How to connect the dots
The thinking behind questions that mix topics.
Ask "what does this do to the body?"
Most mixed questions take a fact you learned in one setting and drop it into another. If you know what something does, not just where you learned it, you can follow it anywhere. Run every new situation through the clinical judgment model Week 2: what are the cues, what do they connect to, what's most dangerous, what do I do?
Epinephrine drives fight or flight: heart rate, BP (blood pressure) and cardiac output go up Week 5.
So when the heart stops in cardiac arrest, epinephrine is given during CPR (cardiopulmonary resuscitation) to stimulate the heart and tighten blood vessels, pushing blood to the heart and brain. Same hormone, new situation.
Learn the job, not the chapter. For every hormone, drug, lab or position, ask "what does it do?" Then ask "where else would I want that, or fear that?"
Assess first, unless something is hurting the client right now
"Assess first" is the default in every unit. The exception: if something you're doing or giving is causing harm, stop it first, then assess.
Assess first
- Fall history: fall-risk assessment Week 7
- Before first walking a client: mobility assessment, dangle at the bedside Week 4
- Before a tube feeding or medication: check placement Week 8
- Suspected retention: bladder scan before a catheter Week 9
- Before teaching: readiness, pain treated Week 4
- Crisis: assess safety and self-harm risk Week 5
- Before food after a seizure: gag reflex Week 7
Stop it first
- IV (intravenous) site cool, pale, swollen: stop the infusion Week 8
- Transfusion reaction: stop the transfusion Week 8
- Coughing or choking during a tube feeding: stop the feeding Week 8
- Heart rate drops during disimpaction or an enema: stop Week 9
- Restraint cutting off circulation: remove it Week 7
- Tenderness on palpation: stop palpating, notify Week 7
If it's going in and it's hurting, stop it. Fluids, blood, formula, an enema, a restraint: stop the source of harm, then assess.
Priority rules that apply everywhere
| Rule | Where it shows up |
|---|---|
| Airway, breathing, circulation first Week 2 | Seizure: side-lying, suction Week 7 · first aid primary survey Week 7 · aspiration during feeding Week 8 · stridor is an emergency Week 7 |
| The ABCs (airway, breathing, circulation) change neuro findings Week 2 | A confused client may be hypoxic, dehydrated or low on sodium before anything else Week 8 Week 8 |
| Physiological before safety before belonging (Maslow) Week 2 | Treat pain before teaching Week 4 · find out why a client refuses a bath before pushing hygiene Week 4 |
| Least restrictive first Week 2 | Reorient, sitter, alarm before restraints Week 7 · fiber and fluids before laxatives, enemas last Week 9 · external catheter before an indwelling one Week 9 |
| Acute and unstable before chronic and stable Week 2 | New confusion beats chronic pain; sudden BP drop beats a routine dressing change |
Who can do what
Delegation rules Week 2 show up in every unit. The nurse keeps assessment, analysis, planning, evaluation, teaching and anything for an unstable client.
| Task | UAP (unlicensed assistive personnel)? | See |
|---|---|---|
| Oxygen saturation reading, vital signs on a stable client | Yes | Week 2 |
| Collecting stool for occult blood; urine specimens | Yes (collection only) | Week 6 |
| Point-of-care occult blood test, throat culture, nasal swab | No | Week 6 |
| Measuring NG (nasogastric) output, oral care | Yes | Week 9 |
| Tube feedings, NG insertion and maintenance | No | Week 8 Week 9 |
| Helping a stable client walk; hygiene | Yes | Week 4 |
| Reinforcing teaching | PN (practical nurse), after the RN (registered nurse) teaches | Week 4 |
Quick check
A client receiving IV fluids develops a cool, pale, swollen site. First action?
Stop the infusion. Something going in is causing harm.
A newly confused older adult: what three things do you think about before blaming dementia?
Low oxygen, fluid or electrolyte problems (dehydration, sodium), and infection such as a UTI (urinary tract infection).
Which comes first for a client who wants to learn insulin injections but is in pain 8/10?
Treat the pain. A physiological need comes before learning, and pain blocks learning.
Numbers that repeat
One normal range, many chapters.
| Value | Normal | Where it comes back |
|---|---|---|
| WBC (white blood cell) count | 5,000–10,000/mm³ | Lab ranges Labs · above 10,000 means infection or inflammation Week 6 · rises with wound infection Week 6 |
| Albumin | 3.5–5 g/dL | Lab ranges Labs · below 3.5 raises wound risk Week 6 · shows nutrition over the past few weeks; low protein → edema Week 8 |
| BUN (blood urea nitrogen) | 10–20 mg/dL | Lab ranges Labs · rises with fluid deficit, falls with overload Week 8 · kidney function Week 9 |
| Hct (hematocrit) | F 37–47% · M 42–52% | Lab ranges Labs · rises when dry (hemoconcentration), falls when overloaded or bleeding Week 8 |
| Glucose (fasting) | 74–106 mg/dL | Lab ranges Labs · retest a meter reading under 60 or over 400 Week 6 · under 70: give sugar, recheck in 15 minutes Week 8 · check with TPN (total parenteral nutrition) and tube feedings Week 8 |
| Sodium · potassium | 136–145 · 3.5–5 mEq/L | Lab ranges Labs · sodium 120 is a critical result Week 7 · highs and lows Week 8 |
| Bicarbonate | CMP (comprehensive metabolic panel) 23–30 · ABG (arterial blood gas) 22–26 mEq/L | Same chemical, two tests: the CMP's "CO2" (carbon dioxide content) is bicarbonate Labs · the ABG range is the one for acid-base questions Week 8 |
| Platelets | 150,000–400,000/mm³ | Lab ranges Labs · low platelets: electric razor Week 4 |
| Urine specific gravity | 1.005–1.030 | Dipstick Week 6 · 1.030+ is dehydration, 1.005 or less is overload Week 8 |
| Urine output | At least 30 mL/hr | Report less Week 8 · under 30 for 2+ hours Week 9 · after urostomy surgery Week 9 |
| Respirations · heart rate · SpO2 (oxygen saturation) | 12–20 · 60–100 · 95–100% | Vital signs Week 2 · rate and breath sounds Week 7 · ABG and oxygenation Week 8 |
| Bowel sounds | 5–35 a minute | Abdominal exam Week 7 · ileus and obstruction Week 9 |
| Capillary refill | Under 3 seconds | Skin and circulation Week 6 Week 7 · slow when fluid is low Week 8 |
| Daily fluids | About 2,500–3,500 mL | Wound healing needs 2,500+ Week 6 · adult intake Week 8 · UTI teaching 2,000–3,000 Week 9 |
| Every 2 hours | Turn and reposition Week 4 Week 6 · restraints off 15 minutes Week 7 |
Thirty shows up everywhere: 30 mL/hr of urine, 30 mL water flushes, 30 mL in an ounce, head of bed at least 30° for tube feedings.
Quick check
An ABG shows HCO3– (bicarbonate) 24 and a CMP shows bicarbonate 28. Are both normal?
Yes. ABG range 22–26, CMP range 23–30. Same chemical, different tests.
Albumin 2.9 g/dL. Name two problems you'd watch for.
Poor wound healing and pressure injuries, and edema from fluid leaking out of the vessels.
Stress hormones & the nervous system
Fight or flight, cortisol and the vagus nerve explain findings in every unit.
Epinephrine (fight or flight)
The SAM (sympathetic-adrenal-medullary) system releases epinephrine and norepinephrine in seconds: HR (heart rate), BP, cardiac output and blood glucose go up; pupils and bronchi dilate; digestion slows Week 5.
- Cardiac arrest: epinephrine is given during CPR to restart and support the heart.
- Severe allergic reaction (anaphylaxis), such as during a blood transfusion Week 8: epinephrine opens the airways and raises BP.
- Pain, fear and anxiety are on the tachycardia list Week 2 because they trigger the same response.
- Glucose rises with stress, so stressed or ill clients with diabetes run high.
Cortisol and corticosteroids
Short-term cortisol helps; chronic cortisol suppresses immunity, slows healing and drives inflammation Week 5.
- Corticosteroid medications act like cortisol: they make a client a more susceptible host for infection Week 6 and block collagen, delaying wound healing Week 6.
- An older adult on steroids may show a serious infection with only mild signs, since inflammation is dampened.
- Long-term steroids are on the lists for low potassium and low calcium Week 8.
The vagus nerve: "bear down, slow down"
CN X (cranial nerve 10, the vagus) is both sensory and motor; with CN IX it controls swallowing and the gag reflex Week 7. In the resistance stage, the parasympathetic system calms the body down Week 5.
- Rectal stimulation fires the vagus: stop a disimpaction if the heart rate drops Week 9; a slowing pulse during an enema means stop Week 9.
- Straining (Valsalva) can cause bradycardia, low BP and fainting Week 9, so constipation is a cardiac safety issue too.
- Never press both carotids at once: heart rate and BP can drop Week 7.
- Gag reflex = CN IX and X: check it before food after a seizure Week 7, before NG insertion Week 8, and before oral care on an unconscious client Week 4.
Bear down, slow down. Straining or rectal stimulation fires the vagus nerve, and the heart slows.
When the nurse asks the client to bear down or hold their breath
The Valsalva maneuver is bearing down with the breath held, like straining to have a bowel movement. It raises the pressure inside the chest and abdomen, and it stimulates the vagus nerve, so the heart rate can drop.
| Situation | Why |
|---|---|
| Inserting a urinary catheter in a female client | Bearing down makes the urethral opening easier to see Week 9 |
| Removing an NG tube | Deep breath and hold: this closes the airway so nothing drips into the lungs as the tube comes out Week 8 |
| Bladder compression (Credé or Valsalva) for reflex incontinence | Pressure helps empty the bladder Week 9 |
| Voiding with a neobladder | The new bladder has no muscle of its own, so the client strains the abdominal muscles to void Week 9 |
Straining can cause bradycardia, low BP and fainting Week 9.
When bearing down is part of a procedure, watch for dizziness or a slow pulse. When straining would be harmful, prevent it: stool softeners and fiber for constipation, and splinting the incision when coughing after abdominal surgery Week 6. Straining also raises pressure in the head, which is one reason enemas are avoided with increased intracranial pressure Week 9.
Stress, mood and the gut, lungs and sleep
- Stress speeds peristalsis (diarrhea, IBS [irritable bowel syndrome] flares); depression slows it (constipation) Week 9.
- Anxiety or panic → hyperventilation → blows off CO2 (carbon dioxide) → respiratory alkalosis Week 8.
- Stage 3 sleep repairs tissue and boosts immunity Week 5, which is why cluster care protects healing Week 6.
- Pain and anxiety block learning Week 4 and sleep Week 5, so treat them first.
Quick check
Which hormone from the fight-or-flight response is given during CPR?
Epinephrine: it stimulates the heart and tightens vessels to push blood to the heart and brain.
A client on long-term prednisone (a corticosteroid) has a wound that won't heal. Connect it.
Corticosteroids act like chronic cortisol: they block collagen and suppress immunity, delaying healing and raising infection risk.
During a digital disimpaction the heart rate drops from 78 to 50. Why, and what do you do?
Rectal stimulation triggered the vagus nerve. Stop the procedure and check the client.
Why does the nurse ask the client to take a deep breath and hold it while pulling out an NG tube?
Holding the breath closes the airway, so the tube can't drip fluid into the lungs on the way out.
A client having a panic attack reports tingling fingers and lightheadedness. Which ABG pattern?
Respiratory alkalosis: fast breathing blows off CO2.
Oxygen from start to finish
Hemoglobin, breathing, blood flow and healing are one chain.
The oxygen chain
| Break in the chain | Cause from earlier units | What you see |
|---|---|---|
| Airway | Aspiration with dysphagia Week 8 · obstruction Week 2 | Coughing, choking, can't speak, stridor Week 7 |
| Lungs | Atelectasis and pneumonia from bed rest Week 4 · opioids slow breathing Week 2 | Diminished sounds, crackles Week 7 · respiratory acidosis Week 8 |
| Hemoglobin | Low Hgb (hemoglobin) Labs · iron deficiency Week 8 · kidney failure lowers red cell production Week 9 | Pallor Week 6 · fast heart rate Week 2 · fatigue |
| Pump and vessels | Fluid deficit Week 8 · heart failure | Weak pulse, slow capillary refill, low BP |
| Tissues | Pressure over bony prominences Week 6 · arterial insufficiency Week 7 | Pressure injury, delayed healing (the H in DIDN'T HEAL is hypoxia) Week 6 |
Cyanosis is a late sign of a broken chain. Earlier clues are a rising respiratory rate, a rising heart rate, restlessness or new confusion, and SpO2 under 95% Week 2.
- Incentive spirometer, deep breathing and turning every 2 hours prevent atelectasis Week 4.
- Head of bed up helps lungs expand: Fowler's Week 4, orthopneic for COPD (chronic obstructive pulmonary disease) Week 7.
- Home oxygen is a fire risk: no smoking, flames 10 ft away Week 7.
- Iron carries oxygen in hemoglobin, and vitamin C helps absorb iron Week 8.
Quick check
A client on bed rest after surgery has diminished breath sounds at the bases and SpO2 92%. Likely cause and prevention?
Atelectasis from shallow breathing. Incentive spirometer, deep breathing and coughing, turning every 2 hours, head of bed raised.
Why does a client with anemia have a fast heart rate?
Less hemoglobin carries less oxygen, so the heart speeds up to deliver more.
The immobility chain reaction
Bed rest touches every system you've studied since.
| System | What bed rest does Week 4 | How you find it | Where it leads |
|---|---|---|---|
| Skin | Pressure blocks blood flow over bony prominences | Nonblanchable redness; Braden score; staging Week 6 | Needs protein and calories Week 8; moisture from incontinence makes it worse Week 9 |
| Veins | Venous stasis → DVT (deep vein thrombosis) | One swollen leg: compare limbs Week 7 | PE (pulmonary embolism); anticoagulants → bleeding precautions (see Bleeding risk) |
| BP | Orthostatic hypotension | Lying vs standing BP Week 2 | Falls Week 7 |
| Lungs | Shallow breathing; secretions pool | Diminished sounds, crackles, dullness Week 7 | Atelectasis, pneumonia, fever, high WBC Week 6 |
| Gut | Slow peristalsis | Hypoactive bowel sounds; Bristol types 1–2 Week 9 | Impaction with liquid stool leaking around it Week 9 |
| Urinary | Urine pools; no gravity | Bladder scan; distention Week 9 | Retention, stones, UTI Week 9 |
| Muscles and bones | Atrophy, contractures, foot drop, bone loss | Strength grades 0–5, ROM (range of motion) Week 7 | Falls, fractures; high calcium from bones Week 8 |
| Mind | Isolation, depression | Mood every shift Week 4 | Depression slows the gut Week 9 and sleep Week 5 |
Turn, move, drink. Turning every 2 hours protects skin and lungs; moving protects muscles, bones, veins and bowels; fluids thin mucus, soften stool and keep urine flowing.
Quick check
Day 4 of bed rest: no bowel movement, hypoactive bowel sounds, and a small amount of liquid stool. What do you suspect?
Fecal impaction: liquid stool leaks around the hard mass.
One calf is swollen and warm. Which unit's assessment tells you what to do, and what is it?
Edema assessment: always compare with the other limb. One-sided swelling suggests DVT; report it.
Too dry, too wet
The same assessments from Units 1–3 tell you which way the fluid went.
| Finding | Too dry (deficit) | Too wet (overload) | Learned in |
|---|---|---|---|
| Pulse | Fast, weak, thready (1+) | Bounding (4+) | Week 2 Week 7 |
| BP | Low; drops on standing | High | Week 2 |
| Neck veins | Flat | Distended (JVD, jugular venous distention) | Week 7 |
| Lungs | Clear | Crackles, shortness of breath | Week 7 |
| Skin | Tenting, dry mouth, slow capillary refill | Pitting edema 1+ to 4+ | Week 6 Week 7 |
| Urine | Low output, dark amber, specific gravity 1.030+ | Dilute, specific gravity 1.005 or less | Week 6 Week 9 |
| Labs | Hct, BUN and sodium up | Hct and BUN down | Labs Week 8 |
| Weight | Quick loss | Quick gain | Week 8 |
| Mind and bowels | Confusion, constipation | Confusion | Week 8 Week 9 |
Dry is fast and flat; wet is bounding and bulging. A fast, weak pulse with flat neck veins means the tank is low. A bounding pulse, bulging neck veins and crackles mean it's overfull.
Any dehydrated client is an orthostatic, high-fall-risk client. Older adults also have a weaker thirst sense and unreliable skin turgor, so use other signs Week 8.
Quick check
Pulse 118 and weak, BP 92/58, urine dark with specific gravity 1.034. Which way did the fluid go?
Fluid volume deficit.
During IV fluids, a client develops crackles, distended neck veins and a bounding pulse. First actions?
Slow the IV, raise the head of the bed, and notify the provider: circulatory overload.
What leaves takes something with it
Where fluid is lost decides which electrolytes and which acid-base problem follow.
| Loss | Fluid | Electrolytes | Acid-base | Also watch |
|---|---|---|---|---|
| Diarrhea | Deficit | Low potassium | Metabolic acidosis (bicarbonate lost in stool) | Perianal skin breakdown Week 9; C. diff (Clostridioides difficile) after antibiotics Week 6 |
| Vomiting or NG suction | Deficit | Low potassium and sodium | Metabolic alkalosis (stomach acid lost) | Count NG drainage as output; report coffee-ground drainage Week 9 |
| New ileostomy | Deficit (up to 2,000 mL a day) | Sodium and potassium loss | Thirst, dizziness on standing Week 9 | |
| Laxative overuse | Deficit | Low potassium, low calcium | Weakens the bowel's natural response Week 9 |
Lose from the top, lose acid (alkalosis). Lose from the bottom, lose base (acidosis).
One antibiotic, five units
Quick check
A client with prolonged vomiting: pH 7.50, HCO3– 31. Interpret and connect.
Metabolic alkalosis from losing stomach acid. Expect low potassium and a fluid deficit too.
Watery diarrhea 4 times a day after antibiotics. Precautions and hand hygiene?
Contact precautions until C. diff is ruled out, and soap and water: alcohol doesn't remove spores.
Potassium, start to finish
The electrolyte that connects the gut, the kidneys, the heart and the menu.
Low (under 3.5)
- Causes: loop and thiazide diuretics Week 9, diarrhea, vomiting, NG suction Week 8
- Signs: muscle weakness, leg cramps, dysrhythmias; can cause ileus Week 9
- Raises digoxin toxicity risk
- Add foods: bananas, baked potatoes, oranges, spinach Week 8
- IV potassium: diluted, on a pump, 10–20 mEq per hour, never IV push Week 8
High (over 5)
- Cause: kidney failure; potassium-sparing diuretics
- Signs: weakness, paralysis, life-threatening dysrhythmias
- Renal diet limits potassium; avoid salt substitutes Week 8
- Treat: sodium polystyrene sulfonate, also given as a retention enema Week 9; insulin moves potassium into cells, so check glucose Week 8
Urine output under 30 mL/hr gets reported Week 8.
Kidneys have to be working before potassium is given. Low output means potassium can build up, so check urine output before giving it.
Quick check
A client on furosemide has leg cramps, weakness and hypoactive bowel sounds. Connect it.
Loop diuretic → low potassium → muscle weakness, cramps and slowed bowel (ileus risk).
Which enema lowers potassium?
A medicated retention enema with sodium polystyrene sulfonate.
The kidneys are the hub
When they fail, what they'd remove stays and what they'd make goes missing.
| Kidney job Week 9 | When it fails | Connects to |
|---|---|---|
| Filter waste | BUN and creatinine rise | Lab ranges Labs |
| Control fluid volume (with ADH, antidiuretic hormone) | Fluid overload, low urine output | Week 8 |
| Remove potassium and magnesium | High potassium, high magnesium (absent reflexes) | Week 8 · reflexes Week 7 |
| Make and keep bicarbonate; excrete acid | Metabolic acidosis | Week 8 |
| Make erythropoietin (red blood cells) | Anemia, low Hgb | Labs · Oxygen section |
| Activate vitamin D | Poor calcium absorption | Week 8 |
| Excrete medications | Drugs build up toward toxicity; doses are lowered | Check BUN and creatinine before drugs the kidneys excrete Week 10 |
| Renin raises BP | Hypertension | Week 2 |
Failing kidneys keep the bad and lose the good: they keep fluid, potassium, magnesium, acid and waste, and lose red cell production and active vitamin D.
Hypertonic sodium phosphate enemas are avoided with kidney impairment Week 9; high magnesium comes from kidney disease and too many magnesium laxatives or antacids Week 8.
For a constipated client with kidney failure, steer away from products that add phosphate or magnesium. The renal diet limits sodium, potassium and phosphorus for the same reason Week 8.
Quick check
A client with kidney failure: potassium 6.0, absent reflexes, pH 7.30 with low bicarbonate, Hgb 9. Connect each one.
Potassium and magnesium build up (absent reflexes = high magnesium); the kidneys can't keep bicarbonate (metabolic acidosis); less erythropoietin means anemia.
Which snack fits a renal diet: banana, orange juice, or strawberries?
Strawberries: lower in potassium.
Infection and devices
Every line, tube and drain is an open door.
| Device or site | Infection it risks | How you keep the door closed |
|---|---|---|
| Indwelling urinary catheter | CAUTI (catheter-associated urinary tract infection): the most common HAI (health care–associated infection) site Week 6 | Only when needed, sterile insertion, closed system, bag below the bladder, daily catheter care, remove early Week 9 Week 4 |
| Peripheral IV | Phlebitis, site infection | Site changes per policy, watch for warmth and redness Week 8 |
| Central line, TPN | CLABSI (central line–associated bloodstream infection) | Sterile technique, scrub the hub, dressing every 7 days Week 6 Week 8 |
| Feeding tube, ventilator, poor oral care | Aspiration pneumonia, VAP (ventilator-associated pneumonia) | Head of bed up, placement checks, oral care Week 8 Week 4 |
| Incision, wound, drain | SSI (surgical site infection) | Asepsis, chlorhexidine wipes, splint when coughing Week 6 |
The five cardinal signs of inflammation: heat, redness, swelling, pain, loss of function Week 6.
Phlebitis is inflammation of a vein: warm, red, painful Week 8. Infiltration is fluid in the tissue: cool and pale. "Hot means inflamed, cold means leaked."
- Culture before antibiotics everywhere: wounds Week 6, urine Week 9, blood.
- Front-to-back perineal care Week 4 and voiding after intercourse Week 9 both keep stool bacteria out of the urethra.
- Finish every antibiotic course: it prevents MDROs (multidrug-resistant organisms) Week 6.
Quick check
An older adult with a 4-day-old indwelling catheter becomes confused and incontinent around the catheter. Next steps?
Suspect CAUTI: check vital signs, get a urine specimen from the sampling port before antibiotics, notify the provider, and ask whether the catheter is still needed.
Which chain-of-infection link does a closed catheter drainage system break?
Portal of entry (and mode of transmission): it keeps bacteria from getting into the urinary tract.
Healing runs on nutrition
The wound chapter and the nutrition chapter describe the same process.
| Healing needs Week 6 | Where you get it Week 8 |
|---|---|
| Protein (albumin 3.5+, prealbumin 19–38) | Beef, poultry, fish, eggs, milk; beans and nuts |
| Vitamin C (collagen) | Citrus, berries, tomatoes, potatoes |
| Vitamin A | Liver, dairy, sweet potatoes, leafy greens |
| Zinc | Meats, fish, whole grains |
| Fluid 2,500+ mL and 1,500+ kcal a day | Unless restricted |
| Oxygen | Hemoglobin and blood flow (see Oxygen) |
Bed rest lowers appetite and causes malnutrition Week 4.
What slows healing across units: diabetes and high glucose Week 6, chronic stress and corticosteroids Week 5, smoking, older age, immobility, infection, and low hemoglobin. Vitamin C helps healing but is stopped 3 days before an occult blood test Week 6.
Quick check
A client with a stage 3 pressure injury: which lab best shows whether nutrition is improving this week?
Prealbumin: it reflects current nutrition; albumin reflects the past few weeks.
Bleeding risk
Why the client is on an anticoagulant, and what it changes everywhere else.
Anticoagulants prevent DVT in immobile clients Week 4. Low platelets (under 150,000) Labs carry the same precautions.
| Situation | What changes |
|---|---|
| Shaving | Electric razor Week 4 Week 7 |
| Nail care | Extra caution Week 4 |
| Starting an IV | BP cuff instead of a tourniquet, smaller catheter Week 8 |
| Occult blood test | Stop anticoagulants, aspirin and NSAIDs (nonsteroidal anti-inflammatory drugs) 7 days before Week 6 |
| Diet | Keep vitamin K intake steady on warfarin Week 8 |
| After surgery | Higher hematoma risk; hemorrhage risk peaks 24–48 hours Week 6 |
| Medication safety | Monitor weight, kidney and liver labs Week 7 |
| Stool | Black, tarry = upper GI (gastrointestinal) bleeding; bright red = lower Week 6 Week 9 |
Large intestine bacteria make vitamin K, needed for clotting Week 9.
Vitamin K reverses some anticoagulants and weakens warfarin, which is why diet must stay steady Week 8.
Quick check
A client on warfarin needs a shave and a new IV. Two changes?
Electric razor; BP cuff instead of a tourniquet and a smaller catheter.
Medications that cross units
Know what a drug does and its effects show up everywhere.
| Medication | Shows up as |
|---|---|
| Opioids | Slow breathing, the vital sign to watch Week 2 → respiratory acidosis Week 8 · constipation Week 4 Week 9 · urinary retention Week 9 · ileus Week 9 · central sleep apnea in overdose Week 5 · reversed by naloxone Week 2 |
| OTC (over-the-counter) antihistamines, anticholinergics | "Can't see, can't pee, can't spit, can't poop" Week 5 → urinary retention Week 9 and constipation Week 9 |
| Diuretics | Low potassium Week 8 · fluid deficit Week 8 · urgency and incontinence; take in the morning Week 9 |
| Antibiotics | Culture first Week 6 · diarrhea and C. diff Week 9 · finish the course Week 6 |
| Benzodiazepines | Short-term sleep aid Week 5 · stop seizures Week 7 · a chemical restraint Week 7 |
| Corticosteroids | Infection risk, slow healing Week 6 Week 6 · low potassium Week 8 |
| Insulin | Moves potassium into cells (treats high potassium), so watch for low glucose Week 8 · glucose checks with tube feedings and TPN Week 8 |
| Oral iron | Constipation and black stool Week 9 · stopped before an occult blood test Week 6 |
| Antacids | Aluminum and calcium: constipation · magnesium: diarrhea Week 9 · too many: metabolic alkalosis Week 8 |
| Opioids, long-term | Tolerance (needs more for the same relief) and dependence; buprenorphine is a partial agonist that prevents withdrawal Week 10 Week 10 |
| Diphenhydramine | The same anticholinergic antihistamine is used for allergies, sleep, motion sickness and Parkinson's Week 10; in older adults it can cause confusion Week 10 |
| Vancomycin | Peak and trough levels Week 10 · can damage cranial nerve VIII (hearing) Week 10 |
| Epinephrine in anaphylaxis | Given IM to raise BP and open the airways Week 10 |
| Warfarin | Vitamin K helps blood clot Week 8 → vitamin K foods weaken warfarin, so keep intake steady Week 10 |
| Any drug given by tube | Same placement check and flushes as a tube feeding Week 8 → liquid forms, no crushing do-not-crush forms, each drug separately, never mixed into the feeding Week 10 |
| Epinephrine | Fight or flight Week 5 · cardiac arrest and anaphylaxis (see Stress hormones) |
Conversions, pounds to kilograms, rounding and the three setup methods Week 9.
Every Week 10 problem builds on them: weight-based and divided doses, safe dose ranges, pump rates, drip rates and heparin drips Week 10. Convert first, round only at the end.
Stridor is an emergency Week 7, and epinephrine raises heart rate and BP in fight or flight Week 5.
In anaphylaxis, stridor means the airway is closing: airway first, oxygen, then epinephrine IM to raise BP and open the airways, then diphenhydramine Week 10.
Low albumin comes from poor nutrition Week 8.
Many drugs ride on albumin. With less of it, more drug is free and active, so the risk of toxicity goes up Week 10.
Check readiness to learn and treat pain before teaching; confirm learning with teach-back Week 4.
Medication teaching uses the same steps: who, what, why, when, how and where in plain words, then teach-back or a return demonstration for skills like insulin Week 10.
Quick check
An older adult takes diphenhydramine to sleep and now can't urinate. Connect it.
Antihistamines are anticholinergic: "can't pee." It causes urinary retention.
A client with kidney failure is prescribed a drug the kidneys excrete. What do you check, and why?
BUN and creatinine: poor excretion lets the drug build up toward toxicity, so the dose may need to be lower.
A tube-fed client needs an extended-release tablet. What do you do?
Don't crush it. Ask for another form, such as a liquid, then give it separately with flushes, never mixed into the feeding.
A client on warfarin starts eating a large leafy green salad every day. Connect it.
Leafy greens are high in vitamin K, which weakens warfarin. Teach the client to keep vitamin K intake steady.
Name four problems an opioid can cause in four different units.
Slow breathing (vital signs), respiratory acidosis (acid-base), constipation (immobility and bowel), urinary retention (urinary).
Positions across units
Same bed, different reasons.
| Position | Used for |
|---|---|
| Semi-Fowler's (30–45°) | Tube feedings: during, and at least 30° for 1 hour after Week 8 · fluid overload Week 8 · checking JVD Week 7 |
| High-Fowler's / upright | NG insertion Week 8 · eating with dysphagia, then 45°+ for 1 hour Week 8 · severe dyspnea Week 7 |
| Head of bed 30° or lower | Prevents shear and pressure injuries Week 6 |
| Left side (Sims') | Enema, disimpaction Week 9 Week 4 |
| Side-lying | Seizure Week 7 · oral care for an unconscious client Week 4 · suspected aspiration during feeding Week 8 |
| Supine, knees bent | Abdominal exam Week 7 · evisceration Week 6 |
| Medication positions | |
| Knee-chest | Ileostomy food blockage Week 9 |
| Modified Trendelenburg | Hypovolemia Week 7 |
A tube-fed client at risk for pressure injury: the feeding rule needs at least 30°, and the pressure rule says 30° or lower. They meet at 30°.
Older adults across units
One aging change explains findings in several chapters.
| Change | Leads to |
|---|---|
| Weaker thirst, less body water | Dehydration; turgor unreliable Week 8 Week 7 |
| Infection shows as confusion, falls, incontinence | Missed UTIs and pneumonia Week 6 Week 9 |
| Slower peristalsis | Constipation and impaction Week 9 |
| Fewer nephrons, smaller bladder | Nocturia → night falls Week 9 Week 7 |
| Thin, fragile skin | Skin tears from tape, pressure injuries Week 6 |
| Less stage 3 sleep, wakes more | Fatigue Week 5 |
| Kyphosis, less muscle, slow TUG (timed up and go) over 12 seconds | Fall risk Week 4 Week 7 |
| Presbycusis (high-frequency hearing loss) | Check for earwax first; face the client when teaching Week 7 Week 4 |
| Slower liver and kidney function | Drugs build up, so doses are often lower; many medications mean more interactions Week 10 Week 10 |
| Thinner skin (medications) | Absorbs topical drugs faster; remove patches slowly Week 10 |
| Lower metabolism, poorer absorption | Fewer calories, more calcium Week 8 |
New confusion is a clue, not a diagnosis. Check oxygen, fluid and sodium, infection, and new medications.
People skills that carry across
Communication, teaching, ethics and safety rules apply to every procedure.
| Rule | Learned | Shows up again |
|---|---|---|
| Certified interpreter, never family | Week 3 | Client teaching Week 4 · DEI (diversity, equity and inclusion) Week 5 · discharge |
| Teach-back, return demonstration | Week 2 Week 4 | Ostomy pouch changes Week 9 · glucometer · call light Week 7 |
| Don't assume: ask | Week 2 Week 5 | Food and religion Week 8 · reading labels without glasses Week 8 |
| Touch without consent is battery | Week 3 | Ask before care Week 2 · restraints need an order Week 7 |
| Informed consent: provider explains, nurse witnesses | Week 3 | Surgery and procedures Week 7 · blood transfusion Week 8 |
| Least restrictive first | Week 2 | Restraint alternatives Week 7 |
| FACT: factual, accurate, complete, timely | Week 3 | Seizures, restraints Week 7 · wound measurements Week 6 · I&O (intake and output) Week 8 |
| I-SBAR-R (identify, situation, background, assessment, recommendation, read back) | Week 2 Week 3 | Calling a rapid response, critical results Week 7 |
| HIPAA (Health Insurance Portability and Accountability Act) | Week 3 | Specimen labels, handoffs, social media |
| Body image and self-esteem | Week 5 | A client who won't look at a new stoma Week 9 |
Case walk-throughs
Each step pulls from a different unit.
Case 1 · Mr. Jones after hip surgery
Mr. Jones, 78, had hip surgery Week 2. He's on bed rest, takes opioids and has an indwelling catheter.
Day 1: temperature 39.0 °C, pulse 122. What do you think about?
Fever with tachycardia after surgery: infection is possible. Check the incision, lungs and urine; report it Week 2 Week 6.
Day 3: no bowel movement, hypoactive bowel sounds, distended abdomen, no flatus.
Opioids plus immobility plus surgery slow the gut: constipation or ileus. Check potassium too, since low potassium can cause ileus Week 9.
Day 3: suddenly confused, cloudy urine.
Think CAUTI. Urine from the sampling port before antibiotics; ask whether the catheter is still needed Week 9.
Case 2 · Diarrhea after antibiotics
A client has had watery stools 5 times a day since finishing antibiotics.
Precautions and hand hygiene?
Contact precautions until C. diff results; soap and water Week 6.
Potassium 3.1. Signs to watch?
Weakness, leg cramps, dysrhythmias Week 8.
pH 7.32, PaCO2 (partial pressure of carbon dioxide) 40, HCO3– 18.
Metabolic acidosis: bicarbonate lost in stool Week 8.
Urine output 20 mL/hr for 3 hours, specific gravity 1.034.
Fluid deficit. Report it; expect isotonic IV fluids Week 8.
Red, moist perianal skin.
Moisture-associated skin damage: clean after each stool and apply a barrier; inspect for pressure injury Week 9 Week 6.
Oral potassium chloride 40 mEq ordered; available 20 mEq/15 mL. How many mL?
40 × 15 ÷ 20 = 30 mL Week 9.
Case 3 · A new ileostomy
The stoma looks dusky purple.
Poor blood supply: report it right away Week 9.
Output is high and the client is thirsty and dizzy when standing.
Fluid, sodium and potassium loss; orthostatic risk Week 9 Week 8.
The client won't look at the stoma.
Body image and negative self-esteem: let them express feelings, don't force teaching yet Week 5.
How do you teach the pouch change?
Psychomotor domain: demonstration and return demonstration Week 4.
The client's daughter offers to interpret.
Get a certified medical interpreter Week 3.
Case 4 · Kidney failure
Crackles, distended neck veins, 3+ edema, weight up 2 kg.
Fluid overload: semi-Fowler's, daily weights, fluid and sodium restriction, diuretics as ordered Week 8.
Potassium 6.0 and absent patellar reflexes.
High potassium (dysrhythmia risk) and high magnesium Week 8.
The client asks for a salt substitute.
No: salt substitutes contain potassium Week 8.