NLE Fundamentals of Nursing & the Nursing Process — Basic Oxygenation, Elimination & NutritionCheat Sheet
Cheat sheet for NLE Fundamentals of Nursing & the Nursing Process — Basic Oxygenation, Elimination & Nutrition. Compact, printable, and organised around the concepts Professional Regulation Commission (PRC) — Board of Nursing tests most frequently in the NLE 2026. Perfect for the week before exam day.
Exam context
For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Fundamentals of Nursing & the Nursing Process under a "Core" label, with Basic Oxygenation, Elimination & Nutrition in the 7th slot across 8 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Fundamentals of Nursing & the Nursing Process questions. Date to watch: Bi-annual.
Basic Oxygenation, Elimination & Nutrition - Cheat Sheet
Your last-minute revision companion for the most frequently tested fundamental nursing skills. Master these quick facts, values, and decision rules to confidently answer oxygenation, elimination, nutrition, and wound-care questions on the NLE.
Sections
Common Values
Value
95–100%
Symbol
SpO₂
Quantity
Normal oxygen saturation (SpO₂)
Value
<90%
Symbol
SpO₂
Quantity
Hypoxemia threshold
Value
1–6 L/min
Symbol
Flow rate
Quantity
Nasal cannula flow range
Value
~32%
Symbol
FiO₂
Quantity
Nasal cannula FiO₂ at 3 L/min
Value
~44%
Symbol
FiO₂
Quantity
Nasal cannula max FiO₂ (at 6 L/min)
Value
5–10 L/min
Symbol
Flow rate
Quantity
Simple face mask flow
Value
40–60%
Symbol
FiO₂
Quantity
Simple face mask FiO₂
Value
≥5 L/min (to flush CO₂)
Symbol
Flow rate
Quantity
Minimum safe flow for face mask
Value
60–75%
Symbol
FiO₂
Quantity
Partial rebreather mask FiO₂
Value
80–95%
Symbol
FiO₂
Quantity
Non-rebreather mask FiO₂
Value
10–15 L/min
Symbol
Flow rate
Quantity
Non-rebreather mask flow
Value
Precise, fixed (24%, 28%, 31%, 35%, 40%, 50%)
Symbol
FiO₂
Quantity
Venturi mask FiO₂
Value
88–92%
Symbol
SpO₂
Quantity
Target SpO₂ in COPD (CO₂ retainers)
Value
21%
Symbol
FiO₂
Quantity
Room air FiO₂
Value
Until resistance felt, then withdraw 1 cm
Symbol
Depth
Quantity
Suction catheter insertion depth
Value
10–15 seconds
Symbol
Duration
Quantity
Maximum suction time per pass
Value
45–90° (near upright)
Symbol
Angle
Quantity
High-Fowler's bed angle
Section Title
Oxygenation & Airway Management
Important Facts
- EARLIEST SIGN OF HYPOXIA: Restlessness and anxiety—do NOT dismiss as behavioral.
- CYANOSIS IS A LATE SIGN—do not wait for cyanosis to intervene; use SpO₂ and clinical signs.
- Room air = 21% oxygen; every supplemental device increases FiO₂.
- Nasal cannula above 6 L/min dries mucosa without significantly increasing oxygen delivery.
- OXYGEN SUPPORTS COMBUSTION—No smoking, open flames, or petroleum-based products near oxygen.
- Hyperoxygenate before suctioning to prevent hypoxia during the procedure.
- COPD patients may be CO₂ retainers—use Venturi mask with target SpO₂ 88–92%, NOT room air aggressively.
- High-Fowler's or orthopneic position (sitting, leaning forward) maximizes lung expansion in dyspnea.
- Suction only as needed; apply suction only on withdrawal (not on insertion); limit each pass to 10–15 seconds.
- Non-rebreather mask can deliver up to 80–95% oxygen; ensure reservoir bag stays inflated.
- Assess airway patency, breathing effectiveness, and circulation (ABCs) first in any respiratory distress.
Key Definitions
Term
SpO₂ (Oxygen Saturation)
Example
Patient with SpO₂ 88% on room air needs oxygen therapy and reassessment.
Definition
Percentage of hemoglobin bound to oxygen; normal is 95–100%; <90% indicates hypoxemia and demands immediate intervention.
Term
Hypoxemia
Example
Pneumonia patient presenting with SpO₂ 85%, restlessness, and tachycardia.
Definition
Inadequate oxygen in arterial blood (SpO₂ <90%); a physiologic emergency requiring rapid assessment and intervention.
Term
Hypoxia
Example
Late-stage hypoxia may manifest as bradycardia and confusion despite supplemental oxygen.
Definition
Inadequate oxygen at the cellular/tissue level; may present with behavioral changes, cyanosis, or altered consciousness.
Term
Cyanosis
Example
Do not rely on cyanosis to identify early hypoxia; use restlessness and SpO₂.
Definition
Blue discoloration of skin/mucosa due to >5 g/dL of deoxygenated hemoglobin; a LATE sign of hypoxia, not an early warning.
Term
FiO₂ (Fraction of Inspired Oxygen)
Example
Nasal cannula at 3 L/min delivers approximately 32% FiO₂.
Definition
Percentage of oxygen in inspired air; room air = 21%; varies by delivery device.
Diagrams To Know
- Signs of early vs. late hypoxia (restlessness/anxiety vs. cyanosis/bradycardia/confusion)
- Oxygen delivery device spectrum by L/min and FiO₂ delivered
- Positioning for dyspnea (high-Fowler's, orthopneic, semi-Fowler's)
- Proper suctioning technique (hyperoxygenate → position → insert → apply suction on withdrawal only)
Common Values
Value
7–10 cm
Symbol
Depth
Quantity
Enema insertion depth (adults)
Value
30–45 cm
Symbol
Height
Quantity
Solution container height above anus
Value
Brown
Symbol
Color
Quantity
Normal stool color
Value
Pink to red, moist
Symbol
Appearance
Quantity
Healthy stoma color
Value
When 1/3–1/2 full; every 3–7 days routine
Symbol
Schedule
Quantity
Ostomy pouch change frequency
Section Title
Bowel Elimination
Important Facts
- Normal bowel pattern varies widely (daily to several times per week); assess patient's usual baseline.
- Constipation management: INCREASE FIBER, FLUIDS, ACTIVITY, and establish regular toileting routine.
- Stool softeners (docusate), bulk formers (psyllium), and laxatives are common pharmacologic interventions.
- Diarrhea priority: FLUID AND ELECTROLYTE REPLACEMENT (oral rehydration solution).
- Children with acute diarrhea: give ORS + ZINC per Philippine DOH program.
- Enema insertion: use left lateral (Sims') position; insert 7–10 cm in adults.
- Solution container height: raise 30–45 cm above the anus for optimal pressure.
- Stop enema infusion if patient reports cramping; do not force.
- Healthy stoma: pink/red and moist; blood-tinged mucus is normal.
- ISCHEMIC STOMA (dusky/dark color): report immediately—potential surgical emergency.
- Empty ostomy pouch when 1/3 to 1/2 full to prevent leakage and odor.
- Assess and document bowel sounds, abdominal distention, and frequency/consistency of stools.
Key Definitions
Term
Constipation
Example
Postoperative opioid use commonly causes constipation; manage with stool softeners and fiber.
Definition
Infrequent, hard, difficult-to-pass stools; causes include low fiber, dehydration, immobility, medications.
Term
Diarrhea
Example
Acute gastroenteritis in children managed with ORS and zinc per DOH guidelines.
Definition
Frequent, loose, watery stools; risk of dehydration and electrolyte imbalance, especially in children and elderly.
Term
Fecal Impaction
Example
Older adult on opioids presents with leaking stool; assess for impaction and obtain order for digital removal if needed.
Definition
Hard, immobile fecal mass in the colon/rectum; may present with liquid stool leaking around it (overflow diarrhea).
Term
Ostomy
Example
Healthy stoma is pink/red and moist; dusky/dark stoma suggests ischemia—report immediately.
Definition
Surgical opening (stoma) from the bowel to the abdominal surface; requires pouch changes, skin care, and psychosocial support.
Term
Sims' Position (Left Lateral)
Example
Patient positioned left lateral with right leg flexed for cleansing enema.
Definition
Left side-lying position used for enema insertion to follow the natural curve of the colon.
Diagrams To Know
- Cleansing vs. retention enema (purpose, solution type, holding time)
- Signs of healthy vs. ischemic stoma
- Enema insertion position and anatomic landmarks (Sims' position, angle of insertion)
- Constipation vs. diarrhea management algorithms
Common Values
Value
~1,500 mL/day
Symbol
Output
Quantity
Normal daily urine output
Value
~30 mL/hr
Symbol
Output rate
Quantity
Minimum acceptable urine output (renal perfusion marker)
Value
5–7.5 cm
Symbol
Depth
Quantity
Female catheter insertion depth
Value
17–20 cm
Symbol
Depth
Quantity
Male catheter insertion depth
Value
<30 mL/hr or <500 mL/day
Symbol
Output
Quantity
Oliguria threshold
Value
<100 mL/day
Symbol
Output
Quantity
Anuria threshold
Value
Clear to pale yellow
Symbol
Appearance
Quantity
Normal urine color
Value
1.005–1.030
Symbol
Specific gravity
Quantity
Normal urine specific gravity
Section Title
Urinary Elimination & Catheterization
Important Facts
- NORMAL ADULT URINE OUTPUT: ~1,500 mL/day; minimum acceptable output is ~30 mL/hr (key renal perfusion marker).
- OUTPUT <30 mL/HR MUST BE REPORTED—it indicates possible renal hypoperfusion.
- Catheterization: use STERILE TECHNIQUE (surgical asepsis); use the SMALLEST appropriate size.
- INFLATE BALLOON ONLY AFTER URINE FLOWS—confirms placement in bladder and prevents balloon inflation in urethra.
- Female catheter insertion: ~5–7.5 cm; male: ~17–20 cm.
- Secure the catheter to prevent tension on the bladder neck and urethral traction.
- DRAINAGE BAG MUST BE BELOW BLADDER LEVEL at all times—prevents backflow and reflux of urine.
- MAINTAIN CLOSED SYSTEM—do not disconnect the catheter and bag unless unavoidable; this is the primary CAUTI prevention measure.
- REMOVE CATHETER AS EARLY AS CLINICALLY POSSIBLE—duration is the greatest CAUTI risk factor.
- Check for signs of UTI (fever, dysuria, cloudy urine, odor, suprapubic tenderness) daily.
- Promote normal voiding: provide privacy, normal position (sitting/standing), running water, warm water over perineum, respond promptly to urge.
- Bladder training: gradually increase voiding intervals to re-establish normal patterns; teach Kegel exercises for incontinence.
- Nocturia (nighttime urination) may indicate overactive bladder, UTI, diabetes, or heart failure—assess context.
- Monitor for signs of urinary obstruction: suprapubic distention, discomfort, no urine output despite full bladder.
Key Definitions
Term
Oliguria
Example
Postoperative patient with urine output of 15 mL/hr—report immediately and assess fluid status.
Definition
Abnormally low urine output (<30 mL/hr or <500 mL/day); indicates possible renal hypoperfusion or acute kidney injury.
Term
Anuria
Example
Anuria following acute blood loss suggests hypovolemic shock affecting renal perfusion.
Definition
Absence of urine output (<100 mL/day); indicates severe renal dysfunction and is a medical emergency.
Term
Dysuria
Example
Patient reports dysuria, frequency, and urgency—obtain urinalysis and culture per protocol.
Definition
Painful or difficult urination; suggests urinary tract infection (UTI), urethritis, or bladder irritation.
Term
Urinary Retention
Example
Postoperative patient unable to void after 6–8 hours; straight catheterization or assessment for obstruction needed.
Definition
Inability to empty the bladder; accumulation of urine in the bladder; may present with overflow incontinence.
Term
Urinary Incontinence
Example
Older adult with urge incontinence benefits from bladder training and pelvic-floor (Kegel) exercises.
Definition
Involuntary loss of urine; types include stress, urgency, overflow, functional, and mixed.
Term
CAUTI (Catheter-Associated Urinary Tract Infection)
Example
ICU patient on day 7 of catheterization develops fever and cloudy urine; assess for CAUTI.
Definition
Infection of the urinary tract due to prolonged catheterization; prevented by removing the catheter as soon as clinically possible and maintaining a closed system.
Diagrams To Know
- Urinary catheter insertion landmarks and depth (female vs. male anatomy)
- Proper catheter positioning and drainage bag setup
- Signs of UTI vs. normal catheter care findings
- Bladder training and urinary incontinence management steps
Common Values
Value
≤5
Symbol
pH
Quantity
Gastric aspirate pH (normal)
Value
30–45°
Symbol
Angle
Quantity
Head of bed elevation during feeding
Value
30–60 minutes
Symbol
Duration
Quantity
Duration to maintain HOB elevation after feeding
Value
Nose to earlobe to xiphoid
Symbol
Measurement
Quantity
NG tube insertion depth estimate (NEX method)
Value
Room temperature (20–25°C)
Symbol
Temperature
Quantity
Feeding temperature
Value
15–30 mL
Symbol
Volume
Quantity
Water flush before/after feeding
Value
15–30 mL
Symbol
Volume
Quantity
Water flush between medications
Value
50 mL (facility-dependent)
Symbol
Volume
Quantity
Maximum residual volume (typical)
Section Title
Enteral (Tube) Feeding & Nutrition Support
Important Facts
- TUBE PLACEMENT VERIFICATION IS NON-NEGOTIABLE BEFORE EVERY FEEDING AND MEDICATION.
- MOST RELIABLE BEDSIDE METHODS: gastric aspirate pH ≤5 + external tube length measured against marked insertion point.
- Air-auscultation (listening for 'whoosh') is UNRELIABLE and NO LONGER RECOMMENDED as sole confirmation method.
- X-RAY CONFIRMATION is the GOLD STANDARD after initial tube insertion.
- Head of bed (HOB) must be elevated 30–45° DURING and FOR 30–60 MINUTES AFTER feeding to prevent aspiration.
- ASPIRATION is the most serious tube-feeding complication—maintain HOB elevation and monitor for signs (cough, crackles, fever, SpO₂ drop).
- Check residual volume per facility protocol; high residuals suggest feeding intolerance or delayed gastric emptying.
- Administer feedings at ROOM TEMPERATURE (not cold from refrigerator).
- FLUSH THE TUBE with water BEFORE and AFTER each feeding and BETWEEN each medication to maintain patency.
- Medications: use LIQUID FORMULATIONS when possible; do NOT crush enteric-coated or sustained-release drugs into the tube.
- Flush 15–30 mL water between each medication if multiple drugs given via tube.
- Monitor for DIARRHEA (often related to formula osmolality or antibiotics), DEHYDRATION, HYPERGLYCEMIA, and REFEEDING SYNDROME in malnourished patients.
- Refeeding syndrome: occurs when feeding is started too aggressively in severely malnourished patients; causes electrolyte shifts, cardiac dysrhythmias, and fluid overload.
- Give feedings CONTINUOUSLY or INTERMITTENTLY per order; intermittent feedings mimic normal eating pattern.
- NG tube insertion: measure using NEX method (Nose → Earlobe → Xiphoid) and mark the point.
- During insertion, ask patient to FLEX HEAD FORWARD (chin to chest) and SWALLOW to promote esophageal entry.
- If patient COUGHS, CHOKES, or becomes CYANOTIC during insertion → WITHDRAW IMMEDIATELY (tube may be in airway).
- Secure tube with tape to prevent dislodgement and minimize pressure on nares.
Key Definitions
Term
Enteral Nutrition
Example
Stroke patient with intact swallow reflex but inability to eat → nasogastric tube feeding initiated.
Definition
Delivery of nutrients directly into the GI tract via feeding tube (nasogastric, gastrostomy, jejunostomy); used when patient cannot eat but has a functioning gut.
Term
Nasogastric (NG) Tube
Example
Postoperative patient NPO until bowel function returns; NG tube placed for decompression and later feeding.
Definition
Small-bore tube inserted through the nares into the stomach for feeding and/or medication administration.
Term
Gastrostomy/PEG Tube
Example
Amyotrophic lateral sclerosis (ALS) patient unable to swallow → PEG tube placed for nutritional support.
Definition
Surgically or endoscopically placed feeding tube directly into the stomach; used for long-term enteral feeding.
Term
Tube Placement Verification
Example
After NG insertion: aspirate gastric contents, test pH (should be ≤5), and mark external tube length before first use.
Definition
Confirmation that the tube is in the stomach (NOT in airways); most reliable bedside methods are gastric aspirate pH ≤5 and measuring external tube length against insertion point; X-ray is gold standard.
Term
Aspiration
Example
Patient on continuous NG feeding with HOB <30° develops cough and crackles—stop feeding, position upright, assess for aspiration.
Definition
Inhalation of formula/stomach contents into the lungs; a serious complication of tube feeding; prevented by HOB elevation and checking residual volume.
Term
Residual Volume
Example
Residual >50 mL (or per facility protocol) → hold feeding, reassess, consider prokinetic agent.
Definition
Volume of formula remaining in the stomach before the next feeding; high residuals may indicate delayed gastric emptying or feeding intolerance.
Diagrams To Know
- NEX tube measurement method (Nose → Earlobe → Xiphoid landmark)
- Proper head positioning during NG insertion (flexion forward)
- Tube placement verification algorithm (pH, length, X-ray)
- HOB elevation protocol during and after feeding
- Troubleshooting: tube clogging, high residuals, diarrhea, aspiration signs
Formulas
Formula
1 kg weight change ≈ 1 L fluid volume
Meaning
A 1-kilogram gain or loss in body weight roughly corresponds to 1 liter of fluid gained or lost; used to assess fluid status.
Watch Out
Do not assume weight change is solely from fluid; edema, muscle loss, or food intake also affect weight. But acute weight change (24–48 hrs) is primarily fluid.
When To Use
Daily weight measurement is the most accurate indicator of fluid balance status; compare weights on the same scale, at the same time, in similar clothing.
Common Values
Value
2,000–2,500 mL
Symbol
Volume
Quantity
Normal daily fluid intake and output
Value
≥30 mL/hr
Symbol
Output rate
Quantity
Urine output marker for renal perfusion
Value
<30 mL/hr or <500 mL/day
Symbol
Output
Quantity
Oliguria threshold
Value
1 kg = 1 L
Symbol
Conversion
Quantity
Weight equivalence to fluid volume
Value
1,000–1,500 mL/day
Symbol
Volume limit
Quantity
Fluid restriction in heart failure/overload
Value
Pale yellow to amber
Symbol
Appearance
Quantity
Normal urine color
Value
Dark yellow to amber
Symbol
Appearance
Quantity
Dehydration urine color
Section Title
Fluid Intake & Output (I&O) Monitoring
Important Facts
- NORMAL DAILY FLUID BALANCE: approximately 2,000–2,500 mL intake and output per day.
- DAILY WEIGHT IS THE MOST ACCURATE INDICATOR OF FLUID STATUS—1 kg ≈ 1 L fluid.
- Weigh patient at the SAME TIME each day, on the SAME SCALE, in SIMILAR CLOTHING.
- Acute weight gain or loss (24–48 hrs) is primarily FLUID, not tissue.
- DEHYDRATION SIGNS: thirst, dry mucous membranes, decreased skin turgor, concentrated urine, weight loss, TACHYCARDIA, HYPOTENSION.
- OVERLOAD SIGNS: edema (peripheral and pulmonary), crackles on lung auscultation, DISTENDED NECK VEINS, weight gain, hypertension, dyspnea.
- Monitor I&O hourly in acute/critical patients; every 4 or 8 hours in stable patients per protocol.
- Record all intake and output on the chart; calculate net balance (intake minus output) at end of shift and every 24 hours.
- Report I&O imbalances: sustained positive balance (overload risk) or negative balance (dehydration risk).
- Assess skin turgor on the sternum or forearm (inner aspect); in elderly, skin turgor is less reliable.
- Dry mucous membranes and thirst are early signs of dehydration; ensure adequate fluid access and encourage intake.
- In hypervolemia, restrict fluids (typically 1,000–1,500 mL/day) and sodium per physician order.
- Urine color: pale yellow (adequate hydration) to dark yellow/amber (dehydration).
- Monitor electrolytes, serum osmolality, and BUN/creatinine ratio in fluid imbalance situations.
Key Definitions
Term
Fluid Volume Deficit (Dehydration)
Example
Vomiting and diarrhea patient: dry mucosa, concentrated urine (dark yellow), tachycardia, hypotension—start IV rehydration and monitor I&O.
Definition
Insufficient total body fluid; causes include decreased intake, increased output, or third-spacing; manifests with thirst, dry mucosa, poor skin turgor, concentrated urine, weight loss, tachycardia, and hypotension.
Term
Fluid Volume Overload (Hypervolemia)
Example
Heart failure patient: bilateral ankle edema, crackles on lung auscultation, elevated JVD, weight gain of 2 kg—restrict fluids and sodium.
Definition
Excess total body fluid; causes include excessive intake, renal/cardiac failure; manifests with edema, crackles, distended neck veins, weight gain, hypertension, dyspnea.
Term
Intake
Example
Oral intake: 240 mL water, 120 mL juice, 180 mL soup; IV: 500 mL normal saline over 4 hrs; NG feeding: 240 mL formula.
Definition
All fluids entering the body: oral intake, IV fluids, feeding tube fluids, and irrigants NOT withdrawn.
Term
Output
Example
Urine: 400 mL; vomit: 50 mL; diarrhea: 200 mL; Jackson-Pratt drain: 25 mL; total output: 675 mL.
Definition
All fluids leaving the body: urine, emesis, diarrhea, wound drainage, tube drainage, and significant blood loss.
Diagrams To Know
- Fluid volume deficit vs. overload: clinical signs and lab findings
- I&O recording methodology and timing
- Daily weight trends and interpretation
- Electrolyte imbalances in fluid deficit and overload states
Common Values
Value
4 kcal/g
Symbol
Energy
Quantity
Carbohydrate energy content
Value
4 kcal/g
Symbol
Energy
Quantity
Protein energy content
Value
9 kcal/g
Symbol
Energy
Quantity
Fat energy content
Value
3–4 weeks
Symbol
Duration
Quantity
Albumin half-life (long-term nutritional marker)
Value
2–3 days
Symbol
Duration
Quantity
Prealbumin half-life (acute nutritional marker)
Value
3.5–5.5 g/dL
Symbol
Concentration
Quantity
Normal serum albumin
Value
20–40 mg/dL
Symbol
Concentration
Quantity
Normal serum prealbumin
Value
Immediate (minutes to hours)
Symbol
Duration
Quantity
Hemostasis phase duration
Value
0–3 days
Symbol
Duration
Quantity
Inflammatory phase duration
Value
4–21 days
Symbol
Duration
Quantity
Proliferative/granulation phase duration
Value
21 days to 2 years
Symbol
Duration
Quantity
Maturation/remodeling phase duration
Value
5–12 days post-surgery
Symbol
Timing
Quantity
Typical dehiscence onset
Section Title
Nutrition Fundamentals & Wound Healing
Important Facts
- PROTEIN, VITAMIN C, AND ZINC are the KEY nutrients for wound healing.
- Wound healing phases: HEMOSTASIS (immediate) → INFLAMMATORY (0–3 days) → PROLIFERATIVE/GRANULATION (4–21 days) → MATURATION/REMODELING (21 days to 2 years).
- WOUND BED COLORS: RED (healthy granulation, keep moist), YELLOW (slough, needs debridement), BLACK (eschar, needs debridement).
- Clean wounds (surgical) from CLEAN to DIRTY (least contaminated to most contaminated) or from incision outward.
- Do NOT use cytotoxic agents (H₂O₂, povidone-iodine) on healthy granulation tissue—they delay healing.
- Normal saline is the SAFEST cleansing solution for most wounds.
- Maintain MOISTURE BALANCE: too dry (crust forms, slows healing) or too wet (maceration of surrounding skin).
- Adequate PERFUSION is critical for healing; assess circulation, manage anemia, ensure oxygenation.
- Nutritional assessment: weight/BMI, intake history, labs (albumin, prealbumin), mobility, comorbidities.
- Monitor for INFECTION: increasing redness, warmth, purulent drainage, fever, elevated WBC.
- DEHISCENCE: partial separation may close with rest; complete separation requires surgical intervention.
- EVISCERATION: SURGICAL EMERGENCY—cover with sterile saline-moistened dressing, keep NPO, keep patient still (low-Fowler's with knees bent), notify surgeon STAT.
- Drain management: maintain sterile technique, record output, assess color/consistency, ensure tubing is not kinked.
- Skin around wound (peristomal area) needs protection from exudate; use skin barriers and change dressings on schedule.
- Follow therapeutic diets: renal (protein-restricted), diabetic (carbohydrate-controlled), low-sodium, high-fiber.
- In the Philippines, use DOH/FNRI PINGGANG PINOY model for nutrition teaching (balanced plate: vegetables, grains, protein, fruits).
Key Definitions
Term
Macronutrients
Example
Carbohydrates: 4 kcal/g (energy); proteins: 4 kcal/g (tissue repair); fats: 9 kcal/g (concentrated energy).
Definition
Carbohydrates, proteins, and fats; provide energy and support body structure and function.
Term
Micronutrients
Example
Vitamin C (collagen synthesis), zinc (wound healing), iron (oxygen transport), calcium (bone health).
Definition
Vitamins and minerals; essential for metabolism, immunity, and tissue function; required in small quantities.
Term
Protein
Example
Wound healing requires increased protein intake; amino acids provide building blocks for collagen.
Definition
Macronutrient essential for tissue building, repair, immune function, and enzyme synthesis; 4 kcal/g; critical for wound healing.
Term
Albumin & Prealbumin
Example
Low albumin or prealbumin suggests malnutrition; improve intake and reassess in 2–3 weeks.
Definition
Serum proteins used as nutritional status markers; albumin reflects long-term nutrition (3–4 week half-life); prealbumin reflects acute changes (2–3 day half-life).
Term
Wound Healing (Primary vs. Secondary vs. Tertiary Intention)
Example
Primary: sutures used immediately. Secondary: pressure ulcer healing. Tertiary: dirty wound closed after infection cleared.
Definition
Primary: clean, approximated edges (surgical incision); secondary: open wound healing from base up; tertiary: delayed closure of wound.
Term
Granulation Tissue
Example
Wound bed red/pink and granulating = healing well; maintain moisture and support continued healing.
Definition
Healthy new tissue (red/pink, beefy appearance) that forms during the proliferative phase of wound healing; contains capillaries and collagen.
Term
Eschar
Example
Burn wound with thick black eschar requires escharotomy or enzymatic debridement.
Definition
Black or dark brown, necrotic (dead) tissue; must be debrided for healing to progress; does not blanch or bleed.
Term
Slough
Example
Pressure ulcer with yellow slough visible on wound bed; wet-to-dry dressing may assist removal.
Definition
Yellow or white dead tissue; softer than eschar; also requires removal (debridement) for healing.
Term
Dehiscence
Example
Postoperative patient with sudden discharge or serosanguinous drainage; if partial, may heal; if complete, surgical closure needed.
Definition
Partial or complete separation of wound edges; occurs typically on days 5–12 after surgery; risk factors include infection, strain, obesity.
Term
Evisceration
Example
Patient coughs and bowel protrudes through incision → cover with sterile saline-moistened dressing, keep NPO, notify surgeon stat.
Definition
Protrusion of abdominal organs through an open surgical wound; a SURGICAL EMERGENCY requiring immediate intervention.
Diagrams To Know
- Phases of wound healing timeline (hemostasis, inflammatory, proliferative, maturation)
- Wound bed assessment color guide (red=healthy, yellow=slough, black=eschar)
- Nutrition assessment and intervention flowchart
- Evisceration emergency response protocol
- Pinggang Pinoy (Filipino food plate) model for nutrition teaching
Must Remember
- SpO₂ <90% = HYPOXEMIA; RESTLESSNESS IS THE EARLIEST SIGN (not cyanosis, which is LATE). Cyanosis requires >5 g/dL deoxygenated hemoglobin and lags clinical deterioration.
- NASAL CANNULA: 1–6 L/min delivers 24–44% FiO₂; above 6 L/min dries mucosa without adding oxygen. NON-REBREATHER: 10–15 L/min delivers 80–95% for emergencies; ensure bag stays inflated.
- OXYGEN SUPPORTS COMBUSTION—no smoking, open flames, or petroleum products near oxygen. Post 'Oxygen in Use' signs.
- In COPD (CO₂ RETAINERS): use VENTURI MASK (precise FiO₂) with target SpO₂ 88–92%; excessive oxygen blunts hypoxic respiratory drive. But DO NOT withhold oxygen from a hypoxic patient.
- TUBE PLACEMENT VERIFICATION: Gastric aspirate pH ≤5 + measure external tube length against marked insertion point BEFORE every feeding/medication. X-ray is gold standard after insertion. Air-auscultation alone is UNRELIABLE.
- HEAD OF BED 30–45° DURING and FOR 30–60 MINUTES AFTER tube feeding to prevent ASPIRATION (most serious complication). ASPIRATION = serious risk; monitor for cough, crackles, fever, SpO₂ drop.
- URINE OUTPUT ≥30 mL/HR = marker of renal perfusion; <30 mL/hr MUST BE REPORTED. Oliguria = <30 mL/hr or <500 mL/day; anuria = <100 mL/day.
- CATHETER CARE: Insert using STERILE technique; inflate balloon ONLY AFTER urine flows (confirms bladder placement). Drainage bag BELOW bladder level ALWAYS. Maintain CLOSED SYSTEM. REMOVE CATHETER AS EARLY AS POSSIBLE—duration is greatest CAUTI risk factor.
- DAILY WEIGHT is most accurate fluid-status indicator (1 kg ≈ 1 L fluid). Weigh at same time, same scale, same clothing. Acute weight change (24–48 hrs) is primarily FLUID.
- EVISCERATION = SURGICAL EMERGENCY: Cover with sterile saline-moistened dressing, keep NPO, low-Fowler's with knees bent, keep patient still, notify surgeon STAT. Do NOT reinsert organs.
Last Minute Tips
- Remember COLORS for wound beds: RED = healthy granulation (keep moist, avoid cytotoxic agents), YELLOW = slough (debride), BLACK = eschar (debride). This single concept appears in nearly every exam wound question.
- Tube feeding failures come from forgetting: (1) verify placement EVERY time, (2) HOB 30–45° during AND after, (3) flush before/after. These three points prevent aspiration and maintain patency—worth 3+ exam points.
- When a patient is dyspneic, position them in HIGH-FOWLER'S or ORTHOPNEIC (sitting, leaning forward). This is tested constantly because it's the easiest, most effective intervention.
- Dehydration vs. overload: DEHYDRATION = dry mouth, dark urine, tachycardia, HYPOTENSION. OVERLOAD = crackles, distended neck veins, weight gain, HYPERTENSION. Use these clinical opposites as memory anchors.
- For COPD patients receiving oxygen: ALWAYS use VENTURI MASK with target SpO₂ 88–92%. This one rule prevents a deadly exam mistake. Do not give them unrestricted nasal cannula or high FiO₂.
Comparison Tables
Rows
Values
- 1–6
- 24–44%
- Mild hypoxemia; chronic oxygen
- Dries mucosa at high flows; comfortable for eating/talking
Property
Nasal Cannula
Values
- 5–10
- 40–60%
- Moderate hypoxemia
- Must maintain ≥5 L/min to flush CO₂; keep mask sealed
Property
Simple Face Mask
Values
- 6–15
- 60–75%
- Higher oxygen needs
- Reservoir bag should remain 1/3–1/2 inflated; higher FiO₂
Property
Partial Rebreather Mask
Values
- 10–15
- 80–95%
- Severe hypoxemia; emergency
- Highest FiO₂; ensure bag stays inflated; emergency use only
Property
Non-Rebreather Mask
Values
- Variable
- Precise, fixed (24–50%)
- COPD (CO₂ retainers); precise FiO₂ needed
- Preferred for COPD; delivers exact oxygen concentration; color-coded
Property
Venturi Mask
Columns
- Device
- Flow Rate (L/min)
- FiO₂ Delivered
- Best Use
- Key Consideration
Table Title
Oxygen Delivery Devices Comparison
Rows
Values
- Infrequent, hard, difficult-to-pass stool
- Frequent, loose, watery stool
Property
Definition
Values
- Increase fiber, fluids, activity, regular toileting
- Replace fluids and electrolytes (ORS in children); identify cause
Property
Primary Intervention
Values
- Stool softeners (docusate), bulk formers (psyllium), laxatives
- Antimotility agents (loperamide) only if not infectious; avoid in shigellosis
Property
Medications
Values
- Fecal impaction; may leak fluid stool around mass (overflow)
- Dehydration, electrolyte imbalance (especially in children/elderly)
Property
Key Risk
Values
- Fiber-rich foods, 8 glasses water/day, daily exercise, bathroom routine
- ORS use, continue breastfeeding/nutrition, seek care if prolonged
Property
Patient Teaching
Values
- Opioids are common cause; prevent with stool softeners
- Acute diarrhea in children (DOH): ORS + zinc supplementation
Property
Special Considerations
Columns
- Aspect
- Constipation
- Diarrhea
Table Title
Constipation vs. Diarrhea Management
Rows
Values
- Present (early sign)
- Absent
Property
Thirst
Values
- Dry
- Moist/normal
Property
Mucous Membranes
Values
- Poor (tents); slow return
- Normal or edematous
Property
Skin Turgor
Values
- Dark yellow/concentrated
- Pale/dilute
Property
Urine Color
Values
- Loss (usually acute)
- Gain (usually acute)
Property
Weight Change
Values
- Tachycardia
- Normal or elevated
Property
Heart Rate
Values
- Hypotension (late sign)
- Hypertension or normal
Property
Blood Pressure
Values
- Flat/collapsed
- Distended (elevated JVD)
Property
Neck Veins
Values
- Clear
- Crackles (pulmonary edema)
Property
Lung Sounds
Values
- Absent
- Present (peripheral, pulmonary, sacral)
Property
Edema
Values
- High (>295 mOsm/kg)
- Low (<280 mOsm/kg) in overhydration
Property
Serum Osmolality
Values
- High (>20:1) due to concentration
- Low (<20:1) due to dilution
Property
BUN/Creatinine Ratio
Columns
- Sign/Lab
- Dehydration (Deficit)
- Hypervolemia (Overload)
Table Title
Fluid Volume Deficit vs. Overload
Rows
Values
- Minutes to hours
- Platelet aggregation, clot formation
- Bleeding stops, clot forms
- Assess bleeding; apply pressure/dressing
Property
Hemostasis
Values
- 0–3 days
- Cleansing; WBC migration; edema
- Redness, warmth, exudate, pain
- Monitor for infection; clean with saline; assess pain
Property
Inflammatory
Values
- 4–21 days
- Collagen deposition; neovascularization; epithelialization
- Red/pink, granular, moist, bleeding easily
- Maintain moisture; support nutrition (protein, vit C, zinc); avoid cytotoxic agents
Property
Proliferative (Granulation)
Values
- 21 days to 2 years
- Collagen crosslinking; scar formation; strengthening
- Pink, flattening, tissue becomes firmer
- Continue scar care; encourage mobility; educate on scar management
Property
Maturation/Remodeling
Columns
- Phase
- Duration
- Key Cellular Activity
- Wound Appearance
- Nursing Action
Table Title
Wound Healing Phases & Nursing Interventions
Rows
Values
- Healthy granulation tissue
- Healing well; active proliferation
- Maintain moisture; support with nutrition; avoid cytotoxic agents
Property
Red/Pink, Beefy
Values
- Slough (dead tissue, softer)
- Impedes healing; requires removal
- Debride via wet-to-dry dressing, enzymatic agent, or surgical debridement
Property
Yellow/Tan
Values
- Eschar (necrotic tissue, hard)
- Does not bleed or blanch; prevents healing progression
- Arrange debridement (enzymatic, surgical, or autolytic); assess for demarcation
Property
Black/Brown, Dry
Values
- May indicate vasoconstriction, anemia, or inadequate perfusion
- Poor blood flow; healing compromised
- Assess circulation; optimize perfusion; manage anemia; reposition
Property
Pale/White
Columns
- Color
- Tissue Type
- Interpretation
- Nursing Action
Table Title
Wound Bed Color Assessment & Interpretation
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Medication Administration & Dosage Calculation
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Documentation, Reporting & Health Informatics
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