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Lab Values: Calcium

• Normal calcium range is 9-11.
• Calcium provides the foundation for bones and teeth.
• Calcium functions within the neuromuscular, cardiovascular, and endocrine systems.
• It aids in blood clotting and can be found in a BMP draw.

Hypocalcemia (Low Calcium)

• 3 main causes are chronic diarrhea, malabsorption (Crohn's Disease), and vitamin D deficiency.
• 3 main symptoms are diarrhea/abdominal cramping, hyperactive deep tendon reflex, and seizures.
• 3 main treatments involve administering supplements orally or IV with Vitamin D, encouraging high calcium foods, and initiating seizure and risk protocols.

Hypercalcemia (High Calcium)

• 3 main causes include Paget's Disease, bone cancer, and hyperparathyroidism.
• 3 main symptoms include decreased level of consciousness or altered mental state, bone pain, and nausea, vomiting, and constipation.
• 3 main treatments involve administering Calcitonin IM or SUBQ, assessing and monitoring for fractures, and reducing or restricting calcium intake.

Lab Values: Blood Urea Nitrogen (BUN)

• Normal BUN range is 10-20; a low BUN is rare.
• BUN helps determine how well the kidneys are functioning.
• 3 main causes of high BUN include liver and kidney disease, dehydration, and high protein diet.
• 3 main symptoms of high BUN include fatigue, swelling, and frequent urination.
• 3 main treatments for high BUN include increasing fluid intake, decreasing protein intake, and blood pressure management.

Patient Safety and Immobility

• Nurses ensure the safety of themselves and their patients.
• Physiological needs (food, water, sleep) always come first, followed by safety.

Safety for Healthcare Workers: Radiation

• Healthcare workers are exposed to small amounts of radiation through CT scans and other medical diagnostic devices.
• Take precautions such as organizing care to limit time with the patient and performing care that is only absolutely necessary.
• Shielding with PPE, such as a lead apron, is essential; wear a film badge to indicate radiation exposure.

Fall Risk Factors and Prevention

• Any patient is at risk for falling.
• Prevention includes fall risk assessment, environmental safety, clean and dry floors, and client education.
• Restraints are used ONLY when absolutely necessary and in emergent situations, a restraint order must be notified immediately.
• All four side rails up are considered a restraint.
• Restraints can increase fall risks as patients try to get out of them.

Factors Affecting Mobility

• Alterations in muscles
• Injury to musculoskeletal system
• Poor posture
• Impaired nervous system
• Health status and age

Patient Positioning

• Supine: Patient is flat on back to maintain alignment.
• Lateral: Patient is on left or right side and used to prevent ulcers.
• Fowler's: Similar to supine but at a 45-60 degree angle, promoting chest expansion and ventilation; used for NG tube insertion and suctioning.
• Semi-Fowler's: 15-45 degree angle that promotes lung expansion, prevents aspiration, and prevents regurgitation.
• High-Fowler's: 60-90 degree angle, relieving dyspnea and preventing meal aspiration.
• Prone: Patient is on their stomach with head turned to the side, promoting mouth drainage and preventing hip contracture after lower amputations.
• Trendelenburg: Head is lowered with legs up, promoting venous return.
• Reverse Trendelenburg: Foot of bed is lower than head, promoting gastric emptying and helping with GERD and reflux.
• Sims: Upper leg is more flexed than lower, limiting pressure on trochanter and sacrum; it is an ideal position for enemas or perineal procedures.
• Patients should be repositioned every 2 hours to prevent pressure injuries.

How to Reposition a Patient

• Moving Up in Bed: If the patient is light in weight, a nurse can reposition the patient.
• Turning in Bed: To prevent pressure injuries.
• Logrolling: Using a transfer roller sheet, scoot sheets, or a roller tray.
• Other Devices: Hoyer lifts (mechanical lifts), gait belts, and transfer boards help prevent back injuries to nurses.

Assisting with Transfer

• Conditioning exercises and assistive devices like mechanical lifts, gait belts, and transfer boards may be required.
• Dangling patients before standing involves having the patient sit upright with their legs dangling on the side of the bed to avoid orthostatic hypotension, reducing the risk of falls.

Orthostatic Hypotension

• Drop in blood pressure when standing up, causing dizziness, lightheadedness, and syncope.
• Treatment involves anti-embolism stockings with compression wraps, abdominal binders, and medications.

Use of Ambulatory Devices

• Canes: Hold on stronger side, distribute even weight, advance cane with weaker leg, then stronger leg; avoid leaning over or on the cane.
• Walkers: Stand erect, pick up and advance the walker without sliding it unless wheels are present.
• Crutches: Axilla should not rest on the crutch pad to avoid nerve damage; distance from axilla to crutch pad should be 1.5 inches or 3 fingers in length.
• Arms should be bent at a 30-degree angle on hand rests, start positioning with the tripod position.

Gaits with Crutches

• 4-point gait: Partial weight-bearing, patient must shift weight constantly; move right crutch (injured side), then left foot, then left crutch, then right leg (4 points on the ground).
• 3-point gait: Used when weight-bearing must be avoided; faster than 4-point gait; both crutches and injured leg swing together, then non-injured leg bears weight.
• 2-point gait: Partial weight-bearing, uses both feet; move right crutch and uninjured leg (left leg) together, then left crutch and right leg together.
• Swing-to gait: Weight-bearing is permitted, uses both feet; move crutches forward, swing both legs into gait, legs should land in between crutches.
• Swing-through gait: Weight-bearing, requires the most coordination and balance; move both crutches forward, then move both legs forward, ensuring legs land past the crutches.

Stairs and Crutches

• Going up the stairs: Lead with the good leg.
• Going down the stairs: Lead with the bad leg.
• Sitting Down: Back up to the chair with the non-injured leg; move both crutches to the injured leg, bend non-injured leg keeping the injured leg extended.
• Standing Up: Put both crutches on the injured side, keep the injured leg extended while using the non-injured leg to push up.

Nutrition

• The study of food.
• Metabolism is the way the body converts food into energy.
• Anabolism: Formation of larger molecules from smaller ones; requires energy for tissue repair.
• Catabolism: Breaks down large molecules into smaller ones; releases energy.
• Nutrition Facts Labels contain: Serving size, number of servings, total calories/calories from fat, list of key nutrients, and % of daily values.

Energy Nutrients: Macronutrients

• Supply the body with energy (kilocalories).
• 3 main nutrient classes: carbohydrates (sugar), proteins, and lipids (fats).

Carbohydrates (Sugar)

• Breaks down into glucose.
• Primary energy source, functions in muscle/organ function, insulin secretion, and brain energy (impacted by Keto diet).
• Diabetics should avoid high carb diets to prevent infections from high sugar levels.
• Simple sugars are found in corn, syrup, honey, milk, table sugar, molasses, sugarcane, sugar beets, and fruits.
• Complex carbs are found in vegetables and breads, cereals, pasta, grains, and legumes.

Proteins

• Tissue, cell, and muscle repair, helps with metabolism, and acid-base balance (nitrogen balance).
• Secondary energy source.
• Broken down into amino acids.
• Patients with wounds benefit from a protein diet to repair tissue.
• Complete proteins come mostly from animal sources like meat, poultry, fish, eggs, and milk products.
• Incomplete proteins come mostly from plant sources like grains, nuts, legumes, seeds, and vegetables.

Lipids (Fats)

• Backup energy source, insulates/protects organs
• Three kinds of fats: Saturated, Unsaturated, and Trans-Fat.
• Saturated fats: Pork, beef, poultry, seafood, egg yolk, dairy, coconut oil, and palm oil.
• Unsaturated fats (healthiest fats): Olives, olive oil, vegetable oils (peanut, soybean, cottonseed, corn, and sunflower oil), nuts, avocados.
• Trans fats (worst kinds of fats): Margarines, packaged baked goods, and processed foods.

Micronutrients

• Vitamins A, D, E, K
• Help sustain, repair, and maintain cells.
• Needed only in small amounts, regulate body function, support the immune system, and stabilize metabolism.

Special Diets

• Cardiovascular Diet: Low sodium and fat-restricted.
• Renal Diet: Restrict fluid and sodium intake.
• Diabetic Diet: Restrict carbs and sugars.
• NPO Diet: Nothing by mouth, even water; usually done before surgeries to prevent aspiration. A bowel obstruction will not improve with food intake!
• Clear Liquid Diet: Any see-through liquids in the light such as water, tea, coffee, broth, clear juice (apple, grape, or cranberry), gelatin, and carbonated beverages.

Caring for Enteral and Parenteral Patients

• Enteral Nutrition: Tube feeding directly into the GI tract in liquid form for bowel obstruction, trouble chewing/swallowing, change in mental status, or if patient is on ventilation.
• NG Tube (Temporary due to risk of aspiration): Placed into nares, down nasopharynx, into the esophagus, and into the stomach; verify placement with X-ray before administering feedings.
• PEG Tube (Percutaneous Endoscopic Gastrostomy) for long-term nutrition; tolerated better than NG tube due to less discomfort and is placed directly in the abdominal area. Risks: Aspiration, bacteria growth.

What to Check and Care For with Enteral Feeding

• Tube placement (X-Ray)
• Aspiration risk (place pt in high fowlers to avoid risk of aspiration)
• Skin condition (skin breakdown w/in the nares)
• Lab values/electrolytes, nutritional deficiencies, feeding residual, GI status, positioning, and bowel sounds.

Parenteral Nutrition

• Outside the GI Tract for patients who cannot meet nutritional needs orally or are severely malnourished, have extensive burns, or trauma to the GI system.
• Total Parenteral Nutrition (TPN): Nutrition via central line IV; highly concentrated nutrition; ONLY THROUGH CENTRAL IV; sterile technique upon insertion; only for patients without a functioning GI tract; high risk for infection.
• Risks: Infections/septic shock, blood clots due to platelet accumulation.
• What to Check/Care for: Catheter insertion site for signs of infection, catheter retraction, ensure tubing is secure and pump is working, weight to determine nutritional status, glucose levels (can cause hyperglycemia), fluid levels (monitor I/O for dehydration), and signs of complications (electrolyte imbalances, sepsis, air embolism, catheter dislodgement/thrombosis).

Oxygenation and Therapy

• Oxygenation: How well cells, tissues, and organs are supplied with O2; consists of respiration and ventilation.
• Ventilation: Movement of air into and out of the lungs.
• Respiration: Exchange of oxygen/carbon dioxide, occurring in the alveoli.
• Hypoxemia: Low arterial blood oxygen levels.
• Hypoxia: Inadequate oxygen of organs and tissues.

Factors Affecting Ventilation

• Rate (12-20).
• Depth (shallow or deep breaths, deep breaths preferred).
• Lung Compliance (the ease of lung inflation, smoking can affect this).
• Lung elasticity.
• Airway resistance (improper oxygen passage due to conditions like COPD or Asthma).

Incentive Spirometers

• Prevents atelectasis (collapse of lung due to deflation of alveoli or filling with fluid).
• Patients take deep breaths to reach a certain volume of air.
• Can delegate this to LPN or UAP.

Maintaining a Sterile Field

• Anything below waist level is NON-STERILE.
• Do not turn your back on a sterile field.
• Do not reach over a sterile field.
• Any spills contaminate a sterile field.
• Hair should be tied up.
• Do not sneeze, laugh, or cough over a sterile field.

Trachea Suction Steps:

1. Position patient in semi-Fowler's and place a linen over the patient's chest.
2. Don gloves, a gown, and a mask.
3. Turn the wall suction according to agency policy (typically 100-150 mm Hg) and test the suction.
4. Remove gloves + perform had hygiene
5. Open suction kit.
6. Pour sterile saline into the sterile container using a non-dominant hand.
7. Don sterile gloves; use the dominant hand as the sterile hand and the NON-DOMINANT hand for non-sterile use.
8. Get the suction catheter with the STERILE (dominant) hand and attach it to the connection tubing.
9. Place the tip of the suction catheter in the sterile water, and suction small amounts by placing a finger over the control port.
10. Hyperoxygenate the patient for one minute (essential because the patient cannot breathe during suctioning).
11. Lubricate the suction catheter tip with normal saline.
12. Use the dominant (sterile) hand to insert it into the trach tube no more than 15 cm, making sure suction is OFF.
13. Start suctioning in circular motions while withdrawing the catheter; DO NOT EXCEED SUCTIONING MORE THAN 15 SECONDS.
14. Repeat as needed, but ensure there are 30-second intervals in between as well as HYPEROXYGENATION in between.
15. Suctioning should not exceed more than 3 suctions.
16. If the patient was removed from an oxygen source, then replace.
17. Wrap the suction catheter in the dominant hand and pull sterile glove off over the wrapped catheter.
18. Don clean gloves and provide mouth care.

Breathing Patterns

• Eupnea: Normal breathing.
• Tachypnea: Rapid breathing.
• Bradypnea: Slow breathing.
• Apnea: Absent breathing.
• Kussmaul's: Rapid, deep breathing (typical for diabetic patients).
• Cheyne-Stokes: Abnormal, a combination of tachy-, brady-, and apnea.
• Dyspnea: Difficulty breathing.

Nasal Cannula: LOW FLOW

• 1-6 L/min, with nasal prongs supplying O2 into nostrils, tubing wrapped around the ears.
• Use for non-critical patients with minor breathing problems.
• Skin care for the nose and behind the ears; assess for changes in condition and document response.

Simple Face Mask: LOW FLOW

• 5-8 L/min, covers the face with a snug fit and elastic strap behind the head, ventilation holes for exhalation.
• Provides moderate flow for a short period.
• Humidify with sterile H2O if using MORE than 4L; do not use less than 5L due to CO2 buildup.
• Secure the seal on face, skin care to the face; assess changes and document response.

Non-Rebreather Mask (NRB): LOW FLOW

• 10-15 L/Min, covers the face snugly with an elastic strap, a reservoir bag where O2 is delivered, exhaled CO2 leaves through one-way valves.
• O2 must be high enough to inflate; use a humidifier and supply almost pure O2.
• Secure seal, provide skin care, assess for changes and document response.

Face Tent: HIGH FLOW

• 10-15 L/min with a soft mask placed under the chin with a loose fit.
• Used for post-nasal/oral surgery, use a humidifier, good for patients with claustrophobia and pediatric patients, difficult to control concentration of O2 (depends on rate/depth of respirations).
• Ensure the mask is secure, assess for changes, and document response.

Trach Collar: HIGH FLOW

• 10+ L/min, fits over the trach site with an elastic strap around the neck.
• Continuous humidifier needed; needs a T-piece and a trach mask.
• Maintain patency of tube, minimize the risk of infection, suction and clean as needed, check skin around the stoma, assess change in condition, and document response.

Drug Formulations (DA)

• Tablets: Hard, solid form that can be scored, enteric-coated (prevents dissolving in the stomach), and chewable.
• Capsules: ENCLOSED
• Caplets: Coated, elongated tablets.
• Lozenges: Sugar-based (DO NOT SWALLOW), dissolves slowly in the mouth.
• Troches or pastilles: Dissolves in the mouth.
• Suppositories: Administered rectally or vaginally.
• Transdermal patches: Applied to skin and into the blood supply.
• Liquids
• Syrups: Thick and sweet.
• Elixir: Drugs mixed in water and alcohol.
• Suspensions: Suspended in oil or water, must be shaken thoroughly.

Rights of Medication Administration

1. Right Person
2. Right Drug
3. Right Dose
4. Right Route
5. Right Reason
6. Right Time
7. Right Documentation

Patient Identifiers (2 Most Commonly Used)

1. First and last name
2. DOB

• The following medications should not be crushed*: Those with specialized coatings; extended-, sustained-, controlled-, or slow-release medications; fizzy tablets when placed in liquid; foul-tasting medications; medications that cause mucous membrane ulcers; buccal or sublingual drugs.

Common Abbreviations

• ac: before meals
• pc: after meals
• ad lib: as desired
• IV: intravenous
• SUBQ: subcutaneous
• IM: intramuscular
• ID: intradermal
• SL: sublingual
• STAT: immediately
• PRN: as needed
• IVP: intravenous push
• IVPB: intravenous piggyback
• PEG: Percutaneous Endoscopic Gastrostomy
• NG: nasogastric
• PR: per rectum
• PO: by mouth
• Supp: suppository
• NPO: nothing by mouth
• b.i.d: twice daily
• t.i.d: three times daily
• q: every
• q2hr: every 2 hours
• q4h: every 4 hours
• gtt: drop
• ER: extended release
• SR: sustained release
• CR: controlled release

If a patient expresses that they are upset to the nurse, the nurse should let the patient talk and avoid asking "why" to promote therapeutic communication.