Fundamentals of Nursing Study Guide

Nursing Process

• Assessment: Involves collecting vital signs, pain levels, and other signs or symptoms of the patient.
• Diagnosis: Focuses on nursing diagnoses derived from patient assessments, distinct from medical diagnoses.
• Planning: Establishes client-centered, measurable goals (e.g., "client will ambulate 10 meters 3x daily for 2 weeks").
• Implementing: Execution of the care plan developed for the patient.
• Evaluation: Determines if goals were met, partially met, or not met and assesses the effectiveness of the care plan.

Normal Vital Signs Ranges

• Temperature: Normal range is 96.8°F to 100.4°F.
• Pulse: Normal pulse rate is 60 to 100 beats per minute.
• Respirations: Normal respiratory rate ranges from 12 to 20 breaths per minute.
• Blood Pressure: Normal range is 100/60 mmHg to 140/90 mmHg.
• Pulse Oximetry: Normal oxygen saturation level should be greater than 95%.

Communication Techniques

• SOLER: A mnemonic for effective communication: Sit close, Observe, Lean forward, Establish eye contact, Relax.

Pain Management

• Types of Pain: Includes acute, chronic, cancer-related pain, inferred pathology pain, and idiopathic pain.
• Pain Threshold: Refers to the specific level of stimulus required to perceive pain.
• Pain Tolerance: Represents the maximum level of pain a patient can endure without affecting daily activities.
• Factors Influencing Pain: Age, fatigue, genetic predisposition, neurological status, social and spiritual contexts, psychological state, and cultural background.

Behavioral Responses to Pain

• Observable behaviors may include clenching teeth, holding the painful area, altered posture, grimacing, or moaning; confusion may mask pain response.

Pharmacological Pain Relief

• Analgesics: Includes non-steroidal anti-inflammatory drugs (NSAIDs), non-opioids, opioids, and adjuvants for managing pain.
• NSAIDs & Non-opioids: Over-the-counter options with analgesic and antipyretic effects; inhibit prostaglandin synthesis; caution due to potential liver toxicity when overdosed.
• Opioids: Prescribed for moderate to severe pain; common side effects include respiratory depression, constipation, and altered mental status.
• Naloxone (Narcan): An opioid antagonist used to reverse respiratory depression caused by opioid overdose.
• Patient Controlled Analgesia (PCA): Allows patients to manage their pain medication delivery within safe limits, reducing overdose risk.

Anesthetics

• Agents that depress the central nervous system for loss of consciousness and sensory responsiveness; may be general or local.

Nutritional Components

• Basal Metabolic Rate (BMR): The energy required for maintaining basic physiological functions.
• Carbohydrates: Primary energy source necessary for brain and muscle function; found in grains, fruits, and vegetables.
• Proteins: Crucial for growth, maintenance, and repair of body tissue; derived from amino acids; needs to be balanced.
• Fats: Comprised of triglycerides and fatty acids; can be classified as saturated, unsaturated, essential, or nonessential.
• Water: Constitutes 60-70% of body weight; essential for cellular function and hydration; illness can increase fluid requirements.

Vitamins and Minerals

• Vitamins: Required for normal metabolic processes; categorized into fat-soluble (A, D, E, K) and water-soluble (C and B complex).
• Minerals: Inorganic elements vital as catalysts in biochemical reactions; assist in maintaining acid/base balance and oxygen transport.

Free Radical Theory

• Suggests that free radicals produced during metabolism can damage cells; some evidence indicates that their effects may be mitigated by antioxidant intake.