Foundations EXAM 1 Bluprint

Identify an appropriate site for assessing client blood pressure

Most common site: brachial artery

• DO NOT use an arm if the client has:

  • Mastectomy on that side

  • Dialysis fistula/AV shunt

  • IV infusion running

  • Other contraindications affecting that extremity

• other sites can be

  • popliteal (most common in babies)

  • forearm

  • ankle

proper BP preparation

• Client rests 5 minutes

• No caffeine/nicotine for 30 minutes

• Sitting position

• Feet flat on floor

• Back supported

• Arm supported at heart level

• Cuff on bare skin

• Correct cuff size

• Cuff size

  • Width ≈ 40% of arm length

  • Bladder ≈ 80% of arm circumference

• Too small → falsely HIGH BP

• Too large → falsely LOW BP

Considerations for taking bp

• Make sure equipment is calibrated and validated

• Do not measure BP in an arm with an IV infusion in progress or on the side where the client had a mastectomy or an arteriovenous shunt or fistula

• Blood pressure should be taken on an arm with no clothing (no heavy sweatshirts, etc.) – should be taken on skin!

• If reading is high, wait 1 minute then recheck in the same arm

• Deflate the cuff completely between attempts. Wait at least 1 full min before re-inflating the cuff. Air trapped in the bladder can cause a falsely high reading

• 
  

systole

heart contracts

• Ventricles contract.

• Blood is pumped out of the ventricles.

• Blood enters the aorta/body and pulmonary artery/lungs.

• Produces the TOP BP number.

• Represents the highest pressure.

Max amount of pressure exerted against the arteries when the heart contracts and forces blood into the aorta to the body and pulmonary artery to the lungs – heart is pumping blood out of ventricles

Diastole

heart relaxes

• Ventricles relax.

• Blood returns to the heart.

• Ventricles fill.

• Produces the BOTTOM BP number.

• Represents the lowest pressure.

Min amount of pressure exerted against the arteries when the heart is relaxed

Ventricles at rest – blood returns to heart and ventricles filling

Nursing interventions regarding vital signs BEFORE applying a warming device

• Assess vital signs, especially temperature.

• Assess the client's overall condition.

• Assess skin integrity.

• Assess sensation/peripheral circulation, especially if the client has:

  • Diabetes

  • Neuropathy

  • Poor circulation

  • Decreased sensation

• Remove wet clothing/linens if applicable.

• Apply the warming device according to facility policy/order.

• Never apply excessive/direct heat to insensate skin.

• Reassess temperature and skin condition.

Identify signs and symptoms of orthostatic hypotension

orthostatic hypotension: a decrease in BP when moving from lying to a sitting/standing position

• Systolic ↓ >20 mmHg

• Diastolic ↓ >10 mmHg with an increase in HR

Signs/symptoms:

• Dizziness

• Weakness

• Fainting/syncope

• Possible tachycardia

nursing interventions

• Have client sit or lie down.

• Do not allow them to get up alone.

• Use call light.

• Have them sit at edge of bed for at least 1 minute before standing.

• Change positions slowly.

• Assist with ambulation.

Causes:

• Peripheral vasodilation

• Medication adverse effects

• Fluid depletion

• Anemia

• Prolonged bed rest

pulse strength grading system

0: Absent

1+: Diminished/weaker than expected

2+: Brisk/expected

3+: Increased/strong

4+: Full volume/bounding

Normal vital sign ranges

• temp: 36–38°C (96.8–100.4°F)

• pulse: 60–100 bpm

  • tachycardia: >100

  • bradycardia: <60

• respirations: 12-20/min

  • tachypnea: >20

  • bradypnea: <12

  • apnea: no breathing

• spO2: 95-100%

• BP: know the clients baseline; generally around <120/80mmHg

factors that affect bp vital sign collection

• Age

• Weight

• Medications

• Emotional state/stress

• Pain

• Body position

• Genetics/family history

• Nicotine

• Caffeine

• Incorrect cuff size

factors that affect respirations vital sign collection

• Age

  • Rate decreases with age

• Acute Pain

  • Increase in rate but may have a decrease in depth

• Anxiety

  • Increases rate and depth

• Medications

  • Opioids depress or slow rate and depth

  • Cocaine increases rate and depth

• Body position – upright is best

• Neurologic injury - brainstem

• Sex

  • Male vs. Female

• Smoking/vaping

factors that affect pulse oximetry vital sign collection

• Darker skin

• Nail polish

• Poor circulation

• Factors affecting respirations

factors that affect temp vital sign collection

• Circadian rhythms, Environmental Conditions, and Stress

• Age: decreased body temp in older adults

• Hormonal Changes

• Exercise, Activity, and Dehydration: can lead to increased temp

• Illness and Injury

• Recent Food or Fluid Intake and Smoking

different ways to take temperature

• rectally

• orally

• axillary (armpit)

• tympanic (ear)

• temporal (forehead)

Identify appropriate measures to take when assisting a client with hygiene who is taking anticoagulants

main concern = BLEEDING

• use:

  • Electric razor

  • Avoid disposable razors that can cut the skin.

  • Be gentle when bathing/grooming.

  • Watch for bruising/skin injury.

  • Avoid unnecessary trauma.

Identify the proper technique when performing perineal care for a male client

• Provide privacy and explain the procedure.

• Have the client lie supine with knees slightly apart.

• Wear gloves and use a clean washcloth with warm water and soap.

• Clean from the least contaminated area to the most contaminated area.

• Clean the tip of the penis first, moving outward from the urinary opening.

• If the client is uncircumcised, retract the foreskin gently, clean underneath, and return the foreskin to its normal position afterward.

• Clean the shaft of the penis, then the scrotum.

• Have the client turn to the side or assist as needed to clean the perineum and anus last, wiping from front to back.

• Use a clean portion of the washcloth for each stroke and rinse/dry the area thoroughly.

• Observe for redness, swelling, sores, discharge, or unusual odor and report abnormalities.

Describe nursing care practices when assisting clients with antiembolism stockings and sequential compression devices

used to prevent venous stasis, DVT, and edema

• Antiembolism stockings

  • Provide graduated compression.

  • Help push venous blood back toward the heart.

• SCDs (Sequential Compression Devices)

  • Intermittently inflate/deflate.

  • Compress the legs.

  • Promote venous return.

  • Reduce venous stasis.

Your mobility lecture specifically identifies elastic stockings and frequent position changes as interventions to reduce thrombus development.

Nursing care

• Assess skin underneath.

• Check circulation.

• Ensure correct fit.

• Remove periodically according to facility policy/order.

• Do not allow bunching/rolling.

• Reapply correctly.

• Do not place stockings/SCDs over impaired skin unless specifically ordered.

Antiembolism stockings (TED hose):

- Measure the client's legs to ensure the correct size.

- Apply stockings smoothly without wrinkles or bunching.

- Make sure they are not too tight or causing pressure.

- Remove them at least once a day to assess the skin and circulation.

- Check for redness, swelling, numbness, tingling, or discoloration.

- Reapply correctly after skin assessment.

Sequential compression devices (SCDs):

- Make sure the sleeves fit properly around the legs.

- Apply them smoothly and connect them to the compression pump.

- Ensure the device is inflating and deflating properly.

- Remove the sleeves regularly to assess skin and circulation.

- Check for pain, numbness, tingling, discoloration, or skin breakdown.

- Encourage ambulation and leg exercises when appropriate.

- Do not allow the client to walk while the SCDs are connected unless the device is specifically designed for ambulation.

- Main purpose: Both help prevent venous stasis and deep-vein thrombosis (DVT) by promoting blood flow back toward the heart.

Identify outcomes that occur when regular oral care measures are not performed on a client

• Plaque buildup

• Tooth decay

• Gingivitis

• Gum irritation/infection

• Oral discomfort

• Increased bacterial load

• Increased risk of pneumonia

• Especially important in:

  • Oxygen therapy

  • NPO clients

  • NG tube clients

  • Unconscious clients

• Client with an impaired gag or swallowing reflex: Avoid pouring water into the mouth because of aspiration risk. Use suction and minimal fluid.

• Client who is actively vomiting: Stop oral care and allow the client to recover to prevent aspiration.

• Client who is having a seizure: Do not put anything in the client's mouth. Wait until the seizure is over and the airway is safe.

• Client with oral surgery or significant mouth trauma: Follow the provider's specific orders because brushing or manipulating the mouth may cause injury.

• Client with severe bleeding in the mouth: Avoid vigorous brushing or flossing and follow the care plan.

Unconscious client:

• Side-lying to reduce aspiration risk. Keep suction availabe

• Do not use large amounts of fluid because they may aspirate. Use a small amount of water/moistened swab and suction as needed.

Describe techniques used when performing foot care on a patient with diabetes/neuropathy

• Inspect the feet every day for redness, blisters, cuts, sores, swelling, or changes in skin color.

• Wash feet with warm (not hot) water and mild soap.

• Test the water temperature with the hand or a thermometer because neuropathy can decrease temperature sensation.

• Dry the feet thoroughly, especially between the toes.

• Apply lotion to dry skin, but do not put lotion between the toes because moisture can promote fungal growth.

• Keep toenails trimmed straight across and file sharp edges.

• Do not cut corns or calluses or use over-the-counter corn removers unless specifically directed by a healthcare provider.

• Avoid heating pads, hot water bottles, and very hot water because the client may not feel a burn.

• Encourage well-fitting shoes and clean, dry socks.

• Check inside shoes for objects or rough areas before putting them on.

• Never walk barefoot, even indoors.

• Avoid tight socks or anything that can restrict circulation.

• Report any open sore, blister, infection, discoloration, or wound to the healthcare provider.

DO NOT

❌ Soak feet
❌ Apply heat/heating pads
❌ Apply lotion between toes
❌ Walk barefoot
❌ Cut diabetic toenails if prohibited by policy

Describe nursing care practices when assisting immobile clients with hygiene.

• Provide privacy and explain the procedure before beginning.

• Perform hand hygiene and use gloves when appropriate.

• Keep the client warm and covered, exposing only the area being cleaned.

• Use warm water and mild soap and avoid water that is too hot.

• Wash from cleanest to most contaminated areas.

• Change the water and washcloth when necessary, especially after cleaning the perineal area.

• Dry the skin thoroughly, especially skin folds, to prevent moisture-related skin breakdown.

• Inspect the skin for redness, pressure injuries, rashes, bruising, or other abnormalities.

• Reposition the client carefully and regularly to prevent pressure injuries.

• Use proper body mechanics and safe-transfer techniques when moving or turning the client.

• Encourage the client to perform as much of the hygiene care as they can safely do to promote independence.

• Provide oral care, hair care, nail care, and perineal care as needed.

• Keep linens clean, dry, and wrinkle-free.

• After care, make sure the client is comfortable, the bed is in a safe position, and the call light is within reach.

• Document the care provided and report any abnormal findings.

Bed bath order

• head to toe in the from and then head to toe in the back

  • use diff wash clothes for perineal area

Identify concepts that are common to all theories of nursing (nursing metaparadigm)

• Person

  • The individual receiving nursing care.

  • Can also include families, groups, or communities.

  • The person is viewed as a whole—physical, emotional, social, and spiritual.

• Environment

  • Everything surrounding the person that can affect their health.

  • includes the physical environment, family, culture, community, and social factors.

  Health

  • The person's level of well-being or illness.

  • Health is more than simply being free from disease.

  Nursing

  • the actions, care, and responsibilities of the nurse.

  • Includes promoting health, preventing illness, caring for the sick, and helping clients reach their best possible level of health.

Discuss the different roles of the nurse and be able to identify a specific role given a scenario

1. Caregiver

2. Critical thinker

3. Communicator

4. Teacher/educator

5. Counselor

6. Leader

7. Researcher

8. Advocate

9. Collaborator

10. Change agent

Florence Nightingale

• Environmental theory.

• Clean environment, sanitation, ventilation, nutrition.

• Helped establish nursing as a profession.

• Used statistics/research to improve care

Hildegard Peplau

• Interpersonal relationships.

• Nurse-patient relationship is central.

Virginia Henderson

Nursing helps patients perform activities they would do independently if able.

dorothea Orem

• Self-care deficit theory.

• Nurse helps when patient cannot meet self-care needs.

Jean watson

• Caring theory.

• Emphasizes caring and human connection.

madeleine Leininger

• Culture/culturally congruent care.

• Nursing should align care with the patient's beliefs and culture.

Who can an RN delegate to?

CNA/PCT/AP can perform:

• Bathing

• Grooming

• Dressing

• Toileting

• Ambulation

• Feeding without swallowing precautions

• Positioning

• Routine tasks/vital signs as appropriate

LPN can perform/delegate:

• Medications within scope

• Reinforce teaching

• Tracheostomy care

• Urinary catheter insertion

RN must retain:

• Nursing judgment

• Initial assessment

• Nursing diagnosis

• Care planning

• Evaluation

• Tasks requiring nursing judgment

If the scenario involves assessment, teaching, evaluation, clinical judgment, or an unstable client → think RN.

If it involves routine care for a stable client → think LPN or CNA/PCT, depending on whether the task requires nursing skill.

And remember: delegation rules can vary by state Nurse Practice Act and facility policy, so the RN must delegate only tasks that the person is legally and appropriately trained to perform.

5 rights of delegation

1. Right Task?

• Is this appropriate to delegate?

2. Right Person?

• Does this CNA/PCT/LPN have the education and competency?

3. Right Time?

• Is the patient stable and is this an appropriate time?

4. Right Directions?

• Did the RN clearly explain:

  • What to do

  • How to do it

  • When

  • What to report

5. Right Supervision?

• Will the RN follow up and evaluate the outcome?

quantitative reaserch

• Numerical data

• Measures variables

• Statistics

• Answers "how much/how many?"

qualitative reaserch

• Experiences/meanings

• Interviews/observations

• Answers "what is the experience like?"

other types of nursing reaserch

Basic research

• Expands knowledge/theory.

Applied research

• Solves practical problems in healthcare.

Define evidence-based practice

Using the best available evidence to inform nursing practice and improve client outcomes.

• Your lecture describes EBP as a problem-solving approach involving evidence, implementation, evaluation, and sharing results.

6 steps of evidence based practice

• Ask - Identify the clinical question or problem.

  • Example: Does turning patients every 2 hours reduce pressure injuries?

• Acquire - Search for the best available evidence related to the question.

  • Look at research studies, clinical guidelines, and other reliable sources.

• Appraise - Evaluate the evidence to determine if it is reliable, valid, and useful.

• Apply - Use the evidence along with clinical expertise and patient preferences to make a decision about care.

• Assess - Evaluate whether the change or intervention worked and make adjustments if needed.

Identify causes of slow onset immobility

- Aging - decreased muscle strength, balance, and endurance

- Chronic illnesses - such as arthritis, osteoporosis, Parkinson's disease, or heart/lung disease

- Progressive neurological disorders - conditions that gradually affect movement

- Chronic pain - can cause a person to avoid movement over time

- Muscle weakness or deconditioning - especially after prolonged inactivity

- Obesity - can make movement more difficult

- Depression or other psychological factors - may decrease motivation to move

- Poor nutrition - can contribute to weakness and loss of muscle mass

- Fear of falling - may cause a person to gradually become less active

Identify nursing interventions to prevent foot drop in clients

Nursing interventions:

• - Maintain the feet in a neutral position with the toes pointing upward.

  - Use a footboard at the end of the bed to prevent the feet from pointing downward.

  - Use ankle-foot orthoses (AFOs) or other prescribed devices when appropriate.

  - Reposition the client regularly to prevent prolonged pressure and muscle shortening.

  - Perform active or passive range-of-motion (ROM) exercises, especially ankle dorsiflexion.

  - Encourage the client to move the feet and ankles regularly if able.

  - Avoid positioning devices that force the foot into plantar flexion.

  - Encourage early ambulation and activity as appropriate.

Identify client complications related to immobility

Integumentary

• Pressure injuries

Respiratory

• Atelectasis

• Pneumonia

• Ineffective airway clearance

Cardiovascular

• Orthostatic hypotension

• Venous stasis

• DVT

Musculoskeletal

• Muscle atrophy

• Weakness

• Contractures

• Foot drop

• Bone loss

Elimination

• Constipation

• Urinary retention

• UTIs

Psychosocial

• Social isolation

• Depression

• Anxiety

supine

lying flat on back

dorsal recumbent

back with knee/lower extremities flexed

prone

lying on abdomen

lateral

side lying

sims

left side with right hip/knee flexed

low fowler

15–30°

semi-fowler

30–45°

high fowler

60–90°

lithotomy

Vaginal exams/procedures

orthopneic

sitting, leaning forward with arms supported

• helps breathing

trendelenburg

promotes venous return; used for hypotension

• makes feet 30 degrees higher than head on a flat surface

Physiologic purpose of SCDs/antiembolism stockings

Prevent DVT by improving venous return and reducing venous stasis.

• Antiembolism stockings

  • Promote venous return.

  • Reduce venous stasis.

  • Help prevent DVT.

• Sequential compression devices (SCDs)

  • Intermittently squeeze the legs.

  • Promote venous blood flow.

  • Reduce venous stasis.

  • Check the skin regularly and make sure the devices are applied correctly.

Identify clients who are more at risk for complications due to immobility given a list of specific clients with ages/diagnoses

• Older adults

• Postoperative clients

• Clients on prolonged bed rest

• Paralysis/spinal cord injury

• Stroke

• Neuromuscular disorders

• Fractures

• Severe weakness

• Sedated clients

• Obese clients with limited mobility

• Clients with chronic illness

Describe proper education of assistive personnel regarding use of a cane

important cane rules:

• If the left leg is weak/injured: → Hold cane in the right hand.

Sequence:

• Cane → weak leg → strong leg

Other points:

• Keep two points of support on the floor.

• Advance the cane first.

• Move weaker leg forward.

• Then stronger leg.

Injury prevention if a client falls during assisted ambulation

If the client starts falling: Do NOT try to hold them upright.

Instead:

• Widen your base of support.

• Support the client.

• Guide them toward the floor.

• Protect the client's head.

• Bend your knees.

• Avoid twisting your back.

• Call for assistance.

• Assess for injury after the fall.

• Do not immediately move them if injury is suspected.

• Notify appropriate personnel/provider.

• Document.

Identify what HIPAA stand for as well as its purpose

Health Insurance Portability and Accountability Act

• Purpose includes protecting the privacy/security of a patient's protected health information (PHI) and regulating how health information is used/disclosed.

• HIPAA = protect patient info

Identify examples of HIPAA violations given a scenario

• Looking at a patient's chart when you don't need the information for your job.

• Discussing a patient in a public elevator.

• Posting about a patient on social media.

• Taking a picture of a patient without appropriate authorization.

• Leaving a computer with PHI open/unsecured.

• Sharing patient information with someone who isn't authorized.

• Giving patient information to family members without appropriate permission.

Identify incorrect statements regarding HIPAA

❌ "I can look at any patient's chart because I'm a nurse."

❌ "It's okay to discuss patients in the hallway as long as I don't say their name."

❌ "I can post a funny patient story on social media if I don't include their name."

❌ "Family members automatically have the right to all of the patient's information."

Correct principle:

• Only access/use/share the minimum necessary information for an appropriate purpose.

Recognize each step of the nursing process (ADPIE) and what each step accomplishes: ASSESSMENT

• What you do: Collect information about the patient.

  • Includes:

    • Vital signs

      • Physical assessment

      • Patient statements

    • Medical history

    • Lab results

    • Observations

  • Accomplishes: Gives the nurse the data needed to identify the patient's problems.

Recognize each step of the nursing process (ADPIE) and what each step accomplishes: DIAGNOSIS

• What you do: Analyze the assessment data and identify a nursing diagnosis/problem.

• Accomplishes: Identifies the patient's actual or potential response to a health problem that nursing can address.

• Think: "What is the patient's nursing problem?"

  • Example: Acute pain related to surgical incision.

Nursing diagnosis ≠ medical diagnosis.

Recognize each step of the nursing process (ADPIE) and what each step accomplishes: PLANNING

• What you do: Establish goals/outcomes and decide which interventions will help achieve them.

• Accomplishes: Creates a plan for the patient's care.

• Think: "What do we want to happen?"

  • Example: "Patient will report pain of 3/10 or less within 1 hour."

• A good outcome should be specific and measurable.

Recognize each step of the nursing process (ADPIE) and what each step accomplishes: Implementation

• What you do: Carry out the nursing interventions in the care plan.

  • Examples:

    • Administer medication

    • Reposition patient

    • Provide hygiene

    • Educate the patient

    • Apply an intervention ordered by the provider

  • Accomplishes: Puts the plan into action.

  Think: "What am I going to do?"

Recognize each step of the nursing process (ADPIE) and what each step accomplishes: EVALUATION

• What you do: Determine whether the patient's goal/outcome was achieved.

  • Ask:

    • Was the goal met?

    • Partially met?

    • Not met?

  Accomplishes: Determines whether the plan of care is effective and whether changes are needed.

Identify what is created by completing each step of the nursing process

A - Database of patient information/data

- Collect the data

D - Nursing diagnosis

- Identify the problem

P - Goals/outcomes + nursing care plan

- Decide what you want to happen

I - INursing interventions are carried out

- Do the plan

E - Determination of whether goals were met

- See if it worked

Discuss which part of the nursing process is taking place given a client scenario

The nurse asks the patient to rate their pain and measures their blood pressure.

✅ Answer: Assessment

After reviewing the patient's assessment findings, the nurse identifies Acute Pain as a nursing diagnosis.

✅ Answer: Diagnosis

The nurse establishes a goal that the patient will report pain at 3/10 or less within one hour.

✅ Answer: Planning

The nurse administers the prescribed analgesic and repositions the patient.

✅ Answer: Implementation

One hour after receiving the medication, the nurse asks the patient to rate their pain again. The patient reports pain decreased from 8/10 to 2/10.

✅ Answer: Evaluation

Identify a well-stated nursing intervention

A good intervention should be:

• Specific — clearly says what the nurse will do.

• Action-oriented — starts with an action verb.

• Individualized — appropriate for that specific patient.

• Clear — another nurse should be able to understand exactly what to do.

• Related to the patient's nursing problem.

• Within nursing scope

• Measurable/observable when possible

GOOD:

"Assist the client to ambulate 50 feet with a walker twice per shift."

BAD:

"Encourage mobility."

The first one tells you exactly what to do, how much, and how often.

Explain the difference between subjective and objective data given a client scenario

Subjective Data = What the patient TELLS you

Subjective data is information that only the patient can report because it involves their feelings, symptoms, or experiences.

Examples:

"My stomach hurts."

"I feel dizzy."

"I am nauseated."

"My pain is 8 out of 10."

"I feel short of breath."

"I am tired."

🧠 Think: SUBJECTIVE = SUBJECT says it.

Objective Data = What you OBSERVE or MEASURE

Objective data is information that the nurse or another healthcare professional can see, hear, feel, measure, or verify.

Examples:

Temperature = 101.2°F

Heart rate = 110 bpm

Blood pressure = 90/60 mmHg

Respirations = 24/min

Wound is red and swollen

Patient is vomiting

Oxygen saturation = 89%

Patient has a bruise on their arm

🧠 Think: OBJECTIVE = You can OBJECTIVELY observe or measure it.

Identify the difference between nurse-initiated vs. physician-initiated interventions given a client scenario

👩⚕ Nurse-initiated interventions

These are actions the nurse can perform independently, based on nursing knowledge and the patient's needs. They do not require a provider's prescription/order.

Examples:

Repositioning the patient

Providing hygiene

Assisting with ambulation

Encouraging appropriate fluid intake

Implementing fall precautions

Performing skin assessments

Providing patient education within nursing scope

👨⚕ Physician/provider-initiated interventions

These are interventions that require an order/prescription from a physician or other authorized provider.

Examples:

Administering a medication that requires an order

Starting prescribed IV fluids

Administering oxygen when an order is required by facility policy

Performing a diagnostic test that requires a provider order

Implementing a prescribed treatment

Scenario:

The provider orders acetaminophen 650 mg PO for the patient's pain. The nurse administers the medication.

Identify appropriate outcome(s) for a client given a specific client scenario

Patient-centered — describes what the patient will do/experience.

Specific — clearly states what is expected.

Measurable — you can determine whether it happened.

Realistic/achievable — appropriate for the patient's condition.

Time-oriented — includes a timeframe when appropriate.

Recognize if a client goal was met or not met given a specific client scenario

Example 1 — Goal Met ✅

Goal:

Patient will report pain of 3/10 or less within 1 hour.

Scenario:

One hour later, the patient reports pain of 2/10.

✅ Goal MET

The patient achieved the expected outcome.

Example 2 — Goal Not Met ❌

Goal:

Patient will report pain of 3/10 or less within 1 hour.

Scenario:

One hour later, the patient reports pain of 7/10.

❌ Goal NOT MET

The patient did not reach the expected outcome.

Identify nursing interventions that prevent pressure ulcers

✅ Important interventions

Reposition the client regularly to relieve pressure.

Assess the skin frequently, especially over bony areas.

Keep the skin clean and dry.

Provide prompt incontinence care to prevent moisture-related skin damage.

Use moisture barrier products when appropriate.

Use pressure-relieving devices/surfaces, such as specialty mattresses or cushions.

Keep the client's heels off the bed when appropriate.

Avoid friction and shearing when moving the client.

Use proper lifting/repositioning techniques rather than dragging the client across the bed.

Encourage adequate nutrition and hydration.

Encourage mobility and activity as tolerated.

Keep linens clean, dry, and wrinkle-free.

🚨 What to watch for

Nonblanchable redness over a bony prominence is an early warning sign of a Stage 1 pressure injury.

The priority is to remove/reduce pressure from the area and protect the skin

Serous wound draniage

clear, thin, watery

sanguineous wound drainage

bloody

serosanguineous wound drainage

clear + pink/bloody

Seropurulent wound drainage

clear + yellow

• infected pus (thin and liquidy and yellow)

purulent

thick, opaque yellow/green/tan; abnormal

• somewhat like pus

Wound healing phases

1. Hemostasis

• Immediately after injury:

  • Vasoconstriction

  • Blood clot forms

  • Stops bleeding

2. Inflammation

• Redness

• Heat

• Swelling

• Pain

• WBCs clear debris/pathogens

3. Proliferation

• New tissue formation

• Angiogenesis

• Granulation tissue

• Re-epithelialization

4. Maturation/remodeling

• Collagen remodeling

• Scar formation

• Wound strengthens

• Final tensile strength remains decreased

stop —> clean —> build —> stregthen

tunneling

A passageway extending from the wound into surrounding tissue.

• hole/pathway

• Example: The wound opening is small, but there is a narrow passage that extends 5 cm deeper.

undermining

The tissue underneath the wound edges becomes eroded, creating a pocket underneath the edge.

• pocket

• Example: The wound edge is intact on top, but tissue underneath the edge has been damaged and creates a space.

functions of the skin

• Protection

• Temperature regulation

• Sensation

• Vitamin D production

• Immunologic function

• Absorption

• Elimination

• Psychosocial function

Deep tissue pressure injury

• Skin may be intact or nonintact.

• Persistent deep red, maroon, or purple discoloration.

• May have a blood-filled blister.

• Usually indicates damage to underlying tissue from pressure and/or shear.

• The area may be painful, firm, mushy, warmer, or cooler than surrounding tissue.

Think: DEEP damage underneath → dark red/maroon/purple

Stage 1 wound

• Skin is intact.

• Nonblanchable erythema (redness that does not turn white when pressed).

• Usually occurs over a bony prominence.

• May be painful or have changes in temperature/texture.

Example: You press on the reddened area and it doesn't turn white → Stage 1.

Stage 2 wound

• Partial-thickness loss of skin.

• Dermis is exposed.

• Wound bed is typically pink/red and moist.

• May appear as an intact or ruptured serum-filled blister.

• No exposed fat, muscle, tendon, cartilage, or bone.

• No slough or eschar obscuring the wound.

• 🧠 Stage 2 = PARTIAL skin loss

stage 3 wound

• Full-thickness skin loss.

• Adipose (fat) may be visible.

• Granulation tissue and/or epibole may be present.

• Slough and/or eschar may be visible.

• Undermining and tunneling may occur.

• Muscle, tendon, cartilage, and bone are NOT exposed.

• 🧠 Stage 3 = FAT can be seen

stage 4 wound

• Full-thickness skin and tissue loss.

• Exposed or directly palpable fascia, muscle, tendon, cartilage, or bone.

• Slough and/or eschar may be present.

• Undermining and tunneling may occur.

• Can involve extensive tissue damage.

• 🧠 Stage 4 = DEEP structures exposed

Unstageable Pressure Injury

• Full-thickness skin and tissue loss.

• The actual depth cannot be determined because the wound bed is completely or partially covered by:

• Slough, and/or

• Eschar

• 🧠 Unstageable = Can't SEE the bottom

Identify nursing interventions for a client who has a Penrose drain (please see drains PP slide on NU 322L Moodle) - we will cover this in skills lab 3

• Assess the drainage for amount, color, consistency, and odor.

• Monitor the insertion site for redness, warmth, swelling, pain, or other signs of infection.

• Keep the surrounding skin clean and dry.

• Change the dressing as needed according to the prescribed/facility procedure.

• Protect the skin around the drain from irritation caused by drainage.

• Secure the drain so it does not become accidentally displaced.

• Perform hand hygiene and use appropriate PPE/aseptic technique when providing drain care.

• Document the appearance and amount of drainage and the condition of the surrounding skin.

• Report increased drainage, purulent/foul-smelling drainage, bleeding, fever, or other signs of infection/complications.

Discuss nursing interventions that protect skin integrity for clients who are incontinent of bowel or bladder

• Clean the skin promptly after each episode of incontinence.

• Use a gentle cleanser and avoid harsh soaps.

• Pat the skin dry rather than rubbing it.

• Apply a moisture barrier product to protect the skin.

• Keep the skin clean and dry.

• Change wet or soiled briefs/linens promptly.

• Assess the skin frequently for:

• Redness

• Irritation

• Excoriation

• Open areas

• Signs of pressure injury

• Avoid excessive friction when cleaning or repositioning.

• Use appropriate absorbent products and change them as needed.

• Encourage adequate nutrition and hydration to support skin integrity.

• 🧠 Why is this important?

• Urine/stool → moisture + irritation → skin breakdown → increased risk of pressure injury

Identify changes in skin related to the aging process

• Thinner skin — the skin becomes more fragile and easier to injure.

• Decreased elasticity — skin becomes less firm and wrinkles develop.

• Decreased subcutaneous fat — there is less cushioning and insulation under the skin.

• Increased dryness — older skin tends to become drier because of decreased oil production.

• Decreased blood supply/circulation — contributes to slower healing.

• Slower wound healing — injuries take longer to heal.

• Increased risk of bruising and skin tears because the skin is thinner and more fragile.

• Decreased ability to regulate temperature — older adults may have more difficulty adapting to heat and cold.

• Changes in pigmentation — age spots and uneven pigmentation can develop.

• Decreased sensation — reduced sensitivity can increase the risk of unnoticed injury.

• 🧠 Easy way to remember

• Older skin = THIN + DRY + FRAGILE + SLOW TO HEAL

Identify clients most at risk for developing infection when given a list of clients

Look for clients with factors that weaken their immune defenses or give microorganisms a way into the body.

1. 👶 Very young or 👵 older adults

• Infants have immature immune systems.

• Older adults may have decreased immune function.

2. 🛡 Immunocompromised clients

• Examples:

  • Receiving chemotherapy

  • Taking immunosuppressive medications

  • Having a condition that weakens immunity

➡ Very high infection risk

3. 🩹 Clients with breaks in the skin

• Examples:

  • Open wounds

  • Burns

  • Surgical incisions

  • Pressure injuries

  • The skin normally acts as a barrier against microorganisms.

4. 💉 Clients with invasive devices

• Examples:

  • Urinary catheter

  • Central venous catheter

  • IV access

  • Drain

  • Ventilator

  • These can provide microorganisms a pathway into the body.

5. 🛏 Clients with prolonged immobility

• Immobility can contribute to:

  • Pressure injuries

  • Respiratory complications

  • Urinary stasis

  • These can increase infection risk.

6. 🍎 Clients with poor nutrition

• Adequate nutrients are needed for:

  • Immune function

  • Tissue repair

  • Wound healing

7. 🩺 Clients with chronic diseases

• Certain chronic conditions can increase susceptibility to infection, especially when they affect immune function, circulation, or tissue healing.

Explain proper technique when donning sterile gloves

• Perform hand hygiene.

• Open the sterile glove package without contaminating the gloves.

• Identify the right and left gloves.

• Use your non-dominant hand to pick up the dominant-hand glove by touching only the inside of the cuff.

• Insert your dominant hand into the glove.

• Leave the cuff folded/turned down.

• Slide the gloved fingers underneath the cuff of the remaining glove.

• Now your sterile glove touches the sterile glove.

• Lift the second glove.

• Insert your non-dominant hand into the glove.

• Adjust the gloves as needed without touching your bare skin with the sterile glove.

• 🚨 The BIG rule

• Bare hand → can touch ONLY the inside of the sterile glove.

• Sterile glove → can touch ONLY sterile surfaces.

• Once one hand is sterile/gloved, do not use that sterile hand to touch anything contaminated.

Discuss what type of patient isolation is required for clients with MRSA

MRSA → Contact Precautions

• MRSA (methicillin-resistant Staphylococcus aureus ) is generally managed with Contact Precautions, in addition to Standard Precautions.

What does Contact Precautions mean?

• The nurse should:

  • Perform hand hygiene before and after patient contact.

  • Wear gloves when entering the patient's room/care area.

  • Wear a gown when contact with the patient or their environment is anticipated.

  • Use dedicated patient equipment when possible.

  • Limit unnecessary transport of the patient.

  • If the patient must leave the room, cover infected/colonized areas and maintain appropriate precautions.

Identify what assessments a nurse should complete when caring for a client with an infection

1. 🌡 Vital Signs

• Monitor for changes in:

  • Temperature — fever can indicate infection

  • Heart rate — may increase

  • Respiratory rate — may increase

  • Blood pressure — may decrease with a severe infection

2. 🩹 Assess the Site of Infection

• Look for:

  • Redness

  • Warmth

  • Swelling

  • Pain/tenderness

  • Drainage

  • Odor

  • For a wound, for example, inspect the wound and surrounding skin.

3. 🩸 Laboratory Data

• Review relevant results, especially:

  • WBC count

  • Culture results, if obtained

  • Other labs related to the suspected infection

4. 🧍 Assess for Systemic Changes

• Look for:

  • Chills

  • Fatigue or weakness

  • Loss of appetite

  • Changes in mental status

  • Difficulty breathing

  • Overall deterioration

Explain nursing interventions that can prevent infections

1. 🧼 Perform proper hand hygiene

• Wash hands with soap and water or use alcohol-based hand sanitizer when appropriate.

• Perform hand hygiene before and after patient contact.

• Clean hands after removing gloves.

• ⭐ Hand hygiene is one of the most important ways to prevent the spread of infection.

2. 🧤 Use appropriate PPE

• Use PPE based on the patient's situation:

• Gloves → protect hands from contamination.

• Gown → protects clothing/skin.

• Mask/respiratory protection → protects against respiratory transmission.

• Eye protection → protects eyes from splashes.

3. 🧴 Use aseptic/sterile technique

• When performing procedures that require asepsis:

• Maintain a sterile field.

• Avoid contaminating sterile equipment.

• Use sterile supplies appropriately.

• Keep contaminated items away from clean/sterile items.

4. 🩹 Protect skin integrity

• Keep wounds clean and appropriately covered.

• Provide proper wound care.

• Keep skin clean and dry.

• Assess wounds and invasive-device sites for infection.

5. 💉 Practice safe handling of equipment

• Clean/disinfect reusable equipment appropriately.

• Use single-use items only once.

• Avoid sharing contaminated equipment between patients.

6. 🫁 Follow respiratory hygiene

• Encourage covering coughs and sneezes.

• Dispose of tissues properly.

• Perform hand hygiene after respiratory secretions.

• Use appropriate transmission-based precautions when indicated.

7. 🛏 Prevent complications of immobility

• For immobile clients:

• Reposition regularly.

• Encourage mobility as tolerated.

• Prevent pressure injuries.

• Promote adequate nutrition and hydration.

8. 🚨 Follow isolation precautions

• Use Standard Precautions for all clients and add the appropriate transmission-based precautions when indicated.

• Remember:

• Contact → MRSA

• Droplet → Influenza

• Airborne → TB

Identify reasons Hospital Acquired Infections occur and from which medical devices

• 
  

• Breaks in the skin such as surgical wounds or other injuries.

• Poor hand hygiene can spread microorganisms between healthcare workers and clients.

• Improper aseptic/sterile technique can introduce microorganisms.

• Prolonged hospitalization increases exposure to healthcare-associated microorganisms.

• Immunocompromised clients have less ability to fight infection.

• Devices that remain in place longer than necessary increase infection risk.

CAUTI

Catheter-associated UTI
→ Foley/urinary catheter

CLABSI

Central line-associated bloodstream infection
→ Central venous catheter

VAP

Ventilator-associated pneumonia
→ Mechanical ventilation

SSI

Surgical-site infection
→ Surgery/incision

MRSA

→ Contact transmission, wounds/devices/hospital exposure

C. difficile

→ Antibiotic use + contaminated environment

Describe when to use standard and transmission-based isolation precautions

1. 🧤 Standard Precautions

• Use Standard Precautions for EVERY client, regardless of whether they have a known infection.

• They are based on the idea that blood and certain body fluids may contain infectious microorganisms.

• Standard Precautions include:

• Hand hygiene

• Gloves when exposure to body fluids is possible

• Gown when clothing/skin may be exposed

• Mask/eye protection when splashing or spraying is possible

• Safe handling of needles and sharps

• Proper cleaning/disinfection of equipment

• 🧠 Remember: STANDARD = EVERYONE

2. 🦠 Transmission-Based Precautions

• These are used IN ADDITION TO Standard Precautions when a client has or is suspected of having an infection that can spread through a specific route.

• There are 3 types:

  • 🟤 Contact Precautions

    • Used when microorganisms spread through direct or indirect contact.

    • Examples:

      • MRSA

      • C. difficile

    • Usually includes:

      • Gloves

      • Gown

      • Hand hygiene

      • Dedicated equipment when possible

    • 🧠 Contact = TOUCH

  • 🔵 Droplet Precautions

    • Used when infection spreads through respiratory droplets.

    • Examples:

      • Influenza

      • Pertussis

      • Meningococcal disease

    • Usually includes:

      • Surgical/procedure mask

      • Hand hygiene

      • Gloves/gown/eye protection as indicated

    • 🧠 Droplet = COUGH/SNEEZE

  • 🟢 Airborne Precautions

    • Used when microorganisms can remain suspended in the air and travel over longer distances.

    • Examples:

      • Tuberculosis (TB)

      • Measles

      • Varicella (chickenpox)

    • Usually includes:

      • Negative-pressure room

      • N95 respirator or appropriate respirator

      • Keep the door closed.

Identify rules of a sterile field (please review, "Sterile gloves and setting up and adding items to a sterile field" power point slide on Moodle) - we will cover this in skills lab 3

• Sterile touches sterile.

• A sterile item can touch another sterile item without contaminating it.

• Sterile touches only sterile.

• Once something sterile touches something contaminated, it is contaminated.

• The outer 1-inch border of a sterile field is considered contaminated.

• Do not place sterile items in the border.

• Keep the sterile field above waist level.

• Items below waist level are considered contaminated.

• Keep the sterile field in your sight.

• Never turn your back on a sterile field.

• Do not reach over the sterile field.

• Your clothing/arms could contaminate it.

• Do not touch the sterile field with anything nonsterile.

• A wet sterile field is contaminated.

• Moisture can allow microorganisms to pass through the barrier.

• Do not talk, cough, or sneeze directly over the sterile field.

• Droplets can contaminate it.

• When in doubt, consider it contaminated.

Identify infection control risks during linen changes

The biggest risk is spreading microorganisms from contaminated linens to the patient, nurse, environment, or other patients.

🚨 Things the nurse should NOT do

❌ Do not shake or snap the linens.

This can spread microorganisms into the air.

❌ Do not place dirty linens on the floor.

The floor is contaminated.

❌ Do not hold dirty linens against your uniform.

This can contaminate your clothing.

❌ Do not place dirty linens on clean surfaces.

Keep contaminated linens contained.

❌ Do not carry dirty linens through the hallway unnecessarily.

❌ Do not reuse contaminated linens.

Explain proper technique when doffing PPE - we will cover this in skills lab 1

1. Gloves: Remove your gloves first, as they are the most contaminated item. Use a glove-to-glove or skin-to-skin technique, touching only the inside/cuff, and discard them.

2. Eye Protection (Goggles or Face Shield): Remove eyewear by handling only the clean headband or ear straps at the back. Pull forward and away from the face. Do not touch the contaminated front.

3. Gown: Unfasten ties or snaps. Pull the gown away from your neck and shoulders, touching only the inside or sterile/clean parts of the gown. Turn it inside out as you roll it down and away from your body, then discard.

4. Mask or Respirator: Remove the mask last by grasping the bottom ties or ear loops first, then the top ties. Pull straight away from your face without touching the front filter material. (Note: If wearing an N95 or particulate respirator, this is typically done after exiting the patient care area).

5. Hand Hygiene: Perform hand hygiene immediately after removing all PPE using an alcohol-based hand rub or washing with soap and water.

pulse physiology

Regulated by the autonomic nervous system through cardiac sinoatrial node

Parasympathetic stimulation—decreases heart rate

Sympathetic stimulation—increases heart rate

Wave-like sensations or impulses you feel in a peripheral arterial vessel or hear over the apex of the heart

Expected reference range for an adult client is 60-100 bpm/min at rest

dysrythmias

irregular heart rhythm, generally with an irregular pulse.

pulse deficit

difference between the apical rate and the radial rate

• Indicated that blood isn’t being perfused correctly and that the heart beat is irregular