Fundamentals of Nursing

⚡

Practice Test

ATI/NCLEX Style Practice Test · Select a module below to practice. Click answer choices to check. SATA = select all that apply. · Practice test generated by Claude

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This Week

              Module 32 · Elimination  |  18 questions
            

              Module 35 · Hygiene  |  19 questions
            

              Module 37 · Pain  |  20 questions
            

              Module 38 · End of Life Care  |  19 questions
            

              Module 30 · Comfort, Rest & Sleep  |  25 questions
            

              Module 39 · The Surgical Client  |  25 questions
            

              Module 40 · Tissue Integrity  |  34 questions
            

✏️ Quiz Yourself

Select a module · Answer all questions · Submit to see results

This Week

Module 32 — Elimination

📋

Factors Affecting Bowel Elimination

Physiological

Age · Diet · Fluid intake · Physical activity · Pregnancy · Surgery & anesthesia · Pain

Behavioral

Personal habits · Position during defecation · Psychological factors

Medical/Pharmacological

Medications · Diagnostic tests

            ⚠️ Narcotics/opioids slow gastric motility → ↑ constipation risk (high-yield exam point)
          

⚠️

Common Bowel Elimination Problems

Problem	Description	Key Causes / Notes
Constipation	Dry, hard-to-pass stool; sensation of incomplete emptying	Narcotics · Low fiber · Low fluid · Immobility → Tx: high-fiber diet
Paralytic Ileus	Bowel obstruction from lack of intestinal activity	Post-surgery · Anesthesia/meds · Electrolyte imbalance · Infection
Diarrhea	Loose, watery stools	Antibiotics (kill healthy GI flora) · Viral/bacterial infection · IBD · Crohn's · Ulcerative colitis
Flatulence	Abdominal distension from gas	Instruct patient to ambulate to help pass gas · Return-flow enema for post-op flatus
Hemorrhoids	Swollen/inflamed rectal blood vessels → bloody stools, pain with defecation	Causes: pregnancy, heart/liver failure · Tx: ointment, gentle wiping, sitz bath, ice pack
Incontinence	Inability to control bowel movements	Monitor skin integrity; keep area clean and dry

            Diarrhea from antibiotics: Antibiotics eliminate healthy GI bacteria → allows harmful bacteria to grow → diarrhea. Risk factors for persistent diarrhea: frequent infections, large dairy intake, antibiotic use (e.g. cephalexin).
          

👝

Ostomy Types & Care

Types of Ostomies

Colostomy — colon diverted to abdominal wall; stool varies by location
Ileostomy — entire large intestine/rectum removed; small intestine to abdominal surface; can be reversed once colon heals
Types: end stoma · loop colostomy · double-barrel colostomy
Complications: hernia, electrolyte imbalance, blockage, prolapse, diarrhea, infection

Stoma Assessment — Know This!

✅ Normal: moist, shiny, pink or reddish
🚫 Abnormal: blue, purple, dull, dry, or black → report immediately
Red, swollen, tender peristomal skin → pouch may be too tight → need larger opening

Ostomy Care Procedure (Step-by-Step)

Step 1

Hand hygiene → gloves

Step 2 ⚡

Push skin AWAY from sticky area when removing pouch — prevents skin stripping

Step 3

Cleanse stoma and peristomal skin with mild soap/water first → dry completely (moisturizing soap interferes with adherence)

Step 4

Measure stoma → cut opening 0.15–0.3 cm (1/8 in) larger than stoma — if too big → leakage

Step 5

Apply skin barrier and pouch → press seal 30 sec–1 min for adhesion

Step 6 ⚡

Empty bag when ⅓–½ full — waiting until more than ½ full ↑ leakage risk (especially ileostomy — effluent irritates skin)

🍽️ Foods: Odor Control

↑ Odor: Fish, garlic, beans
↓ Odor: Buttermilk, cranberry juice, yogurt
Breath mint in pouch can help

🍽️ Foods: Gas Control

↑ Gas: Beer, carbonated drinks, corn, dairy
↓ Gas: Yogurt, crackers, toast
For loose stools (colostomy): low-fiber foods — rice, noodles, white bread, cheese

            Colostomy irrigation = bowel training to prevent unplanned stool passage → allows client to go without a pouch. Ileostomy can allow colon time to heal and may be reversed.
          

💉

Enemas

Type	How it works	Key Notes
Tap water (hypotonic)	Stimulates evacuation	⚠️ NEVER repeated — risk of water toxicity (fluid shift into interstitial spaces)
Soapsuds	Irritant → promotes peristalsis; pure castile soap in tap water or NS	Use cautiously: older adults & pregnant (↑ risk electrolyte imbalance & mucosa damage)
Normal saline ⭐	Volume stimulates peristalsis	Safest — isotonic, equal osmotic pressure
Low-volume hypertonic	Commercially prepared; draws fluid into colon	⚠️ Not for infants or dehydrated clients
Oil retention ⚡	Lubricates rectum/colon, softens stool	Retain ≥ 30 minutes
Medicated	Contains antibiotics or anthelmintics	Retain 1–3 hours
Return-flow (flush) ⚡	Expels flatus, stimulates peristalsis	Post-op abdominal distension/flatus

Enema Procedure — High-Yield Steps ⚡

Position ⚡

Left lateral (Sims) with right leg flexed forward — allows solution to flow by gravity into sigmoid/descending colon

Solution temp ⚡

Warm the solution — cold → abdominal cramping; too hot → mucosal injury

Insertion depth

Adults: 7.5–10 cm (3–4 in) · Children: 5–7.5 cm (2–3 in)

Bag height

Start at hip level → raise 30–45 cm (12–18 in) above anus

Cramping ⚡

Lower the container to slow flow if client reports cramping or fluid leaks

Lubricate

Always lubricate rectal tube/nozzle before insertion

🔬

Diagnostic Procedures

Fecal Occult Blood Test (FOBT / Guaiac) ⚡

Used to detect blood in stool not visible to eye
Collect specimens from 3 different stools
Blue color on test card = positive for blood
Avoid for 72 hrs before test: red meat, citrus, Vitamin C, poultry, beets, raw vegetables (false positives)
Avoid NSAIDs for 7 days before testing

Stool Culture (parasites & ova)

Transfer stool with wooden tongue depressor to specimen container
Label container with client identifying info
Transport to lab in biohazard bag

NG Tube Placement ⚡

Initial placement verified by X-ray only (auscultation and pH NOT reliable for initial check)
First action: sit client upright before insertion
NG for decompression: post-op bowel obstruction
Coughing + SOB + crackles after NG = possible tube displacement or aspiration

⚡

Exam High-Yield Summary

Enema position

Left lateral, right leg flexed (Sims position)

Safest enema

Normal saline — isotonic

Oil retention enema

Retain ≥ 30 min

Cramping during enema

Lower the container

Normal stoma

Moist, shiny, pink/red

Abnormal stoma

Blue, purple, dull, dry, or black → report!

Empty pouch when

⅓–½ full

Remove skin barrier

Push skin away from barrier (prevents stripping)

NG placement verify

X-ray only for initial verification

Constipation diet

High fiber diet

Narcotics → bowel

↑ constipation (slow gastric motility)

Antibiotics → bowel

Kill healthy GI flora → diarrhea

Return-flow enema

Post-op flatus/distension

FOBT: avoid for 72 hr

Red meat, citrus, Vit C, beets, raw veggies

Bladder irritants

Alcohol, acidic fruits, chocolate, soda, spicy foods

Urinary: UTI untreated

Can progress to pyelonephritis

Indwelling catheter: low output

Check for kinks first

Remove indwelling catheter

Deflate balloon completely first

Clean catch (female)

Wipe front to back

Vitamin K produced in

Large intestine

🛁

Bathing

Purposes of Bathing

Cleanse the body, stimulate circulation, provide relaxation, enhance healing
Removes dirt, sweat, pathogens, dead skin
Opportunity for nurse to assess skin for redness or breakdown
Bed bath is less effective than shower — use only when no other option

Types of Baths

Complete bed bath — client cannot get out of bed
Partial bath — client cannot tolerate complete bath or can do part independently
Therapeutic bath — promotes comfort, soothes itchy skin
CHG (Chlorhexidine gluconate) bath — ICU/high-risk infection clients; does not touch face

Bed Bath Procedure — High-Yield ⚡

Prep ⚡

Raise room temperature before bathing — client loses heat when areas are exposed

Order ⚡

Face first → trunk/upper extremities → lower extremities → perineum (clean to dirty). Ask client to perform what they can.

Stroke direction

Long, firm strokes distal to proximal. Light strokes over lower extremities for clients with DVT history (clot can dislodge)

Eye care ⚡

Clean moist cloth, NO soap, wipe from inner to outer canthus

Privacy

Cover client with bath blanket; expose only the body part being washed; raise room temp; give client choices about bathing preference (older adults)

Delegation

Can delegate bathing to AP — nurse remains responsible for data collection and client care

            Linen changes: Blanket/spread can be reused if not wet or soiled. Change linen when soiled. Diaphoresis (excessive sweating) → frequent linen changes needed → moisture causes skin breakdown.
          

            Special populations: Older adults may resist bathing — determine reason, give choices (not abuse if client refuses, but nurse must address). Hemiplegia: dressing → use unaffected arm first, place on affected side. Undressing → remove unaffected side first.
          

🦷

Oral Hygiene

Key Points ⚡

Decreases infection risk especially pneumonia in long-term care
Brush twice daily for 2 min, soft-bristled toothbrush
Use fluoride mouthwash to promote oral health
Poor oral hygiene → gingivitis (swollen, bleeding gums, metallic taste, yellow stain)
Clean the tongue with toothbrush or tongue scraper
NPO clients still need oral care — bacteria present regardless

Unconscious / High-Risk Clients ⚡

Suction apparatus at bedside to prevent aspiration
Do NOT place fingers in unconscious client's mouth (biting risk)
Position: side-lying, head turned toward nurse (semi-Fowler's or flat) — fluid drains out
Chlorhexidine (CHG) for unconscious clients — prevents microbial build-up
Check for aspiration risk, impaired swallowing, decreased gag reflex

Handwashing ⚡

Effective handwashing → decreases hospital infection rates
Soap and water REQUIRED when: hands visibly soiled, C. difficile, infectious diarrhea
Alcohol-based sanitizer: rub all surfaces for 15–20 seconds until dry
Clean least soiled areas first to reduce infection risk

Denture Care ⚡

Handle with care — very fragile
Remove upper denture: pull down and out; lower: up and out
Use denture cleaner NOT regular toothpaste (damages dentures)
Rinse in tepid/cool water (not hot — warps denture)
Store in cup with cool water to keep moist; label cup with client name

            Gingivitis — Exam scenario: Swollen/bleeding gums, metallic taste, yellow stain, pain when brushing/eating → early periodontal disease. Caused by plaque and tartar build-up from poor oral hygiene.
          

👣

Foot & Nail Care

Standard Foot Care ⚡

Inspect feet daily — check between the toes
Use lukewarm water — dry feet thoroughly especially between toes (prevents fungal infection)
Apply moisturizer to feet — NOT between toes (moisture → infection)
Trim nails straight across, file edges — reduces ingrown toenail risk
Wear clean cotton socks daily; check shoes for rough seams
Do NOT self-treat corns/calluses; do NOT apply heat unless prescribed

Diabetes/PVD — CRITICAL ⚡

Podiatrist or qualified professional must perform foot/nail care for: diabetes mellitus, peripheral vascular disease, immunosuppression
Do NOT soak feet — risk of infection
Do NOT cut nails — file only
Do NOT apply lotion between toes
Risk factors for foot/nail injury: DM + peripheral neuropathy + pale skin + ↓ pedal pulses
Impaired sensation → cannot detect temperature → warm (not hot) water only

Nail Care

Observe size, shape, condition of nails and nail beds; check for cracking, clubbing, fungus
Cuticle forms a barrier to prevent infection — do not cut aggressively
Longer nails conceal more pathogens than shorter nails
Nail care: after bath or after soaking hands in warm soapy water for 10 min

Check facility policy before cutting nails — some require a provider prescription or podiatrist
Epidermis = squamous epithelial cells
Skin contains Langerhans cells that sense and kill pathogens
Enamel = first line of defense protecting teeth from pathogens (hardest substance in body)

🧼

Perineal Care & Skin Integrity

Perineal Care Principles ⚡

Maintains skin integrity, relieves discomfort, prevents infection transmission (especially catheter care)
Cleanse front to back (perineum to rectum) — prevents UTI
Dry thoroughly
Female: cleanse labia → perineum to rectum with clean section of cloth each pass
Male uncircumcised: retract foreskin → clean meatus outward in circular motion → replace foreskin (prevents swelling/circulation issues)
Anus = most contaminated → cleanse last

Skin Integrity & Incontinence ⚡

Urinary incontinence → yeast infection (excessive moisture)
Incontinence → ↑ risk skin breakdown (hips, genitals, buttocks, perineum most affected)
Diaphoresis (moisture) → skin breakdown → frequent linen changes required
Skin = largest organ; first line of defense
Mucous membranes (nose, mouth, respiratory tract) → cilia trap particles preventing body invasion
Bariatric clients: deep skin folds → must assist with hygiene — hard to reach areas

            Eye care: Clean moist cloth, NO soap, inner → outer canthus. Ear care: Rotate end of clean moist washcloth gently into ear canal. Drainage from ear = abnormal → possible ear infection.
          

💇

Hair Care & Shaving

Hair Care

Brush/comb daily — removes tangles, massages scalp, stimulates circulation, distributes natural oils
Soft-bristled brush; wide-toothed comb or pick for tightly curled hair
Consider cultural and personal preferences — ask client about their morning routine preference
Bed rest clients: dry/no-rinse shampoos or shampoo caps
Shampoo from hairline toward neck
Observe for: scalp pressure areas, dandruff, lice (notify provider immediately if lice found)

Shaving ⚡

Bleeding precautions → electric razor only
Soften skin with warm water first
Apply shaving cream or liquid soap; hold skin taut
Move in direction of hair growth; long strokes on face, short strokes on chin/lips
Ask about personal shaving preferences

Cultural Considerations

Discuss religious/cultural preferences before care
Many clients prefer nurse of same gender
Expose only necessary body parts, as briefly as possible

⚡

Exam High-Yield Summary

Enamel

Protects teeth from pathogens — hardest substance in body

Older adults bathing ⚡

Give choices re: bathing preferences to encourage compliance

Handwashing ↓ infections

Effective handwashing decreases hospital infection rates

Oral hygiene — clean tongue

Use toothbrush or tongue scraper to clean tongue during oral care

Incontinence → yeast

Urinary incontinence → yeast infection from excessive moisture

Bariatric → assist

Assist bariatric clients with hygiene — cannot reach skin fold areas

Religious preferences

Discuss client's individual perspective on health/illness and hygiene

Epidermis

Consists of squamous epithelial cells

Soap + water REQUIRED

Visibly soiled hands · C. difficile · Infectious diarrhea

Cuticle

Forms barrier to prevent infection of underlying tissue

Dry between toes ⚡

Completely dry between toes — infections develop in moist areas

Langerhans cells

Found in skin — sense and kill pathogens

Nail trim direction

Trim nails straight across (prevents ingrown nails)

Glaucoma client

Educate client/caregivers about importance of routine dental visits

Fluoride + oral hygiene

Fluoride mouthwash · Brush 2×/day for 2 min · Soft bristle · Poor hygiene → gingivitis

Bed bath vs shower

Bed bath is less effective than shower — use only when necessary

Hemiplegia dressing ⚡

Dress: unaffected arm first → place on affected side. Undress: remove unaffected side first

NPO → oral care

Oral care still needed for NPO clients — bacteria present regardless of eating status

Raise room temp

Raise room temperature when giving a bath (client loses heat)

Chlorhexidine ⚡

Oral care for unconscious clients — prevents microbial build-up

Morning routine ⚡

Ask client about their preferred morning routine order before starting care

Clean least soiled first

Clean least soiled areas first to reduce infection spread (clean to dirty)

Reuse blanket/spread

Blanket and spread can be reused if not wet or soiled

Gingivitis ⚡

Early periodontal disease — swollen/bleeding gums, metallic taste, yellow stain from plaque/tartar

DM foot care ⚡

DM + peripheral neuropathy + pale skin + ↓ pedal pulses = risk for foot/nail injury

Mucous membranes / cilia

Cilia in nose trap particles, preventing them from invading the body

🧠

Pain — The Basics

            ⚡ Pain is subjective. The client's self-report is the most reliable diagnostic indicator of pain. Always believe the client.
          

Key Definitions

Pain threshold — point at which a stimulus causes the client to perceive pain
Pain tolerance — how much of a stimulus the client is willing to accept
Nociceptors — sensory receptors for noxious stimuli; activated by tissue damage, extreme temps, chemicals
IASP definition — "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage"

⚡ Factors That Affect Pain Experience

Age & developmental stage
Fatigue & prior experiences with pain
Genetic sensitivity
Cognitive function
Anxiety & stress
Support systems & coping styles
Culture & religion
Disease severity
Language barriers

            ⚡ Biopsychosocial model: Pain is shaped by Biological (disease severity, inflammation), Psychological (mood, stress, catastrophizing), and Social (culture, support, SES) factors.
          

📋

Types of Pain

By Duration

Acute pain — sudden or slow onset; anticipated/predictable end; lasts <6 months. Examples: surgical incisions, trauma, burns.
Chronic pain — constant or recurring; lasts >6 months; no predictable end. Examples: arthritis, back pain, headaches. Can be physically and emotionally debilitating.
⚡ If acute pain is not treated, it can become chronic.

By Origin

Nociceptive — felt in tissues, organs, or as referred pain. Usually localized, throbbing, or aching. Subtypes: somatic (skin/bones/muscles), visceral (internal organs).
Neuropathic — nerve pain from somatosensory system; no tissue damage. Described as intense, shooting, or burning; "pins and needles." Examples: diabetic neuropathy, phantom limb, spinal cord injury.
Cancer pain — newly recognized separate category; includes tumor pain, bone pain, radiation-induced pain, chemo-related neuropathies.

            ⚡ Nociceptive vs. Neuropathic: Medications that work for nociceptive pain are NOT effective for neuropathic pain — different treatment is needed.
          

🔍

Pain Assessment

Subjective vs. Objective

Subjective — client's self-report: pain scale score, location, quality, timing, what precipitates/relieves it
Objective ⚡ — what the nurse observes: grimacing, guarding, restlessness, diaphoresis, crying
⚡ Sweating (diaphoresis) = classic objective pain indicator
For nonverbal/cognitively impaired clients → observe behavior (guarding, grimacing, restlessness, behavioral changes)

⚡ PQRST Mnemonic

P — Precipitating cause: "What were you doing when it started?"
Q — Quality: "Describe what it feels like." (stabbing, burning, dull, throbbing)
R — Region/Location: "Can you point to where it hurts?" ⚡
S — Severity: "Rate it 0–10."
T — Timing: "When did it start? Is it constant or does it come and go?"

⚡ Special Population — Cognitively Impaired / Nonverbal Clients

Observe behavior ⚡

Guarding, grimacing, restlessness, agitation, behavioral changes

Objective signs ⚡

Grimacing, restlessness, increased diaphoresis

Use FLACC or NVPS

Select scale appropriate for cognitive ability — never assume no pain

Older adults ⚡

At risk for under-treatment. May under-report. Nurses must proactively assess.

            ⚡ Influencing factors: Client risk factors, medication trends (especially respiratory rate trending down = too much opioid), anxiety (can mimic pain — assess carefully), cultural/language differences.
          

📊

Pain Scales

Numeric Rating Scale (NRS) ⚡

0–10 scale. Most frequently used. Reliable for clients ≥8 years. 0=no pain, 1–3=mild, 4–6=moderate, 7–10=severe. Most used for cancer pain.

Wong-Baker FACES ⚡

For children ≥3 years. Client selects face. Three-in-one scale (faces + words + numbers). Client rates own pain only — not observer-rated.

FLACC Scale ⚡

For 2 months–7 years AND cognitively disabled adults. Observational. 5 categories scored 0–2: Face, Legs, Activity, Cry, Consolability. Total 0–10.

CRIES Scale

For neonates ≥38 weeks gestation. Crying, Requires O₂, Increased vital signs, Expression, Sleeplessness. Score >4 = further assessment. Score ≥6 = give analgesics.

Nonverbal Pain Scale (NVPS)

For clients who cannot verbalize pain — ICU, sedated, mechanically ventilated. Originally for burn units.

Visual Analog Scale (VAS)

Client marks a point on a line representing pain intensity. Useful when language barrier exists.

            ⚡ Choose the scale based on the client's age, cognitive ability, and communication capacity. Use cultural considerations when evaluating effectiveness.
          

🌿

Non-Pharmacological Interventions

Cutaneous Stimulation ⚡

Heat therapy ⚡ — muscular pain, backache, menstrual discomfort. Apply max 20 min with at least 20-min break.
Cold therapy — decreases swelling (orthopedic injuries, sprains). Apply 20–30 min, check skin frequently.
TENS unit ⚡ — delivers low-voltage electrical impulses to skin. Adjustable intensity, pulse rate, duration. Client can be taught to use at home.
Massage — decreases pain scores; can use aromatherapy oils (check allergies first; sit up slowly after — orthostatic hypotension risk)
Acupuncture — sterile needles into skin; stimulates CNS. No contraindications generally. Must be performed by experienced acupuncturist.
Acupressure — similar to acupuncture without needles

Cognitive / Other Strategies

Cognitive Behavioral Therapy (CBT) — manages negative thoughts; includes distraction, relaxation, imagery, music therapy
Distraction ⚡ — TV, virtual reality; effective in children for IM injections
Music therapy — effective intraoperatively and postoperatively for reducing pain
Biofeedback ⚡ — measures skin tension using electrode sensors; teaches client techniques to control migraines and other pain
Therapeutic touch — nurse uses hands on or near body to balance energy; may help cancer/fibromyalgia
Positioning — reposition every 2 hrs; pad bony prominences (coccyx, sacrum, heels, scapula)

            ⚡ Mild pain (0–3): Ice packs + ibuprofen + distraction. Non-pharm can be used alone for chronic pain or combined with pharm for acute pain. After oral oxycodone — peak effect in 60–90 min; offer non-pharm while waiting.
          

💊

Pharmacological Interventions

Opioids ⚡

Most common pain medications; activate opioid receptors in brain/spinal cord/CNS
Natural: codeine, morphine. Semisynthetic: oxycodone, hydrocodone, hydromorphone, heroin. Synthetic: fentanyl, tramadol
Key adverse effects: sedation, respiratory depression, orthostatic hypotension, nausea/vomiting, constipation
⚡ Monitor: respiratory rate, depth, HR, BP, oxygen saturation, capnography (CO₂)
⚡ Highest risk: first 4 hrs post-op; monitor closely for 24 hrs
⚡ Naloxone — opioid reversal agent for respiratory depression; have available at bedside

Non-Opioids & Adjuvants

NSAIDs (ibuprofen, aspirin, ketorolac) — most prescribed worldwide; effective for acute and chronic pain; reduce inflammation and fever. Contraindicated in surgery and labor.
Acetaminophen — nonopioid analgesic
Adjuvants — address underlying pain generators; used for mild pain, neuropathic pain, or to ↓ opioid dosage. Examples: corticosteroids (↑ glucose, fluid retention), antidepressants (nerve/migraine/arthritis pain — takes weeks to work), botulinum toxin
Gabapentin — anticonvulsant used for chronic pain; fewer side effects than carbamazepine
Sucrose — for infant pain during painful procedures

⚡ PCA Pump

Patient-controlled analgesia — client controls small bolus doses via button
Only RN programs and starts PCA pump; verifies settings
Monitor for OIVI: respiratory rate + capnography + pulse oximetry
Have naloxone at bedside

⚡ Range Orders

Start with the lowest dose when client is opioid-naïve or has never taken the medication
If first dose ineffective, increase incrementally up to maximum in range
Cannot split dose or give more frequently than prescribed — that is prescribing, outside scope of practice
Wait for medication to peak before reassessing and giving more
⚡ Naloxone is NOT an analgesic — it is an opioid antagonist; giving it to an opioid-dependent client causes severe withdrawal

            ⚡ Nursing priorities: Administer pain meds before painful procedures. Use scheduled dosing for persistent pain + PRN for flare-ups. Advise clients to report pain early — before it peaks. Reassess after every intervention.
          

⚖️

Legal, Ethical & End-of-Life

⚡ Legal Principles

Negligence ⚡ — failing to perform as a reasonable, prudent person. Forgetting to assess/administer prescribed pain medication = negligence.
Malpractice — negligent act by a professional
Opioids must be stored in locked cabinet, in original packaging, away from children
⚡ Advise client to keep a pain diary to track effectiveness of interventions

⚡ Ethical Principles

Beneficence — do good; relieve suffering
Nonmaleficence — do no harm; untreated pain = harm
Autonomy ⚡ — client's right of self-determination; offering IM vs. oral medication = example of autonomy
Justice ⚡ — treat all clients fairly regardless of age, ethnicity, or substance use history

⚡ End-of-Life Pain Management

Every client has the right to effective pain management as a basic human right — even at end of life
⚡ Barriers to EOL pain management:
- Fear of addiction (client/family)
- Belief that pain is "expected" part of illness
- Inadequate pain assessment
- Language barriers, nurse assumptions
- Health system: cost, lack of coverage, shortage of palliative providers
ASPMN + HPNA joint position statement: effective pain management = basic human right

⚡

Exam High-Yield Hits

Pain is subjective ⚡

Client's self-report = most reliable diagnostic tool. Always believe the client.

FLACC used for ⚡

Children 2 months–7 years AND cognitively disabled. Face, Legs, Activity, Cry, Consolability — scored 0–2 each, total 0–10.

Heat therapy time ⚡

Max 20 minutes with at least 20-min break. Used for muscular pain, backache, menstrual pain.

Factors affecting pain ⚡

Stress, culture, social support, disease severity, age, fatigue, anxiety, prior experiences, language barriers

Cognitively impaired ⚡

Observe for grimacing, guarding, restlessness, diaphoresis. Cannot self-report — use behavioral observation.

TENS unit ⚡

Low-voltage electrical impulses to skin. Adjustable intensity/pulse rate/duration. Client can learn to use at home.

OIVI monitoring ⚡

Respiratory rate + capnography (CO₂) + pulse oximetry. First 4 hrs post-op = highest risk.

Naloxone ⚡

Reversal agent for opioid-induced respiratory depression. Keep at bedside for PCA clients. NOT an analgesic — causes withdrawal in opioid-dependent clients.

Range orders ⚡

Opioid-naïve = start lowest dose. Wait for peak before reassessing. Cannot change frequency — that's prescribing.

Negligence ⚡

Forgetting to assess and administer prescribed pain medication = negligence. Reasonable prudent person standard.

Objective pain signs ⚡

Diaphoresis (sweating) = objective. Grimacing, guarding, restlessness = objective. Pain scale score = subjective.

Autonomy example ⚡

Offering client choice of IM vs. oral medication = autonomy (right of self-determination).

Justice ⚡

All clients treated fairly for pain regardless of age, ethnicity, substance use history, or economics.

EOL barriers ⚡

Fear of addiction, belief pain is expected, inadequate assessment. Every client has RIGHT to effective pain management.

Neuropathic pain ⚡

Burning, shooting, intense. Diabetic neuropathy, phantom limb, spinal cord injury. Different meds than nociceptive pain.

PQRST — R ⚡

"R" = Region/Location. "Can you point to where you are having your pain?" Ask this to assess region.

Biofeedback ⚡

Uses electrode sensors to measure skin tension; teaches client techniques to relieve migraines/chronic pain.

Breakthrough pain ⚡

Control pain BEFORE it peaks. Advise clients to report pain as soon as they feel it — don't wait.

Older adults ⚡

Risk of under-treatment AND adverse effects from analgesics. Proactively assess — they may under-report.

Pain diary

Encourage client to track pain ratings before and after interventions to evaluate effectiveness over time.

Chronic pain >6 months

Constant or recurring. Arthritis, back pain, headaches. Managed — not cured. Anticonvulsants (gabapentin) often used.

Cutaneous stimulation ⚡

TENS unit, massage, acupuncture, cold therapy = all forms. Used for cutaneous/nonpharm pain relief.

Mild pain intervention ⚡

Pain rated 3/10 → ibuprofen + ice packs + distraction. Non-pharm first line for mild pain.

Oxycodone peak ⚡

Oral oxycodone peaks in 60–90 min. Offer non-pharm strategies while waiting — do not re-dose early.

Culture & pain ⚡

Culture affects reporting and perception. Language barriers → use FACES or VAS scales. Religious beliefs may affect response.

Respiratory depression risk ⚡

Highest in first 4 hrs post-op with IV opioids. Monitor RR, O₂ sat, capnography. Have naloxone ready.

🏠

Hospice Care

            Hospice care = comfort, dignity, and support for clients with terminal illness when treatment will no longer cure or control the disease. Focus is quality of life, not prolonging it.
          

⚡ Admission Criteria

Life expectancy of 6 months or less
Both the hospice provider and primary care provider must officially state the client is terminally ill ⚡
Client must agree to palliative care (not curative treatment) ⚡
Client signs a statement choosing hospice in place of curative treatment ⚡
If client lives beyond 6 months → hospice provider must recertify
Client can stop hospice at any time (condition improves, remission)

⚡ Interdisciplinary Team (IDG)

Hospice care = interdisciplinary team effort ⚡ — providers, nurses, social workers, spiritual leaders
Holistic: physical, mental, social, and spiritual needs
Volunteers must account for 5% of total patient care hours
Volunteers: housekeeping, transport, childcare, sitting with client, reading, music
Nursing: medication administration, ADLs, education, emotional support
Respite care — brief break for caregivers; client admitted to facility for max 5 days

            ⚡ Nursing support in hospice: Assist with medication administration and ADLs · Educate family on what to expect as condition deteriorates · Provide emotional support · Bereavement support for up to 13 months after client's death.
          

💙

Palliative Care

What It Is

Holistic care for clients with severe medical illness — any age, any stage ⚡
Uses a holistic approach — treats whole person: physical and psychosocial ⚡
Improves quality of life, reduces hospital time, improves client satisfaction ⚡
Interprofessional team: providers, nurses, allied health
Examples: advanced cancer, heart failure, renal/respiratory failure, Alzheimer's, Parkinson's

⚡ Palliative vs. Hospice

Palliative care CAN be given while still receiving curative treatment ⚡
Palliative care has NO time constraints — can start at any stage ⚡
Hospice = curative treatment stopped; life expectancy ≤6 months
Any client with a life-limiting disease can receive palliative care regardless of prognosis

⚡ Pain: 3-Step Ladder

Step 1 — Mild pain: NSAIDs (nonopioids)
Step 2 — Moderate: codeine or tramadol
Step 3 — Severe: morphine
Combination of scheduled + PRN + non-pharm is recommended ⚡

🫁

Physiological Changes While Actively Dying

Cheyne-Stokes Respirations ⚡

Irregular breathing — rapid shallow breaths → deep breaths → apnea. Occurs within 3 days of death. Educate family it is expected. Intervention: fan blowing lightly toward client.

Death Rattle ⚡

Noisy respirations from secretion accumulation. Client cannot clear secretions themselves ⚡. Indication of approaching death ⚡. Interventions: turn head/body to side for drainage ⚡ · atropine drops or scopolamine patch to dry secretions ⚡ · moist washcloth / oral suction. Deep suctioning is ineffective.

Dyspnea ⚡

Shortness of breath. First-line Rx: opioids (morphine) — vasodilate, reduce breathing difficulty, decrease anxiety. Also: oxygen therapy, fan, positioning, relaxation, anxiolytics (benzodiazepines).

Mottling ⚡

Purple, pale, or grey marbling of skin ⚡ — starts in feet, moves up legs. Heart cannot pump blood effectively. Indication of impending death. Client feels no discomfort but may feel cold. Intervention: warm blankets.

Hallucinations ⚡

Seeing/hearing deceased family members or places. Do NOT contradict or reorient — causes distress. Clients can still hear even in coma — talk to them, provide reassurance. Priority: ensure client safety and prevent injury ⚡.

Temperature Changes

Nervous system loses ability to regulate temp. Causes: infection, cancer, opioids, anxiety, hypoxia. Management: cold/hot compresses, warm sponge baths, hypothermia blankets, fan, antipyretics (acetaminophen, ibuprofen, naproxen, aspirin).

            ⚡ Family education is key for ALL respiratory changes. Educate the family about expected changes — this is consistently tested. For noisy respirations: head/body to side, medications to dry secretions, cannot clear secretions themselves.
          

✝️

Spiritual, Cultural & Dignity Care

Spirituality ⚡

Spirituality = significance and purpose of life ⚡; relationship with others, nature, and higher power
Religion = specific beliefs/values shared within a community in worship of a higher power — NOT the same as spirituality
Spiritual care: ask if client desires spiritual care before offering it
In-depth spiritual counseling → refer to spiritual leaders/chaplain, not nurse
Benefits: improved quality of life, better coping, prevents depression/hopelessness
"Good death" — determine the client's own definition ⚡

Cultural Competence ⚡

In some cultures, talking about impending death is culturally insensitive ⚡ — understand culture before discussing prognosis
Language barrier → use health care facility's interpreter services ⚡ (NOT family members, NOT housekeeping, NOT apps unless employer-authorized)
Many cultures distrust opioids — educate on myths (opioids ≠ euthanasia, not addictive in dying context, can be increased)
Religion/culture affects pain management decisions and end-of-life preferences

Dignity & Social Isolation ⚡

Ask: "What can I do to help you feel more independent?" ⚡
Involve client in decision-making — preserves control and dignity
Social isolation → schedule visitors when pain and symptoms are controlled
Assist isolated clients: schedule family visits ⚡, online support groups, hospice volunteers

📋

Postmortem Care & Organ Donation

⚡ Postmortem Care

Physical care of body after death: washing, ID tags (min 2 locations: toe, arm, outside body bag), securing belongings
Nurse documents ⚡: date and time of death · name of anyone notified · location of belongings · where body is moved (e.g., funeral home)
Removal of invasive devices (IV, urinary catheter) — per facility policy
Provides nurse with opportunity for closure

⚡ Organ/Tissue Donation

Nurses providing direct care cannot initiate organ donation dialogue ⚡ — conflict of interest
When family/client voluntarily requests donation → nurse makes referral to Organ Procurement Organization (OPO) ⚡
OPC (coordinator) meets with client/family, answers questions
Nurse role: facilitate meeting, evaluate cultural/religious beliefs, allow time for family feelings, provide accurate information, use chaplain if needed
Donation is voluntary — donor must authorize before death or surrogate gives permission

🩺

Managing Nurse Grief & Self-Care

Grief Manifestations in Nurses

Physical: chest tightness, muscle discomfort, headaches, sleep disturbances, GI problems, palpitations
Psychological: anger, irritation, sadness, sleeplessness, exhaustion, difficulty concentrating, altered eating

⚡ Self-Care Strategies

Exercise program ⚡ (tested answer)
Eat well-balanced meals
Set boundaries, take time for oneself
Talk to experienced nurses / seek professional help
Attend the client's funeral (provides closure)
Journal feelings, discover a new hobby
Establish sleep routine (6–8 hours)

⚡

Exam High-Yield Hits

Hospice admission ⚡

Life expectancy ≤6 months. Both hospice provider AND PCP must certify terminal illness. Client agrees to palliative (not curative) care.

Hospice = IDT ⚡

Interdisciplinary team effort — providers, nurses, social workers, spiritual leaders. Holistic care.

Palliative = holistic ⚡

Uses a holistic approach. Improves quality of life. Can be given WITH curative treatment. No time constraints.

Palliative vs Hospice ⚡

Palliative: curative treatment still OK, any prognosis. Hospice: curative stopped, ≤6 months prognosis.

Death rattle ⚡

Client CANNOT clear secretions themselves. Turn head/body to side. Atropine drops or scopolamine patch. Indication of approaching death. Deep suction = ineffective.

Noisy respirations ⚡

Educate family about expected respiratory changes. Not a sign of distress in the client.

Cheyne-Stokes ⚡

Rapid breaths → deep breaths → apnea. Within 3 days of death. Expected and normal — educate family. Fan helps.

Mottling ⚡

Purple/grey marbling of skin. Starts in feet, moves up legs. Impending death sign. No client discomfort. Warm blankets.

Hallucinations ⚡

Do NOT contradict or reorient. Ensure client safety and prevent injury. Client can still hear in coma — talk to them.

Good death ⚡

Determine the CLIENT's own definition of a "good death." Do not impose nurse's definition.

Culture & death ⚡

Some cultures: talking about impending death is culturally insensitive. Understand culture before discussing prognosis.

Language barrier ⚡

Use facility's official interpreter services. NOT family members, NOT housekeeping, NOT unauthorized apps.

Organ donation ⚡

Nurse CANNOT initiate donation dialogue (conflict of interest). Family requests → refer to OPO (organ procurement organization).

Postmortem documentation ⚡

Document: date/time of death · who was notified · where body is moved · belongings accounted for.

Dignified care ⚡

"What can I do to help you feel more independent?" Involve client in decisions. Ask about their preferences.

Social isolation ⚡

Assist in scheduling family/friends to visit. Schedule when symptoms/pain are controlled for best interaction.

Spirituality ⚡

Focuses on significance and purpose of life. Ask if client DESIRES spiritual care before offering. Chaplain for in-depth counseling.

Nurse grief ⚡

Participate in exercise program. Talk to experienced nurses. Attend funeral. Journal. Sleep routine. Set boundaries.

Respite care

Brief caregiver break. Client admitted to facility max 5 days. Provides rest for caregivers.

Pain in EOL ⚡

Combination of approaches recommended: scheduled + PRN + non-pharm. 3-step ladder: NSAIDs → codeine/tramadol → morphine.

Dyspnea Rx

First choice: opioids (morphine). Also: O₂, fan, positioning, benzodiazepines for anxiety. Comfort focus.

Bereavement support

Hospice provides support for up to 13 months after client's death for family/caregivers.

Nurse cannot initiate

Nurse CANNOT start organ donation conversation. Must wait for family to voluntarily bring it up, then refer to OPO.

Postmortem ID tags

Minimum 2 locations: toe, arm, outside of body bag.

Volunteers 5%

CMS requires hospice volunteers account for 5% of total patient care hours provided by paid staff.

🌙

Sleep Physiology & Stages

            Two mechanisms regulate sleep: Circadian Rhythm — internal 24-hr clock synced to light/dark via the SCN in the hypothalamus  ·  Sleep–Wake Homeostasis — pressure to sleep increases the longer you are awake.
          

🎯 High-Yield Brain Structures

Hypothalamus / SCN

Controls circadian rhythm via light exposure. Damaged SCN → erratic sleep.

Pineal Gland

Produces melatonin — the sleep hormone. First-line Rx for all ages.

Thalamus

Relays senses to cortex. Transmits images/sounds during REM → dreams.

Brainstem (Pons)

Sends signals for REM. Relaxes muscles so you don't act out dreams.

🎯 Sleep Stages — Most-Tested

Stage	Type	% of Sleep	Key Facts
Wake	NREM	—	Alpha (8–12 Hz) & Beta (12–30 Hz) waves. Eyes closed, relaxed.
Stage 1	NREM	~5%	Lightest sleep. Easily awakened. Lasts 1–5 min. Muscle twitching possible.
Stage 2	NREM	~50%	Sleep spindles & K-complexes. HR & temp decrease. Older adults spend MORE time here → frequent waking.
Stage 3 ⭐	NREM	~15%	Deepest sleep. Delta waves. Immune system strengthens. Muscles/tissues/bones repair. Awakening → mental cloudiness 30–60 min. Lowest pulse & RR.
REM ⭐	REM	20–25%	Dreaming stage. Beta waves (looks awake on EEG). Muscles atonic (can't act out dreams). Irregular breathing, elevated HR. Begins ~90 min after sleep onset. Older adults have fewer REM cycles.

            Older Adults: ↑ Stage 2 (lighter sleep → frequent waking) · ↓ Stage 3 · ↓ REM · Takes longer to fall asleep.
          

⚠️ Sleep Deprivation Effects

Impaired judgment & ↓ response time

Triggers migraines, seizures

↑ Risk: depression, stroke, obesity

Poorly controlled blood sugars (T2DM)

Shift workers: ↑ DM, obesity, CVD

Smartphone use at night → depression

            Sleep & Weight: Sleep ↑ leptin (reduces hunger) & ↓ ghrelin (hunger hormone). Sleep also ↓ cortisol → better insulin sensitivity → prevents T2DM.
          

⚠️

Sleep Disorders

Insomnia

Ongoing inability to sleep despite opportunity. Difficulty falling/staying asleep or early waking. Associated with heart disease, hypertension, arthritis. Tx: CBT, medications, lifestyle changes.

OSA ⭐

Obstructive Sleep Apnea — recurrent upper airway collapse during sleep. Risk factors: obesity, inactive tongue, enlarged tonsils. Dx: polysomnography. Tx: CPAP (first-line). Symptoms: snoring, daytime sleepiness, fatigue.

CSA ⭐

Central Sleep Apnea — brain fails to send signals to respiratory muscles → breathing stops. Causes: opioid overdose & heart failure. (CSA ≠ OSA — no airway obstruction.)

Narcolepsy ⭐

Sudden uncontrollable sleepiness. NT1 = with cataplexy (brief involuntary muscle tone loss triggered by emotion/laughter) + lacks hypocretin (alertness hormone from hypothalamus). NT2 = without cataplexy. Both: nocturnal hallucinations, sleep paralysis, vivid dreams.

Hypersomnia ⭐

Excessive daytime fatigue that does NOT improve with more sleep (key differentiator). Not from disturbed circadian rhythm. Sx: poor memory, depression, short attention span, irritability.

RLS

Uncontrollable urge to move legs. Worsens at rest/bedtime. Also called Willis-Ekbom disease. Can occur with iron/vitamin deficiencies. Avoid caffeine, nicotine, alcohol.

Night Terrors

Occur during NREM (first ⅓ of night). No dream recall. Mostly in children. Don't wake the child — gently return to bed. Differs from nightmares (REM, dream recalled, second half of night).

            OSA Dx = Polysomnography — records HR, BP, breathing, O₂ sat, brain waves, body movements, snoring. Done in a sleep lab. (Not ECG, not EEG alone.)
          

💊

Nursing Interventions for Sleep

💊 Pharmacologic — Know Adverse Effects

Class	Examples	Key Adverse Effects / Notes
Nonbenzodiazepine hypnotics ⭐	Zolpidem, Zaleplon, Eszopiclone (z-drugs)	Most commonly prescribed. Monitor for hallucinations, gastric discomfort, memory loss. Abuse potential.
Benzodiazepines (GABA agonists)	Alprazolam, Clonazepam, Lorazepam	Retrograde amnesia, drowsiness, muscle relaxation. Use cautiously in older adults (↓ liver/kidney). NOT for long-term use — physical dependence.
Melatonin ⭐	Controlled-release melatonin	First-line for older adults & all ages. Non-habit forming, cost-effective, few adverse effects.
OTC (Antihistamines)	Doxylamine, Diphenhydramine	Urinary retention, dry mouth, daytime drowsiness, visual disturbances, constipation.

🌿 Nonpharmacologic Interventions

Dim lights at bedtime ⭐

Acupuncture & thermotherapy ⭐

Massage (caution: anticoagulants, open wounds)

Guided imagery, meditation, music therapy

Yoga — reduces stress & pain

Sleep diary — identify patterns

🏥 Hospital Sleep Promotion (Sensory Overload Prevention)

Dim lights at night

Lower alarm volumes

Offer blindfolds & earplugs

Cluster/combine care tasks

Organize quiet time

Control pain & monitor meds

            Sleep Hygiene Rules (Exam staples): Avoid caffeine/alcohol/nicotine 4–6 hrs before bed · Keep naps <30 min · Go to another room if not asleep in ~20 min (read/soft music) · Exercise ≥3 hrs before bed · Cool, dark, quiet room · Consistent sleep–wake time.
          

🤝

Promoting Comfort

            Comfort = Easing physical, mental, and emotional distress using warmth, empathy, and compassion. A comforted client feels safe, accepted, valued, and stronger.
          

🎯 Nursing Actions to Promote Comfort

Encourage verbalization of needs/concerns ⭐

Answer questions honestly ⭐

Include client concerns in plan of care

Respect cultural & spiritual beliefs

Be present — active listening

Allow informed choices — client feels in control

            Client is comforted when they say: "My health care team has helped me feel safe during my stay." — feeling safe, accepted, and valued = comfort achieved. PN Nursing Process: Data collection → Planning → Implementation → Evaluation.
          

⚡

Exam High-Yield Summary

Stage 3 sleep

Deepest — immune repair, delta waves, mental cloudiness if awakened

REM sleep

Dreaming, muscle atonia, beta waves, begins ~90 min after sleep onset

Older adults

↑ Stage 2, ↓ Stage 3, ↓ REM → melatonin first-line

Hypersomnia key

Fatigue does NOT improve with more sleep

Narcolepsy NT1

Cataplexy + no hypocretin; NT2 = no cataplexy

OSA dx

Recurrent airway collapse → polysomnography; Tx = CPAP

CSA causes

Opioids or heart failure (brain fails to signal muscles)

Night terrors

NREM, no recall, first ⅓ of night — do NOT wake child

Z-drugs adverse effect

Hallucinations; benzos → retrograde amnesia; OTC → urinary retention

Melatonin

First-line for older adults — non-habit forming

Sleep hormones

Sleep ↑ leptin, ↓ ghrelin, ↓ cortisol → prevents T2DM

Hospital sleep

Dim lights, earplugs, cluster care, lower alarms

RLS

Crawling sensation in legs, worsens at rest, improves with movement (Willis-Ekbom)

Sleep deprivation

Triggers migraines, seizures, ↑ depression, stroke, poorly controlled blood glucose

Shift work risks

↑ T2DM, cardiovascular disease, depression; immune function weakened

Stage 2 sleep

~50% of sleep; sleep spindles & K-complexes; older adults spend more time here

Comfort definition

Easing physical, mental, emotional distress — client feels safe, accepted, valued

📋

Preoperative Phase

            Pre-op begins when client decides to have surgery → ends when transferred to surgical suite. Goals: establish baseline, identify risk factors, obtain consent, educate client.
          

🎯 Health History — What to Collect

Allergies

Apply allergy band. Report to team.

Medications

All Rx, OTC, herbals. Anticoagulants may need to stop.

Tobacco/Alcohol

↑ risk: blood clots, MI, bleeding, infection, longer stay.

Spiritual/Cultural

Document preferences. Affects consent and care.

Malignant Hyperthermia Hx

Family hx → notify intraop team. Life-threatening rxn to anesthesia meds.

Surgical Hx

Prior anesthesia response, complications.

⚖️ Risk Factors for Surgical Complications

Risk Factor	Why It Matters
Type 1 & 2 DM	Poor wound healing, infection risk
Smoking	↑ blood clots, slower healing, ↑ infection
Corticosteroids	Impair wound healing, ↑ dehiscence risk
Age ≥65	↑ delirium, POCD, comorbidities
Obesity (BMI >30)	DVT/PE risk, difficult intubation, ↓ O₂
Anticholinergics + Dementia	↑ postoperative delirium

📝 Informed Consent — Roles

Provider's Role

Explains procedure, risks, benefits, alternatives. Obtains consent. If client has questions → contact the doctor.

Nurse's Role ⭐

Verify signature · Confirm legal age · Confirm competence. Witness only — does not obtain consent.

✅ Who CAN Sign · ✗ Who CANNOT

✓ Alert & oriented adults
✓ Emancipated minors (married or pregnant by choice)
✓ History of mental illness does NOT prevent consent
✓ Implied consent — doctor only, unconscious emergency, no family/contact available

✗ Sedated or medicated clients
✗ Unconscious (unless implied consent applies)
✗ Non-emancipated minors
✗ Client can change their mind at any point

            Pregnancy Testing Pre-Op: Required if LMP > 3–4 weeks ago or client requests it. Refusal is allowed — document it. Also document: allergies including latex and environmental allergens.
          

            Pre-Op Teaching reduces hospital stay length. Topics: NPO timing, skin prep, med cessation, what to expect post-op, incentive spirometry, coughing/deep breathing, splinting, early ambulation.
          

🔪

Intraoperative Phase

🎯 Surgical Team Roles

Circulating Nurse

Coordinates care before/during/after procedure. Verifies ID, checks consent, allergy check, initiates time-out, maintains sterility for sterile team, documents care.

CST — Certified Surgical Technologist ⭐

Ensures instruments are sterile and ready. Hands tools to surgeon. Counts sponges, instruments, sharps. AKA "scrub tech."

Anesthesiologist / CRNA

Administers anesthesia, monitors cardiovascular and respiratory function throughout.

⏱️ Time-Out ⭐

            Performed several times: before starting · before each additional procedure · at completion. Purpose: correct client, correct site, correct procedure. Initiated by circulating nurse.
          

💉 Anesthesia Types

Type	What It Does	Examples
Local	Small area, client awake	Lidocaine, benzocaine
Regional ⭐	Temp loss of feeling in one area, client awake or sedated. Arm, leg, abd sx.	Spinal/epidural block
General	CNS depressed, unconscious. CV and respiratory monitoring required.	—
Moderate Sedation	Drowsy, pain-free, arousable, follows commands. No breathing support needed.	Diazepam, lorazepam, midazolam

🧼 Skin Prep Sequence ⭐

1 Circular scrub, center first

2 Move outward from center

3 Discard sponge at outer edge

4 Repeat with new sponge

5 Drape the client

🔥 Malignant Hyperthermia ⭐

Life-threatening reaction to anesthesia. Triggered by: succinylcholine and volatile anesthetics (sevoflurane).
Early signs: muscle rigidity, jaw rigidity, tachycardia, tachypnea, ↑CO₂
Late signs: high fever, acidosis, hyperkalemia, dysrhythmias
Treatment: Stop triggering agent → Dantrolene → cooling measures → O₂ → correct acidosis

🛏️

Postoperative Phase

            PACU Priority = ABCs. Monitor: O₂ sat (priority), airway, vitals, LOC, wound, pain, I&O.
          

✅ Post-Op Nursing Interventions

Incentive spirometry — 10×/hr, hold 3–5 sec. Prevents atelectasis.

Cough & deep breathe q2h. Splint incision with pillow.

Early ambulation — prevents atelectasis, PNA, DVT.

Reposition q1h — prevents clots, muscle weakness, lung infection.

SCDs while in bed — VTE prevention.

Sit upright to eat — prevents aspiration.

💊 Pain Management

Multimodal Approach

Combines opioids, NSAIDs, nonpharm methods to minimize opioid doses and side effects.

PCA Pump

Client self-administers IV pain med via button. Includes constant flow and/or PRN dosing.

Include client preferences ⭐

Ask what works. Review past analgesic responses. Include nonpharmacological options.

Nonpharm

Music therapy, distraction, breathing, heat/cold, repositioning.

💧 Fluid Imbalances

Hypovolemia

Causes: blood loss, NPO, anesthesia
Signs: hypotension, tachycardia, oliguria

Hypervolemia ⭐

Causes: CHF, renal failure, excess IV fluids
Signs: crackles, edema, hypertension

⚠️

Post-Op Complications

DVT / PE ⭐

DVT: clot in deep vein (extremities) → pain, redness, swelling, warmth. PE: clot travels to lungs → sudden chest pain + SOB + tachycardia. Prevention: SCDs, early ambulation, LMWH/warfarin.

Atelectasis

Collapsed alveoli from anesthesia (↓ surfactant). ↑ risk: smokers, COPD. Tx: incentive spirometry, coughing, early ambulation, supplemental O₂.

Ileus ⭐

Temporary cessation of peristalsis after abdominal surgery. Absent/minimal bowel sounds + nausea/discomfort. Tx: NPO + NG tube + IV fluids.

Dehiscence / Evisceration

Dehiscence = wound edges separate. Causes: infection, corticosteroids, injury. Evisceration = organs protrude through wound → EMERGENCY. Cover with sterile saline-moistened dressing, call provider immediately.

Wound Infection (SSI)

Redness · warmth · pain · fever · purulent/foul drainage · wound widening. Caused by: Staph, Strep, Pseudomonas. Tx: wound culture, antibiotics, debridement.

Aspiration / Pneumonia ⭐

Food/liquid enters airway → pneumonia. Risk: dysphagia, Parkinson's, stroke, dental problems. Prevention: sit upright to eat, stay upright 1 hr after, small bites, eat slowly.

Post-Op Delirium / POCD ⭐

Delirium: temporary confusion, older adults. ↑ risk: anticholinergics, benzodiazepines, opioids, dementia. Prevent: CGA, effective pain mgmt, avoid benzo + opioids. POCD: permanent long-term memory loss — Alzheimer's, stroke, Parkinson's hx.

Hypovolemia / Bleeding

Signs: hypotension, tachycardia, tachypnea, confusion, oliguria, ↓ cap refill. Monitor vitals closely. Tx: fluids, blood products.

⚡

Exam High-Yield Summary

Post-op priority

O₂ saturation — ABCs first

Bleeding sign

BP 88/60 = possible hemorrhage

PE post-op

Sudden chest pain + SOB = emergency

Poor wound healing

DM, smoking, steroids, age ≥65

VTE prevention

SCDs while in bed; tobacco → ↑ clot risk

Ileus

Absent bowel sounds + nausea → NPO + NG tube + IV fluids

Nurse consent role

Witness only — verify signature, age, competence

Time-out

Performed several times by circulating nurse

CST role

Ensures instruments sterile and ready

Malignant hyperthermia

Triggered by succinylcholine/sevoflurane → dantrolene

Evisceration

Sterile saline dressing — never push organs back

Urinary retention

No void 8 hr post-op → straight catheter

Reposition post-op

Every 1 hour — prevents clots, atelectasis

Aspiration → PNA

Sit upright to eat; risk: Parkinson's disease

Who can consent

Alert adults, emancipated minors (married/pregnant by choice); mental illness history ≠ prevents consent

Implied consent

Doctor only — unconscious emergency, no family/contact available

Pregnancy testing

Required if LMP >3–4 weeks; refusal allowed — document it

Latex allergy

Document with all allergies; use latex-free equipment perioperatively

Discharge priority

Meds that cause dizziness = greatest fall risk at discharge

Anticholinergics + dementia

↑ risk of postoperative delirium

Pre-op teaching

Reduces length of hospital stay and costs

Skin prep sequence

Circular, center outward, discard sponge at outer edge, new sponge each pass

Hypervolemia signs

CHF/renal failure/excess IV fluids → crackles, edema, hypertension

POCD

Long-term cognitive decline post-op — Alzheimer's, stroke, Parkinson's hx

🧬

Skin Anatomy & Function

Layer	What's in it	Key Function
Epidermis	Keratinocytes, melanocytes, Merkel cells, Langerhans cells	Outer barrier — protects from water loss, pathogens, UV
Dermis ⭐	Collagen, elastin, fibroblasts, blood vessels, lymphatics	Blood vessels nourish the epidermis. Fibroblasts promote healing. Strength & elasticity.
Subcutaneous	Adipose tissue, blood vessels, nerves	Insulation, shock absorption, thermoregulation, sensation

🔬 Key Cells — Know These

Keratinocytes

Protect skin from water loss, pathogens, injury

Melanocytes

Produce melanin — skin color + UV protection

Merkel Cells

Detect light touch (palms, soles)

Langerhans Cells

Immune response in epidermis

            Older Adults: ↓ collagen → thinner skin, less elasticity → ↑ skin tears & pressure injury risk. Less subcutaneous padding over bony prominences.
          

⚠️

Pressure Injuries

            Caused by prolonged pressure + shearing over bony prominences. Shearing = layers slide opposite directions (e.g., high-Fowler's). Most common sites: heels, sacrum, hips, elbows, back of head.
          

🎯 Staging — Most Tested

Stage	Tissue	Key Feature
Stage 1	Skin intact	Non-blanchable erythema. Dressing: film or barrier cream.
Stage 2	Partial-thickness	Pink/red wound bed or ruptured serum blister. NO slough present. No deeper tissue visible.
Stage 3 ⭐	Full-thickness	Visible adipose. Granulation tissue present. No bone/tendon/muscle. May have slough/tunneling.
Stage 4 ⭐	Full-thickness	Bone, tendon, muscle, or cartilage visible. Undermining/tunneling present.
Unstageable	Obscured	Covered by slough or eschar. Once removed = reveals Stage 3 or 4.
DTPI	Deep tissue	Non-blanchable deep red / maroon / purple. Skin may be intact.

📊 Braden Scale

6 Categories

Sensory perception · Moisture · Activity · Mobility · Nutrition · Friction & Shear

Score Interpretation ⭐

Range: 6–23. Lower = greater risk. Score 9 = highest risk of any listed.

🛡️ Prevention Interventions

Reposition — tilt 30° on side

HOB <30° — reduce sacral shear

Flex knees + pillows to prevent sliding

Wheelchair: shift weight at intervals ⭐

Pressure-relieving mattress

↑ Protein intake for wound healing

🩹

Wound Dressings — Match to Wound

Dressing	Used For	Key Note ⭐
Film (Transparent)	Stage 1, superficial, minimal exudate	Visualize wound without removal. NOT for wounds with significant exudate.
Hydrocolloid	Small abrasions, Stage 2, post-op	Promotes granulation. Do NOT use with infection, tunneling, undermining.
Alginate ⭐	Moderate–high exudate	Requires secondary dressing. Made from seaweed. High absorbency.
Foam	Mild–moderate exudate	Silicone foam on sacrum within 24 hr of admission prevents HAPIs.
Hydrogel ⭐	Dry wounds, necrosis/eschar, suspected infection	Contains water — adds moisture to dry wounds. Soothing, minimal trauma.
Hydrofiber	Moderate–high exudate	Less maceration than alginate. Needs secondary dressing.
Barrier Cream	Stage 1, incontinence-prone skin	Protects from moisture/pressure/shear.

            Rule: Moist (not wet) wound bed = optimal healing. Dressings should absorb excess moisture while maintaining adequate moisture. Films → minimal exudate · Alginate/Hydrofiber → high exudate.
          

🔬

Wound Care, Healing & Drainage

💧 Drainage Types

Serous — clear, watery

Serosanguineous — thin, pink/light red

Sanguineous — bloody

Purulent — green/yellow = infection ⭐

🔄 Wound Healing Types

Primary (1st intention)

Clean wound sutured closed. Fastest. Minimal scarring.

Secondary (2nd intention) ⭐

Wound left open. Granulation tissue forms from wound bed upward. Prolonged healing. High infection risk. Moist wound bed required.

Tertiary / Delayed Primary (3rd intention)

Left open 5–10 days then sutured. Decreases infection risk in contaminated wounds.

⏱️ Phases of Wound Healing ⭐

1. Inflammatory / Hemostasis

Clotting occurs, swelling, defense response activated. Begins immediately after injury.

2. Proliferative

Collagen forms, granulation tissue develops, wound contracts and edges pull together.

3. Remodeling

Scar strengthens over months — but remains weaker than original skin.

🔬 TIME Wound Assessment

T = Tissue — color, necrosis

I = Infection/Inflammation — redness, warmth, drainage

M = Moisture — dry/wet/maceration

E = Edge — describe wound edges

🧠 DIDN'T HEAL — Delayed Healing Factors

Diabetes

Infection

Drugs (steroids)

Nutrition problems

Tissue necrosis

Hypoxia

Extensive tension

Another wound

Low temperature

⚠️ Wound Complications

Infection

Redness, warmth, purulent drainage, fever

Dehiscence

Wound edges separate — reposition to reduce tension

Evisceration ⭐

Organs protrude — emergency. Cover with sterile saline dressing, never push back.

Hematoma

Blood collects under wound — swelling, discoloration

Seroma

Serous fluid collects — clear/yellow pocket under wound

Fistula

Abnormal passage between two organs or to skin surface

🚰 Wound Drains

Penrose Drain

Passive, open, uses gravity. No collection chamber — drainage onto gauze.

Bulb Suction (JP) ⭐

Active, closed, negative pressure. Empty when ¾ full or q8h. Compress to reestablish suction.

            Wound Culture: Clean wound with 0.9% sodium chloride first → then swab wound bed (not edges) → rotate swab → place in culture tube. Cleaning removes normal flora so culture is accurate.
          

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Exam High-Yield Summary

Highest skin risk

Incontinent + diuretic

Braden scale

Lower = greater risk; score 9 = highest risk

Stage 2

Partial-thickness, NO slough, pink/red or blister

Stage 3 document

Full-thickness, visible adipose, no bone/tendon

Unstageable

Covered by slough or eschar — depth unknown

Alginate dressing

High exudate — requires secondary dressing

Hydrogel dressing

Dry wounds, necrosis, suspected infection

Wound culture

Clean with 0.9% NaCl first, then swab bed

Purulent drainage

Green/yellow = infection

Nutrition

Increase protein for wound healing

High-Fowler's risk

↑ shear on sacrum — keep HOB <30°

Bulb drain

Empty when ¾ full

Dermis function

Contains blood vessels that nourish epidermis

Remodeling phase

Scar strengthens but remains weaker than original skin

Stage 4

Full-thickness; bone, tendon, muscle, or cartilage visible

DTPI

Non-blanchable deep red/maroon/purple; skin may be intact

TIME mnemonic

Tissue · Infection · Moisture · Edge

DIDN'T HEAL

Diabetes · Infection · Drugs · Nutrition · Tissue necrosis · Hypoxia · Extensive tension · Another wound · Low temp

Wound healing phases

1 Inflammatory → 2 Proliferative (collagen/granulation) → 3 Remodeling (weaker than original)

Dehiscence vs evisceration

Dehiscence = edges separate; Evisceration = organs protrude (emergency)

Hematoma / Seroma / Fistula

Blood collects / serous fluid collects / abnormal passage between organs

Slough vs eschar

Slough = yellow/tan stringy; Eschar = black/hard → both = unstageable

Staple removal

Approximately 2 weeks (10–14 days)

7-day incision

Expect bright pink, absent exudate — normal

Sepsis sign

Post-op ↑ blood glucose = potential sepsis

Corticosteroids

Delay wound healing — prevent collagen and fibroblast formation

Infant diarrhea

Monitor for dermatitis (MASD)

Skin thermoregulation

Most tested skin function = temperature regulation

Pulsating lavage

Stage 4 mechanical debridement — dislodges exudate and necrotic tissue