

GERD is caused by the relaxation of the lower esophageal sphincter (LES), releasing the reflux
of acidic gastric contents into the esophagus and exposing the esophageal mucosa to those
contents.
RISK FACTORS
 hiatal hernia (bulging of the top of the stomach into the diaphragm);
 being overweight or obese;
 smoking; drinking caffeine or alcohol;
 infection with Helicobacter pylori; pregnancy;
 eating large meals or eating before bed; and
 some medications, such as
aspirin,
calcium channel blockers,
tricyclic antidepressants,
benzodiazepines, and
anticholinergics

ROSUVASTATIN (CRESTOR)
is used along with a proper diet to help lower "bad" cholesterol and fats (LDL,
triglycerides) and raise "good" cholesterol (HDL) blood levels. Rosuvastatin belongs to the statin
class of medications, which work by reducing the amount of cholesterol produced by the liver.
ADVERSE EFFECTS OF ROSUVASTATIN include
 muscle pain and weakness (rhabdomyolysis). Left untreated, rhabdomyolysis
can lead to renal impairment. The medication does not affect blood pressure
or cause orthostatic hypotension. The client should be taught to follow a low-
cholesterol diet. Eating grapefruit, either the fruit itself or as juice, can slow the
body's ability to metabolize statin cholesterol-lowering drugs. Rosuvastatin is
taken daily at any time of the day, before or after eating, but preferably at the
same time each day.

PROMETHAZINE (PHENERGAN)
has antihistaminic effects and antiemetic, anticholinergic, and sedative actions.
Side effects include
 dry mouth,
 reduced nasal congestion,
 drowsiness,

36
  listlessness,
 confusion,
 blurred or double vision,
 loss of coordination,
 slowed breathing,
 tachycardia, and
 palpitations.
 Although promethazine is a sedative, it can also produce restlessness, inability to
sleep, and an elevated mood.

IRON-DEFICIENCY ANEMIA develops when there is not enough iron available for the
formation of RBCs. Insufficient iron stores lead to smaller RBCs than normal and a low
hemoglobin concentration, decreasing the blood's ability to carry oxygen to the tissues and
organs.
Clinical manifestations include the following:
1. Glossitis, a condition in which the tongue is swollen and inflamed. This often makes
the surface of the tongue appear smooth.
2. Craving ice, called pagophagia, a form of pica. About 50% of people with iron-
deficiency anemia develop pagophagia.
3. Angular stomatitis (also called angular cheilitis) is dry, reddened, swollen fissures at
the corners of the mouth.
4. Difficulty concentrating or altered behavior.
5. Leg cramps on exertion or when climbing stairs.
6. Inability to tolerate cold.
7. Tachycardia or palpitations.
8. Brittle, ridged nails.
9. Dizziness or lightheadedness.
10. Pallor.
**** Iron-deficiency anemia affects up to 30% of adults in the United States.

BELL’S PALSY
- Eye Interventions – Dark glasses, artificial tears, cover eye at night
- Cannot close eye on the affected side
- CRANIAL NERVE AFFECTED – Facial nerve (Cranial nerve #7)
- #1 symptom – One sided facial paralysis
- Complete recovery occurs – 4 to 6 months
- Sense of TASTE also affected

BENIGN PROSTATIC HYPERPLASIA (BPH)

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 - Age group – men over 50-yrs-old
- As prostate enlarges – compresses URETHRA, and cause URINARY RETENTION
- INCREASED frequency in urination
- Force of the urinary stream – DECREASED
- FORKED-STREAM OF URINE
- DIFFICULTY STARTING TO VOID – hesitancy
- NOCTURIA – condition which you have to wake up in the night to urinate.
- HEMATURIA – blood in the urine
- TO SCREEN – Digital rectal exam
- Fluid to be forced to the clients
- TURP – Transurethral resection of the prostate
- Most radical resection of the prostate – PERINEAL RADICAL PROSTATECTOMY
- DIET – acid ash diet – decrease pH – make urine acid
- Purpose of 3-way continuous bladder irrigation (CBI) after TURP – KEEP THE
CATHETER CLEAR TO CLOTS AND TO DRAIN URINE
- SOLUTIONS USED – Normal Saline (0.9 NaCl)
- DRUGS USED TO TREAT BLADDER SPASM – B&O suppositories (Belladona and
Opiates)
- Stool softener used
- No to rectal temperatures
- AFTER TURP – call MD if – you see BRIGHT THICK BLOOD, PERSISTENT CLOTS,
PERSISTENT URINE DRAINAGE ON THE DRESSING

CATHETERS
- Most effective way to decrease UTI with catheters – KEEP DRAINAGE CLOSED,
DO NOT DISCONNECT JUNCTION OF TUBING
- Signs of infection in a Foley catheter – CLOUDY URINE, FOUL SMELLING URINE,
HEMATURIA
- Urinary incontinence – NOT AN INDICATION FOR CATHETERIZATION
- 3 Indications are: - URINARY RETENTION, TO CHECK FOR RESIDUAL, TO
MONITOR HOURLY OUTPUT
- Top 2 Diagnoses for a client with a catheter – POTENTIAL FOR INFECTION;
POTENTIAL IMPAIRMENT OF URETHRAL TISSUE INTEGRITY

TRANSFUSIONS
- VS (temp., pulse, respirations, BP, Oxygen Saturations and site observation)
measured and recorded – before start; every 15 mins after commencement of
each pack; hourly until conclusion; at the completion; 4 hourly in the 24 hours
following transfusion.
- IV solutions hung with the blood transfusion – 0.9 normal (no glucose)
- Needle used – 18 gauge
- Hemolytic transfusion reaction occurs – first 10 to 15 mins.
- Febrile reaction occurs – with 30 minutes of beginning the transfusion
- TEST IDENTIFIES Rh factor – COOMB’S TEST (detects antibodies to Rh)

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 - How long to infuse – 1 to 3 hrs.
- Stay 15 to 30 minutes after beginning transfusion
- UNIVERSAL RECIPIENT – TYPE AB
- UNIVERSAL DONOR – TYPE O

BUERGER’S DISEASE
- Also known as Thromboangitis Obliterans
- Extremities affected – Lower only
- Men – most often affected
- Smoker’s – highest incidence
- INTERMITTENT CLAUDICATION – pain in calf upon walking

BURNS
- FIRST DEGREE – red, no vesicles
- SECOND DEGREE – red, shiny, has vesicles, wet
- THIRD DEGREE – white, dry, hard, less pain, nerve damage has occurred
- Do not removed adhered clothes
- 3 Phases of burn – SHOCK, DIURETIC, RECOVERY
- SHOCK PHASE – fluid moves from bloodstream to interstitial space
Last for 24 to 48 hours
Potassium is increased
Metabolic acidosis
Therapy – fluid replacement/resuscitation
**formula for calculating fluid replacement – 3cc X kg X % burned
per day**
If MD orders 2,800cc of fluid in the first 24 hours after burn, - ½ of it
to be infused in the first 8 hours
HEMATOCRIT LAB VALUE – will dictate IV flow rate
- DIURETIC PHASE – urine output will increase
 Lat for 2 to 5 days
 K+ falls – cause hypokalemia
- Sulfamyon cream – burns
- Silver Nitrate cream – Stain’s skin, dressings must be kept wet
- PAIN MEDICATION – administered 30 minutes before wound care

ABRUPTIO PLACENTA
- Placenta separates from the uterine wall prematurely
- Occurs with MULTI-GRAVIDA, AGE 35 (HTN, TRAUMA, COCAINE)
- Painful
- IV-gauge needle use – 18 in preparation to give blood if necessary
- MEASURE – Bleeding and Maternal vital signs – q15
- Continuous Fetal monitoring – deliver at the earliest sign of fetal
distress

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 - Usually delivered C-section
- Higher fetal death incidence than Placenta Previa
- Usually occurs – third trimester

ACNE
- Structures involved in acne vulgaris – SEBACEOUS GLANDS
- 3 drugs given – VITAMIN A, ANTIOBIOTICS, RETINOIDS
- Causative Factors – HEREDITY, BACTERIA, HORMONAL
- Common retinoid given – ACCUTANE
- Accutane Vitamin analog – VITAMIN A
- Common Side Effect of Accutane – INFLAMMATION OF THE LIPS; CAUSES BIRTH
DEFECTS
- Antibiotics most commonly given – TETRACYCLINE
- Acne when being treated – result is 4 to 6 wks.

REMOVAL OF THE ENDOTRACHEAL TUBE

- Once the client has been weaned successfully and has achieved an acceptable
level consciousness to sustain spontaneous respiration, an ET tube may be
removed.
1. The ET tube is suctioned first
2. Then the cuff is deflated
3. Then the tube is removed

ADVERSED EFFECTS OF NASOTRACHEAL SUCTIONING:

- Cyanosis
- Excessively rapid or slow heart rate,
- Sudden development of bloody secretions
*****IF ANY OF THESE SIGNS ARE OBSERVED, THE IMMEDIATELY STOPS
SUCTIONING, AND REPORTS TO THE PHCP. ********

PREPARING TO INSERT NASOGASTRIC TUBE IN AN ADULT CLIENT:

- To determine the accurate measurement of the length of the tube to be inserted
o By placing the tube at the TIP OF THE CLIENT’S NOSE AND EXTENDING
THE TUBE TO THE EARLOBE AND THEN DOWN TO THE XIPHOID
PROCESS.
o The average length for an adult is about 22 to 26 inches (56 to 66 cm)

40
 o Water soluble lubricant is used to lubricate 3 to 4 inches of the tube at the
insertion end.
o Half-inch tape is used to secure the tube after correct placement is verified.
o 50-mL catheter tip syringe is used to aspirate gastric contents to help
verify placement.
o Only chest X-ray can confirm placement
o Client is asked to take a sip of water through a straw to help the passage of
the tube

DISCONTINUING A CLIENT’S NASOGASTRIC TUBE:

- The client is position 45 to 90 degrees unless contraindicated
- The tube is flushed with 15 mL of air to clear the secretions.
- The client should take a deep breath and hold the breath and the tube is
withdrawn slowly and evenly over a course of 3 to 6 seconds (coil the tube around
the hand while removing it) while the breath is held.

NOTE: “TRACHEOSTOMY TUBE NEEDS SUCTIONING IF RHONCHI ARE AUSCULTATED”

“IF CONGESTED BREATH SOUNDS IN THE LUNG FIELDS”

TRACHEOSTOMY TUBE:
- Tracheostomy tube are available in many sizes and are made of plastic or metal.
- Tubes may be reusable; however, most tubes are disposable.
- May or may not have cuff.
- It also may have inner cannula
- FOR CLIENT RECEIVING MECHANICAL VENTILATION – a cuffed tubed is used.
- A NON-CUFFED TUBE – may be used when mechanical ventilation is not required.
- “if a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff,
a nurse should inflate the cuff to prevent aspiration of food or fluids. HOWEVER,
even a cuffed tube does not protect against aspiration because breathing and
swallowing move the tube. The best measure to protect against aspiration is
placing the client in high-fowler’s position”
- NOTE: “ If the endotracheal tube is inserted TOO FAR into the client’s trachea, the
tube will ENTER THE RIGHT MAIN BRONCHUS” It should not enter past the
CARINA.
- CARINA – it is the bifurcation of the right and left main bronchi.

CORRECT SEQUENCE IN SUCTIONING A CLIENT HAVING TRACHEOSTOMY TUBE:

1. The nurse positions the client first – semi-fowler’s position
2. Then prepares the necessary equipment before donning gloves.
3. Turn on the suction device and set the regulator at 80mm Hg
4. Attach the suction tubing to the suction catheter
5. The nurse HYPEROXYGENATES the client both before and after
suctioning.

41
 6. Insert the catheter into the tracheostomy until resistance is met, and
then pull it back 1 cm.
7. Apply intermittent suction and slowly withdraw the catheter while
rotating it back and forth

TRACHEOSTOMY PROCEDURE POST OP:

- A Tracheostomy Tube of the SAME SIZE and an OBTURATOR are kept at the
bedside at all times in case the tracheostomy tube becomes dislodged
- In addition, A CURVED HEMOSTAT that could be used to hold the trachea open if
dislodgement occurs should be kept at the bedside.

TRACHEOSTOMY TUBE WITH A NONDISPOSABLE INNER CANNULA:

- After washing the inner cannula with a HALF STRENGTH PEROXIDE and rinsing it
with a STERILE WATER (PER AGENCY POLICY), the nurse TAPS IT AGAINST A
STERILE SURFACE to remove excess liquid and ALLOWS IT TO DRY.
- The nurse Then Reinserts the Cannula to the tracheostomy tube and
- TURNS IT CLOCKWISE TO LOCK it in place.

AFTER REMOVAL OF ENDOTRACHEAL TUBE:

- Findings that must be reported: - PRESENCE OF STRIDOR – A high-pitched
coarse sound that is heard with stethoscope over the trachea.
- It indicates AIRWAY EDEMA and places the client at risk for airway obstruction.

CHEST TUBE REMOVAL INSTRUCTIONS:

- When the chest tube is removed, the client is asked to take a deep breath and hold
it.
- The tube is then quickly withdrawn, and an airtight dressing is taped in placed.
- The pleura seal themselves off, and the wound heals in less than a week.
- When chest tube is removed, an occlusive dressing, usually consisting of
PETROLATUM GAUZE covered by dry sterile dressing, usually is placed over the
chest tube site.
o The dressing is maintained in place until the primary health care provider
says it may be removed.
o Client should avoid heavy lifting for 4 to 6 weeks after discharge to
facilitate continued wound healing.
o Client is taught to monitor and report any signs of respiratory difficulty or
any signs of infection or increased temperature.

PLAN OF CARE FOR THE PATIENT WITH A CHEST TUBE ATTACHED TO A CHEST TUBE
DRAINAGE:
- Encourage the client to cough and deep breathe when a chest tube drainage is in
place (this will assist in facilitating appropriate lung re-expansion.
- Client is positioned in a semi-fowler’s position to facilitate ease in breathing.

42
- The water seal chamber acts as a 1-way valve. It allow air and fluid to leave the
pleural space but prevents reentry of atmospheric air.
- Water is added to the suction chamber as it evaporates to maintain the full suction
level prescribed.
- The minimum amount needed is 2 cm of water.
- A closed chest drainage system must remain airtight at all time.
- Connections between the chest tube and the drainage system are taped to prevent
accidental disconnection.
- Occlusive dressing is maintained at the chest tube insertion site.
- Drainage is noted and recorded every HOUR during the FIRST 24 HOURS after
insertion and every 8 HOURS thereafter.
- The system is kept below the level of the waist.
- Assessment of crepitus is done once every 8 HOURS.
- Sterile water is added to the suction control chamber only as needed to replace
evaporation losses.

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