Nursing Skills

🧭 Overview

🧠 One-sentence thesis

A general survey assessment is a systematic, whole-person observation using all five senses that begins at first patient contact and guides nurses to identify areas requiring focused assessment and immediate intervention.

📌 Key points (3–5)

• What it is: A holistic observation of appearance, behavior, mobility, communication, nutrition, fluid status, and vital signs—not just isolated measurements.
• When it happens: Begins immediately upon meeting the patient and continues throughout the relationship; always starts with a primary survey to ensure medical stability.
• Common confusion: General survey vs. primary survey—the primary survey is a rapid check for life-threatening conditions (mental status, airway, breathing, circulation), while the general survey is a broader assessment of overall health status.
• Foundation in the nursing process: Assessment (including general survey) is the first step in the ANA's six-component nursing process (ADOPIE: Assessment, Diagnosis, Outcomes, Planning, Implementation, Evaluation).
• Why it matters: Findings guide focused assessments, reveal urgent conditions, and establish a baseline for ongoing care.

🏥 Before you begin: Safety and preparation

🧼 Infection control

Medical asepsis: measures to prevent the spread of infection in health care agencies.

• Hand hygiene is mandatory before and after every patient contact.
• Use soap and water if hands are visibly soiled or the patient has C. difficile; otherwise, hand sanitizer is equally effective and less drying.
• Apply enough sanitizer to cover both hands; rub for ~20 seconds until dry.
• Don't confuse: Gloves are not a substitute for hand hygiene—wash hands after removing gloves.

When to perform hand hygiene:

• Immediately before touching a patient
• Before aseptic tasks or handling devices
• After contact with blood, body fluids, or contaminated surfaces
• Before donning and immediately after removing gloves
• When leaving the patient area

🦺 Personal protective equipment (PPE)

• Perform a risk assessment before entering the room: Is there signage for contact/droplet/airborne precautions? Will you be exposed to body fluids, coughing, or sneezing?
• PPE includes gowns, gloves, masks, eyewear, and face shields as indicated.

👤 Patient identification and introduction

Use two identifiers:

• Ask the patient to state their name and date of birth; compare to the armband or chart.
• If the patient cannot respond, scan the armband or ask staff/family to verify.

AIDET framework for communication:

• Acknowledge: Greet by name; ask preferred name and pronouns.
• Introduce: State your name and role.
• Duration: Estimate how long the task will take.
• Explanation: Describe what will happen step by step.
• Thank you: Thank the patient; ensure the call light is within reach before leaving.

🌍 Cultural safety and developmental adaptation

Cultural safety: the creation of safe spaces for patients to interact without judgment or discrimination.

• Recognize that both you and the patient bring cultural contexts to the interaction.
• Ask open-ended questions: "Can you share what is important about your cultural background that will help me care for you?"
• Adapt to developmental stage: Use demonstrations with dolls for children; allow private interviews for adolescents; ensure glasses/hearing aids are in place for older adults.

🚨 Primary survey: Ensuring medical stability

🚑 What it is

Primary survey: a brief initial check to ensure the patient is medically stable before proceeding with a general survey.

• If any signs of distress are found, defer the general survey and obtain emergency assistance.

🧠 Mental status

• Is the patient responsive or unresponsive?
• Can you awaken them?
• Are they oriented to person, place, and time (name, location, day of the week)?
• Don't confuse: A sudden change in mental status is an emergency—obtain help immediately.

🫁 Airway and breathing

• Is the airway open?
• Is the patient breathing adequately?
• Institute emergency care for respiratory distress as needed.

💓 Circulation

• If unresponsive, perform a sternal rub (firmly rub knuckles on sternum) to try to elicit a response.
• If no response, check the carotid pulse and call for emergency assistance.
• Observe skin color and moisture: cool, moist, pale, or bluish skin can indicate shock.

Example: In a clinic, observe the patient from the moment they are called from the waiting room—watch gait, balance, and communication. If distress is noted, follow agency protocol immediately.

🔍 General survey components

👁️ General appearance

What to observe:

• Signs of pain or distress: Grimacing, moaning, increased anxiety.
• Age: Does the patient appear their stated age? Chronic disease can make patients look older.
• Body type: Reflects nutritional status and lifestyle.
• Hygiene, grooming, dress: Overall cleanliness, odors, appropriateness of clothing for the season.

Why it matters: Poor hygiene or inappropriate dress may reflect cognitive impairment, emotional distress, or inability to complete daily activities.

Example: A patient wearing a heavy winter coat on a warm summer day with an unclean body odor may have cognitive impairment or neglect—this requires further assessment.

🎭 Behavior and mood

Affect: the outward display of one's emotional state (e.g., "flat affect" with few facial expressions is associated with depression).

What to observe:

• Affect and mood: Facial expressions, eye contact, what they say and do. Note if mood seems inappropriate for the situation (e.g., elation when most would be concerned).
• Family dynamics: Patterns of interaction between family members—do they show mutual respect or hostility?
• Signs of abuse: Fearfulness, excessive quietness, bruising, burn marks. Interview the patient alone if abuse is suspected; report per agency policy and state mandates.
• Substance use disorder: Unusual pupil size (dilated or constricted), unusual behaviors. Approach nonjudgmentally; report concerns to the provider.

Don't confuse: Lack of eye contact may indicate depression, but it can also reflect cultural beliefs that direct eye contact is disrespectful—validate cues before making inferences.

🚶 Mobility and posture

What to observe:

• Posture: Normal posture is upright with parallel alignment from shoulders to hips. Note hunching, slumping (e.g., kyphosis), rigidity.
• Gait and balance: Healthy people walk with a smooth gait and arms moving freely; they can stand unassisted. Altered gait or balance increases fall risk.
• Range of motion: Do extremities move equally on both sides? Note tremors or non-purposeful movements. Document use of assistive devices (cane, walker).

Example: A patient with a shuffling, staggering gait who does not use an assistive device appropriately is at high risk for falls and requires further assessment.

🗣️ Communication

What to observe:

• Speech: Is it clear, understandable, at an even pace? Or garbled, slurred, slow? Neurological disorders can affect speech.
• Response to commands: Does the patient follow instructions, or do they have difficulty understanding or cooperating?
• Language barriers: Obtain an interpreter if English is not the patient's primary language.

🍎 Nutritional status

• Visual observation can reveal cues about appetite, diet, food intake, exercise.
• Factors influencing nutrition: financial issues, transportation, swallowing difficulties, missing teeth, poorly fitting dentures.

💧 Fluid status

• Dehydration signs: Dry skin, dry mucous membranes, sunken eyes (adults), sunken fontanel (infants).
• Excess fluid signs: Swelling/edema in extremities, difficulty breathing.

📏 Height, weight, and BMI

Body Mass Index (BMI): a standardized reference range to gauge weight status; represents body fat but may not be accurate for athletes, people with edema/dehydration, or older adults with muscle loss.

BMI categories:

• Underweight: Below 18.5 kg/m²
• Healthy weight: 18.5 to 24.9 kg/m²
• Overweight: 25 to 29.9 kg/m²
• Obesity: 30 to 34.9 kg/m²
• Extreme obesity: Over 35 kg/m²

Formula: BMI = weight (kg) / height (m)² or BMI = weight (lb) / height (in)² × 703

Example: A person 5'9" (69 inches) weighing 155 pounds has a BMI of 23 (healthy weight).

🩺 Vital signs

🌡️ Temperature

Routes and normal ranges:

Method	Normal Range
Oral	35.8–37.3°C (96.4–99.1°F)
Axillary	34.8–36.3°C (96.4–97.3°F)
Tympanic	36.1–37.9°C (97.0–100.2°F)
Rectal	36.8–38.2°C (98.2–100.8°F)
Temporal	35.2–37.0°C (95.4–98.6°F)

Key techniques:

• Oral: Place probe in posterior sublingual pocket; patient keeps mouth closed but does not bite. Wait 15–25 minutes after hot/cold beverages or 5 minutes after chewing gum/smoking.
• Tympanic: Pull helix up and back (adults/older children) or down (infants/children under 3); insert probe just inside ear canal. Do not use if ear infection is suspected.
• Axillary: Place probe high in armpit on bare skin; patient lowers arm until device beeps (~10–20 seconds). Reading is ~0.3–0.6°C lower than oral.
• Rectal: Most invasive; considered gold standard for infants. Lubricate probe; insert 2–3 cm (less for babies). Reading is ~0.3–0.6°C higher than oral.

Don't confuse: Document the route used—temperature varies by location.

💓 Pulse

Pulse: the pressure wave that expands and recoils arteries when the left ventricle contracts.

Normal heart rate by age:

Age Group	Heart Rate (bpm)
Preterm	120–180
Newborn (0–1 month)	100–160
Infant (1–12 months)	80–140
Toddler (1–3 years)	80–130
Preschool (3–5 years)	80–110
School age (6–12 years)	70–100
Adolescent/Adult	60–100

Pulse characteristics (document all four):

• Rhythm: Regular (even tempo) or irregular (regularly irregular or irregularly irregular).
• Rate: Count for a full 60 seconds, especially if irregular. First beat felt is "One."
• Force (four-point scale):
  • 3+: Full, bounding
  • 2+: Normal/strong
  • 1+: Weak, diminished, thready
  • 0: Absent/nonpalpable (use Doppler ultrasound device to verify perfusion)
• Equality: Compare pulse forces on both sides of the body (e.g., both radial pulses). Never palpate both carotid pulses simultaneously—this can decrease blood flow to the brain.

Common pulse sites:

• Radial: Use pads of first three fingers along radius bone on lateral wrist (thumb side). Difficult to palpate in newborns/children under 5—use brachial or apical instead.
• Carotid: Locate medial to sternomastoid muscle, between muscle and trachea, in middle third of neck. Palpate one side at a time. Used in emergencies (last pulse to disappear).
• Brachial: Feel bicep tendon in antecubital fossa; move fingers medially ~1 inch. Hyperextend arm to accentuate pulse. Used for infants/children.
• Apical: Listen with stethoscope over specific position on chest wall. Most accurate; indicated before cardiac medications.

🫁 Respiratory rate

Respiration: breathing and movement of air into (inspiration) and out of (expiration) the lungs. One respiratory cycle = one inspiration + one expiration.

Normal respiratory rate by age:

Age	Normal Range (breaths/min)
Newborn to 1 month	30–60
1 month to 1 year	26–60
1–10 years	14–50
11–18 years	12–22
Adult (18+)	10–20

What to assess:

• Quality: Normally relaxed and silent. Loud breathing, nasal flaring, use of accessory muscles, or tripod position (leaning forward, arms on knees) indicate respiratory distress—notify provider immediately.
• Rhythm: Regular in awake children/adults; irregular in newborns/infants is common.
• Rate: Consider factors like sleep, pain, crying.

🩸 Oxygen saturation (SpO2)

SpO2: estimated oxygenation level based on saturation of hemoglobin measured by a pulse oximeter.

• Target range: 94–100% for adults; 88–92% for patients with chronic respiratory conditions (e.g., COPD).
• Technique: Attach sensor to finger, toe, or earlobe. Remove nail polish or use alternative sensor (earlobe, forehead) if needed. If hands/feet are cold, use earlobe or forehead.
• Limitations: SpO2 is an estimate—not always accurate. Severe anemia or decreased peripheral circulation can affect readings.

🩺 Blood pressure

• Refer to the "Blood Pressure" chapter for detailed measurement techniques.

📋 Expected vs. unexpected findings

Assessment	Expected	Unexpected (report if new)
Signs of distress	None	Unresponsive, difficulty breathing, confused, moaning, grimacing
Mood/appearance	Calm, cooperative, responds appropriately, appears stated age	Depressed, anxious, agitated, signs of substance use (e.g., alcohol scent)
Orientation	Alert and oriented to person, place, time	Unable to provide name, location, or day
Hygiene	Well groomed, clothing appropriate for weather	Unkempt, inappropriate clothing
Family dynamics	Mutual respect, trust, caring	Unfriendly, disrespectful, hostile; signs of abuse
Speech/communication	Clear, understandable, follows instructions	Garbled, difficult to understand, unable to respond or follow commands
Range of motion	Moves all extremities equally with good posture	New facial drooping, altered/unequal movement
Mobility	Smooth, even gait; maintains balance without assistance	Shuffling, staggering, limping; impaired balance; assistive devices not used appropriately
Nutrition	BMI within normal range	BMI out of range; unexplained weight loss/gain
Fluid status	Moist mucous membranes	Dry skin/mucous membranes, sunken eyes (adults), sunken fontanel (infants)

CRITICAL conditions to report immediately: Newly unresponsive or altered mental status, difficulty breathing, vital signs out of range, cool/clammy/cyanotic skin.

📝 Documentation

✅ Sample: Expected findings

"Mrs. Smith is a 65-year-old patient who appears her stated age. Calm, cooperative, alert, and oriented ×3. Well-groomed with clean clothing appropriate for weather. Speech is clear, understandable, and follows instructions appropriately. Moves all extremities equally bilaterally with good posture. Gait is smooth and maintains balance without assistance. Skin warm and mucous membranes moist. 5'4" and weighs 143 pounds with BMI of 24 in normal weight category. Vital signs: BP 120/70, pulse 74 and regular, respiratory rate 14, temperature 36.8°C, SpO2 98% on room air."

⚠️ Sample: Unexpected findings

"Mrs. Smith is a 65-year-old patient with older appearance than stated age. Slightly agitated during interview. Oriented to person only and denies pain. Wearing a heavy winter coat on a warm summer day and unclean body odor. Slow to respond to questions and does not follow commands. Neglect noted of right arm. Gait shuffling with stooped posture with no assistive device. 5'4" and weighs 102 pounds with BMI of 17.5 in underweight category. Vital signs: BP 186/55, pulse 102 and irregular, respiratory rate 22, temperature 38.1°C, SpO2 88% on room air."

🎯 Key takeaways

• Establish trust: Use a calm voice, provide undivided attention, and use all your senses to pick up on important cues.
• Prioritize safety: Always complete a primary survey first; report critical conditions immediately.
• Adapt to the patient: Consider developmental stage, cultural beliefs, and individual circumstances.
• Document thoroughly: Include both expected and unexpected findings; note the context (e.g., patient was crying, in pain).
• Follow up: Analyze findings, recognize deviations from normal, and report appropriately—as a nursing student, notify your instructor and/or the collaborating nurse immediately.

🧭 Overview

🧠 One-sentence thesis

Collecting a health history requires nurses to establish therapeutic relationships, use effective communication techniques, and listen to patients' experiences of their own sickness to understand their responses and advocate for their care.

📌 Key points (3–5)

• Core nursing definition: nursing is both art and science, focusing on caring, health promotion, illness prevention, and alleviating suffering through compassionate presence.
• What health history collection involves: establishing therapeutic relationships, using verbal and nonverbal communication, and gathering data directly from patients.
• Key principle: "sickness" is what is happening to the patient—the emphasis is on listening to the patient's perspective and experience.
• Scope of practice: nursing includes diagnosing and treating human responses (not just diseases) and advocating for individuals, families, groups, communities, and populations.
• Adaptation requirement: assessment techniques must be modified across the life span and for cultural variations.

🤝 Establishing therapeutic relationships

🤝 What a therapeutic nurse-patient relationship means

• The excerpt lists "establish a therapeutic nurse-patient relationship" as a foundational learning objective for health history collection.
• This relationship is the starting point for gathering meaningful health data.
• It is not simply transactional data collection; it requires trust and connection.

💬 Communication techniques

• Effective verbal and nonverbal communication techniques are essential tools.
• The excerpt does not detail specific techniques but emphasizes their importance in the health history process.
• Example: a nurse uses both spoken questions and attentive body language to help a patient feel heard and safe.

🩺 The nature of nursing practice

🩺 Nursing as art and science

Nursing: "the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence."

• Art: caring and compassionate presence.
• Science: systematic protection, promotion, and optimization of health.
• Both dimensions are necessary; neither alone defines nursing.

🧩 What nurses diagnose and treat

• Nursing focuses on diagnosing and treating human responses (not diseases themselves).
• This distinguishes nursing from medicine: the emphasis is on how the patient responds to and experiences health and illness.
• Example: a patient with the same diagnosis may have very different responses—nursing addresses those individual responses.

🗣️ Advocacy across levels

• Nursing advocacy extends to:
  • Individuals
  • Families
  • Groups
  • Communities
  • Populations
• The excerpt emphasizes recognition of these multiple levels of care.

👂 Listening to the patient's experience

👂 "Sickness" vs. disease

• The excerpt opens with a key principle: "'Sickness' is what is happening to the patient. Listen to them."
• This highlights the subjective, lived experience of illness, not just the objective clinical picture.
• Don't confuse: "sickness" (patient's experience) with "disease" (clinical diagnosis)—the former requires listening, not just measuring.

📋 Collecting health history data

• Health history is gathered through direct interaction with the patient.
• The learning objectives emphasize collecting data, not just recording it—active engagement is required.
• The nurse must document actions and observations accurately.

🌍 Adapting assessment across contexts

🌍 Life span variations

• Assessment techniques must be modified to reflect variations across the life span.
• The excerpt does not provide specific age-group details but establishes the principle that one approach does not fit all ages.
• Example: communication and data collection with a child will differ from that with an older adult.

🌐 Cultural variations

• Assessment must also adapt to cultural variations.
• This aligns with the concept of cultural safety (defined in the glossary as creating safe spaces without judgment, racial reductionism, or discrimination).
• The nurse must recognize that patients' cultural backgrounds shape their experiences and responses.

🚨 Recognizing and reporting deviations

• Nurses must recognize and report significant deviations from norms.
• This requires knowing what is "normal" and being alert to what falls outside expected ranges.
• The emphasis is on both recognition (clinical judgment) and reporting (communication and documentation).

🧭 Overview

🧠 One-sentence thesis

Accurate blood pressure measurement is crucial for patient safety because it directly informs critical care decisions such as whether a patient needs fluids or medications.

📌 Key points (3–5)

• Why accuracy matters: Blood pressure measurements guide important clinical decisions about patient care, including fluid administration and medication prescriptions.
• What nurses must do: Measure and document blood pressure using American Heart Association standards.
• Adaptation requirement: The procedure must be adjusted to reflect variations across different life stages.
• Recognition and reporting: Nurses must identify and report significant deviations from normal blood pressure ranges.

🎯 Purpose and clinical significance

🎯 Why blood pressure measurement matters

• Blood pressure measurements are not just routine data—they are used by health care providers to make important decisions about a patient's care.
• The excerpt emphasizes that accuracy is essential for ensuring patient safety and optimizing body system function.

💊 Clinical decisions driven by blood pressure

Blood pressure readings help providers decide:

• Whether a patient needs fluids
• Whether a patient needs prescription medications

Example: If a patient's blood pressure is significantly low, the provider may order IV fluids; if it is significantly high, antihypertensive medication may be prescribed.

📏 Measurement standards and practice

📏 Following proper standards

• Nurses must measure and document blood pressure using American Heart Association standards.
• The excerpt stresses it is crucial to follow the proper steps to obtain a patient's blood pressure.
• Proper technique ensures the measurement is reliable and can be used safely for clinical decision-making.

🔄 Adapting across the life span

• The procedure must be adapted to reflect variations across the life span.
• Don't assume: the same technique does not work identically for all age groups—adjustments are needed for infants, children, adults, and older adults.

🚨 Recognition and reporting

🚨 Identifying deviations

• Nurses must recognize significant deviations from blood pressure norms.
• "Significant deviations" means values that fall outside the expected normal range for a patient.

📢 Reporting responsibility

• When deviations are identified, nurses must report them.
• Timely reporting ensures that providers can intervene appropriately to maintain patient safety.

🧭 Overview

🧠 One-sentence thesis

Aseptic technique encompasses a set of infection-control practices—including hand hygiene, standard and transmission-based precautions, sterile field maintenance, and proper use of protective equipment—that nurses must master to prevent healthcare-associated infections.

📌 Key points (3–5)

• Core skill set: hand hygiene, standard precautions, transmission-based precautions, sterile field maintenance, and proper donning/removal of gloves and PPE.
• Scope of the problem: over 2 million patients in America are affected by healthcare-associated infections (according to CDC data referenced in the excerpt).
• Learning objectives: the chapter aims to teach performance of these techniques, not just recognition.
• Common confusion: standard precautions vs. transmission-based precautions—standard applies to all patients; transmission-based are category-specific for particular infection risks.

🎯 Learning objectives and scope

🎯 What the chapter covers

The excerpt lists six core competencies that learners must develop:

• Perform appropriate hand hygiene
• Use standard precautions
• Use category-specific, transmission-based precautions
• Maintain a sterile field and equipment
• Apply and safely remove sterile gloves and personal protective equipment
• Dispose of contaminated wastes appropriately

📊 The scale of the problem

• The CDC reports that over 2 million patients in America are affected by healthcare-associated infections.
• This statistic establishes why aseptic technique is critical in clinical practice.
• The excerpt does not provide further detail on infection types or outcomes, but the number underscores the public health significance.

🧤 Key infection-control categories

🧤 Standard precautions

• These are baseline infection-control practices.
• The excerpt indicates they are distinct from transmission-based precautions.
• Standard precautions apply universally to all patient care.

🦠 Transmission-based precautions

• These are category-specific, meaning they are tailored to particular modes of disease transmission.
• They supplement standard precautions when specific infection risks are present.
• Don't confuse: standard precautions are for everyone; transmission-based are added for specific pathogens or situations.

🧼 Hand hygiene and sterile technique

• Hand hygiene is listed as a separate, foundational skill.
• Maintaining a sterile field and equipment is another distinct competency.
• Proper application and removal of sterile gloves and PPE prevents contamination during procedures.

🗑️ Waste management

🗑️ Appropriate disposal

• Contaminated wastes must be disposed of correctly to prevent transmission.
• The excerpt does not detail disposal methods, but lists it as a required skill.
• This step closes the infection-control loop after patient care.

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Note: The excerpt provided is primarily an introductory section listing learning objectives and a single CDC statistic. It does not yet explain the mechanisms, procedures, or rationales for each technique. Subsequent sections of Chapter 4 would be expected to elaborate on each competency in detail.

🧭 Overview

🧠 One-sentence thesis

Nurses must master mathematical calculations and critical evaluation of dosages because they are the final checkpoint before medication reaches the patient, and errors occur frequently in hospitalized patients.

📌 Key points (3–5)

• Why math matters: The average hospitalized patient experiences at least one medication error per day; nurses are the last step before administration.
• What calculations involve: Determining tablet counts, solution amounts, and intravenous infusion rates using decimals, fractions, percentages, ratios, proportions, and conversions.
• More than just math: Dosage calculation requires reading drug labels, determining needed information, performing calculations, critically evaluating safety, and selecting appropriate measurement devices.
• Common confusion: Calculation is not only solving a formula—it includes verifying the answer is within a safe dosage range for that specific patient.
• Final responsibility: Nurses bear the final responsibility to ensure medication safety before it reaches the patient.

🎯 Why nurses must calculate accurately

🎯 Medication error frequency

• The Institute of Medicine estimates the average hospitalized patient experiences at least one medication error each day.
• This high frequency makes calculation accuracy a critical safety skill.

🛡️ Nurses as the final checkpoint

• Nurses are the last step in the medication administration process before the drug reaches the patient.
• They bear the final responsibility to ensure the medication is safe.
• Example: Even if a physician orders a dose and a pharmacist dispenses it, the nurse must verify the calculation and safety before giving it to the patient.

🧮 What mathematical skills are required

🧮 Core calculation types

Nurses must accurately perform calculations using:

• Decimals
• Fractions
• Percentages
• Ratios
• Proportions

🔄 Conversions and systems

• Metric and household systems: Nurses must convert between these measurement systems.
• Military time: Used in healthcare settings for precise documentation.
• Dimensional analysis: A method for solving conversion and dosage problems.

💊 Clinical calculation scenarios

Nurses solve calculations related to:

• Conversions between units
• Dosages (how much to give)
• Liquid concentrations
• Reconstituted medications (mixing powders with liquids)
• Weight-based medications (dose depends on patient weight)
• Intravenous infusions (rate and volume over time)

🔍 The complete dosage calculation process

📋 Reading drug labels

• Nurses must extract pertinent information from drug labels.
• This is the first step before any calculation begins.

🧩 Setting up the problem

• Determine what information is needed to set up the math calculation.
• Identify the known values and the unknown value to solve for.

✏️ Performing calculations

• Execute the mathematical operations using the appropriate method (ratio, proportion, dimensional analysis, etc.).
• Example: If a medication is ordered in milligrams but supplied in grams, convert units before calculating the volume to administer.

✅ Critical evaluation of the answer

• Critically evaluate the calculated answer to determine if it is within a safe dosage range for that specific patient.
• Don't confuse: A mathematically correct answer may still be unsafe if it exceeds recommended limits or doesn't match the patient's age, weight, or condition.
• This step distinguishes nursing calculation from pure math—context and patient safety are essential.

📏 Selecting measurement devices

• Choose an appropriate measurement device to accurately measure the calculated dose or set the rate of administration.
• Example: Use a syringe with appropriate graduations for small volumes; use an infusion pump for continuous IV medications.

📚 Scope of the chapter

📚 What will be covered

The chapter explains how to perform dosage calculation tasks using authentic problems that a nurse commonly encounters in practice.

📚 Learning objectives

• Accurately perform calculations using decimals, fractions, percentages, ratios, and proportions
• Convert between metric and household systems
• Use military time
• Use dimensional analysis
• Accurately solve calculations related to conversions, dosages, liquid concentrations, reconstituted medications, weight-based medications, and intravenous infusions
• Evaluate the final answer to ensure safe medication administration

🧭 Overview

🧠 One-sentence thesis

A comprehensive neurological assessment systematically evaluates mental status, cranial nerves, sensory function, motor strength, cerebellar function, and reflexes, with techniques modified across different life stages.

📌 Key points (3–5)

• What the assessment covers: six core domains—mental status, cranial nerves, sensory function, motor strength, cerebellar function, and reflexes.
• How to perform it: systematic evaluation of each neurological domain using specific assessment techniques.
• Why modification matters: assessment techniques must be adapted to reflect variations across the life span (infants, children, adults, elderly).
• Documentation requirement: findings from the neurological assessment must be properly documented.

🧩 Core assessment domains

🧠 Mental status

• One of the six core components of a complete neurological assessment.
• Evaluates cognitive and psychological functioning.
• The excerpt identifies this as a distinct domain requiring specific assessment techniques.

🔍 Cranial nerves

• The second major domain in neurological assessment.
• Involves systematic evaluation of the twelve cranial nerves.
• Each nerve has specific functions that must be tested.

👋 Sensory function

• Assesses the ability to perceive and interpret sensory stimuli.
• A separate domain from motor function, though both are part of the peripheral nervous system evaluation.

💪 Motor strength

• Evaluates muscle power and voluntary movement.
• Distinct from cerebellar function, which assesses coordination rather than strength.
• Don't confuse: motor strength tests power; cerebellar tests coordination.

⚖️ Cerebellar function

• Assesses coordination, balance, and smooth movement.
• Different from motor strength—focuses on quality and coordination of movement rather than raw power.

🔨 Reflexes

• Tests involuntary responses to stimuli.
• Provides information about the integrity of sensory and motor pathways.

🔄 Life span considerations

👶 Variations across age groups

• Assessment techniques must be modified to reflect differences across the life span.
• The same neurological domain may require different testing approaches for different age groups.
• Example: techniques appropriate for adults may need adaptation for infants or elderly patients.

🎯 Why adaptation matters

• Developmental stages affect normal neurological findings.
• Age-appropriate techniques ensure accurate assessment and avoid false interpretations.
• Failure to modify techniques may result in inaccurate conclusions about neurological status.

📝 Documentation requirements

📋 Recording findings

• Documentation is an explicit learning objective alongside performing the assessment.
• All findings from the six assessment domains must be recorded.
• Proper documentation ensures continuity of care and legal accountability.

🧭 Overview

🧠 One-sentence thesis

Head and neck assessment is a routine daily nursing evaluation that inspects the skull, face, nose, oral cavity, and neck to identify and report significant deviations from normal findings.

📌 Key points (3–5)

• What is assessed: the head, neck, and oral cavity as part of routine inpatient care performed by registered nurses.
• Core components: skull, face, nose, oral cavity, and neck structures.
• Adaptation needed: assessment techniques must be modified to reflect variations across the patient's life span.
• Clinical action: nurses must recognize significant deviations from normal and document findings appropriately.

🩺 Scope and purpose of the assessment

🩺 What the assessment includes

The head and neck assessment is a structured inspection that covers:

• Skull
• Face
• Nose
• Oral cavity
• Neck

This is performed as part of routine daily assessment during inpatient care.

👤 Who performs it

Registered nurse (RN): the healthcare professional responsible for performing head and neck assessment during inpatient care.

• The excerpt specifies that this is an RN responsibility in the inpatient setting.
• It is part of the routine daily assessment workflow.

🔄 Assessment considerations

🔄 Life span variations

• Assessment techniques must be modified to reflect variations across the life span.
• The excerpt emphasizes that the same approach does not work for all age groups.
• Example: an infant's skull assessment differs from an adult's due to developmental differences.

📝 Documentation and reporting

Two key nursing responsibilities are highlighted:

1. Recognize and report significant deviations from norms.
2. Document actions and observations.

• "Significant deviations" means findings that fall outside the expected normal range.
• Documentation captures both what the nurse did (actions) and what was found (observations).

📚 Context from the excerpt

📚 Related content

The excerpt includes glossary terms and learning activities from a previous chapter (Chapter 6) on neurological assessment, including:

• Mental status examination (assesses cerebral function)
• Reflexes (e.g., Babinski response)
• Cranial nerve function (e.g., anosmia, ptosis, diplopia)
• Level of consciousness and Glasgow Coma Scale

These neurological concepts may overlap with head and neck assessment but are distinct from the structural inspection of the head, face, nose, oral cavity, and neck described in Chapter 7.

📚 Learning objectives

The excerpt lists four learning objectives for head and neck assessment:

1. Perform the assessment (skull, face, nose, oral cavity, neck)
2. Modify techniques for different life stages
3. Recognize and report deviations
4. Document findings

🧭 Overview

🧠 One-sentence thesis

Eye and ear assessment enables nurses to evaluate vision, hearing, and balance functions by performing structured examinations and recognizing deviations from normal.

📌 Key points (3–5)

• Purpose of assessment: to evaluate the ability to see, hear, and maintain balance—important functions of the eyes and ears.
• Core assessment skills: performing visual acuity, extraocular motion, and hearing acuity tests.
• Adaptation across the lifespan: assessment techniques must be modified to reflect variations across different ages.
• Documentation and reporting: nurses must document actions and observations, and recognize and report significant deviations from norms.

👁️ Vision and hearing as essential functions

👁️ Why eyes and ears matter

• The excerpt emphasizes that the ability to see, hear, and maintain balance are important functions of our eyes and ears.
• These sensory systems are critical for daily functioning and safety.
• Assessment aims to detect problems that could impair these essential abilities.

🔍 What assessment evaluates

The excerpt identifies three main areas:

• Visual acuity: how well a person can see.
• Extraocular motion: how the eye muscles move the eyeball.
• Hearing acuity: how well a person can hear.

🩺 Core assessment components

🩺 Visual acuity testing

• Measures how clearly a person can see.
• Part of the standard eye assessment.
• Example: A nurse tests whether a patient can read letters at a standard distance to detect vision problems.

👀 Extraocular motion assessment

• Evaluates the movement of the eyeball controlled by eye muscles.
• The orbit (bony socket) houses the eyeball and the muscles that move it.
• This test checks whether eye movements are coordinated and complete in all directions.

👂 Hearing acuity testing

• Measures how well a person can hear sounds.
• Part of the standard ear assessment.
• Example: A nurse checks whether a patient can hear whispered words or tuning fork tones to identify hearing loss.

🔄 Adapting assessment across the lifespan

🔄 Lifespan modifications

• The excerpt states that assessment techniques must be modified to reflect variations across the life span.
• Different age groups (infants, children, adults, older adults) may require different approaches or tools.
• Don't confuse: the same assessment goal applies across ages, but the method may change to suit developmental or physical differences.

📋 Example considerations

• Infants and young children may not be able to read letters, so visual acuity tests must use age-appropriate methods.
• Older adults may have age-related changes in vision or hearing that are normal but still need documentation.

📝 Documentation and reporting

📝 What to document

• Nurses must document actions and observations during the assessment.
• This includes recording test results, patient responses, and any abnormalities noted.

⚠️ Recognizing deviations from norms

• A key responsibility is to recognize and report significant deviations from norms.
• "Significant deviations" are findings that fall outside the expected range and may indicate disease or injury.
• Example: If a patient shows sudden vision loss or asymmetric eye movement, the nurse must report this promptly.

🔍 Why reporting matters

• Early recognition of abnormalities allows for timely intervention.
• Documentation creates a record for ongoing care and communication among the healthcare team.

🧬 Anatomical foundations

🧬 Eye anatomy overview

• The excerpt begins to introduce the anatomy of the eye, noting that vision occurs due to transduction (the process of converting light into neural signals).
• The orbit is the bony socket that houses the eyeball and the muscles that move it.
• Understanding anatomy is essential for interpreting assessment findings.

👂 Ear anatomy overview

• The excerpt mentions that the ear is involved in hearing and maintaining balance.
• Detailed anatomy will be covered in subsequent sections.
• Don't confuse: the ear has dual functions—hearing and balance—both of which may be assessed.

🩺 Related anatomical terms from the glossary

🦴 Head and neck structures relevant to assessment

The excerpt includes a glossary of terms that may appear during eye and ear assessment:

Term	Definition	Relevance to assessment
Orbit	Bony socket housing the eyeball and eye muscles	Site of eye examination; protects the eye
Nares	Nostril openings into the nasal cavity	Adjacent structures; may be examined together
Pharynx	Tube from nasal cavity divided into nasopharynx, oropharynx, laryngopharynx	Connected to ear via Eustachian tube (not detailed in excerpt)
Mandible	Lower jawbone	Landmark for head and neck assessment
Maxilla	Bone forming the upper jaw	Landmark for facial structure assessment

🧠 Neurological and muscular terms

• Facial drooping: asymmetrical facial expression due to nerve damage; may indicate stroke or nerve injury.
• Sternocleidomastoid: muscle that laterally flexes and rotates the head; tested during neck assessment.
• Trapezius: muscle that elevates shoulders and tilts the head; also tested during neck assessment.
• These structures may be assessed alongside eye and ear examinations to evaluate overall neurological function.

🩹 Common disorders mentioned

The glossary includes conditions that may be detected during assessment:

• Epistaxis: nosebleed (adjacent structure).
• Pharyngitis: infection/inflammation of the pharynx (may affect ear via connected structures).
• Sinusitis: inflamed sinuses from viral or bacterial infection (may cause referred symptoms).
• Concussion: traumatic brain injury that can affect vision, balance, and hearing.
• Hematoma: collection of blood (may occur around the eye or ear after trauma).

Don't confuse: these are potential findings, not part of the normal assessment procedure; they represent deviations that must be recognized and reported.

🧭 Overview

🧠 One-sentence thesis

Cardiovascular assessment requires nurses to combine thorough medical history with detailed physical examination of the heart and peripheral vascular system to identify potential signs of dysfunction.

📌 Key points (3–5)

• What nurses assess: heart sounds, apical and peripheral pulses (rate, rhythm, amplitude), and skin perfusion indicators (color, temperature, sensation, capillary refill).
• Key skill: distinguishing normal from abnormal heart sounds, including identifying S1 and S2 sounds.
• Assessment approach: integrating both subjective patient statements and objective physical findings to detect dysfunction clues.
• Important variations: assessment techniques must be modified across different life stages.
• Clinical responsibility: recognizing and reporting significant deviations from normal findings.

🫀 Components of cardiovascular assessment

🫀 Heart examination elements

The excerpt identifies specific heart-related assessments nurses perform:

• Heart sounds: listening for and identifying specific sounds (S1 and S2).
• Apical pulse: measuring at the apex of the heart.
• Pulse characteristics: evaluating three dimensions—rate (how fast), rhythm (regularity), and amplitude (strength).

🩸 Peripheral vascular assessment

Skin perfusion is evaluated through four observable indicators:

• Color: visual assessment of skin tone.
• Temperature: warmth or coolness of extremities.
• Sensation: patient's ability to feel touch.
• Capillary refill time: how quickly blood returns after pressure is applied.

Example: A nurse presses on a patient's fingernail and observes how many seconds it takes for color to return—this indicates peripheral circulation quality.

🔍 Clinical integration approach

🔍 Combining subjective and objective data

The evaluation includes a thorough medical history and detailed examination, incorporating subjective statements and objective findings to elicit clues of potential signs of dysfunction.

• Subjective: what the patient reports (symptoms like fatigue, indigestion, leg swelling).
• Objective: what the nurse observes and measures during physical examination.
• Both types of data must be integrated—neither alone provides the complete picture.

📋 Documentation and reporting

Nurses have two key responsibilities:

• Document: record all actions performed and observations made.
• Report: recognize when findings deviate significantly from normal ranges and communicate these to the healthcare team.

🎯 Special considerations

👶 Life span modifications

Assessment techniques are not one-size-fits-all:

• The excerpt emphasizes that methods must be modified to reflect variations across the life span.
• Different age groups (infants, children, adults, elderly) require adapted approaches.
• Don't assume: the same technique used on an adult may not be appropriate or effective for a child or older adult.

🧭 Overview

🧠 One-sentence thesis

Respiratory assessment evaluates the body's ability to obtain adequate oxygen through detailed interview and physical examination, which has significant implications for overall patient health.

📌 Key points (3–5)

• Purpose of respiratory assessment: to collect subjective and objective data about the body's ability to obtain adequate oxygen for daily functions.
• Core respiratory functions: the system provides constant oxygen supply and removes carbon dioxide through ventilation and gas exchange.
• Key distinction: ventilation is the mechanical movement of air in and out of lungs; respiration includes both ventilation and alveolar gas exchange where blood is oxygenated.
• Assessment scope: includes differentiating normal from abnormal lung sounds, modifying techniques across the lifespan, and recognizing deviations from norms.
• Clinical significance: inadequacy in respiratory function can have significant implications for overall patient health.

🫁 Respiratory System Functions

🫁 Main functions

The respiratory system has two primary roles:

• Provide the body with a constant supply of oxygen
• Remove carbon dioxide from the body

These functions are essential for the body to perform daily activities.

⚙️ Ventilation vs respiration

Ventilation: the mechanical movement of air into and out of the lungs, created by muscles and structures of the thorax.

Respiration: includes both ventilation and gas exchange at the alveolar level where blood is oxygenated and carbon dioxide is removed.

Don't confuse: Ventilation is only the air movement part; respiration is the complete process including gas exchange.

Term	What it includes	Where it happens
Ventilation	Mechanical air movement	Thorax and lungs
Respiration	Ventilation + gas exchange	Includes alveolar level

🔍 Assessment Components

🔍 Data collection methods

The evaluation includes two main approaches:

• Subjective data: collected through detailed interview
• Objective data: collected through physical examination of the thorax and lungs

🎯 Key assessment skills

Nurses performing respiratory assessment must be able to:

• Differentiate between normal and abnormal lung sounds
• Modify assessment techniques to reflect variations across the life span
• Document actions and observations accurately
• Recognize and report deviations from norms

Example: The same assessment technique may need adjustment when examining a child versus an elderly adult.

🏗️ Anatomical Understanding

🏗️ Required structural knowledge

To complete an effective respiratory assessment, nurses must understand:

• External structures involved with respiration and ventilation
• Internal structures involved with respiration and ventilation
• Upper and lower respiratory system structures
• Lobular division of the lung structures
• The bronchial tree

🩺 Clinical significance

The examination can offer significant clues related to issues associated with the body's ability to obtain adequate oxygen to perform daily functions.

Understanding anatomy is foundational because inadequacy in respiratory function impacts overall patient health.

🧭 Overview

🧠 One-sentence thesis

Effective oxygenation requires the coordinated function of multiple body systems—from open airways and mechanical lung movement to adequate hemoglobin and effective heart pumping—to deliver the oxygen from air (which contains 21% oxygen) to tissues and remove carbon dioxide.

📌 Key points (3–5)

• What oxygenation requires: collaboration of several body systems working together to take in oxygen, transport it through blood, and deliver it to tissues.
• The complete pathway: airway → mechanical breathing → open bronchial airways → alveolar gas exchange → heart pumping → hemoglobin transport → tissue delivery and CO₂ removal.
• Key bottlenecks: any breakdown in the chain (blocked airway, poor lung mechanics, inadequate hemoglobin, weak heart function) can impair oxygenation.
• Oxygen in air: atmospheric air contains 21% oxygen, which is the starting point for the entire process.
• Common confusion: oxygenation is not just "breathing in air"—it involves mechanical ventilation, gas exchange, circulation, and tissue-level delivery working in sequence.

🫁 The oxygenation pathway

🚪 Airway patency

• The airway must be open and clear for air to enter.
• This is the first gate: if blocked, no oxygen can reach the lungs regardless of other system function.
• Example: An obstructed airway prevents all downstream oxygenation steps.

🌬️ Mechanical ventilation

Ventilation: the mechanical movement of air into and out of the lungs.

• The chest and lungs must physically move air in and out.
• This is distinct from gas exchange—it is the bellows action that brings fresh air into the lungs.
• Without effective mechanical movement, oxygen-rich air cannot reach the alveoli.

🌳 Bronchial airway clearance

• The bronchial airways must be open and clear so air can reach the alveoli.
• Obstruction or narrowing at this level prevents oxygen from reaching the gas-exchange sites.
• Don't confuse: this is about the internal lung passages, not the upper airway or the alveoli themselves.

🔄 Gas exchange and transport

💨 Alveolar gas exchange

Respiration: includes ventilation and gas exchange at the alveolar level where blood is oxygenated and carbon dioxide is removed.

• At the alveoli, oxygen is absorbed into the bloodstream and carbon dioxide is released during exhalation.
• This is the critical interface between air and blood.
• Example: Even with open airways and good ventilation, damaged alveoli (e.g., collapsed alveoli/atelectasis) prevent effective oxygen uptake.

❤️ Cardiac pumping

• The heart must effectively pump oxygenated blood:
  • To and from the lungs (pulmonary circulation)
  • Through the systemic arteries (to tissues)
• Weak or ineffective pumping means oxygen-rich blood does not reach tissues, even if lungs function well.

🩸 Hemoglobin transport

• Hemoglobin in the blood must be in adequate amounts to carry oxygen to tissues.
• At tissues, oxygen is released and carbon dioxide is absorbed and carried back to the lungs.
• Don't confuse: having oxygen in the lungs is not enough—you need sufficient hemoglobin to transport it through the bloodstream.

🎯 Clinical implications

🎯 Atmospheric oxygen baseline

• The air we breathe contains 21% oxygen.
• This is the natural starting concentration; oxygen therapy increases this percentage when the body's oxygenation process is impaired.
• Example: Supplemental oxygen raises the inspired oxygen concentration above 21% to compensate for system failures.

⚠️ System interdependence

System component	Role	Consequence of failure
Airway patency	Entry gate for air	No oxygen can enter
Mechanical breathing	Moves air in/out	Fresh air cannot reach alveoli
Bronchial airways	Conduct air to alveoli	Oxygen cannot reach gas-exchange sites
Alveolar exchange	Oxygen enters blood, CO₂ exits	Blood remains unoxygenated
Heart pumping	Circulates oxygenated blood	Oxygen does not reach tissues
Hemoglobin	Carries oxygen in blood	Insufficient oxygen delivery to tissues

• The excerpt emphasizes that several body systems must work collaboratively—a breakdown at any point disrupts the entire oxygenation process.
• Medical conditions can impair any of these steps, requiring oxygen therapy and other interventions.

🧭 Overview

🧠 One-sentence thesis

A thorough abdominal assessment enables nurses to evaluate gastrointestinal and genitourinary system function and deliver high-quality care by distinguishing normal from abnormal findings.

📌 Key points (3–5)

• Purpose of abdominal assessment: provides valuable information about the patient's gastrointestinal (GI) and genitourinary (GU) systems.
• Core skills required: performing the assessment, differentiating normal and abnormal bowel sounds, and modifying techniques across the lifespan.
• Clinical responsibilities: documenting observations accurately and recognizing significant deviations from normal that require reporting.
• Why proper technique matters: understanding correct assessment methods and recognizing both normal and abnormal findings allows nurses to provide high-quality patient care.

🎯 Learning objectives

🎯 Assessment skills

The excerpt identifies five key competencies nurses must develop:

• Perform an abdominal assessment: execute the physical examination properly.
• Differentiate bowel sounds: distinguish between normal and abnormal sounds during auscultation.
• Modify techniques: adapt assessment methods to reflect variations across the lifespan (e.g., pediatric vs. geriatric patients).

📝 Documentation and reporting

• Document actions and observations: record what was done and what was found during the assessment.
• Recognize and report deviations: identify significant abnormal findings that differ from normal ranges and communicate them appropriately.

🏥 Clinical significance

🏥 What the assessment reveals

A thorough assessment of the abdomen provides valuable information regarding the function of a patient's gastrointestinal (GI) and genitourinary (GU) systems.

• The abdomen contains organs from two major body systems: GI (digestive) and GU (urinary and reproductive).
• Assessment findings reflect how well these systems are functioning.
• Example: abnormal bowel sounds or abdominal distension may indicate GI dysfunction; tenderness in certain areas may suggest GU problems.

💡 Foundation for quality care

• The excerpt emphasizes that proper assessment skills are essential for "high-quality care."
• Understanding how to properly assess (technique) and recognizing findings (interpretation) are both necessary.
• Don't confuse: performing the assessment correctly is not enough—nurses must also know what the findings mean and when they are significant.

🧭 Overview

🧠 One-sentence thesis

The excerpt introduces the musculoskeletal assessment chapter with learning objectives focused on performing assessments and palpating joints for specific clinical findings.

📌 Key points (3–5)

• Primary skill: performing a musculoskeletal assessment is the core competency introduced.
• Palpation focus: assessing joints for pain, swelling, temperature changes (objective data collection).
• Chapter structure: this is an introductory section that sets up the learning objectives for the full chapter.
• Context placement: follows abdominal assessment (Chapter 12) in a nursing skills textbook sequence.

📚 Chapter introduction and scope

📚 What this chapter covers

The excerpt presents the opening of Chapter 13, which focuses on musculoskeletal assessment skills for nursing practice.

• The chapter appears in a larger nursing skills textbook (Part XIII).
• It follows a pattern similar to previous chapters (e.g., Chapter 12 on abdominal assessment).
• The introduction is brief and primarily lists learning objectives rather than providing detailed content.

🎯 Learning objectives stated

The excerpt lists two specific learning objectives:

1. Perform a musculoskeletal assessment - the overall skill competency
2. Palpate joints - a specific technique within the assessment

The palpation objective specifies looking for:

• Pain
• Swelling
• Change in temperature
• (The list appears incomplete in the excerpt)

🔍 Assessment techniques introduced

🔍 Palpation as a key method

Palpate joints for pain, swelling, change in temperature, and [additional criteria not provided in excerpt]

• Palpation means using hands to feel and examine body structures.
• The focus is on joints specifically, not general musculoskeletal structures.
• Clinicians assess multiple parameters during palpation, not just one finding.

🩺 What findings to look for

The excerpt identifies three specific assessment parameters:

Finding	What it indicates
Pain	Potential inflammation, injury, or pathology
Swelling	Fluid accumulation or tissue inflammation
Temperature change	Increased warmth may suggest inflammation; coolness may indicate circulation issues

Note: The excerpt cuts off mid-sentence, so additional assessment parameters are likely included in the full chapter but are not available here.

⚠️ Limitations of this excerpt

The provided text is primarily structural (chapter headings, page numbers, and incomplete learning objectives) rather than substantive content. The actual teaching material about how to perform musculoskeletal assessments, clinical reasoning, and detailed techniques is not included in this excerpt. The chapter introduction appears to continue beyond what is shown.

🧭 Overview

🧠 One-sentence thesis

A comprehensive integumentary assessment of skin, hair, and nails establishes a baseline for patient care and is essential for preventing and treating skin injuries during inpatient care.

📌 Key points (3–5)

• What is assessed: The integumentary system includes the skin, hair, and nails.
• When it's done: A comprehensive skin assessment on admission establishes a baseline and is part of routine head-to-toe assessments by registered nurses.
• Why it matters: The skin performs essential protective, sensory, and regulatory functions including protection from microorganisms, preventing dehydration, temperature regulation, and vitamin D synthesis.
• Documentation requirement: Nurses must document actions and observations, and recognize and report significant deviations from norms.
• Adaptation needed: Assessment techniques must be modified to reflect variations across the life span and ethnic and cultural differences.

🎯 Purpose and scope of integumentary assessment

🎯 What nurses assess

The integumentary assessment covers three main components:

• Skin: The primary organ of the integumentary system
• Hair: Part of the comprehensive assessment
• Nails: Included in routine evaluation

🏥 When and why assessment is performed

• Timing: During inpatient care admission and as part of routine head-to-toe assessments
• Purpose: Establishes a baseline for the condition of a patient's skin
• Clinical importance: Essential for developing a care plan for prevention and treatment of skin injuries
• Example: A patient admitted to the hospital receives a comprehensive skin assessment to document existing conditions before any hospital-acquired changes occur.

🛡️ Functions of the skin

🛡️ Protective functions

The skin serves as the body's first line of defense:

• Against invasion: Protects from microorganisms, chemicals, and other environmental factors
• Against dehydration: Prevents water loss from the body

🌡️ Regulatory and sensory functions

Beyond protection, the skin performs active regulatory roles:

• Sensory organ: Acts as a receptor for external stimuli
• Temperature modulation: Helps regulate body temperature
• Electrolyte balance: Assists in maintaining electrolyte equilibrium
• Vitamin D synthesis: Produces vitamin D when exposed to sunlight

Don't confuse: The skin is not just a passive barrier—it actively regulates multiple body systems and produces essential substances.

🏗️ Skin structure

🏗️ Layered organization

The skin is made of multiple layers of cells and tissues, which are held to underlying structures by connective tissue.

The excerpt identifies the skin's composition:

• Two main layers: The skin is composed of two main layers
• Uppermost layer: The excerpt begins to describe this but is cut off
• Connection: Layers are held to underlying structures by connective tissue

🔬 Cellular composition

• The skin consists of multiple layers of cells and tissues working together
• These layers are not independent but connected to deeper body structures
• The organization allows the skin to perform its multiple functions effectively

📋 Assessment responsibilities

📋 Core nursing competencies

Registered nurses performing integumentary assessments must:

• Perform: Complete the physical assessment of skin, hair, and nails
• Modify: Adapt techniques for different populations and contexts
• Document: Record all actions and observations accurately
• Recognize: Identify significant deviations from normal findings
• Report: Communicate abnormal findings appropriately

🌍 Variations to consider

Assessment techniques must account for:

• Life span variations: Different age groups (infants, children, adults, elderly) present differently
• Ethnic variations: Skin characteristics vary across ethnic groups
• Cultural variations: Cultural factors may affect assessment approach and interpretation

Don't confuse: "Variations" doesn't mean abnormalities—many differences across populations are normal and expected, not pathological.

📝 Documentation and reporting

• All observations must be documented as part of the patient record
• Significant deviations from normal require recognition and reporting
• Proper documentation supports care plan development and continuity of care

🧭 Overview

🧠 One-sentence thesis

Enteral medication administration encompasses all routes that deliver drugs into the gastrointestinal tract—oral, rectal, or via feeding tubes—and requires systematic safety checks, accurate dosing, patient education, and appropriate assessment before and after giving medications.

📌 Key points (3–5)

• What "enteral" means: medications administered into the gastrointestinal tract, not just oral routes.
• Three main routes: orally (PO), rectally (PR), or through tubes (NG, NI, PEG).
• Core safety practices: checking medication rights three times, calculating correct doses, collecting assessment data before and after administration.
• Common confusion: "enteral" is not synonymous with "oral"—it includes rectal and tube routes as long as the medication enters the GI tract.
• Why documentation and patient education matter: nurses must explain medication information to patients and document actions and observations.

💊 What enteral medication means

💊 Definition and scope

Enteral medication: medications administered into the gastrointestinal tract, including orally (PO), rectally (PR), or through a tube such as a nasogastric (NG) tube, nasointestinal (NI) tube, or percutaneous endoscopic gastrostomy (PEG) tube.

• The term comes from "enteral," meaning related to the intestines.
• It is not limited to swallowing pills; any route that delivers medication into the GI tract counts as enteral.
• Example: A patient who cannot swallow may receive medication through a PEG tube—this is still enteral administration.

🔍 Don't confuse enteral with oral only

• Oral (PO) is one type of enteral route, but enteral also includes rectal and tube routes.
• All three share the common feature: the medication enters the gastrointestinal system.

🛡️ Core safety and clinical responsibilities

✅ Medication rights and triple-checking

• The excerpt emphasizes "accurately check medication administration rights three times."
• This systematic verification reduces errors and ensures the correct medication reaches the correct patient.
• Example: Before preparing, during preparation, and before administering, the nurse verifies patient identity, drug name, dose, route, and time.

🧮 Dose calculation

• Nurses must "calculate correct amount of medication to administer."
• Accurate math is essential to avoid underdosing (ineffective treatment) or overdosing (toxicity).

📋 Assessment before and after

• "Collect appropriate assessment data prior to and after medication administration."
• Before: check vital signs, allergies, contraindications, or baseline symptoms.
• After: monitor for therapeutic effects, side effects, or adverse reactions.
• Example: Before giving an antihypertensive, check blood pressure; after, recheck to see if it lowered appropriately.

🗣️ Patient education and documentation

🗣️ Explaining medication information

• Nurses must "explain medication information to patient."
• Patients need to understand what the medication is, why they are receiving it, and what to expect.
• This supports informed consent and adherence.

📝 Documentation requirements

• "Document actions and observations" is a core responsibility.
• Accurate records provide continuity of care and legal protection.
• Example: Document the time given, route, dose, patient response, and any concerns.

🧒 Lifespan considerations

🧒 Modifying procedures across ages

• The excerpt states nurses should "modify procedure to reflect variations across the life span."
• Infants, children, adults, and older adults have different needs (e.g., dose adjustments, swallowing ability, tube size).
• Example: A pediatric patient may need liquid formulations and smaller tube sizes; an older adult may have difficulty swallowing tablets and require crushing or liquid alternatives.

🚪 Routes of enteral administration

🚪 Three main pathways

Route	Abbreviation	Description
Oral	PO	Medication swallowed by mouth
Rectal	PR	Medication inserted into the rectum
Tube	NG, NI, PEG	Medication delivered through nasogastric, nasointestinal, or gastrostomy tubes

• All three deliver medication into the GI tract.
• Choice of route depends on patient ability to swallow, level of consciousness, GI function, and clinical indication.
• Example: A patient with nausea and vomiting may receive an antiemetic rectally; a patient with a stroke and dysphagia may receive medications via NG tube.

🧭 Overview

🧠 One-sentence thesis

Topical and transdermal medications provide both local and systemic effects through skin or mucous membrane application, offering consistent drug levels and alternatives for patients who cannot take oral medications.

📌 Key points (3–5)

• Topical vs transdermal distinction: topical medications are applied to skin/mucous membranes for direct local or systemic action; transdermal specifically refers to patches/disks that deliver medication over extended periods.
• Transdermal advantages: provides consistent bloodstream drug levels and helps patients who are nauseated or have difficulty swallowing.
• Common transdermal medications: analgesics (fentanyl), cardiac medications (nitroglycerin), hormones (estrogen), and nicotine patches.
• Heat application consideration: heat causes vasodilation, enhancing blood flow and improving absorption of some medications.
• Common confusion: not all topical medications are transdermal—inunctions (rubbed-in creams) are topical but not transdermal patches.

💊 Topical medication fundamentals

💊 What topical medications are

Topical medications: medications that are administered via the skin or mucous membranes for direct local action, as well as for systemic effects.

• Applied directly to skin or mucous membranes
• Can work locally (at the site of application) or systemically (throughout the body)
• Broader category that includes multiple application methods

🧴 Inunctions (rubbed-in medications)

Inunction: a medication that is massaged or rubbed into the skin and includes topical creams.

• Requires active rubbing or massaging into the skin
• Example: nystatin antifungal cream
• This is one type of topical medication delivery

🩹 Transdermal medication delivery

🩹 What transdermal means

Transdermal route: patches or disks applied to the skin that deliver medication over an extended period of time.

• Specific subset of topical medications
• Uses patch or disk format
• Key characteristic: delivers medication over extended time periods
• Don't confuse with general topical creams that are rubbed in

💉 Common transdermal medications

Medication Type	Example
Analgesics	Fentanyl
Cardiac medications	Nitroglycerin
Hormones	Estrogen
Smoking cessation	Nicotine patches

⚖️ Why transdermal delivery matters

Consistent drug levels:

• Provides a consistent level of the drug in the bloodstream for distribution
• Avoids peaks and valleys that can occur with other routes

Patient-friendly alternative:

• Helpful for patients who are nauseated
• Helpful for patients having difficulty swallowing (dysphagia)
• Example: A patient who cannot swallow pills can receive pain medication via fentanyl patch instead

🌡️ Heat application with topical medications

🌡️ How heat affects absorption

Mechanism:

• Heat causes vasodilation (blood vessels widen)
• Vasodilation enhances blood flow to the area
• Improved blood flow increases absorption of some medications

When it's used:

• May be applied with the administration of some inunctions
• Not all topical medications require or benefit from heat application

📋 Medication order types (context)

📋 Key prescription categories

The excerpt provides definitions for various order types that apply to medications administered via any route:

Time-based orders:

• Routine order: followed until another order cancels it (e.g., "Lisinopril 10 mg PO daily")
• Scheduled order: given at specific intervals to maintain consistent drug levels (e.g., every six hours)
• One-time order: administered only once (e.g., pre-surgery IV antibiotics)

Urgency-based orders:

• STAT order: administered without delay (e.g., Benadryl for allergic reaction)

Condition-based orders:

• PRN order: given when requested by or needed by the patient, based on symptoms (e.g., "Acetaminophen 500 mg PO every 4-6 hours as needed for pain")
• Standing order/protocol: standard prescriptions for clearly defined circumstances without notifying provider (e.g., chest pain protocol: aspirin, IV, ECG)
• Titration order: dose progressively increased or decreased by nurse based on patient status

📝 Documentation systems

• MAR: Medication administration record in patient's chart
• eMAR: Electronic medication administration record in electronic chart
• Incident report: documents events surrounding a medication error, submitted per agency policy

🧭 Overview

🧠 One-sentence thesis

Enteral tubes serve as alternate routes for feeding, medication administration, and stomach decompression, requiring nurses to assess placement, maintain patency, and prevent complications.

📌 Key points (3–5)

• What enteral tubes are: tubes placed in the gastrointestinal tract for feeding, medication delivery, and decompression.
• What stomach decompression means: removing stomach contents via suctioning to reduce pressure from fluids and gas.
• When decompression is used: commonly after surgery or trauma to prevent pain, nausea, vomiting, and aspiration.
• Core nursing responsibilities: assessing tube placement and patency, cleansing insertion sites, administering tube feeding and medication.
• Common confusion: enteral tubes are not only for feeding—they also deliver medication and decompress the stomach.

🩺 What enteral tubes do

🍽️ Three main functions

Enteral tubes are placed in the gastrointestinal tract and serve multiple purposes:

Function	Purpose
Feeding	Alternate route for nutrition when oral intake is not possible
Medication administration	Deliver medications directly into the GI tract
Stomach decompression	Remove stomach contents to reduce pressure

• The excerpt emphasizes that enteral tubes are not single-purpose devices; they address feeding, medication, and decompression needs.
• Example: A patient who cannot swallow after surgery may receive nutrition and medications through the same enteral tube.

🌀 Stomach decompression explained

Stomach decompression: a medical term that refers to removing stomach contents by using suctioning.

• Why it's needed: fluids and gas can build up in the stomach, causing pressure.
• What it prevents: pain, nausea, vomiting, and potential aspiration of stomach contents into the lungs.
• When it's used: commonly after surgery or trauma.
• The excerpt highlights that decompression is a protective measure, not just a comfort intervention.
• Don't confuse: decompression is about removing contents, not delivering them.

👩‍⚕️ Nursing responsibilities

🔍 Assessment tasks

Nurses must perform two key assessments:

• Tube placement: verify the tube is in the correct position in the GI tract.
• Tube patency: ensure the tube is open and functioning, not blocked.

These assessments are foundational—without correct placement and patency, feeding, medication, and decompression cannot occur safely.

🧼 Insertion site care

• Assessing the insertion site: check for signs of complications (the excerpt does not specify which signs, but assessment is required).
• Cleansing the insertion site: maintain hygiene to prevent infection or irritation.

💊 Administration responsibilities

Nurses are responsible for:

• Administering tube feeding: delivering nutrition through the enteral tube.
• Administering medication: giving medications via the tube when oral administration is not possible.

The excerpt lists these as distinct responsibilities, emphasizing that both require proper technique and assessment.

🎯 Key nursing actions

📋 Core competencies

The excerpt outlines what nurses must be able to do:

• Select appropriate equipment: choose the right tools for tube management.
• Explain the procedure to the patient: provide clear communication about what will happen.
• Implement measures to prevent displacement: take steps to keep the tube in place.
• Perform irrigation and suctioning: maintain tube function and perform decompression.
• Modify procedures across the life span: adjust techniques for different age groups.
• Document actions and observations: record what was done and what was observed.
• Recognize and report significant deviations from norms: identify and communicate problems.

⚠️ Prevention focus

• The excerpt specifically mentions "implement measures to prevent displacement of tube."
• This highlights that tube displacement is a known risk; nurses must actively work to prevent it.
• Example: A displaced tube could deliver feeding into the wrong location, causing aspiration or other harm.

🧭 Overview

🧠 One-sentence thesis

This chapter teaches nurses how to safely administer medications through intradermal, subcutaneous, and intramuscular routes by maintaining aseptic technique, selecting appropriate equipment and sites, and calculating correct dosages.

📌 Key points (3–5)

• Three parenteral routes covered: intradermal, subcutaneous, and intramuscular—each requires different techniques and site selection.
• Core competencies required: aseptic technique, equipment selection, dose calculation, and anatomical landmark identification.
• Safety emphasis: the chapter focuses on safe administration practices across all three injection routes.
• Procedure modification: nurses must be able to adapt procedures appropriately (though the excerpt does not detail specific modifications).

💉 Parenteral medication routes

💉 Three injection types

The chapter addresses three distinct parenteral (non-oral) medication routes:

Route	Description
Intradermal	Injection into the dermis layer of skin
Subcutaneous	Injection into the tissue layer beneath the skin
Intramuscular	Injection into muscle tissue

• Each route serves different medication types and absorption needs.
• The route determines equipment selection, site selection, and technique.

Don't confuse: These are three separate routes with different depths and purposes; selecting the wrong route can affect medication absorption and patient safety.

🎯 Essential skills for safe administration

🧼 Aseptic technique

Aseptic technique: maintaining sterility throughout the medication preparation and administration process to prevent infection.

• Required for all parenteral medication administration.
• Prevents introducing pathogens into the patient's tissues.
• Must be maintained from preparation through injection.

🧮 Dose calculation

• Nurses must calculate the correct amount of medication to administer.
• Accuracy is critical—parenteral medications enter tissues directly and cannot be easily retrieved if an error occurs.
• Example: If an order specifies a dose in milligrams but the vial is labeled in a different concentration, the nurse must calculate the correct volume to draw.

📍 Site selection using anatomical landmarks

• Proper site selection requires knowledge of anatomical landmarks.
• Landmarks help identify safe injection zones and avoid nerves, blood vessels, and bones.
• Different routes require different anatomical sites.

Why this matters: Incorrect site selection can cause nerve damage, tissue injury, or improper medication absorption.

🔧 Equipment selection

• Appropriate equipment must be chosen for each route and medication.
• Equipment considerations likely include needle length, gauge, and syringe size (though specific details are not provided in this excerpt).
• The route and patient characteristics influence equipment choices.

🔄 Procedure adaptation

🔄 Modifying procedures

• The chapter indicates that nurses must be able to "modify procedure to..." (the excerpt cuts off here).
• This suggests that standard procedures may need adjustment based on:
  • Patient-specific factors
  • Clinical circumstances
  • Medication characteristics

Note: The excerpt does not provide complete information about what modifications are taught or when they are needed.

---

Limitation of this excerpt: The provided text includes primarily the chapter title, learning objectives, and introductory material. The substantive content about techniques, specific anatomical sites, step-by-step procedures, and detailed safety considerations is not included in this excerpt. These notes reflect only what is explicitly stated in the learning objectives and introduction.

🧭 Overview

🧠 One-sentence thesis

This chapter teaches nurses how to accurately collect various clinical specimens, including blood glucose samples and nasal swabs, as part of diagnostic testing and patient care.

📌 Key points (3–5)

• Purpose: Specimen collection is a core nursing skill used for diagnostic testing and monitoring patient conditions.
• Types covered: The chapter addresses blood glucose monitoring and nasal swab collection techniques.
• Accuracy matters: Proper collection technique is essential for reliable test results and appropriate patient care decisions.
• Learning focus: The chapter emphasizes performing collection procedures accurately and safely.

🔬 Scope of specimen collection

🔬 What this chapter covers

The excerpt introduces Chapter 19 on specimen collection but provides limited detail about the full content. The learning objectives indicate the chapter will teach:

• Blood glucose monitoring specimen collection
• Nasal swab collection techniques
• Accurate collection methods for these specimen types

🎯 Why specimen collection matters

• Specimens provide diagnostic information that guides clinical decisions
• Proper technique ensures test accuracy
• Nurses are responsible for collecting many types of specimens in clinical practice

⚠️ Note on excerpt content

The provided excerpt consists primarily of:

• The chapter title and introductory heading
• A partial learning objectives list that is cut off mid-sentence
• No substantive instructional content about specimen collection procedures, techniques, or principles

The excerpt does not contain enough information to explain specific collection methods, step-by-step procedures, common errors, or clinical applications. A complete review would require the full chapter text.

🧭 Overview

🧠 One-sentence thesis

This chapter equips nurses with the skills to assess wounds and pressure injuries, perform wound cleansing and irrigation, apply various dressings, obtain cultures, and use appropriate aseptic or sterile techniques.

📌 Key points (3–5)

• Core competencies covered: assessing tissue condition, wounds, drainage, and pressure injuries; cleansing and irrigating wounds; applying wound dressings; obtaining wound cultures; using aseptic/sterile technique.
• Scope of practice: the chapter focuses on practical nursing skills for wound management across different wound types.
• Technique emphasis: appropriate infection control measures (aseptic vs. sterile) are integral to wound care procedures.

🩹 Assessment Skills

🔍 What nurses evaluate

The excerpt identifies several assessment targets for wound care:

• Tissue condition: evaluating the state of the tissue around and within the wound.
• Wounds themselves: characteristics of the wound (size, depth, appearance).
• Drainage: type, amount, and quality of fluid coming from wounds.
• Pressure injuries: specific assessment of injuries caused by sustained pressure on tissue.

These assessment skills form the foundation for appropriate wound care interventions.

🧼 Wound Cleansing and Irrigation

💧 Core procedures

The chapter teaches two related but distinct skills:

• Cleansing wounds: removing debris and contaminants from wound surfaces.
• Irrigating wounds: using fluid to flush out wounds, typically for deeper cleaning.

These procedures prepare wounds for dressing application and promote healing by maintaining a clean wound bed.

🏥 Dressing Application and Specimen Collection

🩹 Applying wound dressings

• Nurses learn to apply a variety of wound dressings, indicating that different wound types and healing stages require different dressing approaches.
• The skill set is comprehensive rather than limited to a single dressing type.

🧪 Obtaining wound cultures

• Wound culture specimen collection is a distinct skill taught in this chapter.
• Proper technique ensures accurate identification of wound pathogens for targeted treatment.

🦠 Infection Control in Wound Care

🧤 Aseptic vs. sterile technique

The excerpt emphasizes using appropriate aseptic or sterile techniques, indicating:

• Not all wound care procedures require the same level of infection control.
• Nurses must understand when to use aseptic technique (clean technique) versus sterile technique (completely pathogen-free).
• Common confusion: The distinction between aseptic and sterile is critical—choosing the wrong technique can either increase infection risk or waste resources.

Note: The excerpt provides learning objectives only; detailed procedural steps and rationales for each skill are presumably covered in the full chapter content.

🧭 Overview

🧠 One-sentence thesis

The general survey assessment is a continuous, holistic observation process that begins at first patient contact and uses all five senses to gather cues about the patient's overall condition, guiding further focused assessments within the nursing process.

📌 Key points (3–5)

• What a general survey is: a component of patient assessment that observes the entire patient as a whole, starting from initial contact and continuing throughout care.
• How it fits in nursing practice: assessment is the first phase of the six-component nursing process (ADOPIE: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation).
• Types of data collected: subjective data (patient/family reports, inferences) and objective data (observable, reproducible findings like vital signs).
• Three sources of assessment data: focused interviews, physical examination techniques (inspection, auscultation, palpation, percussion), and laboratory/diagnostic test results.
• Common confusion: primary vs. secondary subjective data—primary comes directly from the patient; secondary comes from family, charts, or other sources.

🩺 What is a General Survey Assessment

🩺 Definition and scope

General survey assessment: a component of patient assessment that observes the entire patient as a whole.

• It is not a one-time snapshot; it begins with initial patient contact and continues throughout the helping relationship.
• The nurse uses all five senses to gather cues: appearance, posture, gait, verbal and nonverbal communication, and behaviors.
• Cues obtained guide additional focused assessments in areas of concern.
• Example: A nurse notices a patient avoiding eye contact and moving slowly—these cues prompt further questions about pain, mood, or cultural communication norms.

🔄 Connection to the nursing process

• The general survey is part of the Assessment phase, the first step in the nursing process.
• The nursing process has six components (mnemonic ADOPIE): Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation.
• It is a continuous, cyclic process that constantly adapts to the patient's current health status.
• The American Nurses Association (ANA) defines assessment as collecting pertinent data—demographics, social determinants, physical, psychosocial, emotional, cognitive, cultural, spiritual, and economic factors—in a systematic, ongoing, compassionate manner.

📊 Types of Assessment Data

📊 Subjective data

Subjective data: information obtained from the patient and/or family members, offering important cues from their perspectives.

• Includes patient reports, feelings, and perceptions.
• When documenting, use quotation marks and phrases like "The patient reports…" or "The patient's wife states…"
• Inferences (e.g., "The patient appears anxious") are also subjective because they reflect the nurse's interpretation.
• Example: "The patient reports pain severity of 2 on a 0-10 scale."

🔍 Primary vs. secondary subjective data

Type	Source	Example
Primary data	Directly from the patient	Patient describes their own pain level
Secondary data	Family, chart, other sources	Family member reports patient's recent confusion

• Patients are the best source of information about their own bodies and feelings.
• Active listening promotes well-being and uncovers valuable information.
• Secondary data is especially important for infants, children, or patients unable to speak for themselves.
• Don't confuse: both are subjective, but the source differs.

🔬 Objective data

Objective data: anything observable through the senses of hearing, sight, smell, and touch while assessing the patient.

• It is reproducible—another person can easily obtain the same data.
• Examples: vital signs, physical examination findings, laboratory results.
• Example: "The patient's radial pulse is 58 and regular, and their skin feels warm and dry."

🗂️ Three Sources of Assessment Data

💬 Interviewing

• Involves asking questions, listening, and observing verbal and nonverbal communication.
• Review the chart beforehand to eliminate redundancy and focus on significant areas or unclear information.
• Start with questions related to medical diagnoses to understand effects on functioning, relationships, and lifestyle.
• Use critical thinking and active listening to discover cues patients may not volunteer because they don't realize the importance.
• Pay attention to how patients answer and when they don't answer—nonverbal cues and body language matter.
• Validate cues to avoid inappropriate inferences.
  • Example: A patient avoids eye contact. The nurse infers depression but discovers through questioning that the patient's culture views direct eye contact as disrespectful.

🩺 Physical examination

Physical examination: a systematic data collection method using inspection, auscultation, palpation, and percussion.

Technique	Definition
Inspection	Observation of anatomical structures
Auscultation	Listening to sounds (heart, lung, bowel) with a stethoscope
Palpation	Using touch to evaluate organs for size, location, tenderness
Percussion	Tapping body parts with fingers to determine size and fluid presence (advanced technique)

• Registered Nurses (RNs) complete physical examinations and analyze findings as part of the nursing process.
• Collection can be delegated to LPNs/LVNs; vital signs and weight may be delegated to UAP when appropriate.
• The RN remains responsible for analyzing findings.
• Data is documented in the electronic medical record (EMR).

🧪 Reviewing laboratory and diagnostic test results

• An important component of the assessment phase.
• Provides relevant, useful information related to patient needs.
• Understanding normal and abnormal results is essential for implementing the nursing care plan and administering prescriptions.

🤝 Initiating Patient Interaction

🤝 Essential steps before every interaction

• Perform hand hygiene and consider additional personal protective equipment.
• Introduce yourself to the patient.
• Identify the patient using two different identifiers (e.g., name and date of birth).
• Provide a culturally safe space for interaction.
• Consider the developmental stage of the patient (infant, child, adult, older adult).

🧼 Infection prevention

• Hand hygiene is the first step before initiating care with any patient.
• (The excerpt ends here; further details on hand hygiene protocols are not provided.)

🧭 Overview

🧠 One-sentence thesis

Proper hand hygiene, appropriate use of personal protective equipment, and culturally safe patient interaction form the foundation of infection prevention and effective nursing care across all developmental stages.

📌 Key points (3–5)

• Hand hygiene timing and method: Hand sanitizer is generally as effective as soap and water, but soap and water are required for visibly soiled hands or suspected C. difficile infections.
• PPE risk assessment: Nurses must assess infection risk before entering patient rooms by checking for signage, known infections, and potential exposure to body fluids.
• AIDET communication framework: Acknowledge, Introduce, Duration, Explanation, and Thank You structure ensures clear, respectful patient interaction.
• Common confusion—gloves vs. hand hygiene: Gloves do not replace hand hygiene; hands must be washed after glove removal.
• Cultural safety and developmental adaptation: Care must be tailored to both the patient's cultural context and their developmental life stage.

🧼 Hand Hygiene Fundamentals

🧼 When to perform hand hygiene

The CDC specifies critical moments for hand hygiene:

• Immediately before touching a patient
• Before aseptic tasks or handling invasive devices
• Before moving from soiled to clean body sites on the same patient
• After contact with blood, body fluids, or contaminated surfaces
• Before donning gloves and immediately after glove removal
• When leaving the patient area

🧴 Hand sanitizer vs. soap and water

Method	When to use	Key technique
Hand sanitizer	General use; as effective as soap and water	Use enough gel to cover both hands; rub ~20 seconds until dry; coat all surfaces
Soap and water	Visibly soiled hands OR suspected/confirmed C. difficile	Clean all areas: front, back, fingertips, thumbs, between fingers

Don't confuse: Hand sanitizer works for most situations, but C. difficile requires soap and water because alcohol-based sanitizers cannot kill C. diff spores.

🧤 The glove misconception

Gloves are not a substitute for cleaning your hands.

• Hands must be washed after removing gloves.
• Hand hygiene is required both before donning and immediately after glove removal.
• Example: A nurse removes gloves after wound care—hand hygiene is still mandatory before touching another surface or patient.

🦺 Personal Protective Equipment (PPE)

🦺 What PPE includes

Medical asepsis: measures to prevent the spread of infection in health care agencies.

Personal protective equipment (PPE): gowns, eyewear or goggles, face shields, gloves, and masks used based on how infection is transmitted (contact, droplet, or airborne routes).

PPE works alongside environmental controls like surface cleaning and disinfecting.

🔍 Risk assessment before entering a room

Perform a general risk assessment by asking:

• Is there signage for contact, droplet, enhanced barrier, or airborne precautions?
• Does the patient have confirmed or suspected infection or communicable disease?
• Will face, hands, skin, mucous membranes, or clothing be potentially exposed to blood or body fluids by spray, coughing, or sneezing?

Example: A nurse sees a sign on the door indicating droplet precautions—the nurse must follow posted instructions and don appropriate PPE before entering.

🤝 Initiating Patient Interaction

🤝 AIDET communication framework

AIDET: Acknowledge, Introduce, Duration, Explanation, and Thank You.

Step	What to do	Example
Acknowledge	Greet by documented name; make eye contact; ask preferred name and pronouns	"Mr. Doe, how would you like to be addressed?"
Introduce	State your name and role	"I'm John Doe, a nursing student working with your nurse today."
Duration	Estimate timeline	"This should take about 5 minutes."
Explanation	Explain step by step; answer questions	"I will inflate this cuff—it will squeeze your arm for a few moments."
Thank You	Thank patient; ask if anything is needed; ensure call light is within reach	"Thank you. Is there anything I can get before I leave?"

🔐 Patient identification

Use at least two patient identifiers before assessments, vital signs, or care:

• Ask the patient to state their name and date of birth.
• Compare stated information to the armband.
• If no armband or patient cannot respond, scan the armband or ask staff/family to verify.

Confirm with a second source: scan wristband, compare to chart, verify with staff, compare photo on medication administration record (MAR), or ask family.

🌍 Cultural Safety and Developmental Adaptation

🌍 Creating culturally safe spaces

Cultural safety: the creation of safe spaces for patients to interact with health professionals without judgment or discrimination.

• Recognize that both you and the patient bring cultural context to interactions.
• Use open-ended questions to learn what is important to the patient.
• Example question: "I am interested in your cultural background as it relates to your health. Can you share with me what is important that will help me care for you?"

👶 Adapting across developmental stages

Developmentalists break the life span into nine stages: Prenatal, Infancy/Toddlerhood, Early Childhood, Middle Childhood, Adolescence, Early Adulthood, Middle Adulthood, Late Adulthood, and Death/Dying.

Stage	Key characteristics for nursing care
Infancy/Toddlerhood	Parents/guardians are primary information source; include family dynamics
Adolescence (10–19 years)	Sense of invincibility increases risk behaviors; consider abstract thinking development
Late Adulthood	"Young old" (65–79) vs. "old old" (80+); assess optimal, normal, or impaired aging rather than just chronological age
Death and Dying	Advocate for care that allows dignity and choice according to patient wishes

Don't confuse: Chronological age alone does not determine care needs—a person's health status (optimal, normal, or impaired aging) is more informative for older adults.

🌡️ Vital Signs Overview

🌡️ What vital signs include

Vital signs include:

• Temperature (Celsius or Fahrenheit)
• Pulse
• Respiratory rate
• Blood pressure
• Oxygen saturation (pulse oximeter)

📋 Delegation and accountability

• Obtaining vital signs may be delegated to unlicensed assistive personnel (UAP) for stable patients, depending on state Nurse Practice Act, agency policy, and training.
• The nurse is always accountable for analyzing vital signs and instituting appropriate follow-up for out-of-range findings.

🌡️ Temperature measurement methods

Normal oral temperature: 35.8–37.3ºC (96.4–99.1ºF).

Oral thermometer technique:

• Remove probe and slide on a probe cover without touching it.
• Place in the posterior sublingual pocket under the tongue, slightly off-center (near the sublingual artery for reliability).
• Instruct patient to keep mouth closed but not bite the thermometer.
• Leave in place per manufacturer instructions (typically beeps within seconds).
• Read digital display and discard probe cover.

Important: Document the route used because normal temperature varies by body location. Body temperature is typically documented in degrees Celsius in health care agencies.

🧭 Overview

🧠 One-sentence thesis

Vital signs—temperature, pulse, respiratory rate, and oxygen saturation—are measured using specific techniques at different body sites, each with distinct normal ranges and accuracy considerations that guide clinical assessment.

📌 Key points (3–5)

• Multiple measurement routes: Temperature can be measured orally, tympanically, axillary, rectally, or temporally, each with different normal ranges and accuracy levels.
• Route-specific temperature differences: Rectal readings run 0.5–1°F higher than oral; axillary and temporal run 0.5–1°F lower; tympanic runs 0.3–0.6°C higher.
• Pulse assessment characteristics: Pulse is documented by rhythm (regular vs irregular), rate (beats per minute), force (0 to 3+ scale), and equality (comparing both sides).
• Common confusion—pulse vs heart rate: Pulse rate may differ from heart rate if the heart contraction is not strong enough to generate a palpable pulse; pulse is palpated while heart rate is auscultated.
• Age-specific normal ranges: All vital signs have different normal ranges by age group, from newborns to adults.

🌡️ Temperature measurement routes

🌡️ Oral temperature

Oral temperature: measured by placing a thermometer probe under the tongue.

• Normal range: 35.8–37.3°C (96.4–99.1°F).
• Accuracy factors: Hot or cold food/beverages, gum chewing, or smoking can cause false readings.
• Wait times: 15–25 minutes after hot/cold consumption; 5 minutes after gum or smoking.
• Technique: Place probe under tongue, wait for beep, discard cover without touching.

👂 Tympanic temperature

• Typically 0.3–0.6°C (0.5–1°F) higher than oral.
• Normal range: 36.1–37.9°C (97.0–100.2°F).
• Why accurate: The tympanic membrane shares the same vascular artery that perfuses the hypothalamus (the brain's temperature regulation center).
• When not to use: Suspected ear infection or excessive earwax (cerumen), which reduces accuracy.
• Technique for adults/older children: Pull helix (outer ear) up and back; for infants under 3: pull helix down.

🔽 Axillary temperature

• Minimally invasive, commonly used in children.
• Typically 0.3–0.6°C (0.5–1°F) lower than oral.
• Normal range: 34.8–36.3°C (96.4–97.3°F).
• Uses the same blue-colored electronic device as oral thermometers.
• Technique: Place probe high in armpit on bare skin, facing behind patient; wait 10–20 seconds.

🩺 Rectal temperature

• Invasive method; considered gold standard for infants due to accuracy.
• 0.5–1°F (0.3–0.6°C) higher than oral.
• Normal range: 36.8–38.2°C (98.2–100.8°F).
• Technique: Lubricate probe, insert 2–3 cm (0.5–1 inch depending on size); infants in supine position with legs raised; older patients in side-lying position.

⏱️ Temporal temperature

• Infrared scanner measures heat from blood moving through the temporal artery in the forehead.
• Typically 0.5–1°F (0.3–0.6°C) lower than oral.
• Normal range: 35.2–37.0°C (95.4–98.6°F).
• Quick and noninvasive, but accuracy depends on good skin contact and correct forehead placement.

💓 Pulse assessment

💓 What pulse measures

Pulse: the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts.

• Measured in beats per minute at various body locations.
• Normal adult pulse rate at rest: 60–100 beats per minute.
• Don't confuse: Pulse rate may differ from heart rate if contraction force is insufficient to generate a palpable pulse.

📍 Common pulse locations

Location	When used	Technique notes
Radial	Most common for routine vitals	Pads of three fingers along radius bone, thumb side of wrist; difficult in newborns/children under 5
Brachial	Infants and children	Medial to bicep tendon, ~1 inch above antecubital fossa; may need firm pressure
Carotid	Medical emergencies	Medial to sternomastoid muscle; never palpate both sides simultaneously (reduces brain blood flow)
Apical	Most accurate; before cardiac meds	Auscultated with stethoscope over specific chest position

🔍 Pulse characteristics to document

Rhythm:

• Regular: even tempo with equal intervals (like a constant musical beat).
• Irregular: document as "regularly irregular" (pattern repeats) or "irregularly irregular" (no pattern).

Rate:

• Count for full 60 seconds, especially if irregular.
• First beat felt = "One."

Force (four-point scale):

• 3+: Full, bounding
• 2+: Normal/strong
• 1+: Weak, diminished, thready
• 0: Absent/nonpalpable (use Doppler ultrasound device to verify perfusion)

Equality:

• Compare pulse forces on both sides of the body simultaneously (except carotid).
• Provides data about peripheral vascular disease and arterial obstruction.

👶 Normal heart rate by age

Age group	Heart rate (bpm)
Preterm	120–180
Newborn (0–1 month)	100–160
Infant (1–12 months)	80–140
Toddler (1–3 years)	80–130
Preschool (3–5 years)	80–110
School age (6–12 years)	70–100
Adolescents (13–18) and adults	60–100

Context matters: Consider baseline, pain, crying, physical/mental stress; best to assess when patient is resting and comfortable.

🫁 Respiratory rate assessment

🫁 What to assess

Respiration: a person's breathing and the movement of air into and out of the lungs; inspiration (air entering) and expiration (air leaving).

• One respiratory cycle = one sequence of inspiration and expiration.
• Assess quality, rhythm, and rate.

🚨 Quality indicators

• Normal: relaxed and silent breathing.
• Signs of distress: loud breathing, nasal flaring, use of accessory muscles (neck, chest, intercostal spaces), tripod position (leaning forward with arms/elbows on knees or table).
• If new distress appears during vital signs, immediately notify provider or follow agency protocol.

🎵 Rhythm

• Regular rhythm: even tempo with equal intervals (normal in awake children and adults).
• Newborns and infants commonly exhibit irregular respiratory rhythm.

📊 Normal respiratory rate by age

Age	Normal range (breaths/min)
Newborn to 1 month	30–60
1 month to 1 year	26–60
1–10 years	14–50
11–18 years	12–22
Adult (18+)	10–20

Consider context: Sleep cycle, pain, and crying affect respiratory rate.

🩸 Oxygen saturation (SpO2)

🩸 What SpO2 measures

SpO2: an estimated oxygenation level based on the saturation of hemoglobin measured by a pulse oximeter.

• Because most oxygen in blood is attached to hemoglobin in red blood cells, SpO2 estimates how much hemoglobin is "saturated" with oxygen.
• Target range for adults: 94–100%.
• Target for chronic respiratory conditions (e.g., COPD): often lower at 88–92%.

⚠️ Limitations

• SpO2 is an estimate, not a precise measurement.
• Efficient and noninvasive, but should be interpreted in clinical context.