Comprehensive Nursing Notes

Hypoxemia and Hypoxia

  • Hypoxemia: Low oxygen in the blood.
  • Hypoxia: Low oxygen in tissues/cells or organs.

Oxygenation and Nursing Process

  • Assessment:
    • Shortness of Breath (SOB)
    • Cyanosis
    • Tachypnea
    • SpO2 (Oxygen saturation level)
    • Lung sounds
  • Diagnosis:
    • Impaired gas exchange
    • Ineffective breathing pattern
    • Risk for decreased cardiac output
  • Planning:
    • Maintain oxygen levels at 91-100%.
  • Implementation:
    • High Fowler’s position
    • Encourage deep breathing and coughing
    • Administer oxygen as needed

Manifestations of Hypoxia

  • Restlessness
  • Anxiety
  • Confusion
  • Cyanosis
  • Tachypnea
  • Tachycardia
  • Low oxygen saturation (SpO₂ < 90%)
  • Pale sclera and conjunctiva.
  • Darker skin tones: white/grayish.
  • Yellow skin tones: greenish. Check soles and palms.

Oxygen Saturation Monitoring (Pulse Oximetry)

  • Measures percentage of hemoglobin in the blood.
  • Assess for changes in skin and mucous membrane color, pallor, or cyanosis.
  • Assess lung sounds and for clubbing of nails.
  • Central cyanosis (seen in the face) indicates a severe condition.

Oxygen Delivery Devices

  • Nasal Cannula:
    • For mild low oxygen levels.
    • Flow Rate: 1–6 L/min
    • FiO₂: 24–44%
    • Nursing care: Check for dryness/irritation or bleeding in the nose and skin breakdown behind the ears.
  • Simple Face Mask:
    • For moderate oxygen levels.
    • Flow Rate: 6–10 L/min
    • FiO₂: 40–60%
    • Nursing care: Remove mask every 2 hours and ensure it is not too tight.
  • Venturi Mask:
    • Needed for precise oxygen delivery (e.g., COPD patients).
    • Flow Rate: 3–8 L/min
    • FiO₂: 24–50%
    • Nursing care: Keep adapters in place.
  • Non-rebreather Mask (Reservoir Mask):
    • For severe hypoxia.
    • Flow Rate: 10–15 L/min
    • FiO₂: up to 95%
    • Nursing care: Ensure bag stays inflated; if flat, increase oxygen flow.

Lab Work and Diagnostic Testing for Respiratory Illness

  • Sputum Specimen:
    • Diagnosis of lung infections.
    • Collect first thing in the morning before eating or drinking, and ideally before starting antibiotics.
    • Procedure: Patient takes deep breaths to loosen mucus, coughs forcefully, and spits 1 to 2 teaspoons of sputum into a sterile container.
    • If needed, nurse can help loosen mucus via chest physiotherapy or suction.
  • Arterial Blood Gas (ABG):
    • Measures oxygen, carbon dioxide, and pH in blood.
    • Blood is taken from an artery.
  • Imaging:
    • Chest X-ray or CT scan.
  • Tuberculin Test:
    • Checks for tuberculosis.

Peak Flow Meter

  • Indications:
    • Used daily by asthma patients to monitor airway narrowing and peak expiratory flow rate (maximum speed at which air can be blown out).
  • Interpretation of Readings:
    • Green zone (80–100%): Good control.
    • Yellow zone (50–80%): Caution, asthma getting worse.
    • Red zone (<50%): Emergency, seek help.

Incentive Spirometry

  • Indications:
    • Used after surgery or with lung problems to prevent atelectasis.
  • Use:
    • Encourages deep breathing and lung expansion.
    • Perform 10 times every hour.

Chest Physiotherapy

  • Indication:
    • Helps move mucus out of lungs.
  • How to Perform:
    • Percuss on chest wall by cupping hands on chest and back.
    • Used for COPD, cystic fibrosis, bronchiectasis.

Tracheostomies: General Care and Monitoring

  • Always have suction ready in case of mucous block.
  • Keep stoma clean and change dressing at least once a day.
  • Humidify air to keep secretions thin.
  • Monitor for signs of infection, obstruction of secretions, respiratory effort, cyanosis, or change in mental status.
  • Check lung sounds for signs of pneumonia or respiratory complications.
  • Ensure only 2 fingers fit under the tie.

Urinary Elimination and Nursing Process

  • Related to urinary incontinence, retention, and UTI.
  • Clean Catch (Mid-stream):
    • Females: Clean front to back.
    • Males: Wipe the tip.
    • Urinate into the toilet and disregard the first portion, collect the middle portion.

Catheterization and Urinary Incontinence

  • Stress Incontinence:
    • Pee leaks when you laugh, cough, or sneeze due to extra pressure on the bladder.
  • Urge Incontinence:
    • Sudden, strong urge to urinate with inability to reach the bathroom in time because of an overactive bladder muscle (detrusor muscle).
  • Reflex Incontinence:
    • Involuntary loss of urine without warning due to overactivity of the bladder muscle.
  • Functional Incontinence:
    • Loss of urine because the person can’t physically get to the toilet or can't remove clothing in time—NOT due to bladder issues.
  • Transient Incontinence:
    • Temporary pee leaks that can be due to a UTI.
  • Overflow Incontinence:
    • Bladder becomes overfilled and leaks small amounts of urine frequently, can be due to enlarged prostate or weak bladder muscle.
  • Enuresis:
    • Involuntary urination.
    • Bedwetting—usually at night. Normal in children or adults if drinking alcohol, caffeine at night, or due to medications.

Urinary Diversion

  • Surgical procedure to create a new way for urine to leave the body when normal flow is blocked.
  • Nursing Care:
    • Encourage scheduled toileting.
    • Pelvic floor (Kegel) exercises.
    • Bladder training.
    • Address mobility issues.

Urinary Retention

  • Bladder doesn’t completely empty with urination, can be due to prostate enlargement or a cystocele (prolapsed bladder).
  • Assessment Findings:
    • Difficulty starting stream, weak flow, abdominal distention, feeling of incomplete emptying.
  • Nursing Care:
    • Find cause, catheterize if needed, assist with toileting schedule, promote fluid intake, monitor output, and encourage Kegel exercises. Be careful for UTI.

Collection of Urine Specimen

  • Intermittent Straight Catheter:
    • Clean area before inserting a sterile tube, drain urine directly into a container, and remove the tube.
  • Indwelling Foley Catheter:
    • Clamp the tubing for a short time, clean the port, and withdraw fresh urine from port with a syringe (never from the bag!).
  • When Needed:
    • To closely track urine output and manage urine in critically ill or very sick patients.
    • When someone has urinary retention that can’t be treated with a one-time (intermittent) catheter because of urinary blockage or neurological disorders.

Urine Specimen Testing

  • Urinalysis:
    • Examination of urine under a microscope or using a dipstick.
    • Screens for infection, kidney issues, diabetes.
  • 24-hour Urine Collection:
    • Discard the first urine void. Collect all urine over 24 hours into an opaque and refrigerated container. Place signage to prevent discarding the urine.
  • Urine Culture & Sensitivity:
    • Done after urinalysis to identify the type of bacteria and determine the best antibiotic.

Care and Monitoring of Catheters

  • Intermittent (Straight) Catheter:
    • Use sterile technique, pre-clean with antiseptic wipes, remove after urine drains, monitor amount, color, or odor.
  • Indwelling (Foley) Catheter:
    • Maintain sterile closed drainage system, ensure drainage bag is below bladder level, secure catheter to thigh, provide catheter care every shift, empty when 2/3 full or every 8 hours.
  • CAUTI Prevention:
    • Use sterile technique, clean patient before inserting catheter, ensure the tape is sealed during draining, clean the drainage port tip with alcohol, and don’t let the spout touch the container.
  • External Catheters:
    • Purewick: Place wick in between labia, connect to low suction, clean the tip with alcohol. Clean every shift and check every 2 hours for skin breakdown. Replace after 8-12 hours and clean the perineal area every 8 hours.
    • Condom Catheter: Roll condom over the penis, attach to drainage bag (below bladder level), ensure it's not too tight, inspect skin daily, and remove at least every 24 hours to clean and inspect.

Signs and Symptoms of Urinary Tract Infection (UTI)

  • Risk Factors:
    • Females (due to location of urethral meatus and anus) and indwelling catheters.
  • Symptoms:
    • Urgency, frequency, pain, fever, flank/suprapubic pain, cloudy or foul-smelling urine, blood-tinged urine.
  • In Older Adults:
    • Changes in mental status, confusion, falls, fatigue, anorexia.
  • Client Education:
    • Drink > 2-3 liters of water per day, complete course of antibiotics, avoid wearing tight-fitting pants, wipe perineum front to back, wear cotton undergarments, urinate after intercourse, avoid bubble baths or powder.

Medication Treatment for UTI

  • Phenazopyridine (Pyridium):
    • Analgesic that relieves pain, burning, or urgency.
    • Can turn urine bright orange or red.
  • Antibiotics (Sulfamethoxazole/Trimethoprim):
    • Kills bacteria causing UTI.

Bowel Elimination

  • Constipation: Hard, dry stool/< 3 bowel movements a day.
    • Management: Increase fluid, fiber, exercise, and toilet regularity at the same time every day.
    • Laxative/stool softening medications and enema administration.
    • Safety: Listen to bowel sounds for obstruction, avoid overuse as it can cause dependency and make constipation worse, encourage fluid intake, teach not to strain as it reduces the risk of vagal stimulation, avoid enemas in patients with recent rectal surgery, severe hemorrhoids, or neutropenia.
Laxatives/Stool Softeners Medications
  • Bulk: Fibercom, Metamucil
  • Emollient (stool softeners): Colace
  • Osmotic: Saline, Milk of Magnesia, Magnesium citrate, Miralax
  • Stimulant: Castor oil, Peri-colace, Senna (Senokot), Ex-Lax
  • Laxative enema: Docusate (Colace)
Enema Administration

  • Left lateral administration (Sims’ position), apply lubricant to the tip of the enema tube, squeeze the liquids and retain it inside until you feel the need to defecate.

  • Diarrhea: Loose, watery stool.

    • Management: Clear liquid or low residue (low fiber) diet.

  • Fecal Incontinence: Not being able to control bowel movements. Management: Provide easy bathroom access such as bedpans or bowel training.

  • Diversions such as Colostomies and Ileostomies.

Medications for Diarrhea
  • Bismuth subsalicylate (Kaopectate)
  • Loperamide (Imodium)
  • Diphenoxylate-atropine (Lomotil)

Risk Factors for Bowel Dysfunction in the Elderly

  • Decreased peristalsis, decreased muscle tone, decreased stomach elasticity and motility, reduced fluid intake, reduced fiber intake, cognitive decline, immobility.

Nutrition Related to Bowel Function

  • To prevent constipation: Increase fiber intake to 25-30g per day, encourage same time toileting each day, increase activity, and drink 2,000-3,000ml fluids a day. Consume whole grains, fresh fruits (with skin), vegetables, and legumes.
  • To manage diarrhea: Consume clear liquids first and avoid dairy temporarily. Consider bananas, plain rice, applesauce, and toast.

Fecal Occult Blood Test (FOBT)

  • To check for blood in stool; collect stool sample, smear stool with a wooden stick on test card, add drops, and if it is blue, blood is present.
  • Note: Avoid red meat, beets, broccoli, and turnips prior to FOBT. Avoid ASA, ibuprofen, and Vitamin C prior.

Pain Assessment and Scales

  • Numeric Rating Scale (0–10): Patient picks a number (subjective).
  • Wong-Baker FACES Scale: Patient picks a face that matches how they feel (subjective).
  • FLACC Scale: Used for babies or people who can't talk; checks Face, Legs, Activity, Cry, Consolability (objective).
  • NIPS Scale: (objective).
  • CRIES Scale: Crying, Requires oxygen for low oxygen levels, Increased vital signs, Expression, and Sleeplessness (objective).
  • PQRST Assessment:
    • P: precipitating/alleviating (what provokes it)
    • Q: quality of pain (dull, sharp, aching)
    • R: region and radiation
    • S: severity (0-10)
    • T: timing (time of pain)

Pain Management

  • Pharmacologic:
    • Non-Opioids:
      • NSAIDs: Aspirin, ibuprofen (up to 2400 mg), ketorolac (Toradol).
      • Acetaminophen (up to 3000 mg); watch for liver damage.
      • Used for mild to moderate pain.
    • Opioids:
      • Morphine, codeine, fentanyl, oxycodone, hydrocodone, hydromorphone, methadone, tramadol.
      • Used for mild to severe pain.
    • Adjuvant Medications:
      • Used together with opioids for neuropathic/chronic pain, potentially decreasing the dose of opioids needed.
      • Anticonvulsants (Gabapentin), Anti-anxiety agents (SSRIs and TCAs), corticosteroids, Botulinum toxin (Botox), cannabis.
  • Non-Pharmacologic:
    • Cutaneous stimulation (heat/cold, massages, acupuncture, transcutaneous electronic stimulation).
    • Cognitive strategies (deep breathing).
    • Therapeutic touch (hugs).

Types of Pain

  • Acute: Sudden, lasts less than 6 months, goes away once cause is treated (e.g., after surgery, broken bones).
  • Chronic: Lasts more than 6 months, even if the injury is healed (e.g., arthritis, migraines).
  • Neuropathic: From diseased or damaged nervous system by diabetes, phantom limb pain, trigeminal neuralgia.
  • Nociceptive: Felt in tissue, organs, skin, joints (e.g., cut, bone break, sore muscles).

Characteristics of Neuropathic vs. Nociceptive Pain

  • Neuropathic Pain: Burning, shooting, electric-like, pins-and-needles feeling.
  • Nociceptive Pain: Aching, throbbing, sharp or dull pain.

Patient-Controlled Analgesia (PCA) Pump

  • A computerized pump that allows the patient to self-administer small, frequent, safe doses of opioid pain medicine by pressing a button.
  • Gives patients control over their own pain.
  • Not for confused patients.
  • Only the patient should push the button.

Medication Management of Pain and Assessments

  • Pain Assessment:
    • Pain is subjective; pain is the 5th vital sign; look for behavioral indicators (facial expressions) and ask about OLDCARTS.
  • Tolerance: Body adapts; higher doses needed over time.
  • Dependence: Body needs the drug to function; withdrawal if stopped.
  • Addiction: Compulsive, inappropriate use, strong craving.
  • Reassess pain 30 minutes to 1 hour after giving oral medication and 15-30 minutes after IV meds.
  • Watch out for respiratory depression, bradypnea, sedation, orthostatic hypotension, constipation, urinary retention, N/V, and itching.
  • Older adults may undermine pain; check for guarding or inability to perform ADLs.