NLE Fundamentals of Nursing & the Nursing Process — Basic Nursing Care & ComfortRevision Notes

Exam tips

• NLE PRIORITY: Eye care sequence — INNER to OUTER canthus, different cloth section for each eye.
• NLE PRIORITY: Perineal care — ALWAYS front to back; foreskin must be REPLACED after care.
• NLE PRIORITY: Unconscious patient oral care — SIDE-LYING position with suction available.
• Water temperature 43–46°C is a frequent numerical recall item on the NLE.
• The bath is the BEST time for a comprehensive skin assessment — this is the rationale behind why the nurse performs the bath rather than delegating it entirely.
• Filipino context: Always involve the bantay (family caregiver) in hygiene teaching while maintaining patient privacy and dignity.

Key points

• Hygiene promotes cleanliness, comfort, circulation, and psychological well-being, and provides the BEST opportunity for complete skin assessment and therapeutic communication.
• Complete bed bath: for totally dependent patients; partial bath covers face, hands, axillae, back, and perineum.
• Therapeutic bath (e.g., sitz bath) promotes perineal or rectal comfort and healing.
• Water temperature for bathing: 43–46°C (comfortably warm); always test temperature before applying to patient skin.
• Wash principle: CLEAN to DIRTY, DISTAL to PROXIMAL.
• Eye care: wash from INNER to OUTER canthus (inner canthus nearest the nose); use a DIFFERENT section of the cloth for EACH eye to prevent cross-contamination.
• Perineal care: always cleanse FRONT TO BACK (urethra → anus) to prevent fecal contamination of the urinary tract.
• In uncircumcised male patients: RETRACT foreskin, cleanse glans, then REPLACE foreskin immediately after to prevent paraphimosis.
• Oral care for unconscious patients: position in SIDE-LYING with head turned to the side to prevent aspiration; have suction available; perform every 2–4 hours.
• Foot care for diabetic patients: inspect daily, dry thoroughly between toes, cut nails STRAIGHT ACROSS, never go barefoot, AVOID prolonged soaking — patient education is a high-priority nursing action.
• Special mouth care for the unconscious: every 2–4 hours; denture care as needed.
• Privacy, warmth, and dignity must always be maintained; expose ONLY the area being washed at any time.

Definitions

Common mistakes

• Washing from dirty to clean (e.g., starting at the perineum and moving upward) — this spreads microorganisms.
• Using the same cloth surface for both eyes — always fold or use a new corner for each eye.
• Forgetting to replace the foreskin in uncircumcised male patients after perineal care.
• Positioning an unconscious patient supine (flat on back) during oral care — this greatly increases aspiration risk.
• Soaking the feet of diabetic patients — this softens the skin too much and increases risk of skin breakdown and infection.
• Cutting diabetic patient toenails in a curved shape — always cut straight across to prevent ingrown nails.

Exam tips

• NLE PRIORITY: Reposition immobile patients EVERY 2 HOURS — this is the single most important pressure injury prevention measure.
• NLE PRIORITY: Orthopneic = severe dyspnea; Semi-Fowler's (30°) = VAP/aspiration prevention in tube-fed patients.
• Remember 'SIMS for STOOL' — Sims' position is used for enemas and rectal procedures.
• For unconscious patients: LATERAL or SIMS' — never supine, to prevent aspiration of secretions.
• Assistive devices: TROCHANTER ROLL = prevents hip external rotation; FOOTBOARD = prevents footdrop; HAND ROLL = prevents hand contractures.
• Trapeze bar allows the patient to assist with repositioning and strengthens upper extremities — important for patients preparing for ambulation.

Key points

• Proper positioning promotes comfort, prevents complications, and supports therapeutic goals.
• Fowler's position: Semi-Fowler's = 30–45°; High Fowler's = 60–90°. Promotes lung expansion; used for dyspnea, feeding, and post-operative patients.
• Semi-Fowler's (30°) specifically reduces aspiration risk and ventilator-associated pneumonia (VAP) in tube-fed and mechanically ventilated patients.
• Supine (dorsal recumbent): flat on back; standard resting position.
• Prone: lying on abdomen; promotes drainage of oral secretions; used therapeutically in ARDS (acute respiratory distress syndrome) for lung recruitment.
• Lateral (side-lying): relieves pressure on the sacrum; used for unconscious patients as the recovery position.
• Sims' position: semi-prone on the LEFT side; used for enemas, rectal examinations, and unconscious patients to facilitate drainage.
• Trendelenburg: head lower than feet; historically used for shock but now largely controversial or contraindicated.
• Reverse Trendelenburg: head higher than feet; useful for reducing reflux.
• Orthopneic (tripod) position: patient sits upright, leaning FORWARD over a bedside table; maximally eases severe dyspnea (e.g., COPD, acute bronchial asthma).
• Lithotomy: patient supine with legs elevated in stirrups; used for perineal and gynecologic examinations.
• Knee-chest (genupectoral): patient kneels with chest resting on bed; used for rectal and perineal procedures.
• IMMOBILE PATIENTS MUST BE REPOSITIONED AT LEAST EVERY 2 HOURS to prevent pressure injuries and improve circulation.
• Chair-bound patients: shift weight every 15 minutes or reposition every 1 hour.

Definitions

Common mistakes

• Confusing Semi-Fowler's angle (30–45°) with High Fowler's (60–90°) — know the exact degree ranges.
• Placing an unconscious patient in supine instead of lateral or Sims' — increases airway aspiration risk.
• Forgetting that Sims' is specifically the LEFT lateral semi-prone position for enemas and rectal procedures.
• Not repositioning immobile patients every 2 hours — a direct cause of pressure injuries.
• Confusing Trendelenburg (head down) with Reverse Trendelenburg (head up).
• Using orthopneic position for a patient without dyspnea — it is specifically for severe respiratory distress.

Exam tips

• NLE frequently tests body mechanics through a clinical scenario where the nurse must choose the safest technique for a transfer.
• Remember the 3 core rules: WIDE BASE, BEND KNEES, LOAD CLOSE.
• When in doubt: PUSH/PULL > LIFT; use mechanical aids; get help.
• Body mechanics protects BOTH nurse and patient — always frame answers with dual safety rationale.

Key points

• Proper body mechanics protect both the nurse and the patient from musculoskeletal injury.
• WIDEN the base of support: feet shoulder-width apart for maximum stability.
• BEND at the HIPS and KNEES, NOT at the waist; keep the back straight and spine in neutral alignment.
• Use the LARGE MUSCLE GROUPS of the LEGS to do the lifting — NOT the back muscles.
• Keep the load CLOSE to the body and at WAIST LEVEL to minimize leverage and strain.
• PUSH or PULL rather than lift when possible; use MECHANICAL AIDS (e.g., transfer boards, lift machines) for heavy patients.
• PIVOT the feet instead of twisting the spine when changing direction.
• FACE the direction of movement to prevent spinal rotation.
• Lower bed rails and raise the bed to a comfortable WORKING HEIGHT before patient care.
• Use team lifts and assistive devices for bariatric or heavy patients — this is a patient and nurse safety standard under Filipino hospital practice.

Definitions

Common mistakes

• Bending at the WAIST instead of the HIPS AND KNEES — the number one cause of nurse back injury.
• Twisting the spine while carrying a load — always pivot the feet instead.
• Holding the load far from the body at arm's length — this multiplies the effective weight many times over.
• Attempting to lift a heavy or uncooperative patient alone without a mechanical aid or help.
• Forgetting to adjust bed height before care — working at an improper height forces awkward body mechanics.

Exam tips

• NLE FAVORITE: Know ALL hazards of immobility by system — questions often ask 'which complication is MOST likely' in a specific scenario.
• NLE FAVORITE: DVT prophylaxis — leg exercises + compression stockings + early ambulation + anticoagulants (enoxaparin).
• The FIRST step before ambulating a post-bed rest patient: DANGLE at bedside and assess for dizziness/orthostatic hypotension.
• Nursing diagnosis for immobility complications: 'Impaired Physical Mobility,' 'Risk for Disuse Syndrome,' 'Ineffective Breathing Pattern,' 'Risk for Impaired Skin Integrity.'
• Incentive spirometry goal: post-op patients should use it every 1–2 hours while awake to prevent atelectasis and pneumonia.

Key points

• Immobility affects EVERY body system — a patient confined to bed is at risk for multiple simultaneous complications.
• MUSCULOSKELETAL: muscle atrophy, contractures (shortening of muscles/tendons), disuse osteoporosis (calcium loss from bones).
• CARDIOVASCULAR: orthostatic hypotension (sudden drop in BP upon standing), venous stasis leading to DEEP VEIN THROMBOSIS (DVT), increased cardiac workload.
• RESPIRATORY: decreased chest expansion, pooling of secretions → HYPOSTATIC PNEUMONIA, atelectasis (alveolar collapse).
• GASTROINTESTINAL: constipation, decreased appetite, paralytic ileus in severe cases.
• GENITOURINARY: urinary stasis, RENAL CALCULI (kidney stones from calcium mobilization), urinary tract infections.
• INTEGUMENTARY: PRESSURE INJURIES (most well-known complication of immobility).
• PSYCHOSOCIAL: depression, anxiety, disorientation, sensory deprivation.
• PREVENTIVE INTERVENTIONS: Active and passive ROM exercises; early ambulation; deep breathing and coughing exercises; incentive spirometry; DVT prophylaxis (leg exercises, compression stockings, sequential compression devices, anticoagulants such as enoxaparin as ordered); adequate hydration.
• ORTHOSTATIC HYPOTENSION prevention: dangle the patient at the bedside BEFORE full ambulation to allow cardiovascular adjustment.
• Passive ROM: nurse moves the joint through its full range; active ROM: patient performs movements independently.
• Each joint should be moved through ROM exercises at least 2–3 times per session, 2–3 times per day.

Definitions

Common mistakes

• Not anticipating orthostatic hypotension — always DANGLE (sit at edge of bed) before ambulation, never go straight from supine to standing.
• Omitting passive ROM for unconscious or paralyzed patients — 'passive' means the NURSE does the movement for the patient.
• Confusing DVT prevention with treatment — prophylaxis (compression, exercises, enoxaparin) is different from managing an established DVT (which requires anticoagulation and elevation, NOT massage).
• Massaging a calf that is tender, warm, and swollen — this could dislodge a thrombus and cause pulmonary embolism (Homan's sign is no longer considered definitive, but clinical vigilance is still required).
• Forgetting psychosocial complications of immobility — depression and disorientation are legitimate nursing diagnoses.

Exam tips

• NLE HIGH-YIELD: Know ALL stages by their key distinguishing feature: Stage 1 = non-blanchable intact skin; Stage 2 = partial-thickness/blister; Stage 3 = subcutaneous fat visible; Stage 4 = bone/tendon/muscle exposed; Unstageable = covered by slough or eschar.
• NLE HIGH-YIELD: DO NOT MASSAGE reddened areas or over bony prominences — this is almost always a wrong answer.
• Braden Scale: LOWER score = HIGHER risk. A score of ≤18 indicates the patient is AT RISK.
• Key nutrients for wound healing: PROTEIN + VITAMIN C + ZINC. Remember the trio.
• DONUT CUSHIONS are CONTRAINDICATED — they concentrate pressure around the ring and worsen ischemia.
• Prevention is the priority nursing action over treatment — a NANDA nursing diagnosis of 'Risk for Impaired Skin Integrity' requires proactive interventions.

Key points

• Pressure injuries (formerly called decubitus ulcers or bedsores) are localized damage to the skin and underlying tissue over a BONY PROMINENCE, caused by PRESSURE alone or in combination with SHEAR and FRICTION.
• Most common bony prominence sites: SACRUM (most common), heels, ischial tuberosities, trochanters, occiput, malleoli, elbows.
• FOUR CAUSATIVE FACTORS: Pressure, Shear (internal tissue distortion), Friction (surface rubbing), Moisture (maceration).
• STAGE 1: Intact skin with NON-BLANCHABLE erythema (redness that does NOT turn white when pressed); skin is warm and firm.
• STAGE 2: Partial-thickness skin loss involving the EPIDERMIS and DERMIS; presents as a shallow open ulcer (pink/red wound bed) OR intact or ruptured blister.
• STAGE 3: Full-thickness skin loss; SUBCUTANEOUS FAT MAY BE VISIBLE; no bone, tendon, or muscle exposed.
• STAGE 4: Full-thickness tissue loss with EXPOSED BONE, TENDON, OR MUSCLE; may have undermining and tunneling.
• UNSTAGEABLE: Base of ulcer is completely covered by SLOUGH (yellow/tan) or ESCHAR (black/brown); true depth cannot be determined until removed.
• DEEP TISSUE INJURY (DTI): Persistent non-blanchable deep RED, MAROON, or PURPLE intact skin discoloration; indicates deeper tissue damage beneath intact skin.
• PREVENTION BUNDLE: Reposition every 2 hours; pressure-redistributing mattresses; keep skin clean and DRY; manage incontinence promptly; maintain nutrition (protein, vitamin C, zinc); avoid friction and shear; offload heels; keep HOB at or below 30°.
• DO NOT MASSAGE over bony prominences or reddened areas — this causes additional tissue damage by increasing friction and potentially rupturing fragile capillaries.
• BRADEN SCALE assesses pressure injury RISK: evaluates Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear. LOWER SCORE = HIGHER RISK. Normal = 23; risk threshold ≤18.
• Nutrition for wound healing: adequate PROTEIN (tissue repair), VITAMIN C (collagen synthesis), and ZINC (epithelialization).

Definitions

Common mistakes

• MASSAGING reddened areas or bony prominences — this is explicitly CONTRAINDICATED and a classic NLE trap.
• Confusing Stage 3 (subcutaneous fat visible) with Stage 4 (bone/tendon/muscle exposed) — a precise distinction tested on the NLE.
• Thinking an unstageable wound is 'not serious' — it may actually be a Stage 3 or 4 underneath the eschar.
• Forgetting that moisture (from incontinence, perspiration) is a MAJOR independent risk factor for pressure injuries.
• Elevating the head of bed above 30° for prolonged periods — increases shear forces on the sacrum.
• Using a donut/ring cushion — this is CONTRAINDICATED as it creates a ring of pressure and reduces blood flow to the area.

Exam tips

• NLE PRIORITY: Sleep apnea is treated with CPAP — not oxygen alone, not surgery as first line.
• NLE PRIORITY: Non-pharmacologic measures FIRST for both sleep and pain; sedatives are LAST RESORT.
• Heat and cold application time limit: 15–20 MINUTES maximum; this is a specific numerical recall item on the NLE.
• The 90-minute sleep cycle is the basis for recommending that nurses cluster care to prevent sleep fragmentation.
• Rebound effect: prolonged heat or cold application eventually triggers the OPPOSITE vascular response — vasodilation from cold, vasoconstriction from heat.
• Elderly patients require EXTRA caution with heat — decreased peripheral sensation increases burn risk.

Key points

• Sleep restores physical and mental function; adequate rest is essential for healing and recovery.
• NREM Sleep: four stages progressing from light to deep, slow-wave, restorative sleep. Stages 3–4 (slow-wave sleep) are most physically restorative.
• REM Sleep: Rapid Eye Movement sleep; associated with dreaming; brain is active; emotionally and cognitively restorative. Inhibited by alcohol and many sedative medications.
• Sleep CYCLE: One full cycle (NREM + REM) lasts approximately 90 MINUTES; adults have 4–6 cycles per night.
• INSOMNIA: difficulty falling or staying asleep; most common sleep disorder.
• SLEEP APNEA: repeated episodes of upper airway obstruction during sleep; signs include loud SNORING and excessive DAYTIME SLEEPINESS; treated with CPAP (Continuous Positive Airway Pressure).
• NARCOLEPSY: uncontrollable daytime sleep attacks.
• RESTLESS LEGS SYNDROME: unpleasant leg sensations with an urge to move legs, worse at rest.
• PARASOMNIAS: abnormal behaviors during sleep — sleepwalking, night terrors, bruxism (teeth grinding).
• FACTORS DISRUPTING SLEEP: pain, illness, anxiety, noise, light, unfamiliar environment (hospital), caffeine, nicotine, alcohol, shift work, medications.
• Hospitalization is a MAJOR disruptor of normal sleep — cluster nursing care to allow uninterrupted 90-minute rest periods.
• NON-PHARMACOLOGIC sleep measures are ALWAYS preferred FIRST: consistent schedule, comfortable environment, limit caffeine and heavy meals before bedtime, warm bath, relaxation techniques, reduce daytime naps.
• Sedative-hypnotics are the LAST RESORT — high risk of dependence, falls, and confusion especially in the ELDERLY.
• COMFORT MEASURES: proper positioning, back rubs (avoid over bony prominences), environmental control (temperature, noise, odor), non-pharmacologic pain relief.
• NON-PHARMACOLOGIC PAIN RELIEF: heat/cold application, relaxation techniques, guided imagery, distraction, music therapy, therapeutic touch, and nurse presence.
• HEAT THERAPY: promotes vasodilation, relaxes muscles; used for muscle spasm, arthritis, chronic pain.
• COLD THERAPY: causes vasoconstriction; reduces acute inflammation, swelling, and pain; used within first 24–48 hours of acute injury.
• BOTH heat and cold application: limit to 15–20 MINUTES at a time; ALWAYS protect the skin with a cloth or towel; use with CAUTION in patients with impaired sensation or circulation (e.g., diabetic neuropathy).
• The elderly have reduced heat sensation — EXTRA CAUTION is needed to prevent burns.

Definitions

Common mistakes

• Recommending sedative-hypnotics as a FIRST LINE for sleep — non-pharmacologic measures MUST come first.
• Forgetting to cluster nursing care activities — waking a patient every 30 minutes for vitals, medications, and assessments fragments sleep dangerously.
• Applying heat or cold for MORE than 20 minutes — this triggers the REBOUND EFFECT (opposite of intended effect) and risks tissue injury.
• Using heat therapy directly on skin without insulation — burns, especially in elderly patients with reduced sensation.
• Recommending cold therapy for chronic pain conditions — cold is for ACUTE inflammation (within 24–48 hours); chronic pain benefits more from heat.
• Advising patients that alcohol improves sleep — alcohol suppresses REM sleep and causes fragmented, non-restorative sleep.

Exam tips

• NLE CRITICAL: Nurse stands on the WEAK side; cane is held on the STRONG side — these are opposite to each other and frequently mixed up.
• NLE CRITICAL: If patient begins to fall — EASE THEM DOWN to the floor; protect the head; do NOT catch/hold upright.
• LOCK WHEELS before EVERY transfer — this appears in NLE safety questions regularly.
• The first sign of orthostatic hypotension during dangling: dizziness, pallor, or drop in BP — return patient to bed immediately if these occur.
• Four side rails raised = RESTRAINT — requires physician's order, informed consent, and regular reassessment per RA 9173 nursing practice standards.

Key points

• BEFORE ambulating a post-bed rest patient, DANGLE them at the bedside first — allows cardiovascular adjustment and assessment for orthostatic hypotension and dizziness.
• Use a GAIT/TRANSFER BELT for unsteady patients during ambulation — never hold the patient by the arm or clothing.
• The nurse stands on the patient's WEAKER SIDE during ambulation to provide support and prevent falls.
• CANE USE: hold the cane on the STRONGER SIDE; advance the cane WITH the WEAKER LEG (cane and weak leg move together).
• CRUTCH GAIT: 3-point (NWB), 4-point (most stable), 2-point, swing-through — know each pattern and its indication.
• If a patient begins to FALL: DO NOT attempt to hold them upright — EASE THEM DOWN SLOWLY by sliding them along your leg to the floor, protecting the head, while keeping your OWN back straight and base of support wide.
• LOCK ALL WHEELS on beds, wheelchairs, and stretchers BEFORE any transfer.
• Bed should be in the LOWEST position when the patient is not receiving active care.
• Side rails: raise TWO side rails (not four — four raised rails constitutes a restraint).
• FALL PREVENTION: Call bell within reach; non-slip footwear; clear environment; adequate lighting; orient patient to surroundings; assess fall risk using a validated scale (e.g., Morse Fall Scale in Philippine hospitals).
• RESTRAINTS: used only as a LAST RESORT; require a physician's ORDER and informed consent; must be reassessed every 30–60 minutes; reposition and provide ROM, skin care, and toileting every 2 hours.

Definitions

Common mistakes

• Ambulating a patient immediately after long bed rest WITHOUT dangling first — high risk of orthostatic hypotension and falls.
• Standing on the STRONGER side of the patient — the nurse should be on the WEAKER side to provide maximum support.
• Telling a patient to hold the cane on the WEAK side — the cane goes on the STRONG side to support the weak leg.
• Trying to CATCH a falling patient by holding them upright — this often causes injury to both the patient and the nurse; the correct action is to EASE THEM DOWN safely.
• Forgetting to LOCK WHEELS before transfers — one of the most preventable causes of patient falls.
• Raising ALL FOUR side rails — this is legally considered a form of restraint.