Basic Nursing Care & Comfort - Cheat Sheet
Your last-minute revision companion for Basic Nursing Care & Comfort. This cheat sheet covers all high-yield topics: hygiene, positioning, body mechanics, immobility hazards, pressure injury staging, and comfort measures. Master these in 30 minutes before your NLE exam.
Personal Hygiene & Bath Types
Common values
Value
43–46°C
Symbol
T
Quantity
Water temperature for bathing
Value
Every 2–4 hours
Symbol
Interval
Quantity
Oral care frequency for unconscious patients
Important facts
- Wash CLEAN TO DIRTY and DISTAL TO PROXIMAL — prevents cross-contamination.
- Wash EYES FIRST, INNER TO OUTER CANTHUS using separate cloth section for each eye — prevents cross-infection.
- Water temperature 43–46°C (comfortably warm) — test before use to prevent burns.
- PERINEAL CARE: wash FRONT TO BACK (urethra toward anus) — prevents fecal contamination.
- Uncircumcised male: RETRACT foreskin, clean, and REPLACE to prevent paraphimosis (paraphimosis = foreskin stuck in retracted position = medical emergency).
- Unconscious oral care: position SIDE-LYING with head turned to side — prevents aspiration of secretions.
- Oral care for unconscious: frequency every 2–4 hours — critical to prevent aspiration pneumonia.
- Foot care in diabetics: INSPECT DAILY, never soak, cut nails STRAIGHT ACROSS, never go barefoot.
- Hair and nail care: provide DAILY — improves circulation and promotes psychological well-being.
- Best time to assess skin thoroughly: DURING THE BATH — allows complete visualization under good lighting.
Key definitions
Complete bed bath
Example
Comatose patient requiring full assistance with all hygiene needs.
Total body washing for totally dependent patients; done by nurse.
Partial bath
Example
Post-op patient who can wash upper body but needs help with lower extremities.
Washing of face, hands, axillae, back, and perineum; patient assists where able.
Therapeutic bath
Example
Sitz bath after episiotomy repair to reduce pain and promote healing.
Bath for medical/therapeutic purpose (e.g., sitz bath for perineal/rectal comfort; oatmeal bath for pruritus).
Diagrams to know
- Order of washing body parts (eyes → face → upper body → abdomen → legs → perineum → back)
- Perineal care technique (front to back direction arrows)
- Proper position for unconscious oral care (side-lying with head turned)
Positioning
Common values
Value
30–45°
Symbol
°
Quantity
Semi-Fowler's elevation angle
Value
60–90°
Symbol
°
Quantity
High Fowler's elevation angle
Value
Every 2 hours minimum
Symbol
Interval
Quantity
Reposition frequency for immobile patients
Important facts
- REPOSITION IMMOBILE PATIENTS AT LEAST EVERY 2 HOURS — prevents pressure injuries and circulation stasis.
- Maintain PROPER BODY ALIGNMENT in every position — joints neither hyperextended nor abnormally flexed.
- Trochanter roll: prevents EXTERNAL ROTATION of hips — place under lateral hip.
- Hand roll: prevents FINGER/HAND CONTRACTURES — place in patient's palm.
- Footboard or high-top sneakers: prevent FOOTDROP (plantar flexion contracture) — keep foot DORSIFLEXED.
- Trapeze bar: helps patient REPOSITION and BUILD UPPER-BODY STRENGTH — use pillows and wedges for support.
- Semi-Fowler's (30°) is STANDARD for aspiration/VAP prevention — NOT high Fowler's.
- Orthopneic position: patient LEANING FORWARD over table — maximum opening of airway.
- Sims' position: primarily LEFT side-lying for enemas — promotes drainage and ease of administration.
- Do NOT use Trendelenburg for shock in modern practice — increases ICP and impairs breathing.
Key definitions
Fowler's position
Example
Use for dyspneic patients, post-prandial (after meals), post-op — promotes lung expansion and reduces aspiration.
Semi-Fowler's = 30–45° elevation; High Fowler's = 60–90° elevation; head of bed elevated.
Supine (dorsal recumbent)
Example
Most relaxed resting position; used for general rest and assessment.
Flat on back; baseline resting position.
Prone
Example
Used in some ARDS patients; patient can be proned to improve oxygenation.
Lying on abdomen; promotes drainage of oral secretions.
Lateral (side-lying)
Example
Recovery position for unconscious patient or to prevent pressure on sacral area.
On side; relieves pressure on sacrum.
Sims' (semi-prone)
Example
Position for administering enema or preparing for rectal procedure.
Left side-lying; promotes drainage; used for enemas and rectal exams.
Orthopneic
Example
Patient with acute dyspnea assuming this position for maximum respiratory comfort.
Sitting upright, leaning forward over bedside table; eases severe dyspnea.
Trendelenburg
Example
Rarely used in modern practice; may impair breathing and increase intracranial pressure.
Head lower than feet (controversial; historically for shock — NOW LIMITED USE).
Semi-Fowler's (30°)
Example
Standard head-of-bed elevation for patients at high aspiration risk.
Specific elevation to reduce aspiration and VAP (ventilator-associated pneumonia) in tube-fed and ventilated patients.
Diagrams to know
- Degrees of elevation: Semi-Fowler's (30–45°), High Fowler's (60–90°), Orthopneic (seated, leaning forward)
- Assistive devices placement: trochanter roll location, hand roll, footboard, trapeze bar
- Body alignment in different positions
Body Mechanics
Important facts
- WIDEN BASE of support (feet shoulder-width apart) — improves stability.
- BEND AT HIPS AND KNEES, NOT WAIST — protects lumbar spine.
- KEEP BACK STRAIGHT — prevents injury.
- USE LARGE MUSCLE GROUPS of legs, NOT back, to lift — legs are stronger than back.
- KEEP LOAD CLOSE TO BODY at waist level — reduces strain on back.
- PUSH or PULL rather than LIFT when possible — reduces effort needed.
- PIVOT FEET instead of twisting the spine — prevents torsional injury.
- FACE DIRECTION OF MOVEMENT — avoid twisting the torso.
- Use MECHANICAL AIDS (lifts, sliders) and GET HELP for heavy patients — safer and faster.
- LOWER BED RAIL and RAISE BED TO WORKING HEIGHT — reduces strain during patient handling.
- Never attempt to lift alone if patient weighs >50 kg (varies by facility protocol).
- Lock ALL WHEELS on beds, wheelchairs, and stretchers BEFORE transfers — prevents accidents.
Key definitions
Body mechanics
Example
Using legs instead of back to lift a heavy patient prevents back strain.
Correct use of muscles and skeletal system to move, lift, and position patients safely — protects both patient and nurse from injury.
Diagrams to know
- Correct lifting posture: feet apart, knees bent, back straight, load at waist
- Incorrect posture: bending at waist, twisting spine, keeping load far from body
- Base of support diagram: wide stance vs narrow stance
Hazards of Immobility
Important facts
- MUSCULOSKELETAL: contractures, muscle atrophy, disuse osteoporosis.
- CARDIOVASCULAR: orthostatic hypotension, venous stasis → DVT, increased cardiac workload.
- RESPIRATORY: decreased chest expansion, pooling of secretions, hypostatic pneumonia, atelectasis.
- GI: constipation, decreased appetite.
- GU: urinary stasis, renal calculi (kidney stones), infection.
- INTEGUMENTARY: PRESSURE INJURIES — single biggest complication.
- PSYCHOSOCIAL: depression, disorientation.
- DVT PROPHYLAXIS: leg exercises, early ambulation, anti-embolism (compression) stockings, sequential compression devices, anticoagulants (e.g., enoxaparin, unfractionated heparin) as ordered.
- ACTIVE ROM (patient performs) vs PASSIVE ROM (nurse performs) — both prevent contractures.
- Encourage DEEP BREATHING, COUGHING, and INCENTIVE SPIROMETRY — prevents atelectasis and pneumonia.
- Adequate HYDRATION — prevents renal calculi and constipation.
- EARLY AMBULATION is GOLD STANDARD — single best intervention for immobility prevention.
Key definitions
Immobility
Example
Bedridden patient post-stroke at high risk for DVT, pneumonia, contractures, and pressure injuries.
Inability or reduced ability to move; leads to multiple systemic complications across all body systems.
Deep Vein Thrombosis (DVT)
Example
Immobile patient develops calf pain, swelling, and positive Homan's sign (pain on foot dorsiflexion).
Venous stasis and thrombus formation in deep veins; serious complication of immobility.
Contracture
Example
Immobilized patient develops hand contracture because hand roll was not used.
Abnormal shortening of muscle or tissue around a joint; permanent loss of motion if untreated.
Hypostatic pneumonia
Example
Bedridden patient develops pneumonia due to secretion pooling and decreased chest expansion.
Pooling of respiratory secretions in dependent areas of lungs in immobile patients; leads to infection.
Diagrams to know
- Hazards of immobility by body system (mind map)
- DVT pathophysiology: venous stasis → thrombus formation → embolism risk
- Preventive interventions for each system
Pressure Injury Prevention & Staging
Common values
Value
Every 2 hours
Symbol
t
Quantity
Reposition interval for immobile patients
Value
Every 1 hour or weight shift every 15 min
Symbol
t
Quantity
Reposition interval for chair-bound patients
Important facts
- Pressure injuries form over BONY PROMINENCES: sacrum, heels, ischium, trochanters, occiput, ears, elbows.
- REPOSITION AT LEAST EVERY 2 HOURS — cornerstone of prevention.
- In CHAIR: reposition EVERY 1 HOUR or shift weight EVERY 15 MINUTES.
- Use PRESSURE-REDISTRIBUTING SURFACES: special mattresses, heel offloading, pillows to bridge bony areas.
- Keep skin CLEAN and DRY — moisture is a MAJOR RISK FACTOR.
- MANAGE INCONTINENCE PROMPTLY — wet/soiled skin breaks down faster.
- DO NOT MASSAGE over bony prominences or reddened areas — WORSENS tissue damage by disrupting fragile tissues.
- Maintain ADEQUATE NUTRITION and HYDRATION — protein, vitamin C, and zinc support healing.
- Use LIFTING DEVICES to avoid SHEARING and FRICTION.
- Keep HEAD OF BED at or BELOW 30° when possible — high elevation increases shearing force.
- Use BRADEN SCALE to assess risk (lower score = higher risk) — identify high-risk patients early.
- Staging is BASED ON TISSUE DEPTH, not size — use NPUAP/EPUAP staging system.
- Once healed, a pressure injury does NOT go back to a lower stage — it is documented as healed Stage X.
- Stage 1 = ONLY non-blanchable erythema on INTACT skin — reversible if pressure relieved immediately.
Key definitions
Pressure injury (decubitus ulcer, bedsore)
Example
Sacral pressure ulcer in immobile post-op patient — Stage 2: partial-thickness loss with intact blister.
Localized tissue damage from unrelieved pressure, usually over bony prominences (sacrum, heels, ischium, trochanters, occiput); staging: Stage 1–4, Unstageable, Deep Tissue Injury.
Stage 1 pressure injury
Example
Red area over sacrum that does not blanch when you press it — reversible if pressure relieved immediately.
Intact skin with NON-BLANCHABLE ERYTHEMA (redness that does not blanch/turn white with pressure).
Stage 2 pressure injury
Example
Fluid-filled blister or shallow open wound over heel.
PARTIAL-THICKNESS loss of dermis; shallow open ulcer or INTACT/RUPTURED BLISTER.
Stage 3 pressure injury
Example
Deep crater with visible yellow fat in the base; bone not visible.
FULL-THICKNESS loss; SUBCUTANEOUS FAT MAY BE VISIBLE; no bone/tendon/muscle exposed.
Stage 4 pressure injury
Example
Deep ulcer with visible bone or tendon at the base.
FULL-THICKNESS loss with EXPOSED BONE, TENDON, or MUSCLE; most severe.
Unstageable pressure injury
Example
Cannot determine stage until slough/eschar is debrided to visualize the wound base.
Base of ulcer is OBSCURED by SLOUGH (yellow/tan dead tissue) or ESCHAR (black/brown dead tissue).
Deep Tissue Injury (DTI)
Example
Dark purple/maroon area over hip that does not blanch — may indicate deeper tissue damage.
PERSISTENT NON-BLANCHABLE deep RED/MAROON/PURPLE discoloration of intact skin over area of pressure; may evolve into Stage 3–4.
Diagrams to know
- Pressure injury staging visual: Stage 1 (erythema) → Stage 2 (blister/shallow) → Stage 3 (subcutaneous fat visible) → Stage 4 (bone/tendon visible)
- Bony prominences where pressure injuries form (anatomical diagram)
- Braden Scale components: sensory perception, moisture, activity, mobility, nutrition, friction/shear
Rest & Sleep
Common values
Value
~90 minutes
Symbol
t
Quantity
One sleep cycle duration
Value
7–9 hours nightly
Symbol
h
Quantity
Recommended adult sleep duration
Important facts
- NREM (Non-REM) sleep: stages progressing to DEEP, RESTORATIVE SLOW-WAVE SLEEP — physical restoration.
- REM (Rapid Eye Movement) sleep: DREAMING, BRAIN-ACTIVATING — mental restoration.
- One sleep cycle = ~90 minutes (NREM → REM).
- Factors affecting sleep: age (older adults have lighter, more fragmented sleep), illness/pain, environment (noise, light, unfamiliar hospital), lifestyle, stress/anxiety, stimulants (caffeine, nicotine), alcohol, medications.
- HOSPITALIZATION DISRUPTS SLEEP — cluster nursing care to allow uninterrupted rest periods.
- SLEEP-PROMOTING (NON-PHARMACOLOGIC) MEASURES are PREFERRED FIRST-LINE: consistent schedule, comfortable environment, avoid caffeine/heavy meals near bedtime, relaxation techniques, limit daytime naps.
- Sedative-hypnotics are LAST RESORT — risk of dependence, falls, confusion (especially in elderly).
- Sleep apnea: loud snoring + gasping/choking during sleep + daytime sleepiness = CPAP therapy.
- Narcolepsy: UNCONTROLLABLE daytime sleep attacks.
- Bruxism: teeth grinding — can cause TMJ pain and dental damage.
- Cluster care: batch nursing interventions together — allows longer uninterrupted sleep periods.
- Environmental control: dim lights, reduce noise, comfortable temperature, quiet room — basic but critical for hospitalized patients.
Key definitions
Sleep
Example
Adult needs 7–9 hours nightly; one complete cycle = ~90 minutes NREM + REM.
Restorative physiologic state; cycles of NREM (deep, slow-wave restorative) and REM (dreaming, brain-activating) lasting ~90 minutes per cycle.
Insomnia
Example
Patient lies awake for 2 hours despite being tired or wakes at 3 AM and cannot return to sleep.
Difficulty falling asleep (sleep onset) or staying asleep (sleep maintenance); most common sleep disorder.
Sleep apnea
Example
Patient snores heavily, gasps/chokes during sleep, and feels exhausted all day despite 8 hours in bed.
Repeated airway obstruction during sleep with loud snoring and daytime sleepiness; treated with CPAP.
Narcolepsy
Example
Patient unexpectedly falls asleep during conversation or work.
Uncontrollable daytime sleep attacks; neurologic condition.
Restless Legs Syndrome (RLS)
Example
Patient experiences creeping/crawling sensation in legs at bedtime and keeps moving to relieve it.
Uncomfortable sensations in legs, especially at night; urge to move legs disrupts sleep.
Parasomnia
Example
Patient grinds teeth loudly during sleep or walks around house while asleep.
Abnormal behavior during sleep: sleepwalking, night terrors, bruxism (teeth grinding).
Diagrams to know
- Sleep cycle: 90-minute cycle of NREM stages + REM; repeated multiple times nightly
- Factors affecting sleep (mind map: age, illness, environment, lifestyle, stress, stimulants, etc.)
Comfort Measures & Pain Management
Common values
Value
15–20 minutes
Symbol
t
Quantity
Heat/cold application duration
Value
At least 1 hour
Symbol
Interval
Quantity
Time between reapplication (if needed)
Important facts
- Comfort measures include: positioning/support with pillows, back rubs/massage, environmental control (temperature, quiet, cleanliness, odor), and non-pharmacologic pain relief.
- DO NOT MASSAGE over bony prominences or REDDENED SKIN — can worsen tissue damage.
- Back rub: promotes circulation, comfort, and relaxation; avoid over bony areas (sacrum, trochanters).
- Environmental control: adjust temperature (cool comfortable room), minimize noise, keep room clean and odor-free.
- Heat therapy: promotes VASODILATION and RELAXATION; limit to 15–20 minutes — protect skin; caution with impaired sensation/circulation.
- Cold therapy: reduces SWELLING and PAIN; limit to 15–20 minutes — protect skin; caution with impaired sensation/circulation.
- CONTRAINDICATIONS for heat: acute inflammation, open wounds, impaired sensation/circulation, malignancy.
- CONTRAINDICATIONS for cold: vasospasm, Raynaud's phenomenon, impaired circulation.
- Relaxation techniques: deep breathing, progressive muscle relaxation, meditation — reduce pain perception.
- Guided imagery: patient visualizes peaceful scene — distracts from pain, reduces anxiety.
- Distraction: music, TV, conversation, games — redirects attention away from pain.
- Therapeutic touch: presence of caring nurse — provides reassurance and emotional support.
- Nurse presence: simply being with patient, listening, offering support — powerful comfort measure.
Key definitions
Comfort (holistic)
Example
Comfortable patient: free from pain, positioned safely, in a clean quiet room, with family present, spiritual needs met.
Physical, psychospiritual, environmental, and sociocultural well-being; nursing goal and a form of caring.
Non-pharmacologic pain relief
Example
Heat pack on sore muscle, guided imagery for anxiety-related pain, or nurse presence reassuring anxious patient.
Pain management without medication: heat/cold application, relaxation, guided imagery, distraction, therapeutic touch, presence.
Heat therapy
Example
Warm compress on stiff joint increases blood flow and eases pain.
Application of warmth; promotes vasodilation, relaxation, and pain relief.
Cold therapy
Example
Ice pack on swollen ankle immediately after injury reduces swelling.
Application of cold; reduces swelling, pain, and inflammation.
Diagrams to know
- Heat vs Cold therapy: indications, contraindications, application time, safety precautions
- Non-pharmacologic pain relief modalities and when to use each
Transfer, Ambulation & Fall Safety
Important facts
- Before ambulating, DANGLE PATIENT AT BEDSIDE FIRST — assesses for orthostatic hypotension and dizziness.
- Dangling: patient sits at edge of bed with feet hanging; observes for lightheadedness, pallor, or diaphoresis for ~1–2 minutes.
- Use GAIT/TRANSFER BELT for unsteady patients — provides safety handhold.
- Nurse stands on patient's WEAKER SIDE — can catch/support if patient begins to fall.
- CANE: hold on STRONGER SIDE; advance cane with WEAKER LEG — cane supports weaker leg.
- If patient BEGINS TO FALL: do NOT try to hold upright — EASE THEM DOWN SLOWLY, protecting head, by sliding them down your leg to floor while keeping your own back straight and base of support wide.
- LOCK ALL WHEELS on beds, wheelchairs, and stretchers BEFORE TRANSFERS — prevents equipment movement.
- Pivot transfers: bend knees, widen base, keep back straight, use leg muscles.
- Slide board/transfer aids: for heavy or immobile patients — reduces friction.
- Orthostatic hypotension risk: prolonged bed rest, dehydration, certain medications (antihypertensives), older adults.
- Prevention of orthostatic hypotension: gradual positional changes, adequate hydration, compression stockings, early ambulation.
Key definitions
Orthostatic hypotension
Example
Patient stands up quickly from bed and feels lightheaded or faints.
Drop in blood pressure upon standing; causes dizziness and syncope risk.
Gait belt (transfer belt)
Example
Nurse uses gait belt to support unsteady patient during ambulation.
Safety device worn around patient's waist to assist with transfers and ambulation.
Footdrop
Example
Patient walks with toe scraping ground due to foot hanging in plantarflexed position.
Plantar flexion contracture; inability to dorsiflex foot; caused by immobility/weakness; prevented with footboard/high-top sneakers.
Diagrams to know
- Dangling position: feet hanging, patient upright at edge of bed
- Proper cane use: cane on strong side, advance with weak leg
- Nurse positioning for transfers: on patient's weaker side
- Emergency fall management: easing patient down with straight back and wide base
Cultural & Filipino Context
Important facts
- Filipino patients value FAMILY PRESENCE (pakikisama) — involve family in care and teaching.
- INVOLVE FAMILY CAREGIVERS (bantay) in basic care where safe — empowers family, improves compliance.
- Respect MODESTY — provide privacy during hygiene; some patients uncomfortable with opposite-gender care.
- Accommodate SPIRITUAL/RELIGIOUS PRACTICES — prayer, religious items, visits from clergy.
- Culturally sensitive comfort care STRENGTHENS TRUST and COOPERATION.
- Ask family about patient preferences: traditional remedies, communication style, pain expression norms.
- Recognize language differences — use interpreter if needed; avoid assumptions.
- Filipino patients may be indirect about pain/discomfort — observe nonverbal cues, ask open-ended questions.
Key definitions
Pakikisama
Example
Family member (bantay) stays overnight and helps with basic hygiene and feeding.
Filipino value of family unity and presence; patients want family involved in care decisions and daily activities.
Bantay
Example
Mother sleeps in hospital room to help feed, bathe, and provide emotional comfort.
Filipino family caregiver who stays with hospitalized patient; provides emotional and practical support.
Diagrams to know
- Cultural sensitivity in basic nursing care: key considerations for Filipino patients
Must remember
- REPOSITION IMMOBILE PATIENTS AT LEAST EVERY 2 HOURS — single most important intervention to prevent pressure injuries and complications of immobility. In chairs: every 1 hour or weight shift every 15 minutes.
- PRESSURE INJURY STAGING — Stage 1: non-blanchable erythema on INTACT skin (reversible if pressure relieved immediately). Stage 2: partial-thickness/blister. Stage 3: full-thickness with subcutaneous fat visible (no bone). Stage 4: bone/tendon/muscle exposed. Unstageable: base covered by slough/eschar.
- DO NOT MASSAGE REDDENED AREAS OR OVER BONY PROMINENCES — worsens tissue damage by disrupting fragile tissue. Instead: use pressure-relieving surfaces, offload heels, reposition regularly.
- BODY MECHANICS FOR PATIENT SAFETY — Widen base of support, bend at hips/knees (NOT waist), keep back straight, use leg muscles, keep load close to body, push/pull rather than lift, pivot feet instead of twisting spine, lock all wheels before transfers.
- PRESSURE INJURY PREVENTION ESSENTIALS — Maintain adequate nutrition (protein, vitamin C, zinc), hydration, skin cleanliness/dryness, use Braden Scale to assess risk, avoid head-of-bed elevation >30°, use pressure-redistributing surfaces, manage incontinence promptly.
- HYGIENE PRINCIPLES — Wash CLEAN TO DIRTY and DISTAL TO PROXIMAL. Eyes: INNER TO OUTER canthus. Perineal care: FRONT TO BACK (urethra to anus). Unconscious oral care: SIDE-LYING with head turned to side every 2–4 hours to prevent aspiration. Uncircumcised males: retract foreskin, clean, replace.
- POSITIONING FOR ASPIRATION/VAP PREVENTION — Semi-Fowler's (30–45°) is STANDARD, NOT high Fowler's (60–90°). Orthopneic position (sitting, leaning forward) for severe dyspnea. Sims' (left side-lying) for enemas. Lateral for unconscious patients.
- HAZARDS OF IMMOBILITY — Musculoskeletal: contractures, atrophy, osteoporosis. Cardiovascular: DVT. Respiratory: hypostatic pneumonia. GI: constipation. GU: renal calculi. Integumentary: PRESSURE INJURIES. Psychosocial: depression. Prevention: ROM, early ambulation, compression stockings, anticoagulants, incentive spirometry.
- DVT PROPHYLAXIS — Leg exercises, early ambulation, anti-embolism (compression) stockings, sequential compression devices, prescribed anticoagulants (e.g., enoxaparin, unfractionated heparin). Early ambulation is GOLD STANDARD.
- COMFORT & FALL SAFETY — Before ambulating, dangle to assess for orthostatic hypotension. Use gait belt for unsteady patients; nurse on weaker side. If patient falls, ease them down slowly, protecting head, while keeping back straight. Lock all wheels. Heat/cold: limit to 15–20 minutes; protect skin; caution with impaired sensation/circulation.
Last minute tips
- STAGING IS TISSUE DEPTH, NOT SIZE — A small Stage 4 ulcer (bone visible) is more severe than a large Stage 2 (blister). Remember: Stage 1 = intact skin ONLY; Stage 3 = fat visible; Stage 4 = bone/tendon visible.
- REPOSITION EVERY 2 HOURS IS NON-NEGOTIABLE — This appears in almost every NLE question on pressure injuries, immobility, and hygiene. If the question doesn't explicitly say 'reposition,' repositioning is almost always part of the correct answer.
- SEMI-FOWLER'S = 30–45°, NOT HIGH FOWLER'S — Many students mix these up. Semi-Fowler's (30°) is STANDARD for aspiration/VAP prevention in tube-fed and ventilated patients. High Fowler's (60–90°) is NOT routine.
- NEVER MASSAGE REDDENED SKIN — This is an NLE favorite because students often think massage helps. WRONG. Massage over pressure areas or redness WORSENS damage. Use surfaces and offloading instead.
- DANGLE BEFORE AMBULATING — Always check for orthostatic hypotension before ambulating. Dangle patient at bedside 1–2 minutes, assess for lightheadedness/pallor. This is a safety essential and commonly tested.
Comparison tables
Body Positions: Indications, Uses, and Key Points
| Position | Degrees/Description | Primary Use/Indication | Key Benefit | Precaution |
|---|---|---|---|---|
| Fowler's (Semi) | 30–45° elevation | Feeding, post-op, rest | Lung expansion, comfort | Avoid high elevation for aspiration risk |
| Fowler's (High) | 60–90° elevation | Severe dyspnea (not standard) | Maximum chest expansion | Not used routinely; 30° is standard for aspiration prevention |
| Semi-Fowler's (Standard) | 30–45° elevation | Aspiration/VAP prevention | Reduces regurgitation/aspiration | Gold standard for tube-fed, ventilated patients |
| Orthopneic | Sitting, leaning forward | Severe dyspnea, respiratory distress | Maximum airway opening | Temporary measure; use comfort measures |
| Supine | Flat on back | General rest, baseline | Relaxation, comfort | Risk of aspiration; monitor for pressure on sacrum |
| Prone | On abdomen | ARDS proning, drainage | Airway drainage, oxygenation | Uncomfortable; limit duration; risk of facial pressure |
| Lateral (Side-lying) | On side | Unconscious patient, pressure relief | Drainage, comfort, safety | Use recovery position with head turned; prevents aspiration |
| Sims' | Left side-lying, semi-prone | Enemas, rectal exams | Ease of access, drainage | Left side to facilitate administration |
Pressure Injury Staging: At-a-Glance
| Stage | Tissue Depth | Appearance | Reversible? | Key Feature |
|---|---|---|---|---|
| Stage 1 | Intact skin only | Non-blanchable erythema (red) | YES—if pressure relieved immediately | ONLY intact skin; does NOT blanch when pressed |
| Stage 2 | Partial-thickness (dermis lost) | Shallow open ulcer or blister (intact/ruptured) | Possible with intervention | Blister or shallow crater; dermis visible |
| Stage 3 | Full-thickness (subcutaneous fat visible) | Deep crater with yellow fat visible | No—scarring permanent | Bone/tendon NOT visible; fat visible |
| Stage 4 | Full-thickness with exposed structures | Deep ulcer with bone/tendon/muscle exposed | No—severe scarring/tissue loss | BONE, TENDON, or MUSCLE visible at base |
| Unstageable | Base obscured | Covered by black eschar or yellow slough | Unknown until debrided | CANNOT see base; stage unknown until slough/eschar removed |
| Deep Tissue Injury (DTI) | Potentially full-thickness (deeper tissue damage) | Persistent non-blanchable deep red/maroon/purple | Possible if caught early | May indicate deep damage; monitor for worsening |
Immobility Hazards by Body System
| Body System | Complications | Prevention Strategy | Priority Intervention |
|---|---|---|---|
| Musculoskeletal | Contractures, muscle atrophy, disuse osteoporosis | ROM exercises (active/passive), positioning aids | ROM exercises daily |
| Cardiovascular | Orthostatic hypotension, venous stasis, DVT | Leg exercises, compression stockings, anticoagulants, early ambulation | Early ambulation & DVT prophylaxis |
| Respiratory | Decreased chest expansion, pooling of secretions, hypostatic pneumonia, atelectasis | Deep breathing, coughing, incentive spirometry, position changes | Incentive spirometry & early ambulation |
| GI | Constipation, decreased appetite | Hydration, dietary fiber, activity, stool softeners if needed | Hydration & increased fiber |
| GU | Urinary stasis, renal calculi, infection | Hydration (2–3 L/day if not contraindicated), frequent voiding, catheter care | Adequate hydration |
| Integumentary | Pressure injuries (PRIMARY COMPLICATION) | Reposition every 2 hours, pressure-relieving surfaces, skin care, nutrition | Reposition every 2 hours |
| Psychosocial | Depression, disorientation, anxiety | Communication, visits, mental stimulation, activities | Early ambulation & family support |
Heat vs. Cold Therapy: Indications, Contraindications & Precautions
| Property | Heat Therapy | Cold Therapy | Key Difference |
|---|---|---|---|
| Mechanism | Promotes vasodilation, relaxation | Reduces swelling, numbs pain | Heat dilates; cold constricts |
| Indications | Muscle tension, stiffness, chronic pain, poor circulation | Acute swelling, inflammation, acute pain, fresh bruising | Heat for chronic; cold for acute |
| Contraindications | Acute inflammation, open wounds, malignancy, impaired sensation/circulation | Vasospasm, Raynaud's, impaired circulation | Avoid heat in acute; avoid cold with vascular disease |
| Duration | 15–20 minutes per application | 15–20 minutes per application | SAME limit for both |
| Safety Precautions | Protect skin with cloth barrier; caution with impaired sensation; monitor for burns | Protect skin with cloth barrier; caution with impaired sensation; monitor for frostbite | Both need skin protection & sensation checks |
| Reapplication Interval | Wait at least 1 hour before reapplying | Wait at least 1 hour before reapplying | SAME interval for both |
Diagrams
Basic Nursing Care & Comfort — Complete Concept Map
Comprehensive mind map showing all major concepts in Basic Nursing Care & Comfort, organized by topic. Use this as your master reference to see how all components relate. The seven main branches represent the core knowledge areas tested on the NLE.
Pressure Injury Prevention & Management Decision Tree
Decision tree for assessing pressure injury risk and managing the patient based on findings. This diagram shows the progression from risk assessment through staging and appropriate interventions. Key decision points: Braden Scale, observation of skin, and clinical progression.
Safe Patient Transfer & Ambulation Protocol
Protocol flowchart for safe patient ambulation and transfer. Emphasizes critical safety checks: dangling, orthostatic hypotension assessment, use of gait belt, correct positioning of nurse, and proper emergency response if patient falls. The correct fall management technique is highlighted.
Sleep Cycle & Sleep Architecture
State diagram showing progression through one complete sleep cycle (~90 minutes). Shows the transitions from wake to NREM Stages 1–3 (deep sleep) and then to REM (dreaming). Each cycle is repeated multiple times during a full night of sleep. NREM = physical restoration; REM = mental restoration.
Pressure Injury Staging & Depth Recognition
Diagnostic flowchart for rapid pressure injury staging. Uses key visual/tactile features to differentiate between stages and common presentations. Critical distinctions: Stage 1 (intact), Stage 2 (shallow), Stage 3 (fat visible), Stage 4 (bone visible), Unstageable (covered), and Deep Tissue Injury.
Immobility Complications Prevention Matrix
Comprehensive prevention matrix showing all major complications of immobility and corresponding preventive interventions. This visual shows that preventing immobility is a multi-system approach requiring coordinated nursing interventions across all body systems. Early ambulation appears multiple times because it is the gold-standard intervention.