Summary Fundamentals of nursing - Hesi study guide

Fundamentals HESI Study Guide

Vital Signs:
August 22
 Temperature, pulse, respiration, blood pressure, pulse ox
 Temperature: lower in the morning, highest in the evening,
98.6 F-100.4 F, 36-38 C
 Pulses: carotid, brachial, radial, ulnar, femoral, popliteal,
dorsalis pedis, posterior tibial
 Loudest heart sounds heard at apical pulse
 Normal heart rate:
o Infants: 120-160
o Toddler: 90-140
o Adolescent: 60-90
o Adult: 60-100
 Tachycardia vs. bradycardia
o Tachycardia: greater than 100
o Bradycardia: less than 60
 Strength of pulse: 0: absent, 1: weak, 2: normal, 3: full, 4:
bounding
 Amplitude: volume of blood pushed against the wall of an
artery during ventricular contraction
 Ox saturation: usually 95% to 100%
 Systolic: force exerted as left ventricle contracts and pumps
blood into aorta  MAX PRESSURE
 Diastolic: force exerted during ventricular relaxation, when
heart is filling  MINIMUM PRESSURE
 Blood pressure ranges
o Normal: <120, <80
o Prehypertension: 120-139, 80-89
o Stage 1 Hypertension: 140-159, 90-99
o Stage 2 Hypertension: >160, >100
 Blood pressure cuff…
o Too wide: false low
o Too narrow: false high

Patient Safety and Quality:
August 22

,  Fall risk: age, medication, post op, confusion, previous
history, repeated falls, bone fractures, etc.
 Make sure patient is aware of environment  items at reach,
call light, phone, etc.
 Restraint:
o Last resort – try all other options first ** all other
possibilities have been tried and failed, benefits
outweigh the risks
o Behaviors that result: wandering, restlessness,
violence, agitation, pulling out tubes, resisting care
o Alternatives: treat pain, rule out physical causes for
agitation, involve family, reduce stimulation, noise,
light, environmental factors, use therapeutic touch,
discontinue bothersome treatment
o NEED ORDER WITHIN 1 HOUR AFTER APPLICATION
o RENEWED EVERY 24 HOURS
o Only one restraint at a time (physical or chemical – no
two at once)
o REMOVE EVERY 2 HOURS FOR ASSESSMENT AND
NEEDS (skin integrity, ROM, circulation)
 Fire Safety
o RACE
 Rescue, alert, contain, extinguish
o PASS
 Pull, aim, squeeze, sweep

Hygiene:
August 24
 Wash legs from distal to proximal to promote venous return
 Observe skin for warmth, redness, swelling, rashes,
tenderness, pain, etc. while bathing
 Do not massage reddened areas on client’s skin
 Wear gloves when: washing perineum, anal areas, skin
infections, skin not intact, open wounds, draining, oozing
skin, performing oral care
 Female: front to back
 Male: retract foreskin, wash from urethral meatus and
outward, return foreskin to natural position
 Apply lotion  skin barriers especially on pressure points

,  Empty urine drainage bag at least every 8 hours
 Keep catheter bag lower than patient to prevent backflow of
urine
 Condom catheter: check for skin irritation, change in 24
HOURS

Infection Prevention and Control
August 24
 Infectious agent  reservoir  portal of exit  mode of
transmission  portal of entry  susceptible host
 Susceptible host for germs: strength in numbers, impaired
nutritional status, chronic disease, trauma
 Blood borne pathogens: HEP B, HEP C, HIV
 Transmission: accidental injuries (needle pricks, sharps,
blood/fluid splashes), sharing needles, blood and blood
product transfusion, sexual contact
 Universal precaution  treat all patients as if they were
infectious
 Hand hygiene: wash for 15 seconds, GLOVES DO NOT TAKE
PLACE OF HAND HYGIENE
 PPE:
o PUT ON: 1: gown, 2: mask, 3: goggles, 4: gloves
o TAKE OFF: 1: gown, 2: gloves, 3: goggles, 4: mask, 5:
wash hands
 Precautions:
o Airborne
 Mask
 Negative pressure (door shut)
 Common: TB, measles
o Droplet
 Mask
 Gloves
 Common: meningitis, pneumonia, influenza,
rubella
o Contact
 Gown
 Gloves
 Common: MRSA, VRE, lice, major draining wounds,
e-coli

, o Contact (C. Diff)
 Gown
 Gloves
 WASH HANDS  NO HAND SANITIZER
o Airborne/Contact
 Mask
 Gown
 Gloves
 Common: varicella, herpes, SARS, small pox
o Droplet/Contact
 Gown
 Gloves
 Mask
 Common: flu, MRSA, pneumococcus, VRSA, ESBL

Nutrition
August 29
 Digestion: begins in mouth ends in small and large intestine
 Absorption: small intestine is primary site
 Enteral tube feeding:
o Orogastric  mouth to stomach
o Nasogastric  nose to stomach
o Nasointestinal  nose to intestines
o Gastrostomy  stomach tube from outside
o Jejunostomy  intestine tube from outside
 NG Tube: measure from nose to ear lobe to xiphoid process
 NG tube placement: pH of 1 to 4 is good indication
 Continuous feeding: always going
 Intermittent or bolus feeding: nurse gives food at certain
time through tube
 Complications
o Clogged tube: flush 30 mL of water every 4 hours after
checking residual volume, flush  med  flush
o Develops nausea and vomiting: withhold feeding, notify
physician, check patency of tube, aspirate for gastric
residual, for cramping and nausea, decrease the
administration rate
o Gastric residual exceeds normal volume: notify
physician, elevate to at least 30 degrees, reassess